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Tag Archives: Accreditation

Briefings on Accreditation and Quality, December 2017

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Editor’s Note: Click the PDF button above for a full edition of the December 2017 edition of Briefings on Accreditation and Quality

Joint Commission elaborates on accreditation reports, suicide risks, and toilet seats

The 2017 Chicago session of The Joint Commission’s annual Executive Briefings saw a far-ranging discussion on the future of accreditation. Attendees from around the country came and listened to the latest news on risk assessments, the SAFER Matrix, documentation, and suicide prevention.

Test your knowledge of the new emergency prep CoPs

CMS is offering providers a version of its online training for surveyors on the new emergency preparedness Conditions of Participation (CoP), set to go into effect November 15. Use this test—taken from the course material—to see how well you do before and after taking the training.

Being compliant isn’t hard when you have a library card

Starting on January 1, 2018, healthcare organizations will need to create and maintain an accessible library of service manuals, instructions for use, technical bulletins, and other information manufacturers provide, and keep it as rigorously updated as other required documentation of tests, inspections, and maintenance.

Bringing innovation to your facility

Taking a good idea for your own seems like it ought to be simple. But in reality, many facilities struggle to adopt new innovations—or worse, they give up on ideas they didn’t come up with themselves. So how do you go about taking someone else’s innovation and incorporating it at your facility? How do you get staff and leadership to buy into a new way of doing things?

Joint Commission updates EM standards to match CMS

In response to CMS’ final emergency preparedness rule issued earlier this month, The Joint Commission announced revisions to its Emergency Management (EM) standards. CMS is expected to approve the updated standards before they go into effect November 15.

USP deadline on hazardous drug handling postponed until 2019

The U.S. Pharmacopeial Convention (USP) has announced it intends to push back the compliance deadline for USP Chapter <800> “Hazardous Drugs; Handling in Healthcare Settings” from July 1, 2018, to December 1, 2019.

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Joint Commission elaborates on accreditation reports, suicide risks, and toilet seats

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The 2017 Chicago session of The Joint Commission’s annual Executive Briefings saw a far-ranging discussion on the future of accreditation. Attendees from around the country came and listened to the latest news on risk assessments, the SAFER Matrix, documentation, and suicide prevention.

HCPro.com – Briefings on Accreditation and Quality

Briefings on Accreditation and Quality, November 2017

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Editor’s Note: Click the PDF button above for a full edition of the November 2017 edition of Briefings on Accreditation and Quality

CMS immediate jeopardy follows possible restraint, seclusion issues

This September, a Missouri hospital found out the hard way that when not addressed quickly, restraint and seclusion deficiencies can threaten a hospital’s ability to remain open, as well as who keeps their job. CMS twice this year ruled that Mercy Hospital Springfield was putting patients in immediate jeopardy for what it deemed abusive incidents, including some involving restraint and seclusion. This included one incident where a nurse pinned a violent patient to the floor and didn’t report it.

Surveyors on the lookout for suicide hazards

Annually, there are 460,000 emergency department visits that occur following cases of self-harm, and the patients treated during those visits are six times more likely to make another suicide attempt in the future. Nationally, suicide is the 10th leading cause of death, a fact that hasn’t gone unnoticed by CMS or The Joint Commission.

Q&A: How to improve patient handoffs

Patient handoffs continue to be a major concern for hospitals. In September, The Joint Commission published Sentinel Event Alert 58 on inadequate handoff communications and its effect on patient care. Handoffs (also known as transitioning) are the passing of patients between caregivers, plus the information that caregivers exchange during the process. The latter represents a major point of failure for healthcare; each handoff runs the risk of key treatment information being garbled, forgotten, or not passed on.

Joint Commission’s top-cited standards list gives hospitals plenty to work on

In what is likely a result of a new survey matrix, new or revised Life Safety and Environment of Care requirements, and increased pressure from CMS, hospitals scored much worse across the board on The Joint Commission’s list of most challenging standards for the first half of 2017, compared to the same period last year. The Joint Commission released its list in the September issue of Perspectives.

 

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Briefings on Accreditation and Quality, October 2017

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Editor’s Note: Click the PDF button above for a full edition of the October 2017 edition of Briefings on Accreditation and Quality’

Time’s almost up: CMS emergency prep CoPs kick in soon

There’s no more excuses for getting ready to meet the new emergency preparedness Conditions of Participation (CoP). The final version of the rules came out in late June, and surveyors with CMS and The Joint Commission will begin assessing compliance with the new emergency management (EM) CoPs on November 15, regardless of the revision timetable.

The Joint Commission pain management dead-line is approaching fast

The Joint Commission finally has prepublished its new and revised pain management standards. They’ll go into effect on January 1, and there is a lot of work to do between now and then. Facilities should assign teams to research best practices in pain management, get the medical staff working on revising protocols and determining how to gather data on pain management effectiveness, and alert your information technology and electronic health records experts that they will be needed.

How to handle malignant hyperthermia

Malignant hyperthermia (MH) is a key focus for surveyors. Schedule drills for staff on finding the emergency carts with the proper drugs to treat MH, ensure the drugs in those carts are kept up to date, and document education and training in their use.

CMS report focuses on AOs’ life safety short-comings

The annual CMS evaluation of accreditation organizations (AO) is out and in the hands of Congress. CMS thinks all the AOs aren’t doing as well as they should in catching violations and is promising Congress that it’s actively working to change that.

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Briefings on Accreditation and Quality, September 2017

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Editor’s Note: Click the PDF button above for a full edition of the Septmeber 2017 edition of Briefings on Accreditation and Quality

Q&A: Accreditation 101

The accreditation world can be a perplexing place. Accreditation specialists are expected to be up to date on forever-shifting healthcare regulations. They have to make sure every aspect of their facility is compliant with federal, state, and private standards and guidance. And when something is wrong, they have to ensure it gets and stays fixed. This article is a primer for accreditation beginners: people who want to do their jobs well but need an idea of where to start.

Quick look: Immediate Jeopardy

In healthcare, the words “Immediate Jeopardy” carry roughly the same meaning as  “why is the tiger enclosure empty?” In other words, something has already gone horribly wrong and you have to act fast before it gets exponentially worse.

Gender identity and healthcare: How hospitals should approach gender issues in care delivery

A patient is being registered at a hospital. Registration requests to see identification, which states that the patient is male. However, the patient identifies as female, and the electronic medical record (EMR) only has male or female fields. Which one should the registrar select?

Fire doors, drills, and the ED; Joint Commission clarifies Life Safety Code requirements

In May, The Joint Commission issued clarifications on its 2012 Life Safety Code® (LSC)–related requirements for fire doors, fire drills, and emergency department (ED) occupancy. Here’s a look at the four clarifications and what they mean
 

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Q&A: Accreditation 101

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Two experts explain what new accreditation specialists need to know

The accreditation world can be a perplexing place. Accreditation specialists are expected to be up to date on forever-shifting healthcare regulations. They have to make sure every aspect of their facility is compliant with federal, state, and private standards and guidance. And when something is wrong, they have to ensure it gets and stays fixed. This article is a primer for accreditation beginners: people who want to do their jobs well but need an idea of where to start.

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Briefings on Accreditation and Quality, August 2017

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Editor’s Note: Click the PDF button above for a full edition of the August 2017 edition of Briefings on Accreditation and Quality

High- and low-risk devices are all the same to surveyors; New maintenance standards could prove costly for hospitals

Many were shocked by The Joint Commission’s newest standards and elements of performance (EP) on medical device maintenance. The accreditor will no longer distinguish between “high-risk” and “non-high-risk” equipment when surveying maintenance and inspection compliance. Instead, facilities are expected to achieve 100% inspection compliance for both types of devices.

But hold off before panicking over how you’re supposed to track down and inspect 100% of the medical devices in your facility. The new standards have exceptions written into them for items that are in use or have gone missing.

CMS tells surveyors to double check for Legionella contamination

On June 2, CMS issued a new memo to surveyors on the importance of reducing cases of Legionella infections. Not long after, the Centers for Disease Control and Prevention (CDC) sent out a Vital Signs report underlining the bacterium’s risk to patients. Accredited facilities should double-check their waterborne pathogens compliance, as surveyors will likely pay more attention to it in upcoming surveys. The contents of this memo go into effect immediately.

Experts weigh in on CMS transparency proposal: Balancing public’s right to know with quality

This April, CMS published its hospital inpatient prospective payment system (IPPS) proposed rule for fiscal year 2018. One section in particular would require accrediting organizations (AO) to make survey reports or plans of corrections (PoC) publicly available online within 90 days of the information becoming available to the healthcare organization. However, there are concerns that this move creates an uneven playing field in hospital quality and oversight. It’s also argued that the public might have trouble deciphering the contents of accreditation reports, leading to more confusion. 

Q&A: What you need to know about compounding medicine

The Joint Commission unveiled a new Medication Compounding Certification (MCC) program in January with the goal of reducing the harm stemming from drug compounding and ensuring compliance with U.S. Pharmacopeial Convention (USP) and Joint Commission standards. All compounding pharmacies are eligible to enroll in the program, including organizations not accredited by The Joint Commission. Meanwhile, USP Chapter <800> goes into effect on July 1, 2018 and contains major changes aimed at protecting healthcare workers from exposure to hazardous drugs and materials. The following is an edited Q&A with Kurt Patton, MS, RPh, a former director of accreditation services for The Joint Commission and founder of Patton Healthcare Consulting in Naperville, Illinois. He spoke with BOAQ on the details surrounding medication compounding.

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Briefings on Accreditation and Quality, July 2017

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CMS updates transparency and termination notices; Ex-Joint Commission exec calls for fairness in how hospitals are held to standards

This April, CMS sent out a memo with big proposals for accrediting organizations (AO). If passed, The Joint Commission, DNV, HFAP, and others would have to post final survey reports online within 90 days of that information becoming available to the healthcare organization.
However, there are concerns that this move creates an uneven playing field in hospital quality and oversight. It’s also argued that the public might have trouble deciphering the contents of the report.

Navigating the laws and benefits of telemedicine

This is the first year that all 50 states have adopted some form of telemedicine coverage. Telemedicine is the remote diagnosis and treatment of patients using an audiovisual platform—a doctor’s appointment over Skype, remotely monitoring a patient’s vitals, messaging pictures of rashes and illnesses, etc. And while certain issues will still require an in-person examination (e.g., setting a broken arm), the field is opening several new options for treatment.

Because telemedicine is still so new, the laws pertaining to it have yet to keep pace with the technology. The rules surrounding telemedicine vary greatly between states, and wading through the list of best practices and guidelines can be difficult. So why should hospitals set up a telemedicine program? And what do they need to navigate the disparate laws and regulations around telemedicine?

Holding hospitals for ransom; The WannaCry virus and the lack of cybersecurity in hospitals

Over the course of one weekend in May, more than 300,000 computers in 150 countries were held hostage by a ransomware virus called “WannaCry.” The virus locked down computer systems and forced hospitals, corporations, universities, and individuals to pay $ 300 apiece in Bitcoin to regain access to their files. One of the most notable victims of WannaCry was the United Kingdom’s National Health Service (NHS). About one-fifth of NHS trusts (which oversee British hospitals) were affected, forcing them to reroute ambulances, postpone surgeries, and cancel appointments.

While American hospitals were mostly unaffected by this particular attack, there has been a worrying jump in successful ransomware attacks in the U.S.

Q&A: Changes to Joint Commission maintenance standards and AEMs

This is an edited Q&A from the Association for the Advancement of Medical Instrumentation’s (AAMI) webinar, “Clarifying the Changes to Joint Commission and CMS Standards.” The webinar talked about the changes to The Joint Commission’s maintenance standards, which no longer differentiate between inspecting high-risk and non-high-risk devices for an alternative equipment management (AEM) program. The speakers for the event were George Mills, MBA, FASHE, CEM, CHFM, CHSP, Joint Commission director of engineering, and Stephen Grimes, FACCE, FAIMBE, FHIMSS, managing partner and principal consultant for Strategic Healthcare Technology Associations, LLC.

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