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Volume 10, Issue 3 | March 2012

Making It Work: Adapting Tools for Use in Your Organization
Nearly every month as you read through The Source™, you notice an interesting tool developed by another health care organization that you think might work nicely in your facility. Because every health care organization is unique, you know to make it work in your organization you need to adapt the tool to your organization’s specific patient population and the care, treatment, and services you provide. But how do you begin the process of customizing this tool? What factors should you consider?

5 Sure-Fire Methods: Complying with Standard HR.01.06.01
Joint Commission Human Resources (HR) Standard HR.01.06.01 requires accredited organizations to ensure that staff are competent to perform their responsibilities (see Related Requirements for the standard). Although this standard applies to all accreditation programs, the elements of performance (EPs) differ by program. This standard has been particularly problematic for home care (23% noncompliance) and Medicare/Medicaid-based long term care (12% noncompliance) organizations. This article provides five strategies for complying with this standard.

Tracer Methodology 101: Suicide Prevention Tracers in the Hospital Setting
During an onsite program-specific suicide prevention tracer, surveyors will focus on ensuring that an organization has an effective suicide prevention strategy in place. The details of that strategy should depend on the needs of the patient population and types of care, treatment, and services an organization provides. This tracer took place in a Level-1 trauma center with 372 beds located in a medium-sized city in a Southwestern state. The hospital provides multiple services, including having an inpatient psychiatric unit. During an earlier tracer, the surveyor learned of a patient who was being treated in the inpatient psychiatric unit after he had been admitted for an unsuccessful suicide attempt. The patient—a 23-year old man—had been brought to the emergency department by his sister when she had discovered him in the family home.

Focus on Certification: Promoting a Collaborative Environment in Palliative Care
The Joint Commission’s palliative care standards address the importance of interdisciplinary teams in Program Management Standard PCPM.7, which requires the certified palliative care program to have “an interdisciplinary team which includes individuals with expertise in and/or knowledge about the program’s specialized care, treatment, and services. Further, Standard PCPM.8 requires programs to “promote interdependence among program staff and with the organization’s staff who are involved in the patient’s care.”

Voice of the Patient: Family Works with Hospital to Improve Patient Safety
In 2008, Michelle Malizzo-Ballog was admitted to the University of Illinois Medical Center in Chicago (UIC) to have a temporary stent in her liver replaced. During the replacement surgery monitoring errors were made, which led to undetected respiratory depression and subsequently, cardiac arrest. Nine days after her scheduled surgery, she died. This article discusses the steps the hospital took to address the errors, change their policies and procedures, and disclose the error. The article also includes the family’s perspective and discusses how the Malizzo family became involved in the hospital’s patient safety committee.

The Future of Performance Measures: From Paper-Based Measures to eMeasures
This article examines eMeasures, the legislation behind them, and steps hospitals and other organizations can take to help them prepare to meet the challenges of converting from paper-based measures to eMeasures. The article also describes The Joint Commission’s role in developing eMeasures and their plans to implement eMeasures in their performance measurement system.