Month: February 2017

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Critical Alarm Reduction Highlighted

The February 2017 issue of The Joint Commission Perspectives includes a table of contents from The Joint Commission Journal of Quality and Patient Safety. This is a publication you can purchase, but for now you have free access to the January, February and March issues by clicking on the link published in the article.

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Joint Commission Laboratory Accreditation Changes

In the February 2017 issue of The Joint Commission Perspectives there is a very detailed and complex article on laboratory accreditation changes made within the TJC  manual to align with CMS requirements. This article reminds us that laboratory science is a very precise and complex performance area that most of us as hospital clinicians have limited knowledge of. Rather than trying to explain these changes we suggest that our readers use a management approach by sharing these changes with your laboratory managers or section heads and asking them three questions: Read more

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More Changes Announced to the TJC Life Safety Code (LSC) Standards

The “Clarifications and Expectations” column in the February 2017 issue of The Joint Commission Perspectives describes key changes to the LSC standards. The article identifies a publication date discrepancy where the standards you now see on the extranet or read in your published CAMH do not exactly match all the new CMS K tag requirements. This is because TJC hit its publication dates prior to CMS having all the details published. TJC will be working to bring these into complete alignment later in 2017 or in 2018.In the interim TJC has created what they are calling “wild card” elements of performance such as LS.03.01.70, EP 6 which states: The organization meets all other LSC requirements related to NFPA 101-2012.

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CMS Memo on End Stage Renal Disease Includes Helpful Compliance Checklist

We wish to call your attention to CMS SC Memo 17-02 dated Oct 21, 2016 addressing End Stage Renal Disease (ESRD) that contains a wealth of information, tools and techniques to evaluate the adequacy of dialysis services. Dialysis is a highly specialized service that the average quality professional knows a little about, but in most cases, is not a content expert. At the same time, contracted or in-house dialysis services are often a very frequent trouble spot on Joint Commission or CMS surveys. As consultants, we have developed tracer tools and we have seen TJC tracer tools that their surveyors use.

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Antibiotic Stewardship: Joint Commission Survey Activity Guide

In the 2017 Survey Activity Guide (SAG) The Joint Commission has delineated how they will use six different tracer sessions to explore compliance with the new Antibiotic Stewardship Program (ASP) standards. These include individual patient tracers, competence assessment session, medical staff session, data management system tracer, medication management system tracer and lastly the leadership session on the last day. So clearly getting ready for these new standards is going to be far more complex than anyone might have anticipated based on past experience.

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