TJC & CMS News Blog Information
for Hospitals and Behavioral Healthcare
To read articles written prior to January 2015, please view our Newsletter Archive.
TJC Competence Assessment Session: Survey Management Strategies
Fourth in our series on TJC Survey Management Strategies. It’s Day 3 of your TJC survey. Time for the TJC Competence Assessment Session. Surveyors have given you a list of staff names. Now they’ll review your Human Resource and Staff Training files for those individuals. We’ve seen this session go smoothly. And we’ve seen it descend into chaos. The result can be several finding on your survey report in the Human Resources chapter. So, what are the current high focus areas? And the common compliance challenges? Let’s review those and help you get prepared for this session.
CMS Resurvey: Strategies for Survey Success
Has your psychiatric hospital been put in Immediate Jeopardy by CMS? Or, had a CMS survey with Condition level findings? Either way, you need to prepare for your CMS resurvey. So, it’s time to shift into high gear. In our last article Immediate Jeopardy and CMS Surveys: How to Respond, we covered Immediate Jeopardy and your response strategy. In this article, we address how to prepare for your CMS resurvey.
Immediate Jeopardy & CMS Surveys: How to Respond
Has your psychiatric hospital been cited by CMS for an Immediate Jeopardy situation? If so, “Immediate Jeopardy” can be a somewhat frightening term. What exactly does it mean and what are the implications? Most importantly, how should you respond? In this article, we provide important information on CMS Immediate Jeopardy and your response strategy. In our next article, we’ll discuss how best to prepare for your CMS resurvey.
TJC Medical Staff Credentialing & Privileging: Survey Management Strategies
Third in our series on TJC Survey Management Strategies. Don’t think you can fly on auto-pilot for the TJC Medical Staff Credentialing & Privileging Session. Yes, it’s been a standard part of hospital surveys for a long time. Yet, we still see a significant number of survey findings in the Medical Staff chapter for many organizations. And, recently, even some Condition Level Deficiencies. So, what are the current high focus areas for Medical Staff Credentialing & Privileging? And the common compliance challenges? Let’s review those and help you get prepared for this session.
Suicide Risk Reduction: Two New FAQs from TJC
Have you seen The Joint Commission’s two new FAQs on suicide risk reduction? The first one relates to monitoring of patients at high risk for suicide. The second FAQ clarifies the requirement for self-closing and self-locking doors. Both are critically important. Get...
TJC Medication Management Tracer: Survey Management Strategies
Second in our series on TJC Survey Management Strategies. The TJC Medication Management Tracer has been part of the survey process for awhile. For this reason, some organizations underestimate its importance. Don’t make that mistake. Safe medication management is a high focus area for TJC right now. Consequently, this session is more important than ever. So, what exactly is the Medication Management Tracer all about? And how do you prepare for it?
Suicide Risk Reduction: Be Clear on TJC’s New July 1 Requirements
The countdown is on. July 1st is when the new Joint Commission requirements for suicide risk reduction go into effect. The revised National Patient Safety Goal NPSG.15.01.01 has seven new and revised elements of performance. We do a lot of education on the new...
TJC Document Review Session: Survey Management Strategies
First in our series on TJC Survey Management Strategies. “You don’t get a second chance to make a first impression.” We’ve all heard that. And you can be sure it applies to your Joint Commission survey.You know the drill. The surveyors arrive at your facility. After introductions, their first real task is the Document Review …
Intimidating Behavior Undermines a Culture of Safety
Intimidating behavior has been called the “healthcare equivalent of road rage.” As more and more healthcare organizations work on building a Culture of Safety, they’re forced to address this issue head on. Intimidating Behavior and a Culture of Safety A hallmark of a...
Suicide Risk Assessment: Q&A on July 1 Revisions to NPSG 15.01.01
Are you ready for the new Joint Commission requirements effective July 1, 2019 for suicide risk assessment? TJC has revised National Patient Safety Goal (NPSG) 15.01.01. There are seven new and revised elements of performance. We covered this topic in previous posts...