TJC & CMS News Blog Information
for Hospitals and Behavioral Healthcare
To read articles written prior to January 2015, please view our Newsletter Archive.
Refresher on Waived Testing Requirements
We still sometimes see organizations (both psychiatric hospitals and behavioral health organizations) receiving TJC survey findings related to waived testing. So, this month, we are recapping the requirements for waived testing and answering some frequently asked...
Psychiatric Hospital CMS Worksheets
In October 2014, CMS distributed the final version of the three worksheets to be used by the State Survey Agencies (SAs) when conducting their surveys. The worksheets are for Infection Control, Discharge Planning, and Quality Assessment/Performance Improvement (QAPI). They will be used by the state surveyors to assess compliance with the Conditions of Participation (CoPs) associated with those areas.
Life Events Checklist Trauma Assessment
As discussed in previous articles, the TJC Behavioral Health standards have a specific standard in the Care, Treatment, and Services chapter on trauma assessment. It is standard CTS.02.02.05 (added in 2011): “The organization identifies individuals served who may have experienced trauma, abuse, neglect, or exploitation.”
TJC Top Standards Compliance for 2014
The April issue of TJC Perspectives has the Top 10 compliance issues for all programs including hospitals and behavioral health organizations. There are no surprises here. For hospitals, once again, the majority of findings are in the Life Safety and Environment of Care chapters.
Preventing Copy-and-Paste Errors in EHRs
TJC now publishes Quick Safety. It’s a brief informational posting on patient safety issues. Issue 10 has an article that’s relevant as many organizations transition to an electronic health record. The topic is the practice of “copying and pasting” in EHRs.
TJC Blog for Chief Medical Officers
TJC publishes a monthly e-newsletter titled Physician Leader Monthly. The target audience is Chief Medical Officers and the topics are geared toward physician leaders. So, check it out and see if it might be a good resource for your CMO.
A Look at a Suicide Prevention Tracer
For a few years now, TJC surveyors have been conducting suicide prevention tracers when applicable to the setting they are surveying. This is known as a “program specific tracer.” We recently had a client that had this type of tracer during their survey and thought it would be helpful to share their impressions.
Patient Safety: Evaluating your Organization’s Culture
The standard is LD.03.01.01 Element requires leaders to “regularly evaluate the culture of safety and quality.” With this standard, TJC is emphasizing that the culture within an organization directly impacts the safety and quality of care provided.
Provision of Care Chapter: Highlights from 2014 TJC Surveys
Findings in the Provision of Care chapter typically account for a significant number of Requirements for Improvement (RFIs) on surveys for both psychiatric hospitals and behavioral health organizations/programs. These findings relate primarily to assessment, treatment...
New Patient Safety Systems Chapter
There is a new Patient Safety Systems Chapter in the 2015 Hospital Accreditation Manual. There are no new standards in this chapter. Rather, it describes how existing standards can be used to build an integrated patient safety system. While this new chapter exists...