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Volume 8, Issue 9 | September 2010

What’s New With Joint Commission Requirements for January 2011?
September is traditionally a time to watch the kids get back to school, enjoy the start of a new NFL football season, and prepare for the cooler weather. If you’re an accredited organization, you most likely are planning for any changes in The Joint Commission requirements and accreditation process that are going into effect in January 2011. The updates for the comprehensive accreditation manuals will mail in late September and the E-dition will be updated in November. For a quick review, this article provides a summary of the major changes to Joint Commission requirements for 2011.

5 Sure-Fire Methods: Complete and Accurate Medical Records
Maintaining complete and accurate medical records is important because that information can affect when and how a patient continues to receive ongoing care or treatment. For example, missing or incomplete information can keep a patient from receiving the required medication that he or she needs on time. Although this might seem like a regular daily task, many hospitals and critical access hospitals continue to have difficulty complying with Standard RC.01.01.01, which requires an organization to maintain complete and accurate medical records for each individual patient. According to Joint Commission statistics, 62% of hospitals surveyed during the first six months of 2010 and 49% of hospitals surveyed during 2009 were not in compliance with this standard. This article provides five strategies to help your hospital or critical access hospital better comply with this standard.

Conducting Focused Professional Practice Evaluations: How to Improve Compliance with MS.08.01.01
According to Joint Commission statistics, 25% of hospitals surveyed in 2009 and 27% of critical access hospitals surveyed during the first six months of 2010 did not comply with Standard MS.08.01.01, which requires that the organized medical staff define the circumstances requiring monitoring and evaluation of a practitioner’s professional performance. Does your hospital or critical access hospital appropriately monitor and document the performance of physicians to ensure they are qualified to practice in their specialties? And with new medical techniques and equipment, does your hospital ensure that practitioners can perform the procedures for which they were granted privileges? This article provides strategies on how to improve your current process for Focused Professional Practice Evaluations.

Tracer Methodology 101: The Laboratory Tracer
Laboratory tracers are unique because they do not focus solely on direct patient contact as tracers do in other accreditation programs. Instead, the laboratory tracer evaluates the performance of processes, with particular focus on integrating and coordinating distinct but related processes. The tracer also assesses the interrelationships among departments, programs, services, or units to identify strengths and weaknesses and potential concerns in the relevant processes. This month’s tracer column focuses on how to conduct an individual laboratory tracer that involves information management, analytical procedures, and equipment use. Sample tracer questions and tips are included, along with an online laboratory tracer tracking worksheet.

Click here to view the entire 2-page Mock Tracer Tracking Worksheet.

It’s All in the Details: How to Write Acceptable Corrective ESC
Some health care organizations have difficulty writing acceptable corrective Evidence of Standards Compliance (ESC) because they don’t include enough of the right details. Remember that your corrective ESC is considered incomplete if you simply state that a policy or procedure will be developed or revised at a future date. You need to provide detail showing what actions your organization has taken to reestablish compliance with the standard or element of performance found not compliant. This charticle includes an example of how to write acceptable corrective ESC.