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PCS and Ambulatory TJC Groups February 2010. Today’s Agenda BIDMC’s Readiness for TJC 2010 -- –What's Happening? –What Are We Learning From Others? –What.

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Presentation on theme: "PCS and Ambulatory TJC Groups February 2010. Today’s Agenda BIDMC’s Readiness for TJC 2010 -- –What's Happening? –What Are We Learning From Others? –What."— Presentation transcript:

1 PCS and Ambulatory TJC Groups February 2010

2 Today’s Agenda BIDMC’s Readiness for TJC 2010 -- –What's Happening? –What Are We Learning From Others? –What Do We Do Now??? Ambulatory Vulnerabilities Brainstorming TJC’s Speak Up™ program

3 Looking Back TODAY Looking Forward!!!

4 BIDMC through the lens of TJC - Strategic Surveillance Report Lower PFP Index  BETTER Continue to see effects of sentinel events (Ortho, OB) and other Serious Complaints (Media Reports). No activity in >4 months Continue to see effects of suboptimal performance in Core Measures (SCIP, Pneumonia, Heart Failure) – current performance improved

5 Major Changes to Survey Process for 2010 Significant number of TJC Standards have aligned with CMS Conditions of Participation. Examples: HRTransfusion Competency MMDiversion -- Reporting to Governance Level LDQI Projects – Reporting to Governance Level PCRestraints LD/MSCredentialing of Telemedicine Clinicians Changes to NPSG requirements/survey process –11 in CY2010 Will assess based on match between PPGDs and Performance Important for ALL levels of personnel to be able to answer “How do we monitor our processes and own internal standards?”

6 Making the Connections… How TJC will assess PPGDs DocumentationPractice Informed Consents Patient Problem Lists Labeling Medications and Syringes Pain Reassessment Restraints Response to First Dose of New Medication

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8 Let’s brainstorming around vulnerabilities…

9 CQI Update for today… The Joint Commission has a new education campaign, the award-winning Speak Up™ program, which urges patients to take an active role in their own health care. We’ll discuss this initiative more next month regarding ordering in bulk and which brochures. In the meantime here is the link so that you can look at the materials.

10 Check out all the Brochures Speak Up™ brochures are available in English and Spanish at: http://www.jointcommission.org/PatientSafety/SpeakUp/


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