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CMS announces five-star rating for Hospital Compare

Yesterday, CMS officially unveiled the star ratings on its Hospital Compare website in an effort to make it easier for consumers to choose a hospital and understand the quality of care each delivers.

After the new rating system went into effect, only 251 out of approximately 3,300 hospitals have all five stars. The Hospital Compare site notes that a hospital with a one-star rating doesn’t indicate a consumer will receive poor care and encourages consumers to consider multiple factors when choosing hospitals, rather than focusing solely on the star rating.

CMS levies heavy fines on Medicare Advantage plans

The CMS has fined 12 Medicare Advantage plans nearly $4 million in civil money penalties (CMP) since the beginning of the year. Nearly all of the plans were cited for failing to comply with contract requirements, such as incorrect prescription information or coverage disputes.

CMPs are the lowest enforcement penalty the CMS orders, although the financial penalties can be steep. Penalties issued so far range from approximately $21,000 to $1 million. The highest penalty is plan termination.

Additionally, CMS ordered one plan to suspend enrollment and three plans were released from sanctions after correcting deficiencies.

Thousand-year-old medical treatment may cure antibiotic-resistant infections

Medical practices from the “Dark Ages” are usually discounted, but the recent discovery that a 1000-year-old remedy for eye infections may cure antibiotic-resistant infections may change that.

The recipe, found in Bald’s Leechbook (an old English text known as one of the earliest medical textbooks), contains ingredients such as garlic, onion and or leek, wine, and oxgall (bile from a cow’s stomach).

Researchers followed the recipe as closely as possible, including letting it stand for nine days before straining it. They decided to test the finished recipe on cultures of MRSA, methicillin-resistant Staphylococcus aureus. The recipe worked, while it didn’t wipe out all of the cells, it wiped out enough cells (think billions) to be considered a success.

Researchers in the United States have performed similar tests on lab mice with similar success rates. In each case, the Dark Ages medical cure performed better than the regular antibiotic treatment.

Source: CNN

CMS to add five-star rating to Hospital Compare website

The Centers for Medicare & Medicaid Services (CMS) will add the five-star quality rating to its Hospital Compare website later this month. The five-star quality rating is already used on the Nursing Home Compare and Physician Compare sites.

CMS will add twelve HCAHPS Star Ratings to the Hospital Compare; one for each of the 11 publicly reported measures, plus an overall Summary Star Rating that represents a weighted average of the individual HCAHPS Star Ratings.

According to CMS, the star ratings will make it easier for consumers to use the information on the Compare websites and spotlight excellence in healthcare quality.

White House announces plan to fight antibiotic resistance

Over the past year, the Administration has taken important steps to address the threat of antibiotic resistance. In September 2014, the President issued Executive Order (EO) 13676: Combating Antibiotic-Resistant Bacteria, which outlines steps for implementing the National Strategy on Combating Antibiotic-Resistant Bacteria and addressing the policy recommendations of the President’s Council of Advisors on Science and Technology (PCAST)’s report on Combating Antibiotic Resistance. Furthermore, the President’s FY 2016 Budget released earlier this year proposed nearly doubling the amount of Federal funding for combating and preventing antibiotic resistance to more than $1.2 billion.

The long-term plan announced March 27, National Action Plan for Combating Antibiotic Resistant Bacteria (NAP), outlines a five-year approach to addressing the issue:
1. Slow the emergence of resistant bacteria and prevent the spread of resistant infections
2. Strengthen national “One-Health” surveillance efforts
3. Advance development and use of rapid and innovative diagnostic tests
4. Accelerate basic and applied research and development
5. Improve international collaboration and capacities

Read the full release at

Editor’s choice: CMS Conditions of Participation and Interpretive Guidelines

Save time searching the CMS website for the regulations and interpretations you need.

Navigating the CMS website to find accurate Medicare and Medicaid hospital regulations is a difficult and confusing task, and printing out hundreds of pages is costly and time-consuming. HCPro has taken the most recent version of CMS’ Conditions of Participation and the corresponding Interpretive Guidelines and reprinted them in an easy-to-use format.

For more information or to order a copy, visit

New Sentinel Event Alert issued

The Joint Commission issued a new Sentinel Event Alert (SEA) yesterday that encourages healthcare organizations to take precautions to ensure the safe use of healthcare information technology (IT). The new alert, SEA #54, expands upon SEA #42, published in 2008, which focused on the safe implementation of health information and converging technologies.

SEA #54 concentrates on the broader issue of health IT and provides steps that center on safety culture, process improvement, and leadership.

Read the SEA to see The Joint Commission’s suggestions to increase safe health IT use.

New name, new direction

Welcome to Accreditation & Quality Advisor, HCPro’s relaunched healthcare accreditation-centric blog! This site previously hosted the AHAP Blog (the archives are still available to read), which ran through November 2013. Going forward, we’ll be providing you three or more posts every week about issues of interest to accreditation professionals such as CMS and The Joint Commission requirements, patient safety and quality initiatives, infection control, and much more. We’ll also highlight HCPro products and free offerings for accreditation professionals. We hope you’ll find the blog useful, return often, and comment on the posts to make your opinions heard.

A look at the future of accreditation

AHAP’s own Jodi Eisenberg was recently interviewed on the changing world of accreditation. AHAP has been given permission to reprint the contents of that Q and A below.

Q: The fall is always a big, looking-ahead period in accreditation as The Joint Commission holds its annual Executive Briefings conferences. What do you anticipate will be big topics in 2014 for The Joint Commission and other accrediting bodies?

JE: I’m hopeful there won’t be many substantive standards changes, and I anticipate that most of the changes will be to the survey process. I believe The Joint Commission has been working hard to streamline its survey processes and ensure consistency from surveyor to surveyor.

For the field, this has been good news. Over the years, the annual meeting has evolved from reporting changes to standards into a forum to discuss problematic standards. This is an opportunity for those of us in the field to provide input into potential resolutions to the problems, and for the accrediting bodies to share best practices and processes that have helped move organizations to compliance.

For example, there continues to be findings under Life Safety relative to firewall penetrations. Organizations that have taken the hint and fully implemented an “above ceiling work permit” process have seen the number of penetrations drop, getting closer to overall control of the process. These standards are written for organizations of all sizes, and it is important for larger organizations with more resources to share their knowledge with smaller organizations. By doing this, we are collectively improving healthcare across the country. This annual meeting is a good forum for us to provide and receive that information.

As for the other accreditation agencies, I think they are all looking at each other, as well as to CMS, to identify ways to differentiate themselves in a positive way as accrediting leaders in the field. In the end, it all boils down to the CMS Conditions of Participation. My hope is that we will continue to hear how these accrediting bodies are working with CMS to align standards, patient safety initiatives and survey processes so that “bottom line” patient care is provided in a safe and effective manner.”

Q: There have been a lot of big changes in the field in the past year. How do you think the increased number of accrediting organization options has altered the landscape of hospital accreditation?

JE: My hope is the more accrediting bodies that connect with and work with CMS and healthcare organizations to advocate for safe and effective care, the better it will be for all patients in any healthcare setting. The ultimate goal is to push healthcare organizations to embed foundational standards and continuous survey readiness into their organizations and daily operations so that accreditation is seen as less of an event and more of a validation of the safe and effective care organizations provide every day.

Additionally, the more accrediting bodies in the field … the hope would be that we would continue to see positive changes at CMS due to the advocacy of these accrediting bodies. Some of our federal regulations and many of our state regulations are antiquated and in need of update. The more voices pushing and advocating for current regulations – and regulations that support safe, efficient and effective patient care – the better.

Q: Disease-specific program accreditation has come a long way in the past few years. How do you feel these programs and options have changed or improved since they first arrived on the scene?

JE: I’m a bit ambivalent about the disease-specific certification programs. I’m not entirely convinced that they bring added value to the organization. But, do we need a certification survey to push us to do the right thing for our patients? I would encourage organizations to take a strong look at whether the disease-specific program (DSP) is necessary and adds value. For those DSPs that are tied to reimbursement, such as Ventricular Assistive Device Certification and Lung Volume Reduction Surgery Certification, the value is in the qualification to be reimbursed. Advanced Primary Stroke and Comprehensive Stroke Certification are programs where the market is primarily driving certification. Again, organizations have to determine individual value and return on investment.

Having said that, I do believe these DSP standards can bring a level of consistency in practice across organizations, which is a good thing and of benefit to patients. Therefore, regardless of whether an organization is going to move forward with DSP or not, I think it is valuable to use the standards to establish a foundation for new programs or to assess the status of an existing program. As a result, organizations will also strengthen their overall compliance with hospital regulations and standards, helping to build compliance into operations across and throughout their organization.

Q: We’ve seen a real culture shift in The Joint Commission’s approach to surveys in the past few years. How has this impacted your work as an accreditation specialist?

JE: Culture shift or response to their customers? I believe The Joint Commission is listening to healthcare organizations. I also believe that healthcare organizations are more vocal. They have limited resources and most are in this business to take care of patients safely, effectively and efficiently. Culture shift or not, this is a positive change and in my mind the biggest benefit will be directed toward the patient. This shift can also be attributed to the fact there are more deeming authorities and healthcare organizations have more of a choice.

To be honest, this particular aspect hasn’t impacted my work significantly as an accreditation specialist. While it has likely opened up opportunities for communication and collaboration between healthcare organizations and The Joint Commission, and this can be viewed as a definite benefit to accreditation specialists, I believe that each and every day, we need to be ready to care for patients regardless of who is accrediting our organization.”

Q: What do you perceive as the biggest challenge moving forward for accreditation specialists?

JE: The healthcare regulatory front is changing rapidly; keeping up with the changes is challenging. Over the past three to five years, I have seen more changes from CMS relative to the Conditions of Participation than I have in the 10 years prior. Keeping track of the changes; implementing changes to policies and practices within healthcare organizations; and helping staff and management understand the reasons, benefits and the impact of these changes is always challenging. Organizations across the country are trying to balance limited resources to ensure they are being utilized effectively and efficiently – accreditation is just one aspect of operations.

Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, is the program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago. She is responsible for leading the full range of Joint Commission and other accreditation and regulatory compliance activities, including organization of continuous compliance activities for Joint Commission and other regulatory agencies. Eisenberg has authored, co-authored, edited and contributed to several HCPro, Inc. books and training programs including The Joint Commission Survey Coordinator’s Handbook. She has also served as an expert trainer for Accreditation Specialist Boot Camp. Eisenberg’s evolution in healthcare administration began in medical staff services and quality. She holds a master’s degree in Healthcare Administration from the University of St. Francis.

Note: The ideas and opinions expressed in this article are in no way linked to those of Northwestern Memorial Hospital.

Joint Commission releases annual report on quality and safety

The Joint Commission has released its 2013 annual report on quality and safety, which also recognizes 1,099 hospitals as “top performer” organizations.

The report provides a summary of 3,300 Joint Commission-accredited hospitals on 47 accountability measures of evidence-based care processes.

The annual report can be found online here.