The Joint Commission: Speak Up About Your Care

Speak up

• If you don’t understand something or if something doesn’t seem right.

• If you speak another language and would like a translator.

• If you need medical forms explained.

• If you think you’re being confused with another patient.

• If you don’t recognize a medicine or think you’re about to get the wrong medicine.

• If you are not getting your medicine or treatment when you should.

• About your allergies and reactions you’ve had to medicines.

Pay attention…

• Check identification (ID) badges worn by doctors, nurses and other staff.

• Check the ID badge of anyone who asks to take your newborn baby.

• Don’t be afraid to remind doctors and nurses to wash their hands.

Educate yourself…

• So you can make well-informed decisions about your care.

• Ask doctors and nurses about their training and experience treating your condition.

• Ask for written information about your condition.

• Find out how long treatment should last, and how you should feel during treatment.

• Ask for instruction on how to use your medical equipment.

Advocates (family members and friends) can help…

• Give advice and support — but they should respect your decisions about the care you want.

• Ask questions, and write down important information and instructions for you.

• Make sure you get the correct medicines and treatments.

• Go over the consent form, so you all understand it.

• Get instructions for follow-up care, and find out who to call if your condition gets worse.

Know about your new medicine…

• Find out how it will help.

• Ask for information about it, including brand and generic names.

• Ask about side effects.

• Find out if it is safe to take with your other medicines and vitamins.

• Ask for a printed prescription if you can’t read the handwriting.

• Read the label on the bag of intravenous (IV) fluid so you know what’s in it and that it is for you.

• Ask how long it will take the IV to run out.

Use a quality health care organization that…

• Has experience taking care of people with your condition.

• Your doctor believes has the best care for your condition.

• Is accredited, meaning it meets certain quality standards.

• Has a culture that values safety and quality, and works every day to improve care.

Participate in all decisions about your care…

• Discuss each step of your care with your doctor.

• Don’t be afraid to get a second or third opinion.

• Share your up-to-date list of medicines and vitamins with doctors and nurses.

• Share copies of your medical records with your health care team.
The goal of Speak Up™ is to help patients and their advocates become active in their care.

Speak Up™ materials are intended for the public and have been put into a simplified (i.e., easy-to-read) format to reach a wider audience. They are not meant to be comprehensive statements of standards interpretation or other accreditation requirements, nor are they intended to represent evidence-based clinical practices or clinical practice guidelines. Thus, care should be exercised in using the content of Speak Up™ materials. Speak Up™ materials are available to all health care organizations; their use does not indicate that an organization is accredited by The Joint Commission.
SpeakUp™ Speak Up™ About Your Care
©2018 The Joint Commission | May be copied and distributed | Department of Corporate Communications

Announcing a New Partnership!

I am pleased to announce that MBD Consulting, LLC has a new partnership with MSL Healthcare Partners.  MSL Healthcare Partners will be partnering with MBD Consulting to provide Life Safety and Environment of Care expertise to our already highly experienced group.  Our Principal, Maureen D’Agostino said, “their website states a clear vision that fits well with MBD Consulting. One belief, one philosophy”

From their web site, At MSL Healthcare Partners, we have an obsession with safety. We will never conceal, compromise or apologize for our dedication to making the healthcare environment safer, with an ultimate goal of completely eliminating preventable errors. Yes, we’re saying it, and we’ll say it again: We believe that all members of the healthcare community can work together to one day eliminate preventable errors in our healthcare environments. To achieve such a goal, the status quo will not suffice. The lowest common denominator, the bare minimum, the excuses, the don’t-raise-your-head-up philosophy will never do.

Welcome to the MBD Consulting family.


Joint Commission Advises Hospitals to Help Staff After Traumatic Events


By Maria Castellucci Modern Healthcare | January 31, 2018
The Joint Commission issued an advisory report this week urging its accredited healthcare organizations to provide support services to staff after traumatic patient events.

Healthcare providers can experience psychological trauma when their patients experience adverse health events like an unexpected death or medical error. The emotional toll such events can have on providers has been coined “second victims” and although healthcare organizations have begun to address the issue, programs and tools haven’t been widely adopted, according to the Joint Commission.

“We are trying to improve the awareness and importance of this issue,” said Dr. Ana McKee, executive vice president and chief medical director of the Joint Commission.

In its advisory, which was sent out to the roughly 21,000 healthcare organizations it accredits, the Joint Commission offers various tactics for healthcare leaders to support staff after traumatic events. The commission recommends organizations create a culture that encourages communication about defects and errors, engage all team members to share lessons learned when an adverse event occurs and provide guidance to staff about how they can properly support each other during trauma.

“(Doing) nothing is not the right answer … an organization has to find some approach to raise awareness about the second victim,” McKee said.

The commission also offers ways for healthcare organizations to implement “second victim” programs. These programs provide peer-to-peer support services to staff and have been adopted at some hospitals and health systems across the country like Johns Hopkins University and Health System.

Rise, which was launched in 2011 at Johns Hopkins, is a 24/7 call center staffed by roughly 30 clinicians at the organization who have volunteered to be part of the program. The participants are trained in psychological first aid, a technique used to help victims debrief soon after a traumatic patient event.

“It’s intended to be a safe (space for staff) — we don’t report it to managers,” said Dr. Albert Wu, a professor of health policy and management at Johns Hopkins who helped launched the program.

The program has encouraged staff at Johns Hopkins to be more open about their emotions, Wu said. Whole clinical teams will go together for support after a particularly traumatic event. “It is changing the culture,” he said.

The Joint Commission took best practices from “second victim” programs like Johns Hopkins in its recommendations. Healthcare organizations are encouraged if they want to form such a program to obtain buy-in from leadership, emphasize the importance of patient safety and develop an educational campaign.

At Nationwide Children’s Hospital, resources to establish the YOU Matter Second Victim Program were initially scarce.

Jenna Merandi, director of the “second victim” program, said she partnered with the marketing department to raise awareness. Informational messages were displayed on digital quality boards and Merandi and her team spoke at meetings across various departments.

“The first several years we didn’t have funds, we started from the ground up,” she said. “(After) we showed the value of the program and how it was changing the culture, we did receive funding and support.”

YOU Matter Second Victim Program, which first launched in 2013, has now trained more than 700 Nationwide staff members to be peer supporters.

The Columbus, Ohio-based children’s hospital has surveyed its staff on feelings of burnout and stress since the program has been in place, and the results are promising.

“We have been able to show the effectiveness of the program … it’s improving negative psychological impact on front line staff,” she said

CMS Bans Texting of Patient Orders!

By Debra A. Geroux

January 3, 2018

In a Letter to State Surveyors, the Centers for Medicare & Medicaid Services (“CMS”) has clarified its position on texting patient information, and more notably Orders, among members of a patient’s care team. In a nutshell: Don’t Do It!
In its December 28, 2017 Memo regarding Texting of Patient Information among Healthcare Providers, CMS recognizes the benefits and long standing practice of texting patient information among members of a patient’s healthcare team, but explains that it is only permissible if performed through a secure, encrypted platform in accordance with HIPAA privacy and security regulations. CMS expects that providers and organizations that utilize secure, encrypted texting systems will implement procedures for regularly assessing the security of the system.
However, CMS also indicates that, as it concerns Orders from a provider to a member of the care team, texting is never permissible, encrypted or otherwise, as the Conditions of Participation and Conditions for Coverage mandate that Orders be dated, timed, authenticated and promptly placed in the medical record. See 42 CFR 482.24(b).[1] According to CMS, the best (and preferred) practice for entering orders is through Computerized Provider Order Entry (CPOE), which ensure immediate and authenticated entry into the electronic health record.
While the texting prohibition has not yet been addressed in the Interpretative Guidelines,[2] Interpretive Guideline A-0454 concerning section 482.24(c)(2) provides slight guidance on the “promptly” directive, noting that it is to be “performed readily or immediately” so that all members of the patient’s care team have access to it. The use of texting for Orders does not meet either the requirements for authentication or prompt placement, at a minimum.
Healthcare providers and entities must take steps to educate staff about the problems associated with texting generally, and texting Orders specifically. While CMS recognizes texting is commonplace, it does not mean it can be condoned. If not already in place, hospitals and entities that are subject to certification surveys should take steps to eradicate these standard practices through policy changes and education.



Thanks to AHRQ: Toolkit To Promote Safe Surgery In Hospitals

The Toolkit To Promote Safe Surgery helps perioperative and surgical units in hospitals identify opportunities to improve care and safety practices and implement evidence-based interventions to prevent surgical site infections. The toolkit has evidence-based, practical resources that reflect the real-world experiences of the frontline clinicians and subject matter experts who participated in the AHRQ Safety Program for Surgery, a national implementation project in which approximately 200 hospitals participated and successfully reduced surgical site infections. It builds on AHRQ’s Comprehensive Unit-based Safety Program (CUSP) and the core CUSP toolkit by providing specific tools focused on the surgical setting to help hospitals reduce surgical site infections and other complications.
The toolkit has two complementary guides that should be used together and are a good starting point: Applying CUSP To Promote Safe Surgery, and Surgical Complication Prevention. These two guides address respectively adaptive and technical work, which are both critical elements for improvement to occur. Technical work changes procedural aspects of care that can be explicitly defined, such as surgical skin preparation procedures. Adaptive work is designed to change the attitudes, values, beliefs, and behaviors of the people who deliver care and improve safety culture within an organization, thereby enabling consistent use of evidence-based practices. Both guides should be used simultaneously. Supplemental tools accompany the guides.
The toolkit also includes 15 instructional modules to help clinical teams address specific areas of competency. The modules are spread across the three phases that clinical teams will undergo as part of their quality improvement efforts: onboarding, implementation, and sustainability.
Toolkit Materials
The toolkit includes two guides, supplemental tools for each guide, and 15 instructional modules within three phases to support change at the unit level.
Applying CUSP To Promote Safe Surgery
Supplemental tools
Surgical Complication Prevention
Supplemental tools
Instructional modules

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Geisinger Holy Spirit Hospital Cited After Patient Dies Under Restraint

December 27, 2017

The patient became combative and was held down by two security guards while a physician and a nurse applied the restraints.
A hospital in central Pennsylvania has been cited by the Pennsylvania Department of Health after a patient died while being placed in restraints.
An investigation into Geisinger Holy Spirit Hospital’s handling of a restrained patient indicated staff failed to “protect the patient’s safety during restraint application” on September 26, reports Penn Live.
According to the health department’s investigative report, the patient became agitated and belligerent and attempted to exit the hospital, pushing through staff members.
Two security guards then held the patient down on a bed while a physician and a nurse applied restraints. The unidentified patient’s body went limp, their face turned blue and they began foaming at the mouth, according to the report.
The hospital staff declared a code blue, used to label a patient in cardiac arrest. The patient later died from what the hospital called a “diffuse anoxic brain injury,” which is typically caused by severe head trauma, according to The Sentinel.
The department says some of the restraints that were used did not have a required order from a doctor.
Another violation included failure to report the death to the Pennsylvania Patient Safety Authority within a week of the incident. The hospital also did not notify the patient’s family of the event, says the report.
The hospital submitted a plan of correction but the first version was rejected by the state.
The second plan was approved and includes educating staff about the use of restraints and the establishment of a “code grey team” to be trained in handling a combative patient who does not have a weapon. The report did not give elaborate details on the hospital’s plan to institute the team.

While we would prefer not to restrain patients, at times such measures are indicated for the safety of all involved. We are saddened whenever a patient passes away, and are confident that the care our team provided was consistent with Geisinger Holy Spirit’s mission of delivering professional and compassionate care to all,” says Lori Moran, director of corporate communications at Geisinger Holy Spirit.
Holy Spirit has a locked mental health unit and specializes in mental health crisis situations.

About the Author

Amy Rock, Web Editor
Amy Rock is the Campus Safety Web Editor.

The CMS Clarifies What It Means To Be A Hospital

“Hospitals must have at least two inpatients at the time of the survey in order for surveyors to conduct the survey. However, just because a facility has two inpatients at the time of a survey does not necessarily mean that the facility is primarily engaged in inpatient care and satisfies all of the statutory requirements to be considered a hospital for Medicare purposes. Having two patients at the time of a survey is merely a starting point in the overall survey and certification process.”

One of the industry’s fastest-emerging trends—micro-hospitals—could take a hit thanks to new CMS guidance that has hospital accreditors tweaking their policies regarding what counts as a hospital.

Micro-hospitals are small-scale, inpatient facilities with eight to 15 short-stay beds. They perform many of the same acute-care and emergency services done at larger hospitals, but are cheaper to operate. Micro-hospitals have cropped up in 19 states, mostly in underserved urban locations or areas that are farther away from large hospitals.

Prior to the CMS’ declaration in the fall, there was no guidance with respect to what it took to be considered “primarily engaged” or to count as an inpatient provider.

If smaller hospitals are not deemed to be primarily engaged in inpatient care, they may be prohibited from providing medical services or be paid at a lower rate for free-standing facilities.

Concerns are that the guidance was released without a public comment period, is effective immediately, and has a 12-month look-back period for compliance when there was not any clear guidance on expectations. That could affect the validity of surveys already performed.

Excerpts from Modern Healthcare Virgil Dickson | December 16, 2017