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		<title>The Joint Commission: The Source</title>
		<link>http://www.jcrinc.com</link>
		<description>Blog</description>
		<language>en-us     </language>
		
		
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					<title>April Issue Available Now!</title> 
					<link>http://www.jcrinc.com/Blog/2012/3/15/April-Issue-Available-Now/</link> 
					<description><![CDATA[The April 2012 issue of The Source is now available, containing the following articles:
• Spotlight on Success: St Joseph Hospital Improves Handoff Communication
• 5 Sure-Fire Methods: Complying with QSA.01.01.01
• Tracer Methodology 101: Second Generation Tracer—Diagnostic Imaging
• CMS: Joint Commission/CMS Close the Gap on Credentialing and Privileging Staff at Distant Sites
• Perspectives on Patient Safety: Your Patient Safety News
• E-Talk: The Joint Commission Prepares for the Future of eMeasures
To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 15 Mar 2012 20:25:32 GMT</pubDate>
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					<title>March Issue Available Now!</title> 
					<link>http://www.jcrinc.com/Blog/2012/3/15/March-Issue-Available-Now/</link> 
					<description><![CDATA[The March 2012 issue of The Source is now available, including the following articles: 
• Making It Work: Adapting Tools for Use in Your Organization
• 5 Sure-Fire Methods: Complying with Standard HR.01.06.01
• Tracer Methodology 101: Suicide Prevention Tracers in the Hospital Setting
• Focus on Certification: Promoting a Collaborative Environment in Palliative Care
• Voice of the Patient: Family Works with Hospital to Improve Patient Safety
• The Future of Performance Measures: From Paper-Based Measures to eMeasures
To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 15 Mar 2012 20:23:48 GMT</pubDate>
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					<title>February Issue of &amp;lt;I&amp;gt;The Source&amp;lt;/I&amp;gt; Now Available!</title> 
					<link>http://www.jcrinc.com/Blog/2012/1/20/February-Issue-of-The-Source/-Now-Available/</link> 
					<description><![CDATA[The February issue of The Source is available now, including the following articles:
• Managing Health Care Worker Fatigue:  Maximizing Alertness to Keep Patients Safe
• 5 Sure-Fire Methods: Complying with Standard PC.02.03.01
• Tracer Methodology 101: Fall Reduction Tracer in the Ambulatory Setting
• The CREW Initiative: Veteran’s Health Administration Civility Program Improves Safety and Quality
• Easing the Pain: Complying with CMS–Related Anesthesia Requirements in Ambulatory Care
• Focus on Certification: The Joint Commission Strengthens Certification Alliance
• Perspectives on Patient Safety: Joint Commission Center Launches New Partnership Opportunity
• Benchmark: Institute of Medicine Report Addresses Downsides of Health Information Technology
To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 20 Jan 2012 15:37:08 GMT</pubDate>
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					<title>January 2012 issue of &amp;lt;I&amp;gt;The Source&amp;lt;/I&amp;gt; Coming Soon!</title> 
					<link>http://www.jcrinc.com/Blog/2011/12/16/January-2012-issue-of-The-Source-Coming-Soon/</link> 
					<description><![CDATA[The January 2012 issue of The Source is coming soon, including the following articles:
• Looking Ahead: What to Expect from The Joint Commission in 2012
• Welcome to the New Source5 Sure-Fire Methods: Complying with NPSG.03.04.01
• Tracer Methodology 101: Infection Prevention and Control System Tracer
• Creating and Implementing a Utilization Review Plan: Meeting CMS Expectations Under LD.04.01.01
• Focus on Certification: Standardizing Processes Based on Clinical Practice Guidelines
• Perspectives on Patient Safety: Your Patient Safety News
• Benchmark: How Does Your Hospital Measure Up? Accountability Measure Requirements for 2012
To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 16 Dec 2011 16:12:46 GMT</pubDate>
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					<title>December issue available in print and online!</title> 
					<link>http://www.jcrinc.com/Blog/2011/12/9/December-issue-available-in-print-and-online/</link> 
					<description><![CDATA[The December 2011 issue of The Joint Commission: The Source newsletter is now available, including the following articles:
 
• Immediate Threat to Health and Safety: Complying with APR.09.04.01
• 5 Sure-Fire Methods: Complying with WT.03.01.01
• Managing Patient Flow: Is High Hospital Occupancy a Root Cause of Ambulance Diversion? 
• Tracer Methodology 101: Medication Management in an Opioid Treatment Progam
• Key Findings from the Joint Commission’s Improving America’s Hospitals Annual ReportTo subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 09 Dec 2011 20:11:20 GMT</pubDate>
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					<title>Your New Source:  Expanded and Enhanced for 2012!</title> 
					<link>http://www.jcrinc.com/Blog/2011/10/12/Your-New-Source-Expanded-and-Enhanced-for-2012/</link> 
					<description><![CDATA[
		
				You, the readers, have told us that you’d like all the information you need on Joint Commission accreditation requirements, the accreditation process, performance measurement, and patient safety conveniently delivered, affordably priced, and in one place. To better meet your needs, JCR will introduce an improved, expanded version of The Source in January 2012.   The new Source will be enhanced with coverage of the National Patient Safety Goals and other emerging patient safety issues, as well as coverage of Joint Commission accountability measures and performance measurement, and Joint Commission certification programs. This includes content formerly covered in JCR’s newsletters Benchmark and Perspectives on Patient Safety.  The Source will be the most comprehensive, authoritative monthly resource on accreditation, performance measurement, and patient safety. Three newsletters, now rolled into one comprehensive Source.   If you are already a subscriber to The Source, you will automatically receive the new Source starting with your January 2012 issue. You don’t need to do anything! You’ll enjoy more content and more value every month, with all the Joint Commission information that you need in one Source.   Current subscribers to Benchmark and Perspectives on Patient Safety will automatically receive a subscription to the new Source. Both of those newsletters will discontinue publication at the end of 2011, and their content will be rolled into the new and expanded Source starting with the January 2012 issue.   I am looking forward to communicating with you regarding the new Source. I’d love to hear from you, the readers, on what you would like to see in this newsletter. What topics would you like to see us cover?  Let me know by commenting on this blog. Thank you!  
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					<pubDate>Thu, 13 Oct 2011 00:50:04 GMT</pubDate>
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					<title>Visit the JCR Ambulatory Care Conference in Chicago</title> 
					<link>http://www.jcrinc.com/Blog/2011/8/26/Visit-the-JCR-Ambulatory-Care-Conference-in-Chicago/</link> 
					<description><![CDATA[Greetings!

With more than 1 billion patient visits to ambulatory health care organizations taking place every year, safe, high-quality ambulatory health care is of critical importance. I hope all the readers from ambulatory health care organizations will consider attending Joint Commission Resources’ Annual Ambulatory Care Conference 2011, October 3-5 in Chicago.  This year features a one-day preconference focused on the role of the Primary Care Medical Home (PCMH) initiative. Come learn about the PCMH standards, integration into the on-site survey process, and other PCMH issues.  

In addition to being a great opportunity to network with other ambulatory health care professionals, this year’s program is focused on solutions to some of the most challenging issues facing ambulatory health care organization. Highlights include the following:
• For the first time, the conference has features a panel discussion to review the latest on standards, survey process, National Patient Safety Goals, and hot-off-the-press updates.  
• A panel discussion focused on medication reconciliation is also planned.  Learn the latest challenges from our Standards Interpretation Group representative regarding frequently asked questions, complimented by our surveyor expert, who will provide guidance on solutions for overcoming these challenges and obstacles
• A session focused on compliance issues for credentialing and privileging in ambulatory care clinics. 
• A number of sessions focused in adopting and integrating electronic health records in ambulatory care. 

For more information on this conference, go to the Annual Ambulatory Care Conference 2011 home page at http://www.jcrinc.com/Conferences-and-Seminars/Ambulatory-Care-Conference/2262/.To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 26 Aug 2011 16:59:31 GMT</pubDate>
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					<title>Home Care Executive Briefing </title> 
					<link>http://www.jcrinc.com/Blog/2011/8/1/Home-Care-Executive-Briefing/</link> 
					<description><![CDATA[Every year Joint Commission Resources invites home care organization administrators, directors, and managers to this critical update on the home care accreditation.  This year, this one-day event will take place October 13 at The Joint Commission headquarters, located just outside of Chicago in Oakbrook Terrace, IL.

The event will focus on recent and forthcoming changes to the accreditation process, the most challenging standards for Home Care in 2011, the National Patient Safety Goals, and other emerging issues that affect home care organizations. 

Don’t miss this opportunity to meet with experts from The Joint Commission and Joint Commission Resources, hear the latest information, and ask your questions face-to-face.

Additional information about the briefing is available here.

Register now to take advantage of early bird pricing!

For questions related to registration fees and early bird discounts, please contact JCR Customer Service at 877-223-6866. For questions related to specific content or faculty discussions, please contact Alma Harrell, Program Manager at 630-792-5409.To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Mon, 01 Aug 2011 16:18:56 GMT</pubDate>
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					<title>Hospital Executive Briefings</title> 
					<link>http://www.jcrinc.com/Blog/2011/6/22/Hospital-Executive-Briefings/</link> 
					<description><![CDATA[For the most in-depth and up-to-date information about revisions to Joint Commission standards, the accreditation and on-site survey process, and strategies for complying with standards that many hospitals find challenging, come to one of JCR’s Hospital Executive Briefings.  At the briefings, health care providers have the unique opportunity to talk face-to-face with Joint Commission experts about hot topics in accreditation, Joint Commission standards, performance and quality improvement, and patient safety.  
This year’s briefings will take place on the following dates and locations:

Hospital Executive BriefingsNew York, NY
September 9, 2011
Product Code: EDU1136 

Hospital Executive BriefingsGrapevine, TX (near Dallas)
September 15, 2011
Product Code: EDU1137

Hospital Executive BriefingsCosta Mesa, CA
September 21, 2011
Product Code: EDU1138  

Hospital Executive BriefingsRosemont, IL
September 26, 2011
Product Code: EDU1139

Don’t miss them!
To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Wed, 22 Jun 2011 20:51:42 GMT</pubDate>
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					<title>New Resources for Understanding Tracers</title> 
					<link>http://www.jcrinc.com/Blog/2011/6/17/New-Resources-for-Understanding-Tracers/</link> 
					<description><![CDATA[
		Understanding tracer methodology is critical to your Joint Commission accreditation and survey process. Tracer methodology is also a valuable tool that organizations can use to assess their own processes. In addition, tracer methodology is also helpful during your risk assessments for infections prevention and control and other potential threats.
		
		
				The Source includes a mock tracer scenario in every single issue. These scenarios provide examples of what a surveyor might do during a tracer in your organization. They also serve as a handy guide to conducting your own mock tracers. In addition to that monthly resource, JCR is now offering a number of Webinar--taught by experts from The Joint Commission--that provide in-depth looks at different aspects of tracer methodology, covering everything from the basic principles to the most recent evolution of tracer methodology: Second-Generation Tracers. 
		
		
				Tracer Methodology: How to Get Started
				
				This 60 minute “How to Get Started” webinar is designed to provide participants knowledge into the practical insights of tracer methodology—what it is, how it is used, and how it dramatically improves the way your organizations’ systems and processes are reviewed for continuous improvement.
		
		
		
				
						Find out more about this Tracer Methodology Webinar/Audio Conference
				 
		
				Tracer Methodology: Types of Tracers
				
				This 60 minute webinar is designed to provide participants with knowledge to enhance their systems and processes in providing safe care for patients by examining the different types of tracers methods—patient, systems and program, how they are conducted, and aggregating the results.
		
		
		
				Find out more about this Tracer Methodology Webinar/Audio Conference
		
		
		
		
				Tracer Methodology: Second Generation Tracers
				
				This 60 minute webinar is designed to provide participants helpful knowledge around Second Generation Tracers—what they are, differences between original and Second Generation, and how they are conducted in order to improve the way your organizations’ systems and processes work to provide safe care for patients.
		
		
		Find out more about this Tracer Methodology Webinar/Audio Conference
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					<pubDate>Fri, 17 Jun 2011 21:43:21 GMT</pubDate>
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					<title>Visit the Joint Commission/JCR Annual Conference! </title> 
					<link>http://www.jcrinc.com/Blog/2011/5/20/Visit-the-Joint-Commission/JCR-Annual-Conference/</link> 
					<description><![CDATA[Make sure you have registered for the upcoming Joint Commission and Joint Commission Resources Annual Conference on Quality and Patient Safety, June 8–10.  Several of my fellow editors and I will be in the exhibit hall and attending sessions. We are eager to meet as many of our readers as we can! 

This year’s conference includes the following expected keynote presentations: 
• Human Factors in Patient Safety – Retrospect and Prospect,  James Reason, PhD, Professor Emeritus of Psychology University of Manchester, United Kingdom 
• Presidential Overview - The Joint Commission, Mark R. Chassin, MD, MPP, MPH, President, The Joint Commission 
• If Disney Ran Your Hospital,  Fred Lee, Author, If Disney Ran Your Hospital: 9½ Things You Would Do Differently, awarded the 2005 Book of the Year from the American College of Healthcare Executives 
• Assessing and Improving Pediatric Patient Safety and Quality of Care Through In-Situ Simulation, Jane L. Holl, MD, MPH, Associate Professor of Pediatrics and Preventive Medicine and Director, Institute for Healthcare Studies, Medical Director for Patient Safety Children's Memorial Hospital Feinberg School of Medicine, Northwestern University 
Click here to sign up!To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 20 May 2011 17:26:21 GMT</pubDate>
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					<title>Happy National Medical Laboratory Professionals Week!</title> 
					<link>http://www.jcrinc.com/Blog/2011/4/29/Happy-National-Medical-Laboratory-Professionals-Week/</link> 
					<description><![CDATA[
		This week The Joint Commission and health care organizations nationwide recognize National Medical Laboratory Professionals Week.  To commemorate this observance,  Ann Scott Blouin, Ph.D., R.N., executive vice president, The Joint Commission and Jennifer F. Rhamy, M.B.A., M.A., MT (ASCP) SBB, HP, executive director of the Laboratory Accreditation Program, wrote a letter [http://www.jointcommission.org/assets/1/18/NMLP_week__4_25_11.pdf] thanking lab professionals for all of their great work and their contributions to health care quality and patient safety.
In the May issue of The Source, which will be in your mailboxes this week, lab professionals will find an article explaining the revamped laboratory accreditation standards for 2011, along with some helpful tips for compliance. 

Readers from all types of health care organizations will also be interested in our coverage of The Joint Commission’s second generation tracers, complete with a sample mock second generation tracer that focuses on cleaning, disinfection and sterilization.  These are just a few of the features you will find in our May issue.  

In honor of the many lab professionals who serve your organizations and your patients, I invite lab staff and other health care pros to share a story with your fellow blog readers of a lab professional who has done extraordinary work or whom you have found inspiring. 

To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 29 Apr 2011 16:57:43 GMT</pubDate>
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					<title>Check out the JCR Accreditation Summit!</title> 
					<link>http://www.jcrinc.com/Blog/2011/4/7/Check-out-the-JCR-Accreditation-Summit/</link> 
					<description><![CDATA[For those of you looking for face-to-face authoritative guidance on Joint Commission accreditation and standards compliance, I hope you’ll attend the Third Annual Accreditation Summit in Lombard, IL, on May 3-4. (And, you’ll earn continuing education credits in the process!)

At the summit, experts from The Joint Commission’s Standards Interpretation Group, surveyor cadre, and business development unit will update you on evolving Joint Commission standards, the tracer methodology, and what you can expect during a survey. The faculty will provide hands-on strategies organizations can adapt and implement to improve their compliance, quality of care, and patient safety in eight separate tracks: Hospital, Home Care, Ambulatory Care, Behavioral Health Care, Long Term Care, Laboratory, Advanced Disease Specific Care Certification in Heart Failure, and Staffing Services Certification. 

Organizations that are new to the accreditation process will benefit from attending the Accreditation Primer session on May 2, the day before the conference officially opens.  More experienced staff may also may want to attend the  May 2 program on tracer methodology, where you’re sure to hear more about second generation tracers. 

An Accreditation Summit Fair on May 3 gives you the chance to meet account executives in person!

Click here for registration information!

To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 07 Apr 2011 15:36:39 GMT</pubDate>
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					<title>DELETECheck out the JCR Accreditation Summit!</title> 
					<link>http://www.jcrinc.com/Blog/2011/4/7/DELETECheck-out-the-JCR-Accreditation-Summit/</link> 
					<description><![CDATA[For those of you looking for face-to-face authoritative guidance on Joint Commission accreditation and standards compliance, I hope you’ll attend the Third Annual Accreditation Summit in Lombard, IL, on May 3-4. (And, you’ll earn continuing education credits in the process!)

At the summit, experts from The Joint Commission’s Standards Interpretation Group, surveyor cadre, and business development unit will update you on evolving Joint Commission standards, the tracer methodology, and what you can expect during a survey. The faculty will provide hands-on strategies organizations can adapt and implement to improve their compliance, quality of care, and patient safety in eight separate tracks: Hospital, Home Care, Ambulatory Care, Behavioral Health Care, Long Term Care, Laboratory, Advanced Disease Specific Care Certification in Heart Failure, and Staffing Services Certification. 

Organizations that are new to the accreditation process will benefit from attending the Accreditation Primer session on May 2, the day before the conference officially opens.  More experienced staff may also may want to attend the  May 2 program on tracer methodology, where you’re sure to hear more about second generation tracers. 

An Accreditation Summit Fair on May 3 gives you the chance to meet account executives in person!

Click here for registration information!

To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 07 Apr 2011 15:34:38 GMT</pubDate>
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					<title>New Resource for Standards Information</title> 
					<link>http://www.jcrinc.com/Blog/2011/3/4/New-Resource-for-Standards-Information/</link> 
					<description><![CDATA[Every wonder how The Joint Commission comes up with all those standards?  Now accredited organizations and other interested health care professionals can get a behind-the-scenes look

The Joint Commission recently released its first R3 Report, covering the three R’s of requirement, rationale, and reference. These reports reveal the rationales and references that The Joint Commission uses in its development process for standards and other requirements. The rationales in the R3 report go into considerably more depth than the brief rationales that are included in the accreditation manuals. 

This first R3 Report addresses development of requirements for The Joint Commission patient–centered communication standards, including the following:
Non-discrimination in care (RI.01.01.01, EP 29)
Access to a support individual (RI.01.01.01, EP 28)
Collecting race and ethnicity data (RC.02.01.01, EP 28)
Effective communication (PC.02.01.21, EPs 1 and 2) 
Click here to view the complete report. 

To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 04 Mar 2011 16:21:15 GMT</pubDate>
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					<title>Revised Standard MS.01.01.01: Are you ready?</title> 
					<link>http://www.jcrinc.com/Blog/2011/2/1/Revised-Standard-MS010101-Are-you-ready/</link> 
					<description><![CDATA[Just a friendly reminder:  Revisions to Standard MS.01.01.01 become effective on March 31. The revisions were announced last year and organizations had a one year period in which they could make any preparations they needed to adjust to the new requirements, some of which are based on Centers for Medicare & Medicaid Services Conditions of Participation (CoP).

The revisions to the standard address the issue of what needs to appear in the bylaws. They also address the relationships between the organized medical staff (OMS), the MEC, and the governing body. To help ensure organizations have all their bases covered. The Source has published a status check in the February issue, which will be in your mailbox any day. 

The article discusses what’s new in the standard, focusing on the requirements that are also CoPs, and includes a checklist designed to help organizations ensure they have included all the required information in their bylaws.

The Joint Commission revised the standard based on questions raised from the field regarding the intent of the standard’s requirements. In response to these concerns, The Joint Commission in 2007 developed a task force of health care professionals from leading organizations nationwide to analyze the potential impact of implementing the revised standard. The Task Force concluded that a revision of the June 2007 standard was necessary. The version of MS.01.01.01 that goes into effect March 31 is the culmination of their efforts.  

To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Tue, 01 Feb 2011 17:24:38 GMT</pubDate>
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					<title>Joint Commission Names New Chief Medical Officer</title> 
					<link>http://www.jcrinc.com/Blog/2011/1/7/Joint-Commission-Names-New-Chief-Medical-Officer/</link> 
					<description><![CDATA[Some big news is on the horizon for The Joint Commission and accredited organizations should be  among the first to know. The Joint Commission has a new Chief Medical Officer as of Valentine’s Day—Feb. 14, 2011. 

Ana Pujols-McKee, M.D., will be executive vice president and chief medical officer of The Joint Commission enterprise, which includes Joint Commission Resources, Joint Commission International, and The Joint Commission Center for Transforming Healthcare. Presently Dr. McKee is chief medical officer and associate executive director at Penn Presbyterian Medical Center, University of Pennsylvania Health System, and associate professor of medicine at the University of Pennsylvania School of Medicine.

Dr. McKee’s role will focus on developing policies and strategies for promoting patient safety and quality improvement in health care. Much of this work will directly affect standards and accreditation. For example, Dr. McKee will, among other responsibilities, oversee work related to the National Patient Safety Goals and the Sentinel Event Policy, as well as the Standards Interpretation Group, to whom many accredited organizations go for answers to standards and accreditation questions. 

I look forward to updating you on new developments related to the standards, Sentinel Events Policy, other key accreditation news in this blog and The Source.To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 07 Jan 2011 20:58:55 GMT</pubDate>
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					<title>Joint Commission Standards Support Efforts to Curb Smoking</title> 
					<link>http://www.jcrinc.com/Blog/2010/12/6/Joint-Commission-Standards-Support-Efforts-to-Curb-Smoking/</link> 
					<description><![CDATA[New developments from health care policymakers provide a good opportunity to examine how your organization complies with Joint Commission standards that address smoking cessation. 

The U.S. Department of Health and Human Services recently announced a new national effort to curb smoking among the U.S. population. The Joint Commission quickly issued a statement about these new measures. The statement begins, “new tobacco elimination efforts by the U.S. Department of Health and Human Services underscore the need for multiple strategies to help Americans avoid cigarettes and other tobacco products.”  

Joint Commission Environment of Care (EC) Standard EC.02.01.03 requires accredited hospitals to develop a written policy prohibiting smoking except for specific, defined exceptions. If a hospital decides to allow smoking in some circumstances, then it should designate smoking areas that are physically separate from care, treatment, and service areas. At a time of renewed national interest in smoking cessation, organizations can take some time to self-assess their compliance with EC.02.01.03.  The Joint Commission also offers accredited hospitals performance measures that address smoking cessation advice for patients.

According to the National Cancer Institute, smoking is the leading cause of preventable illness and death in the United States, causing an estimated 443,000 deaths each year. About 49,400 deaths are a result of exposure to secondhand smoke. Protecting patients from secondhand smoke—and helping patients who smoke quit the habit—is an important patient safety and health care quality problem. How is your organization a part of the solution? 

To subscribe to The Source, click here.

More resources for The Source:Home • Current Issue • FREE Sample Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Mon, 06 Dec 2010 20:21:27 GMT</pubDate>
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					<title>A Closer Look at Handoff Communications</title> 
					<link>http://www.jcrinc.com/Blog/2010/11/2/A-Closer-Look-at-Handoff-Communications/</link> 
					<description><![CDATA[
		Chester, a 47-year-old registered nurse at a 200-bed hospital, is stressing out. He has to leave early to get to his daughter’s high school graduation, and the nurse scheduled to relieve him hasn’t shown up yet. They have to discuss a 69-year-old male diabetic patient who arrived in the ER the previous night with a suspected stroke. At last, he spots the nurse he’s been waiting for coming down the corridorhe approaches her and says, “Glad you made it! Thanks for covering these last two hours. You’ll want to keep an eye on Mr. Burnside in Room 543. Here’s his file. Call my cell if you have questions. I’ve got to run…”
		
		The above scenario is a recipe for disaster. Patients—and the health care providers that care for them—need to have a detailed, standardized handoff process in place that includes an opportunity to ask questions. Inadequate handoff processes, or failure to adhere to them, puts patients at tremendous risk for a host of sentinel events. 

The Joint Commission’s Standard PC.02.02.01, Element of Performance 2, requires organizations to have in place handoff communication processes that “provide the opportunity for discussion between the giver and receiver of patient information.” And according to The Joint Commission, an estimated 80% of serious medical errors involve miscommunication between caregivers when responsibility for patients is transferred.  For this reason, the Joint Commission Center for Transforming Healthcare worked with a consortium of 10 leading U.S. health care systems to identify root causes and find solutions for this serious health care problem. 

The Center and its partners launched the project in August 2009. The participating organizations soon found that nearly 40% of handoffs were not effective and did not transfer all the right information to the receiver to ensure safe, quality care. Some of the identified causes for these ineffective handoffs included the following:
• Incomplete information
• Lack of opportunity to discuss the handoff
• No handoff occurred at all
• Too many delays 
• Receiver (of patient/information) not returning a call
• Receiver too busy to take a report

You can see almost all of these factors at play in the scenario about. What occurred could hardly be considered a “handoff” at all. The process was both delayed and rushed, and no opportunity was given to ask questions. 

The Center and its partners developed targeted solutions, that, when fully implemented, reduced the incidence of defective handoffs by 52% in the participating organizations. 

The Center has compiled a list of those solutions and is incorporating them into its automated Targeted Solutions Tool™ (TST). These solutions are expected to roll out online by late 2011.  All Joint Commission-accredited health care organizations can access the TST on their secure Joint Commission Connect extranet site. The tool currently has hand hygiene tools uploaded and ready to go. Because it’s automated, any organization can track and improve performance without having extensive or exclusive performance improvement experience.

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					<pubDate>Tue, 02 Nov 2010 17:08:33 GMT</pubDate>
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					<title>Meet Your New Editor</title> 
					<link>http://www.jcrinc.com/Blog/2010/10/5/Meet-Your-New-Editor/</link> 
					<description><![CDATA[My name is Jim Parker. Since March 2006, it’s been my privilege to participate in the sharing of critical patient safety information with the health care community through The Joint Commission’s Perspectives on Patient Safety newsletter.  Now, I will have the honor of helping organizations work through accreditation-related challenges in The Source, beginning with the upcoming November 2010 issue. My thanks to my predecessor on The Source, Janet Pimentel, who truly made the newsletter what it is today.

My professional background is in magazine journalism. Prior to joining Joint Commission Resources, I spent seven years as a writer and editor of publications covering pre-hospital emergency health care, homeland security, emergency response, and transportation safety. I look forward to this upcoming year of working with you to promote quality and patient safety in health care.



With this blog, you and I can communicate with each other directly. It gives me an opportunity to share with you supplemental information to the articles in The Source and other accreditation-related news. More importantly, it’s a chance for you—the accreditation and quality professional—to share your comments with me and your colleagues nationwide. I hope to hear from you soon.

Be safe,
Jim Parker

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					<pubDate>Wed, 06 Oct 2010 03:28:38 GMT</pubDate>
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					<title>Safe Injection Practices Added to On-site Surveys</title> 
					<link>http://www.jcrinc.com/Blog/2010/8/31/Safe-Injection-Practices-Added-to-On-site-Surveys/</link> 
					<description><![CDATA[No matter how old I am, I can’t help but be afraid whenever I receive a shot from a nurse or physician. I have always hated the pinch of the needle and always will – no matter how nicely the nurse or physician talks to me or makes me laugh beforehand. But, my fears have another focus. Articles in recent years have described health care professionals causing outbreaks by reinserting used needles into multi-dose vials or using a single needle to administer doses to multiple patients. So I can’t help but feel glad that injection practices will be observed during an on-site survey in all Joint Commission accredited organizations to ensure that staff members follow standard precautions for disease-free injections (as you know, safe injection practices are a key component of standard precautions required in Standard IC.02.01.01, EP 2). If you need to review what the proper precautions are, injection safety is directly addressed in the “2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings” provided by the Centers for Disease Control and Prevention (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC). It would also help to find out if your staff understand and adhere to safe injection practices, which can be done through regular training or conducting quality assurance assessments. I, myself, learned a great deal about safe injection by watching a video highlighting the CDC/HICPAC guidelines provided on the One & Only Campaign Web site (think one needle, one syringe, only one time). I know that I will be thinking about the One & Only Campaign (and what I learned) the next time I get a shot. Whenever that happens, my hope will be that the staff and the health care organization understand and follow the right precautions. (And that they passed their most recent survey!) More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Tue, 31 Aug 2010 06:58:31 GMT</pubDate>
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					<title>By Request, Continuum of Care Tracers Addressed</title> 
					<link>http://www.jcrinc.com/Blog/2010/8/25/By-Request-Continuum-of-Care-Tracers-Addressed/</link> 
					<description><![CDATA[I enjoyed meeting several of our readers when I attended The Joint Commission Accreditation Summit this April in Lombard. A few summit attendees asked me to cover continuum of care tracers in the “Tracer Methodology 101” column in The Source. I’m happy to say that we delivered on that request in the August 2010 issue. In fact, Dr. Joel Yohai, senior vice president for medical affairs and chief medical officer for Catholic Health Services of Long Island, New York, gave such a good presentation on continuum of care tracers at the Accreditation Summit that we interviewed him for the August article. Since starting the monthly tracer column, I’m often asked if I’ve ever conducted a tracer or witnessed one during an on-site survey. No, I have not. As an employee of Joint Commission Resources, I am not allowed to observe surveys or have knowledge about the results of an organization’s survey. Instead, I learned most of what I know about tracers by attending a JCR seminar taught by JCR consultant Jane Schetter. I walked away with a good understanding of what a tracer is, and how to formulate tracer follow-up questions. I even consider them to be somewhat “fun.” I also learned about program-specific tracers by talking with Joint Commission surveyors and staff and discussing the monthly tracer column with expert reviewers. Each month I certainly keep learning about tracers, and I hope the monthly tracer scenario, sample questions, and tips checklist help you keep learning, too. If there are any topics that you would like addressed in the tracer column, take a minute to reply to my blog. More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Wed, 25 Aug 2010 06:00:25 GMT</pubDate>
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					<title>Time to Comment on Preventing Surgical Site Infections</title> 
					<link>http://www.jcrinc.com/Blog/2010/8/13/Time-to-Comment-on-Preventing-Surgical-Site-Infections/</link> 
					<description><![CDATA[Whenever an accredited health care organization has an opportunity to comment on a standard or requirement, they should do so because their input can make a difference on what future changes are considered or ultimately made. So if you have any comments or input regarding surgical site infections, you’ll be interested to know that The Joint Commission wants to hear from you. In this situation, your input will be used to create a free how-to implementation guide for NPSG.07.05.01, which took effect in January. The Source is mainly about ‘how to’ comply with Joint Commission standards and requirements, so I’m very interested in what evidence-based practices and recommendations for preventing surgical site infections will be included in this guide. Your input could have a positive impact on another health care organization.  I’m encouraging you to access a survey located on The Joint Commission’s Web site through Sunday, September 5. 

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 13 Aug 2010 08:14:33 GMT</pubDate>
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					<title>Physical Holding of Children Standards Are a Good Idea</title> 
					<link>http://www.jcrinc.com/Blog/2010/7/28/Physical-Holding-of-Children-Standards-Are-a-Good-Idea/</link> 
					<description><![CDATA[Sometimes children with special needs can’t express themselves so they act out more aggressively than they should. As the aunt of a special needs child, I’ve seen my young nephew be physically held because there was concern that his head banging would harm himself. It’s never easy to see a family member--especially a child--physically held, but I understood that it was a way to help keep him safe. It’s for this reason that physical holding is a sensitive topic for me to discuss. As an aunt of a special needs child, I can appreciate that The Joint Commission has outlined 11 standards that specifically address the physical holding of children and youth as well as the philosophy that physical holding should be used as a last resort. These standards address every aspect of the situation--including assessment and reassessment, trying nonphysical techniques as a first response, the safety of the child, debriefing afterward, and collecting and monitoring data. If you haven’t seen them yet, these standards will be published in the 2010 Update 2 for the Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) publishing in September.  Behavioral health care organizations can also find a helpful article about how to comply with these physical holding of children and youth standards in the August 2010 issue of The Source. My goal was to provide some practical how-to suggestions that could help behavioral health care organizations consider what they needed to do in order to comply with these requirements, which go into effect January 1, 2011. Make sure to take advantage of the next six months to get prepared! 

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Wed, 28 Jul 2010 06:22:34 GMT</pubDate>
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					<title>Displaying Your Accreditation Award Makes a Difference</title> 
					<link>http://www.jcrinc.com/Blog/2010/7/19/Displaying-Your-Accreditation-Award-Makes-a-Difference/</link> 
					<description><![CDATA[It’s been so hot and humid in the Chicago area recently that I fainted during a 4-mile bike ride. (I know, I know, I shouldn’t have attempted such a feat in the first place but I thought I would have some fun!)  I ended up seeking emergency medical attention at the nearest healthcare center that was open and, at first, felt a little uneasy about what to expect when I slowly walked through the doors. My apprehension was immediately relieved when I saw The Joint Commission accreditation certificate properly displayed in the waiting room area. I felt reassured that the doctor and nurses would take good care of me, especially after editing the comprehensive accreditation manuals and being familiar with the requirements and rules that a health care organization needs to comply with in order to earn the award. If you ever wonder if your patients look at or even care about the award displayed in your facility, please take this blog as reassurance that it does make a difference. During that visit I received a blood test and an EKG, which is a lot for someone like me who is afraid of needles and seeing the doctor. I noticed the National Patient Safety Goal posters on the wall and staff wearing the “Stopping infection is in our hands” buttons that are all made in the Publications Department where I work. Luckily, my diagnosis was dehydration and I was allowed to go home two hours later.

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Tue, 20 Jul 2010 04:00:45 GMT</pubDate>
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					<title>Patient Flow Wait Times Discourage Trust</title> 
					<link>http://www.jcrinc.com/Blog/2010/7/6/Patient-Flow-Wait-Times-Discourage-Trust/</link> 
					<description><![CDATA[A crowded emergency room--and feeling like you are waiting too long--can sure make a patient and their loved ones feel frustrated. I experienced it recently when accompanying a sick elderly parent to a hospital emergency room. I kept looking down at my watch and kept asking the nurse at the desk how long it will be before my mom could see someone. Waiting in line at the grocery store or movie theater ticket booth is expected, but you don’t want that kind of wait to get care for a loved one. When it finally was our turn, the staff seemed stressed and rushed as they took care of my mom and asked us both questions. I couldn’t help but wonder if the staff was doing everything they were supposed to be doing because they seemed to be moving too fast. I lost a little bit of trust in them. Ironically, part of me felt glad that I chose patient flow strategies as the cover story for the July issue of The Source newsletter. The article offers several systemwide strategies that hospitals can use to help direct patients in a timely manner to the best place in the hospital to care for them. My hope is that the article’s how-to suggestions will keep other patients from what I and my mom experienced. If your hospital has any other how-to suggestions to help minimize or eliminate patient flow, please send me your ideas. 

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Wed, 07 Jul 2010 03:34:00 GMT</pubDate>
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					<title>Interim Staffing Requirements Take Effect Soon</title> 
					<link>http://www.jcrinc.com/Blog/2010/6/18/Interim-Staffing-Requirements-Take-Effect-Soon/</link> 
					<description><![CDATA[Don’t forget that interim requirements to the staffing effectiveness standards will go into effect for hospitals and long term care organizations on July 1, 2010. The interim standards (which are the last bullet under Standard LD.04.04.05, EP 13, and Standard PI.02.01.01, EPs 12, 13, 14) will remain in effect while The Joint Commission continues to research staffing effectiveness issues. Those hospitals and long term care organizations still working on compliance strategies for these interim standards can find some answers in the cover story of the May 2010 issue of The Source.  In the article, Joint Commission experts offer several practical how-to suggestions, such as the following:

Collect and compile data relevant to the population your organization serves
Review the data analysis processes that already exist for the data that your organization already collects
Remember that staffing effectiveness goes beyond just assessing number, skill mix, and competency. It involves making sure those three components are addressed within your organization based on the services that your organization provides. 
I don’t want to give away too many details here, but just wanted to remind you that there are resources available to help you. As always, I look forward to hearing from you on this or any compliance topic.More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Sat, 19 Jun 2010 05:06:07 GMT</pubDate>
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					<title>Take Advantage of Resources about Revised Medical Staff Standard</title> 
					<link>http://www.jcrinc.com/Blog/2010/6/9/Take-Advantage-of-Resources-about-Revised-Medical-Staff-Standard/</link> 
					<description><![CDATA[I don’t know if any of you had an opportunity to participate in the free April 22 conference call about the revised Medical Staff Standard MS.01.01.01. I did and found it to be very helpful because Chuck Mowll, executive vice president of Business Development, Government, and External Relations for The Joint Commission, led the discussion by summarizing each element of performance and outlining the changes to this standard, which will take effect March 31, 2011.  He described the revisions as minimal changes that will add flexibility to allow hospitals, the medical staff, and governing bodies to address content in the medical staff bylaws and really should require a limited amount of resistance. If you missed it, you are in luck because a replay of that conference call and a free transcript are available on The Joint Commission’s Web site until late July. It’s important for hospitals and critical access hospitals to take advantage of these resources because they will need time to assess what requirements in the revised standard have already been addressed in their medical staff bylaws, what information is missing, and how they will decide to resolve it. If you are looking for additional how-to strategies for this revised standard, you can also check out the cover story on the June 2010 issue of The Joint Commission: The Source newsletter.More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Wed, 09 Jun 2010 08:46:01 GMT</pubDate>
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					<title>JCR’s e-Books Worth Checking Out!</title> 
					<link>http://www.jcrinc.com/Blog/2010/5/19/JCR’s-e-Books-Worth-Checking-Out/</link> 
					<description><![CDATA[I recently discovered the joy of reading an electronic book on my laptop. I’m someone who has always enjoyed holding the actual book, smelling its pages, and keeping it on a bookshelf for later reference. But it was really convenient to download the book on my computer and conduct a search for the information that I wanted to know right away. It was also cheaper to download the book since I didn’t have to pay for shipping and handling. (I’ll just have to learn to get used to not being able to keep the book on my bookshelf). Now, you too can enjoy the same convenience since Joint Commission Resources offers many of its print books as e-Books, which are PDFs that can be available on demand. 

For those of you preparing for your next Joint Commission survey, you’ll be happy to know that many accreditation-related topics are available as e-Books, such as Applied Tracer Methodology, the Mock Tracer Workbook, and The Joint Commission Unannounced Survey Process. If you are more interested in e-Books that will help you during and after the survey process, then you might want to consider the 2010 Accreditation Process Guides or A Guide for Addressing RFIs After Your Joint Commission Survey. If you have interests beyond the accreditation survey, you can click here and find other e-Books on topics such as medication safety, infection prevention and control, patient safety, environment of care, and quality and performance improvement. In case you were wondering, the e-Books also offer free Online Extras, such as tools, forms, and other helpful information, just like the print books. It’s worth checking out if you are interested in buying more with limited funds, like me!

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 20 May 2010 01:43:51 GMT</pubDate>
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					<title>Interrupting a Nurse Increases Chances for Medication Errors</title> 
					<link>http://www.jcrinc.com/Blog/2010/5/13/Interrupting-a-Nurse-Increases-Chances-for-Medication-Errors/</link> 
					<description><![CDATA[
I recently accompanied my 72-year-old father to the hospital for eye surgery. While waiting in the pre-op area before the procedure, my dad decided he wanted his wallet from a locked cabinet so he called out to a nurse he saw in the hallway. He failed to realize that the nurse was standing at a medication cart and closely looking over a clipboard, as she may have been double checking the medications on the cart. I quickly asked my dad to stop calling out to her because she was busy working with medications. I told him that interrupting a nurse when she is working with medications can increase the chances of a medication error occurring. I then asked him how he would feel if someone else kept interrupting a nurse who was preparing his much-needed heart medication. He answered that he wouldn’t like that at all.

Later that day I was driving my dad home from the hospital. While we were listening to the radio, a news announcer mentioned that a new study by the University of Sydney in Australia determined that as the number of distractions for nurses increases, so do the number of medication errors and the risk to patient safety. For instance, the study says that four interruptions in the course of a single drug administration doubled the likelihood that the patient would experience a major mishap. One suggested remedy was for hospitals to have a “protected hour” during which nurses would focus on medication administration without having to do such things as take phone calls or answer pages. I reminded my dad that the news announcer was discussing the same thing that we did in the pre-op area. My dad said it never occurred to him that interrupting any nurse could have a negative affect on her job or even another patient. I think it never occurs to most people. It occurs to me because two of my best friends are nurses and I hear their point of view quite a bit while meeting for coffee on a Sunday morning. In fact, I made sure to give both of them a big hug during Nurses Week (celebrated May 6 through May 12).
More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 13 May 2010 06:48:31 GMT</pubDate>
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					<title>More How-To Help Coming for Ongoing Professional Practice Evaluations</title> 
					<link>http://www.jcrinc.com/Blog/2010/5/7/More-How-To-Help-Coming-for-Ongoing-Professional-Practice-Evaluations/</link> 
					<description><![CDATA[

Ongoing professional practice evaluations (OPPEs) was the lead article for the April 2010 issue of The Source and you can expect it to be covered in future issues later this year. Many Joint Commission accredited hospitals and critical access hospitals have questions about this standard (MS.08.01.03) and find it to be challenging to comply with. Many of you who attended the Joint Commission’s 2010 Accreditation Summit in late April saw the newsletter article and asked me if this topic would continue to be covered in future newsletter issues. I can certainly work with Joint Commission staff members to find more ways to write articles to help you with conducting OPPEs. You might also be happy to know that The Joint Commission is working on developing a BoosterPak about OPPEs that is expected to be available sometime this summer on The Joint Commission Connect™ extranet sites. (This was mentioned during a presentation at the summit.)

In case you have forgotten, a BoosterPak is a searchable, online document that provides detailed information about a single standard or topic that has been associated with a high volume of inquiries or noncompliance scored in the field. The Joint Commission developed the BoosterPak concept as one way to improve the consistency of standards interpretation and understanding. I am looking forward to this BoosterPak for OPPEs because it will help me learn more about this complex topic as well. 

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Sat, 08 May 2010 01:43:55 GMT</pubDate>
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					<title>Time to Provide Feedback on Suggested Medication Reconciliation Changes</title> 
					<link>http://www.jcrinc.com/Blog/2010/4/14/Time-to-Provide-Feedback-on-Suggested-Medication-Reconciliation-Changes/</link> 
					<description><![CDATA[Don’t forget to review the latest draft of the revised Medication Reconciliation National Patient Safety Goal, also known as NPSG.08.01.01, which has been posted on The Joint Commission’s Web site. The proposed changes include critical risk points associated with maintaining and communicating patients’ medication information in the medication reconciliation process. Since medication reconciliation is a medication safety issue, The Joint Commission is proposing to relocate those risk points in the medication reconciliation requirements from NPSG.08.01.01 to NPSG.03.07.01 since NPSG 3 focuses on improving the safety of using medications. Some risk points mentioned include obtaining medication information when the person enters the organization and comparing the person’s current medications to any new medications ordered for that person. NPSG.03.07.01 is proposed for ambulatory care, behavioral health care, critical access hospital, hospitals, home care, long term care, and the office-based surgery. 

Organizations will have until May 11, 2010, to review and comment on the proposed changes to the Medication Reconciliation requirement, but The Joint Commission would prefer if comments were received before April 30. It’s important to provide your input by the designated field review deadline because your comments will be considered and could make a difference in the final outcome. The current plan is to present revisions to the medication reconciliation requirement to The Joint Commission’s Standards and Survey Procedures (SSP) Committee for approval by the end of May. If those recommendations are well received, it could mean this revised NPSG could be implemented as early as January 2011. But if your comments suggest that more revisions need to be made, the plan’s time frame could be changed.

The draft information for medication reconciliation that is posted on the Web site is very easy to follow. The history tracking reports for each program clearly show the old information on the left side of the page and the new proposed language and relocation on the right side of the page. Check it out!

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Wed, 14 Apr 2010 06:50:26 GMT</pubDate>
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					<title>Your Tracer Feature Feedback Has Been Helpful</title> 
					<link>http://www.jcrinc.com/Blog/2010/3/29/Your-Tracer-Feature-Feedback-Has-Been-Helpful/</link> 
					<description><![CDATA[

I sometimes get calls from The Source readers asking for help finding a specific tracer topic that published in the newsletter. I enjoy helping you track down a specific “Tracer Methodology 101” article and hearing what you think about it. Your comments have helped me improve this monthly feature over the past year by making such tweaks as providing more sample questions and focusing on tracer topics beyond hospitals to include other accreditation programs. Tracer Methodology 101 is also one of my favorite monthly features that I enjoy planning and bringing to you with each issue.

I often get asked if I’ve ever conducted a tracer or witnessed a Joint Commission surveyor conducting one during an on-site survey. No, I have not.  As an employee of Joint Commission Resources, I am not allowed to witness surveys or know anything about any information or results of an organization’s survey.  A firewall policy is in place and respected between The Joint Commission and Joint Commission Resources. I have learned about tracers by communicating with Joint Commission experts, such as survey directors or surveyors, and JCR consultants who have taught education seminars about them. I also have been the editor of three JCR books about tracer methodology. If you have any questions about the tracer process and would like to see them addressed in The Source, let me know. Your feedback is always welcome!

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Tue, 30 Mar 2010 05:02:46 GMT</pubDate>
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					<title>Share Your Success Stories </title> 
					<link>http://www.jcrinc.com/Blog/2010/3/24/Share-Your-Success-Stories/</link> 
					<description><![CDATA[
I’m glad to share a health care organization’s success story with you in the April 2010 issue of The Joint Commission: The Source, which is in the mail to subscribers. The article highlights how Crystal Run Healthcare, an ambulatory care/office-based surgery practice in the state of New York, developed an “in-the-trenches” training program to achieve and sustain staff and physician buy-in for accreditation. That’s a difficult task that Crystal Run leaders have been able to achieve using creative tools, such as games and tracer rounds, to encourage staff to demonstrate standards compliance every day. Staff has been able to make the connection with how The Joint Commission standards fit in with their daily job tasks. I’m hoping this article will help other organizations that are looking for better ways to engage staff in continuous standards compliance and to be better prepared for an on-site survey.  

This was Crystal Run’s success story. What’s yours? I encourage you to contact me about highlighting your accredited organization’s accomplishments, whether it is a new policy or procedure that helped you improve compliance with a specific standard or how you have effectively used tracers to improve the quality of care for patients. I am interested in hearing from you and highlighting your achievements in the newsletter’s Spotlight on Success column.

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 25 Mar 2010 02:33:09 GMT</pubDate>
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					<title>Field Review Postponed for Revised Medication Reconciliation Requirement</title> 
					<link>http://www.jcrinc.com/Blog/2010/2/11/Field-Review-Postponed-for-Revised-Medication-Reconciliation-Requirement/</link> 
					<description><![CDATA[Those of you interested in commenting on the revised Medication Reconciliation National Patient Safety Goal, also known as NPSG.08.01.01, will need to wait just a little while longer. The Joint Commission originally planned to post this revised NPSG in February so health care organizations could share their opinions, but has decided to postpone it so an advisory board and board committee can review the information prior to the field review. Having some additional internal groups and experts look over the draft NPSG is a good decision, especially since medication reconciliation is a tough topic for many organizations.

In the meantime, NPSG.08.01.01 continues to be evaluated during the on-site survey, but survey findings are not factored into the organization’s accreditation decision and Requirements for Improvement are not generated. The Joint Commission will post information on its Web site in upcoming weeks alerting you about when this revised NPSG will be posted for field review. Don’t forget to watch for it!

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 11 Feb 2010 21:05:35 GMT</pubDate>
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					<title>Smoke-free Campus Trend Growing</title> 
					<link>http://www.jcrinc.com/Blog/2010/2/1/Smoke-free-Campus-Trend-Growing/</link> 
					<description><![CDATA[I don’t know if you heard, but a Joint Commission-accredited hospital in Chattanooga, Tennessee has decided to stop hiring workers who smoke. The hospital has been a smoke-free campus since around 2008, but hospital leaders decided to implement a smoker-free hiring policy beginning this month (February) because they think a hospital should set a healthy example for its community. The new rule won’t affect the hospital’s current employees who do smoke, but they will be offered smoking cessation help.
Personally, I don’t smoke and never have, so I’m OK with a hospital putting some measures in place to make sure it truly is a smoke-free campus. I find it disappointing to have to walk through a crowd of smokers when I visit a sick friend/loved one in the hospital or if I go for my own doctor appointment. Perhaps I’d feel differently about this hiring policy if I worked at that specific hospital. 

If anything, this hospital’s new policy shows me that the trend of smoke-free hospital campuses is truly growing. When The Joint Commission first introduced standards in 1992 requiring accredited hospitals to prohibit smoking (except in specific circumstances), only about 3% of U.S. hospitals at that time had a smoke-free policy. The number of U.S. hospitals with smoke-free campus policies has increased to slightly more than 45% by February 2008, according to statistics included in The Joint Commission study titled, “The Adoption of Smoke-Free Hospital Campuses in the United States.”  Who knows what else hospital leaders will think of to reinforce their smoke-free campus? 
All I know is, if employers in other industries start implementing a weight hiring policy, then I’m going to be in trouble!





More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Mon, 01 Feb 2010 18:45:42 GMT</pubDate>
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					<title>New Survey Agenda Process Allows Flexibility</title> 
					<link>http://www.jcrinc.com/Blog/2010/1/25/New-Survey-Agenda-Process-Allows-Flexibility/</link> 
					<description><![CDATA[I don’t know if you’ve heard yet, but The Joint Commission is implementing a new approach for developing the agenda for on-site surveys that is more customer friendly. The survey agenda will still look similar to what it has been in the past; no survey activities are changing. The major change is that The Joint Commission will inform organizations before their survey about the survey length and the number of surveyors. The organization also will work with the surveyors during the survey to determine the best time for the various survey activities. This gives the organizations more flexibility about when the activities will occur. This new process is intended to be more sensitive to the time demands of the organization and its staff members while still providing a thorough survey. 

Not sure what to expect? The Joint Commission will send an e-mail to the organization to confirm the programs to be surveyed and to direct the organization to go to its Extranet page to find the list of survey activities for each applicable accreditation program. Shortly later, the Joint Commission account executive will call the organization to confirm that it has reviewed and understands the information on the Extranet site. The account executive also will provide the anticipated number of days and the number of surveyors that will be assigned to the organization’s survey. On the first day of the survey, surveyors will work with the organization to confirm that the agenda considers the organization’s operations and needs. That’s when the organization can provide input regarding when activities should occur. I don’t know about you, but I like it when I can have some input on important things that happen to me. 

Any organization due for an on-site survey this year can expect to experience this new survey agenda process. I think this is a great way to start of 2010! What do you think?

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Mon, 25 Jan 2010 17:56:28 GMT</pubDate>
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					<title>H1N1 Forum Gaining Momentum</title> 
					<link>http://www.jcrinc.com/Blog/2010/1/19/H1N1-Forum-Gaining-Momentum/</link> 
					<description><![CDATA[I’m impressed with the comments that have already been posted on the H1N1 electronic forum that The Joint Commission launched in mid-December. In case you haven’t heard, the January 2010 issue of The Source had an article about how this new forum was established for health care organizations to freely exchange information about challenges associated with the H1N1 pandemic and the seasonal flu. This forum is worth checking out because participants have already begun exchanging thoughtful ideas about this challenging issue. Participants are sharing ideas on how they are preparing for a possible third wave of H1N1 flu anticipated to peak during January and February. Participants are also warning others not to be “lulled” into a false sense of security that “it’s over” because the Centers for Disease and Prevention is still providing information and reminding organizations that the virus is still circulating globally. 

Health care organizations have also expressed concerns that their staff members are not taking the hint and receiving their vaccinations. One organization even had its chief officer send out a special memo to staff, but the compliance rate for vaccinations didn’t increase as expected. I was proud to see that one forum participant commented that The Joint Commission’s free monograph, called Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination, has some good ideas on how to improve influenza vaccination rates. If you have time, check out this forum and share some ideas that have been successful at your organization. 

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Tue, 19 Jan 2010 18:37:33 GMT</pubDate>
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					<title>Staff Vaccinations Important to Patients</title> 
					<link>http://www.jcrinc.com/Blog/2010/1/8/Staff-Vaccinations-Important-to-Patients/</link> 
					<description><![CDATA[Happy 2010!  I hope your new year has started better than mine. I had the stomach flu for five days over the holidays and ended up visiting my doctor. I’m pleased to note that the nurse who collected my latest medical information and took my temperature wore an “I got my flu shot. Did you?” button. I felt relieved that she received her flu vaccination and wore evidence to let me and others know.  I thanked her for caring enough to protect herself and her patients by receiving her shot, especially since the average rate of staff participation for flu vaccinations in the United States is about 42%, according to The Joint Commission monograph entitled “Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination: Strategies from Research and Practice.”

The nurse seemed surprised that I mentioned her flu shot button, let alone that I knew the low statistic about staff vaccination rates or about Joint Commission Standard IC.02.04.01, which requires organizations to annually evaluate vaccination rates, provide reasons for staff declining the vaccination, and take steps to increase the flu vaccination rates. I let her know that I worked as an editor for Joint Commission Resources and couldn’t help but share information (it’s just my nature!). But I also let her know that I liked her button because it encouraged staff and patients to be vaccinated for influenza (either seasonal or H1N1) and thereby prevent its spread. Patients will care about whether you are vaccinated for the flu and appreciate you making an effort to let them know. Other than wearing a button, are there other ways that you let patients know you have been vaccinated? Do you do anything to encourage your colleagues to get vaccinated? If so, please share your ideas.




More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 08 Jan 2010 15:09:05 GMT</pubDate>
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					<title>Feedback Wanted on Effective Working Relationships</title> 
					<link>http://www.jcrinc.com/Blog/2009/12/22/Feedback-Wanted-on-Effective-Working-Relationships/</link> 
					<description><![CDATA[Joint Commission accredited organizations that want clearer direction on the relationship between medical staff and hospital leaders will be interested in reviewing the latest draft of Standard MS.01.01.01 (formerly known as MS.1.20). This draft standard was posted for field review December 17 on The Joint Commission’s Web site and has some significant improvement over the June 2007 version of Standard MS.1.20.

This latest draft standard provides more flexibility for governing bodies and medical staff to determine what will be placed in the medical staff bylaws and what will be placed in other documents. This working draft also provides for medical staff to notify the medical executive committee when it wishes to propose a change to a rule, regulation, or policy directly to the governing board. At the same time, the medical executive committee must provide notice to the medical staff concerning proposed changes to rules or regulations (however, policy changes by the medical executive committee do not require notification). 

If you have any thoughts on this topic, make sure to review the draft standard and comment by the January 28, 2010 deadline. The Web site offers an online survey, e-mail and regular mail feedback options for your convenience. Your feedback can make a difference.

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Tue, 22 Dec 2009 22:14:32 GMT</pubDate>
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					<title>White Paper Clarifies Leadership Expectations</title> 
					<link>http://www.jcrinc.com/Blog/2009/12/11/White-Paper-Clarifies-Leadership-Expectations/</link> 
					<description><![CDATA[A few times a year I work at the Publications booth at JCR conferences and I am always asked which books on the table contain more information about the Leadership standards. Those of you interested in more guidance on this topic will be happy to know that The Joint Commission recently published a free white paper titled, “Leadership in Healthcare Organizations: A Guide to Joint Commission Leadership Standards.”  

Some common questions about the leadership requirements include the following: 
• Who are the ‘leaders’ in healthcare organizations?
• What is ‘good leadership’ in healthcare organizations?
• What is the success that healthcare leadership should strive toward?  

These are the types of questions that The Joint Commission Leadership standards attempt to answer and are the focus of this white paper. Paul Schyve, M.D., senior vice president at The Joint Commission, wrote this paper and made sure it addressed such important components as leaders and systems; what leaders do; leadership structure; leadership relationships; hospital culture and system performance; and leadership operations. This comprehensive monograph is easy to download from the Web link provided above and could serve as an additional guide to the leadership standards. It’s worth checking out when you have time!







More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 11 Dec 2009 18:44:53 GMT</pubDate>
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					<title>E-dition Compliance Monitor Provides Special Resource for Hospitals</title> 
					<link>http://www.jcrinc.com/Blog/2009/11/19/E-dition-Compliance-Monitor-Provides-Special-Resource-for-Hospitals/</link> 
					<description><![CDATA[
		Guest blog by Michelle McDonald, RN, MPH, Product Manager Healthcare Software, Joint Commission Resources
		
		Prior to working for JCR, I was the Vice President of Clinical Affairs and was responsible for maintaining regulatory requirements for various healthcare programs within a large healthcare system. For sometime now, healthcare organizations have stated that they wish there was a tool available that would house all regulatory requirements in one central area. It is estimated that there are 128,000 pages of regulations a healthcare organization must follow. This equates to approximately 35 to 40 three-ring binders that we all know or have seen sitting on shelves and bookcases of those individuals who are responsible for maintaining compliance for an organization. 

New this year for hospital programs is E-dition Compliance Monitor, also referred to as ECM. E-dition Compliance Monitor is built on the current E-dition functionality and provides links at the chapter level to additional regulatory content. When a user is looking at a Joint Commission Hospital Standards Chapter, they can click on the ECM link and gain access to a myriad of regulatory content, including information from the Centers of Medicare & Medicaid Services (CMS), Centers of Disease Control and Prevention (CDC), Federal Drug Administration (FDA), and Occupational Safety and Health Administration (OSHA) and provides access to state regulations as well. 

The benefit of ECM is that these various regulations are spread across multiple government web sites and manuals, so locating exactly what you are looking for can be very arduous and extremely time consuming. ECM provides access to up-to-date regulatory information by the click of a mouse. As changes or revisions in regulations are published, the system automatically sends e-mail messages to each licensed user notifying of the new information. Specifically, ECM allows users to:
• Eliminates time and effort spent searching manuals and internet sites 
• Links to relevant regulatory content from within The Joint Commission E-dition tools with full search capabilities and filters
• See requirements by applicable federal and state oversight bodies by Joint Commission chapter
• Receive automated e-mail alerts regarding changes from the regulatory bodies selected by the userFor more information about ECM, go to http://www.jcrinc.com/monitor/.

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 19 Nov 2009 17:00:35 GMT</pubDate>
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					<title>More Clarification about Sterilizing Equipment</title> 
					<link>http://www.jcrinc.com/Blog/2009/10/22/More-Clarification-about-Sterilizing-Equipment/</link> 
					<description><![CDATA[In late August I wrote a blog about The Joint Commission’s latest statement regarding steam sterilization. Questions from the field have prompted The Joint Commission to provide more clarification and specific direction for the requirements for Standard IC.02.02.01, which addresses reducing the risks associated with medical equipment, devices, and supplies. Organizations will notice the clarification and more specific direction in the 2009 Update 2 that will arrive in the mail in early November for hospitals, critical access hospitals, home care, ambulatory care and office-based surgery practices or the 2010 Comprehensive Accreditation Manuals (CAMs) for behavioral health care, long term care, and laboratories. 

Element of Performance (EP) 1 for Standard IC.02.02.01 has been modified to address lower risk processes, such as cleaning and low-level disinfection for such items as stethoscopes and blood glucose meters. Changes in the text for EP 2 address high-risk processes, specifically intermediate- and high-level disinfection and sterilization for such items as respiratory equipment and specula. The changes to EPs 1 and 2 are effective immediately.

If you want to view the EP changes and you haven’t yet received your 2009 Update 2 or 2010 CAMs, you can view the pre-publication standards posted on The Joint Commission’s Web site at http://www.jointcommission.org/Standards/Pre-PublicationStandards/ through October 31, 2009.

More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Thu, 22 Oct 2009 16:22:03 GMT</pubDate>
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					<title>Making the Most of Your HR Processes</title> 
					<link>http://www.jcrinc.com/Blog/2009/10/9/Making-the-Most-of-Your-HR-Processes/</link> 
					<description><![CDATA[One of the most challenging standards for hospitals right now is HR.01.02.05, which requires hospitals to verify staff qualifications. About 25% of hospitals surveyed during the first six months of this year have received Requirements for Improvement for this standard, according to data from The Joint Commission. One of the reasons that many hospitals are struggling with this requirement and similar HR process issues is because of the complexity in the paperwork and other human resources processes due to the numbers and varieties of staff in any given hospital, says Kathy Eichner, a health care expert and consultant for Joint Commission Resources. 
Hospitals interested in tips on how to better handle HR processes and be in better compliance with HR requirements can find some answers in the October 2009 issue of The Source. I plan on scheduling some follow-up articles on the ever-growing numbers of HR topics in future editions of my newsletter. If any of you have any specific HR topics that you would like me to include in any future articles, please send your suggestions to my blog. I’d like to hear from you! Also, staying current with this blog is easier than ever now with our new RSS feed. Click here to find out more.More resources for The Source: • Home • Current Issue • About • FAQ • Subscribe • Online Access • Contact]]></description> 
					<pubDate>Fri, 09 Oct 2009 14:35:12 GMT</pubDate>
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