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Joint Commission releases analysis of eCQM data

The analysis found that missing data was the biggest cause of discrepancies. Some examples of missing data are:

•    Missing data on medication route
•    Use of wrong template ID
•    Diagnosis Active is missing, which puts the case in denominator

The Joint Commission also unveiled its Core Measure Solution Exchange®,which allows hospitals to share how they implemented the eCQMs. Users can post about the implementation issues they’ve had, challenges they’ve faced, and solutions they’ve come up with. They can learn from other facilities about the problems and solutions they came up with as well.

The Exchange is free and is part of your facility’s Joint Commission Connect extranet.

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AHRQ toolkit teaches how to face up to medical errors

Medical errors happen too often, and can cause irreversible and irreparable injury to patients when they do. While there is a myriad of ways to try and prevent errors from happening, every hospital needs to have policies in place for when they occur.

A common approach of responding to medical errors is to hide the details of them from patients, also known as the “deny-and-defend” strategy. Often this is done out of fear that a patient or their family will get angry and sue if they find out a mistake was made during their care. There’s also the possibility that the hospital would have to foot the bill for any follow-up care necessitated by the mistake, or waive a patient’s bills.

That said, studies have found that patients are more inclined to sue if they think their physician has been hiding something from them. Therefore, the Agency for Healthcare Research and Quality (AHRQ) published an online toolkit this May that suggests that physicians do the exact opposite. The toolkit,Communication and Optimal Resolution (CANDOR), emphasizes openness with patients and family when a mistake happens.

Some hospitals are now having physicians and medical students go through role-playing scenarios where they have to explain a mistake to a patient or their family. MedStar Health, a provider in Maryland and Washington, D.C., created a “Go Team” of physicians trained in disclosing medical errors that remains on standby to provide support to staff when they need to tell a patient about a mistake.

“We felt horrible that we couldn’t openly talk to patients and families … our attorneys would tell us we can’t do that because we’re going to give them all the information that will cause us to lose a lawsuit,” David Mayer, vice president of MedStar told Kaiser Health Media.  “There were no winners”

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Three new Joint Commission questions for building tours

During your next Joint Commission survey, be prepared to answer three new questions before even starting your building tour. Jim Kendig, the Joint Commission’s field director for surveyor management and development, told the American Society for Healthcare Engineering (ASHE) that the questions are intended to spur conversations among surveyors and healthcare facility managers about common areas for findings.

The three new questions are:

1. What type of fire-stopping is used in the facility?
2. What is the organization’s policy regarding accessing interstitial spaces and ceiling panel removal?
3. Which materials are used (e.g., glutaraldehyde, ortho-phthalaldehyde, peracetic acid) for high-level disinfection or sterilization?

“They’re pretty straight forward—there’s no hidden agenda here,” Kendig said. “We’re just trying to get some information before we start the building tour.”

Joint Commission and CDC team up on ambulatory infection prevention

The Joint Commission and the Centers for Disease Control and Prevention (CDC) are working on a new initiative to improve infection control in ambulatory care settings. The Adaptation and Dissemination Outpatient Infection PrevenTion (ADOPT) project will promote existing CDC infection prevention (IP) guidance while also making updates and alterations. The collaboration will involve:

•    Evaluating organizations’ infection prevention and control guidelines and materials to find gaps between what’s done in practice and what’s in the CDC materials.
•    Finding new ways and opportunities to raise awareness of IP guidance.
•    Adapting model infection control plans for outpatient-focused professional organizations.
•    Developing new ways of disseminating these materials and models to healthcare organizations to increase their reach, uptake, and adoption in outpatient settings.

There are 12 outpatient-focused professional organizations and 11 ambulatory healthcare systems participating in ADOPT. Other healthcare organizations or state health departments interested in learning more can reach out to Barbara Braun, PhD, at

For examples of CDC ambulatory-focused infection prevention and control guidance, check out the following links:
•    CDC Guide to Infection Prevention for Outpatient Settings:  Minimum Expectations for Safe Care
•    CDC Outpatient Settings Policy Options for Improving Infection Prevention
•    CDC Basic Infection Control and Prevention Plan for Outpatient Oncology Settings
•    The CDC One and Only Campaign
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Share the trials and tribulations of eCQM success

Are you wondering how you’ll ever be prepared for the CMS’ updated Electronic Clinical Quality Measures (eCQM) due for release February 28, 2017? Don’t worry, you don’t have to face it alone.

The Joint Commission recently unveiled its Core Measure Solution Exchange®, which allows hospitals to share how they implemented the eCQMs. Users can post about the implementation issues they’ve had, challenges they’ve faced, and solutions they’ve come up with. They can learn from other facilities about the problems and solutions they came up with as well.

The Exchange is free and is part of your facility’s Joint Commission Connect extranet. There is already an eCQM solution posted by Wooster Community Hospital for viewing.

Introducing the PSQH Forum!

We’re proud to release the newest feature of the Patient Safety & Quality Healthcare website, the PSQH Forum. The forum is for you, the patient safety professional, to voice your opinions, share tools and policies, and receive answers to industry-related questions.

PSQH LogoWe’ve updated the former Patient Safety Talk forum, that long-time readers of Patient Safety Monitor Insider will remember, into a more traditional online forum with different categories in which you can post (and receive email notifications).

We’ve kept the valuable talk threads in a Patient Safety Talk archive on the new site.

Stop by the forum, introduce yourself or just browse through the archives.

CMS to save millions by increasing hospital readmission fines

CMS LogoWith spending on inpatient hospital services expected to increase by $746 million next year, CMS is in need of new ways to save and raise revenue. On August 2, the agency announced a change that will help ease some of its money woes.

At the beginning of the 2017 fiscal year in October, CMS will add new criteria to the Hospital Readmissions Reduction Program that’s expected to save CMS $538 million; $108 million over the previous fiscal year. The new criteria will increase the number of hospitals that are penalized for high readmission rates, as well as the amount for which they are penalized.

CMS has added coronary artery bypass grafts as a surgery for which hospitals can receive a readmission penalty, as well as alter how it calculates readmissions for pneumonia. Other readmission penalty procedures include heart failure, heart attacks, chronic obstructive pulmonary disease, and hip and knee replacements. It’s estimated that 2,588 hospitals will be fined next year due to the update, losing 0.73% of their Medicare payments on average. Only 49 hospitals are expected to receive the maximum penalty of 3% according toKaiser Health News.

Readmissions have been a major point of contention between hospital groups and CMS. Many argue that since CMS’ program doesn’t take socioeconomic factors into account, hospitals that serve poorer or sicker patients are disproportionately fined for high readmissions.

“We are disappointed CMS missed another opportunity to adjust for the social and economic challenges of vulnerable patients in its quality improvement and reporting programs,” said Beth Feldpush, senior vice president at America’s Essential Hospitals, in a statement. “The evidence is clear that these programs disproportionately penalize hospitals that serve disadvantaged patients and communities.”

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Overview of upcoming Joint Commission changes

Over the next couple of months, several Joint Commission programs, standards, and updates will go into effect. Here is a brief overview of some of the bigger changes and the months they’ll go into effect.
•    Elimination of Plans for Improvement (PFI)—After August 1, all PFIs will be replaced by Requirements for Improvement (RFI) issued by the surveyor.
•    Updated diagnostic imaging standards—The accreditor published a checklist to help healthcare organizations prepare for new standards.
•    2012 Life Safety Code® (LSC)—CMS and The Joint Commission will begin surveying hospitals on the 2012 LSC on November 1. HFAP has published itsprepublication standards for LSC surveys as well.
•    Antibiotic stewardship programs (ASP)—On January 1, ASPs will be mandatory in CMS- and Joint Commission-accredited facilities.
•    Survey Analysis for Evaluating Risk (SAFER) matrix—As of January 1, the SAFER matrix will replace the current Category A and C scoring methodology.
•    Catheter-associated urinary tract infections (CAUTI) National Patient Safety Goal (NPSG)—On January 1, The Joint Commission’s newest NPSG will go into effect, with facilities expected to drastically cut the rate of CAUTIs.
•    Updated Integrated Care (ICC) program standards—Effective as of January 1 for Joint Commission-accredited facilities
•    Updated advanced heart failure certification—Effective as of January 7 for Joint Commission-accredited facilities

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Joint Commission updates Integrated Care Program standards

The Joint Commission has updated and released its Integrated Care (ICC) Program standards, which will go into effect on January 1, 2017. The standards are aimed at improving key ICC processes and promoting the use of common patient risk screening criteria. The standards also try to eliminate duplicative care coordination and case management efforts.

See Joint Commission accreditation changes of 2016

There have been several changes to the accreditation process this year, with more to come in 2017. The Joint Commission has released notes on all changes that went into effect on August 1, such as the elimination of Plans for Improvement. The changes can be viewed in the 2016 Survey Activity Guide.