January, 2010
1. The Joint Commission (TJC) has released the 2010 Survey Activity Guide. Download the document from www.jointcommission.org. This version includes, for all programs, updated document lists, survey readiness notes and a survey activity list. In an effort to continue to improve customer and surveyor satisfaction, TJC has implemented a new process for developing the survey agenda. The survey team will work with the organization, while onsite, to develop an agenda that meets survey requirements and the needs of the organization. (See the January 2010 edition of The Joint Commission Perspectives for more information.)
2. Just another reminder about “pre-charting.” Any orders for post-procedure medications, treatment and other care that are written pre-procedure must be activated post procedure for use with the patient. This means, for example, if an anesthesiologist completes a pre-anesthesia evaluation and writes post-procedure orders at that time, prior to the procedure, the orders would have to be activated after the procedure or should be signed, dated and timed after the procedure to indicate they are now active for use with the patient. (Courtesy of TJC’s Standards Interpretation Group (SIG) 12/30/10.)
3. The Centers for Medicare & Medicaid Services (CMS) have published revised Anesthesia Services Interpretive Guidelines to clarify which anesthesia services fall under this Condition of Participation (COP) and provide further details on pre, intra, and post-operative anesthesia requirements. See a future edition of C&A News for a summary of the revisions to these Interpretive Guidelines.
4. TJC has published revised interim staffing effectiveness requirements that become effective July 2, 2010. These revisions are applicable to the Hospital and Long Term Care programs and focus on the adequacy of staffing based on number, skill mix and staff competency. (See the January edition of Perspectives.) These requirements are expected to help organizations focus on assuring appropriate staffing to provide safe care without the onerous burden of the previous prescriptive staffing effectiveness data requirements.
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