JOINT COMMISSION RESOURCES EDUCATION
The Joint Commission Annual Conference on Quality and Safety Selected References
CONDITION H
“Condition Help (Condition H)”, Baltimore: Josie King Foundation, 2007, available on the internet at: http://www.josieking.org/page.cfm?pageID=18 (accessed 10/07/08)
Dean, BS, et al., “Condition HELP: A Pediatric Rapid Response Team Triggered by Patients and Parents”, Journal for Healthcare Quality, 2008 May-June; 30(3):28-31.
Greenhouse PK, et al., “Calling a Condition H(elp)”, American Journal of Nursing, 2006 November; 106(11):63-6.
Strobel, S, et al., “Condition H”, American Journal of Nursing, 2007 April; 107(4):15-6.
CULTURE OF SAFETY
Harden, S, “Creating and Sustaining a Culture of Safety”, Patient Safety & Quality Healthcare, 2008 September/October; 5(5):12-4.
Leonard, M and Frankel, A, “Make Safety a Priority; Create and Maintain a Culture of Patient Safety”, Healthcare Executive, 2006 March/April; 21(2):12-8.
Runy, LA, “Creating a Culture of Patient Safety”, Hospitals and Health Networks, 2007 May; 81(5):51-6.
Sexton, JB, et al., “Tool Tutorial: A Check-Up for Safety Culture in ‘My Patient Care Area’,” The Joint Commission Journal on Quality and Patient Safety, 2007 November; 33(11):699-703.
Singer, S, et al., “Workforce Perceptions of Hospital Safety Culture: Development and Validation of the Patient Safety Climate in Healthcare Organizations Survey”, Health Services Research, 2007 October; 42(5):1999-2021.
Yates, GR, et al., “Building and Sustaining a Systemwide Culture of Safety”, The Joint Commission Journal on Quality and Patient Safety, 2005 December; 31(12):684-9.
DISCLOSURE FROM THE CONSUMER’S PERSPECTIVE
Dunn, WF, et al., “Iatrogenic Delirium and Coma: a ‘Near Miss’,” Chest, 2008 May;133(5):1217-20.
Iedema, R, et al., “Patients’ and Family Members’ Experiences of Open Disclosure Following Adverse Events”, International Journal for Quality in Health Care, 2008, September 17 [Epub ahead of print], 12 pages
Iedema, RA, et al., “The National Open Disclosure Pilot: Evaluation of a Policy Implementation Initiative”, Medical Journal of Australia, 2008 April 7; 188(7):397-400.
Sheridan, S; Conrad, N; et al., “Disclosure through Our Eyes”, Journal of Patient Safety, 2008 March; 4(1):18-26.
FACILITY DESIGN
Hampton, T, “Hospitals and Clinics Go Green for Health of Patients and Environment”, JAMA, 2007 October 10; 298(14):1625-9.
Hegland, LT and Kruger, M, “From the Ground Up: Building an All-Digital Hospital”, Physician Executive, 2008 September/October; 34(5):6-11.
Peota, C, “Going Green”, Minnesota Medicine, 2008 March; 91(3):26-9,45. available online at: http://www.minnesotamedicine.com/PastIssues/March2008/CoverStoryMarch2008/tabid/2486/Default.aspx (accessed 10/07/08)
Zborowsky, T and Kreitzer, MJ, “Creating Optimal Healing Environments in a Health Care Setting”, Minnesota Medicine, 2008 March; 91(3):35-8. available online at: http://www.minnesotamedicine.com/PastIssues/March2008/ClinicalZborowskyMarch2008/tabid/2489/Default.aspx(accessed 10/07/08)
FIRE SAFETY
“ASA Advisory Addresses Operating Room Fires”, Same Day Surgery, 2008 June; 32(6):64-5.
Ball, K, “No Smoking in the OR”, Outpatient Surgery, 2003 November; 4(11):63-7.
Mathias, JM, “Scoring Fire Risk for Surgical Patients”, OR Manager, 2006 January; 22(1):19-20.
Ulmer, BC, “The Hazards of Surgical Smoke”, AORN Journal, 2008 April; 87(4):721-34.
Wasek, S, “Preventing Surgical Fires”, Outpatient Surgery, 2003 December; 4(12):28-35.
HANDOFFs
Adamski, P, “Implement a Handoff Communications Approach”, Nursing Management, 2007 January; 38(1):10,12.
Arora, VM, et al., “A Theoretical Framework and Competency-Based Approach to Improving Handoffs”, Quality and Safety in Health Care, 2008 February; 17(1):11-4.
Carr, DD, “On The Case: Effective Care Transitions”, Nursing Management, 2008 January; 39(1):25-31.
Dracup, K and Morris, PE, “Passing the Torch: the Challenge of Handoffs”, American Journal of Critical Care, 2008 March; 17(2):95-7.
Henkind, SJ and Sinnett, JC, “Patient Care, Square-Rigger Sailing, and Safety”, JAMA, 2008 October 8; 300(14):1691-3.
Mikos, K, “Monitoring Handoffs for Standardization”, Nursing Management, 2007 December; 38(12):16-20.
Runy LA, “Patient Handoffs”, Hospitals and Health Networks, 2008 May; 82(5):41-7.
HUMOR IN HEALTH CARE
Buxman, K, “Humor in the OR: A Stitch in Time?”, AORN Journal, 2008 July; 88(1):67-77.
Buxman, K, “Humor in Critical Care: No Joke”, AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 2000 February; 11(1):120-7.
Buxman, K, This Won’t Hurt a Bit! And Other Fractured Truths in Healthcare, Hannibal, MO: LaMoine Press, 2000, 96 pages.
Buxman, K, Nursing Perspectives on Humor, Staten Island, NY: Power Publications, 1995, 274 pages.
Montgomery, B; Passanisi, KK; and Buxman, K, Humor Me: America’s Funniest Humorists on the Power of Laughter, Denver: Brad Montgomery, 2003, 208 pages.
LEADERSHIP FOR QUALITY
Jiang, HJ, et al., “Board Engagement in Quality: Findings of a Survey of Hospital and System Leaders”, Journal of Healthcare Management, 2008 March-April; 53(2):121-35.
Maas, D, “Assuming Quality Leadership”, Trustee, 2008 May; 61(5):16-8,20.
Mastal, MF, et al., “Nursing Leadership: Championing Quality and Patient Safety in the Boardroom”, Nursing Economics, 2007 November-December; 25(6):323-30
Moore, ML and Putman, PA, “Cultural Transformation toward Patient Safety: One Conversation at a Time”, Nursing Administration Quarterly, 2008 April-June; 32(2):102-8.
LEADERSHIP IN GENERAL
Bisognano, M, “Leadership’s Role in Execution. Change Must Happen Organizationwide to be Successful”, Healthcare Executive, 2008 March-April; 23(2):66,68,70.
Blaschke, GS, et al., “Choosing the Bright Futures Guidelines: Lessons from Leaders and Early Adopters”, Pediatric Annals, 2008 April; 37(4):262-72.
Caldwell, DF, et al., “Implementing Strategic Change in a Health Care System: The Importance of Leadership and Change Readiness”, Health Care Management Review, 2008 April-June; 33(2):124-33.
Eisenstat, RA, et al., “The Uncompromising Leader”, Harvard Business Review, 2008 July-August; 86(7-8):50-7.
Gottfredson, M, et al., “The New Leader’s Guide to Diagnosing the Business”, Harvard Business Review, 2008 February; 86(2):62-73.
Greene, L and Burke, G, “Artful Leadership in Healthcare: Encouraging the Possible”, Journal of Health Administration Education, 2007 Fall; 24(4):377-89.
Hill, LA, “Where Will We Find Tomorrow’s Leaders?”, Harvard Business Review, 2008 January; 86(1):123-8.
Jahrami, H, et al., “Leadership Competencies in the Context of Health Services”, Health Services Management Research, 2008 May; 21(2):117-30.
Jones, G, “How the Best of the Best Get Better and Better”, Harvard Business Review, 2008 June; 86(6):123-7.
Kaiser, RB, et al., “Leadership and the Fate of Organizations”, American Psychologist, 2008 February-March; 63(2):96-110.
Kellerman, B, “What Every Leader Needs to Know about Followers”, Harvard Business Review, 2007 December; 85(12):84-91.
Kinard, J and Kinard, B, “Straight Talk for Health Care Managers: Back to the Basics of Leadership”, Health Care Manager, 2008 January-March; 27(1):89-93.
Lorsch, JW and Clark, RC, “Leading from the Boardroom”, Harvard Business Review, 2008 April; 86(4):104-11.
McCullough, D, “Timeless Leadership”, Harvard Business Review, 2008 March; 86(3):45-9.
Montgomery, CA, “Putting Leadership Back Into Strategy”, Harvard Business Review, 2008 January; 86(1):54-60.
O’Brien, M, “Leading Innovation in a Risk-Averse Healthcare Environment”, Healthcare Financial Management, 2008 August; 63(8):112-4.
O’Neil, E, et al., “Developing Nursing Leaders: An Overview of Trends and Programs”, Journal of Nursing Administration, 2008 April; 38(4):178-83.
Peters, T, “Tom Peters: Experiment Your Way to Excellence (interview)”, Healthcare Financial Management, 2008 May; 62(5):48-51.
Sanfilippo, F, et al., “Strong Leadership and Teamwork Drive Culture and Performance Change: Ohio State University Medical Center 2000-2006”, Academic Medicine, 2008 September; 83(9):845-54.
Shore, DA, “Good Medicine, Good Business, Great Leadership: The Trust Prescription for Health Care”, Managed Care, 2008 March; 17(3 Suppl 2):4-6, 25-6.
Surakka, T, “The Nurse Manager’s Work in the Hospital Environment During the 1990’s and 2000’s: Responsibility, Accountability and Expertise in Nursing Leadership”, Journal of Nursing Management, 2008 July; 16(5):525-34.
MEDICATION RECONCILIATION
Bails, D, et al., “Implementing Online Medication Reconciliation at a Large Academic Medical Center”, The Joint Commission Journal on Quality and Patient Safety, 2008 September; 34(9):499-508.
LaLonda, L, et al., “Effectiveness of a Medication Discharge Plan for Transitions from Hospital to Outpatient Settings”, American Journal of Health-System Pharmacy, 2008 August 1; 65(15):1451-7.
Pippins, JR, et al., “Classifying and Predicting Errors of Inpatient Medication Reconciliation”, Journal of General Internal Medicine, 2008 September; 23(9):414-22.
Strunk, LB, et al., “Impact of a Pharmacist on Medication Reconciliation on Patient Admission to a Veteran Affairs Medical Center”, Hospital Pharmacy, 2008 August; 43(8):643-9.
Turchin, A, et al., “Evaluation of an Inpatient Computerized Medication Reconciliation System”, Journal of the American Medical Informatics Association, 2008 July/August; 15(4):449-52.
Wong, JD, et al., “Medication Reconciliation at Hospital Discharge: Evaluating Discrepancies”, Annals of Pharmacotherapy, 2008 October; 42(10):1373-9.
META-LEADERSHIP
Marcus, LJ, et al., “Meta-Leadership and National Emergency Preparedness; Strategies to Build Government Connectivity”, Working Papers, 2005 issue, p.41-64. Center for Public Leadership, John F. Kennedy School of Government, Harvard University. Available on the internet at: http://content.ksg.harvard.edu/leadership/index.php?option=com_content&task=view&id=84&Itemid=63&phpMyAdmin=LTiBtEu99qkd5KYdIryaR2-3Jp7(accessed 10/07/08)
Marcus, LJ, et al., “Meta-Leadership and National Emergency Preparedness: A Model to Build Government Connectivity”, Biosecurity and Bioterrorism, 2006, June 1; 4(2):128-34.
Marcus, LJ, et al., “National Preparedness and the Five Dimensions of Meta-Leadership”, Cambridge, MA: National Preparedness Leadership Initiative, 2007, one page. Available on the internet at: http://www.medicalreservecorps.gov/resources.asp?mode=ResourceDetails&ResID=85&RefID=Category&Category=5(accessed 10/07/08)
NATIONAL PATIENT SAFETY GOALS
Catalano, K and Fickenscher, K, “Complying with the 2008 National Patient Safety Goals”, AORN Journal, 2008 March; 87(3):547-66.
“Exactly Where Are You Now With Overall NPSG Compliance?”, Hospital Peer Review, 2008 September; 33(9):113-5.
Murdaugh, L and Jordin, R, “Preparing Your Hospital for Compliance with The
Joint commission’s National Patient Safety Goals”, Hospital Pharmacy, 2008 September; 43(9):728-33.
“The Joint Commission Announces the 2009 National Patient Safety Goals and Requirements”, The Joint Commission Perspectives, 2008 July; 28(7):1,11-5.
PEDIATRIC PATIENT SAFETY
Barata, IA, et al., “Pediatric Patient Safety in the Prehospital/Emergency Department Setting”, Pediatric Emergency Care, 2007 June; 23(6):412-8.
McDonald, KM, et al., “Preliminary Assessment of Pediatric Health Care Quality and Patient Safety in the United States Using Readily Available Administrative Data”, Pediatrics, 2008 August; 122(2):e416-e425.
Otero, P, et al., “Medication Errors in Pediatric Inpatients: Prevalence and Results of a Prevention Program”, Pediatrics, 2008 September; 123(3):e737-e743.
Rinke, ML, et al., “Prescribing Errors in a Pediatric Emergency Department”, Pediatric Emergency Care, 2008 January; 24(1):1-8.
Sharek, PJ, et al., “An Intervention to Decrease Narcotic-Related Adverse Drug Events in Children’s Hospitals”, Pediatrics, 2008, October; 122(4):e861-e866. Available on the internet at: http://pediatrics.aappublications.org/cgi/content/abstract/122/4/e861 (accessed 10/07/08)
Slonim, AD, et al., “Pediatric Patient Safety Events during Hospitalization: Approaches to Accounting for Institution-Level Effects”, Health Services Research, 2007 December; 42(6):2275-93.
SUICIDE RISK
Adamski, P, “Recognizing the Issues Behind Patient Suicide”, Nursing Management, 2007 May; 38(5):10.
American Psychiatric Association, “Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors”, American Journal of Psychiatry, 2003 November; 160(11 supplement):1-60. Also available on the internet at: http://www.psychiatryonline.com/pracGuide/pracGuideTopic_14.aspx (accessed 10/07/08)
Ballard, ED, et al., “Suicide in the Medical Setting”, The Joint Commission Journal on Quality and Patient Safety, 2008 August; 34(8):474-81.
Buckingham, CD, et al., “Cues and Knowledge Structures Used by Mental Health Professionals When Making Risk Assessments”, Journal of Mental Health, 2008 June; 17(3):299-314.
Draper, B, et al., “A Pilot Study of the Suicide Victim’s Last Contact with a Health Professional”, Crisis, 2008; 29(2):96-101.
Keogh, B, et al., “Suicidal Behaviour. A Study of Emergency Nurses’ Educational Needs When Caring for This Patient Group”, Emergency Nurse, 2007 June; 15(3):30-5.
Lynch, MA, et al., “Assessment and Management of Hospitalized Suicidal Patients”, Journal of Psychosocial Nursing and Mental Health Services, 2008 July; 46(7):45-52.
Young, JT and Erwin, J, “Documenting the Risk of Suicide”, Behavioral Healthcare, 2008 July; 28(7):36-8.
TEAMWORK
Devdutta, S, et al., “Defining High-Performance Teams and Physician Leadership”, Physician Executive, 2008 March-April; 34(2):44-51.
Jain, AK, et al., “High-Performance Teams for Current and Future Physician Leaders: An Introduction”, Journal of Surgical Education, 2008 March-April; 65(2):145-50.
Runy, LA, “High-Performing Executive Teams”, Hospitals and Health Networks, 2008 April; 82(4):4 page foldout following p.48.
“What Works for Teamwork Training” (TeamSTEPPS), OR Manager, 2008 September; 24(9):22.
TRACER METHODOLOGY
“Make Your Next Mock Tracer More Effective”, Hospital Peer Review, 2005 July; 30(7):93-4,99.
Murphy-Knoll, L, “Nurses and the Joint Commission Tracer Methodology”, Journal of Nursing Care Quality, 2006 January/March; 21(1):5-7.
“Spotlight on Success: Blount Memorial Hospital Conducts Weekly Mock Tracers”, Joint Commission: The Source, 2007 May; 5(5):9-11.
Thompson, EM, et al., “JCAHO Preparation: An Educational Plan”, Journal of Continuing Education in Nursing, 2008 May; 39(5):225-7.
Thurber, R and Read, LE, “A Comprehensive Education Plan: the Key to a Successful Joint Commission on Accreditation of healthcare Organizations Survey”, Journal for Nurses in Staff Development, 2008 May-June; 24(3):129-32.
“Tracers: They’re Not Just for Accreditation Surveys”, ED Management, 2005 August; 17(8):88-9.