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Patton Healthcare Consulting, Inc.

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New from The Joint Commission: Updated EC and LS Chapters Published

The Joint Commission recently published new EC and LS chapters with two documents posted to the TJC website, one being just the new standards and the second being a side-by-side comparison of the new standards and the old standards. This latter document is the most useful of the two to analyze because it allows you to scan each requirement to see what is identical and what is new. You want someone with great attention to detail and reading skills to read this document and highlight each requirement that is new, or now includes new NFPA references.

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CMS adds new Emergency Management Requirements

On September 8th CMS published Survey and Certification memo 16-38 notifying us of the publication of its final rule for emergency preparedness. The details of this rule were published in the Federal Register on September 16th and the new regulation goes into effect November 16, 2016. Accredited hospitals should have a relatively easy time with this, but the scope of this regulation goes far beyond hospitals. This rule will also affect community mental health centers, residential treatment centers, ambulatory surgery centers, hospice, PACE programs, long term care facilities, intermediate care facilities, home health agencies, comprehensive outpatient rehabilitation facilities, end stage renal dialysis centers, rural health clinics and even your organ procurement organization. Read more

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Joint Commission EC/LS Changes

The October 2016 issue of The Joint Commission Perspectives has a must read for your facilities leadership team in its Clarifications and Expectations column. Here George Mills summarizes all the changes brought about by eliminating the regular PFI, the elimination of clarifications for delayed handling of required documents in the survey process, ILSM documentation, time limited waivers and equivalencies.  There are many new acronyms to learn too with TLW, time limited waivers, SPFI, survey related plans for improvement, and SCD for scheduled completion date. Read more

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Joint Commission’s New “SAFER™ Matrix”

The lead article in the October 2016 issue of Perspectives discusses the new SAFER Matrix and the many changes planned for 2017. As you will recall from earlier articles on the SAFER Matrix each finding will be color-coded one of 4 colors by order of significance and scope. The lowest level findings will be bright yellow, or lemon colored. The somewhat moderate level findings will be a pale yellow/orange sort of like French’s mustard. The next highest ranking is a darker golden/orange color, somewhat like Guldens spicy mustard. Lastly there is a red color for the highest significance and most widespread scope. (Dare we say the color of ketchup?) The way in which these different levels will be handled during the ESC is different also, with the 2 highest levels requiring:

Leadership involvement

Preventative analysis

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Summary of Hospital Sentinel Event Statistics for 2016

The August 2016 issue of The Joint Commission Perspectives summarizes the sentinel event statistics for the first half of 2016. The top 5 most common sentinel events identified so far in 2016 are:

1. Unintended retention of a foreign object
2. Falls
3. Wrong patient, site or procedure
4. Suicide
5. Delay in treatment.

Each of these 5 issues also has a recent reference from TJC either as a Sentinel Event Alert, a Quick Safety Newsletter or Targeted Solutions reference. We would encourage all of our readers to look at the references and discuss their own risks and what might be done to reduce them. Read more