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Safety Standards Pose Problems for TJC-Accredited Hospitals

Safety-related requirements continue to plague hospitals, according to The Joint Commission’s latest list of most-cited standards data through the first six months of 2018.

Released in the September issue of Perspectives, the data was aggregated from 676 applicable Joint Commission hospital surveys from January 1 through June 30.

The top-cited standard is LS.02.01.35, related to providing and maintaining fire extinguishing systems, with 88% (86% in 2017). The rest of the list is as follows:

  • EC.02.05.01 – The hospital manages risks associated with its utility systems (80%; 73% in 2017)
  • IC.02.02.01 – The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (74%; 72% in 2017)
  • EC.02.06.01 – The hospital establishes and maintains a safe, functional environment (73%; 70% in 2017)
  • LS.02.01.30 – The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72%; 72% in 2017)
  • LS.02.01.10 – Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (69%; 66% in 2017)
  • LS.02.01.20 – The hospital maintains the integrity of the means of egress (66%; 62% in 2017)
  • EC.02.05.05 – The hospital inspects, tests, and maintains utility systems (64%; 62% in 2017)
  • IC.02.01.01 – The hospital implements its infection prevention and control plan (61%; not on list in 2017)
  • EC.02.02.01 – The hospital manages risks related to hazardous materials and waste (61%; 63% in 2017)

See the September Perspectives for lists of the most-cited standards for critical access hospitals, home health, nursing care centers, and other Joint Commission certification programs.

WEBINAR – Preliminary Denial of Accreditation: Actions, Recovery, and Prevention

Presented on: Tuesday, August 28, 2018 |1:00-2:30 p.m. EST

Presented by: Kurt A Patton, MS, RPh.\

Register: http://hcmarketplace.com/denial-of-accreditation 

When the Joint Commission hands out a Preliminary Denial of Accreditation (PDA) decision, you have a small window to set things right. If you can’t get your hospital to band together to fix the problem, a PDA can cost you your accreditation, reputation, and ability to treat patients. And that’s before CMS gets involved.

Join former Joint Commission surveyor Kurt Patton, MS, RPh, this August as he reviews how you might get a PDA, what you can do about it, and what surveyors will expect during their follow-up.

At the conclusion of this program, participants will be able to:

  • Contest a PDA decision
  • Develop a corrective action plan in less than 10 days
  • Focus and prepare for the 60-day PDA follow-up survey
  • Get organized and keep staff and leaders accountable for deadlines
  • Prioritize the most difficult performance-based findings in preparation for the 60-day follow-up survey

Agenda

  • What to do if you think an “immediate threat” or “immediate jeopardy” situation is pending
  • What to do if your report is posted and you are surprised to learn it is PDA
  • How to develop a strategy to dig your way out of this situation
  • How to do a corrective action plan in contrast with an Evidence of Standards Compliance (ESC)
  • How to prepare for the most difficult survey you’ve ever experienced: the 60-day PDA follow-up survey
  • Live Q&A

IHI Launches Maternal Care Improvement Project

The Institute for Healthcare Improvement (IHI) has begun a three-year project that aims to improve maternal outcomes for women and babies in the U.S. Supported by a grant from Merck for Mothers, the project’s goals are to spread the use of evidence-based care practices to reduce complications such as hemorrhaging, hypertension, and blood clots. It also plans to implement strategies to reduce disparities in maternal outcomes, and partner with women, their caregivers, healthcare providers, and community initiatives to better learn and address factors to improve health outcomes for mothers and newborns.

“IHI has proven experience in helping healthcare providers adopt and scale up best practices that save lives across whole systems, regions, and countries,” said Trissa Torres, MD, MSPH, FACPM, chief operations and North American programs officer at IHI, in a release. “We believe that by forging partnerships with others working on these problems and combining existing expertise with IHI’s improvement methodology, we can significantly improve care delivery outcomes for new and expectant mothers.”

Annually, an estimated 750 women die in the U.S. as a result of complications of childbirth, with more than 50,000 suffering serious complications, according to the IHI. African-American women have maternal mortality rates estimated to be three to four times higher than those of white women.

Merck for Mothers is a 10-year, $500 million initiative to help improve maternal mortality rates. The program began in 2011 and has expanded to more than 30 countries.

HFAP ligature risk updates

To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care Manual with new prepublication requirements on removing ligature (hanging) risks in rooms meant for suicidal patients. Several standards have been affected:

04.01.01 – Staff Training – Identification of Patients at Risk for Harm

11.01.01 – Periodic Monitoring for Safety Issues

11.01.02 – Building Safety

11.01.08 – Review of Safety Policies and Procedures

11.02.01 – Building Security

13.00.01 – Life Safety Code Compliance

13.01.06 – Exit Discharge

13.05.09 – Utility Systems

15.01.17 – Privacy and Safety: Safe Setting

15.01.19 – Privacy and Safety: Identify Patients at Risk

15.01.20 – Privacy and Safety: Environmental Risk Assessment

27.03.01 – Privacy and Safety: Identify Patients at Risk

27.03.02 – Privacy and Safety: Environmental Risk Assessment

To see the changes to the standards, visit the HFAP website. And for more analysis of the changes read Briefings on Accreditation and Quality. 

Editor’s note: HFAP announced these standards won’t be revised again due to the July CMS memo on ligature risks. 

Catheters Pose More Risks Than Just CAUTIs

Catheter-associated urinary tract infections are a well-known issue related to urinary catheters. However, a new study in JAMA Internal Medicine finds the devices can cause more issues that previously thought. In fact, UTIs are five times less common than non-infectious problems caused by indwelling urinary catheters.

In-depth interviews and chart reviews from more than 2,000 patients found more than half of catheterized hospital patients experienced a complication of some kind.

The issues ranged from pain, bloody urine and activity restrictions while the catheter was in, to problems with urination and sexual function after it was removed.

“Our findings underscore the importance of avoiding an indwelling urinary catheter unless it is absolutely necessary, and removing it as soon as possible,” says the study’s lead author Sanjay Saint, MD, MPH, chief of medicine at the VA Ann Arbor Healthcare System, George Dock professor of internal medicine at the University of Michigan and director of the U-M/VA Patient Safety Enhancement Program.

A wide array of issues

For the study, Saint and his colleagues from U-M, VAAAHS, and two Texas hospitals analyzed data from 2,076 patients who had recently had a catheter placed for short-term use. Most catheters were placed because the patients were having surgery. Researchers followed-up with patients two weeks after catheter placement and again one month after their catheter placement to ask about their catheter-related experience.

Nearly three quarters of the patients were male, and the catheter was removed within three days of the insertion for 76% of patients. Among the study’s findings:

  • Just over 10% of patients reported infections
  • 55% of patients reported at least one complication of a non-infectious kind
  • 31% of patients whose catheters had been removed at the time of the first interview said it hurt or caused bleeding coming out.
  • More than half of those interviewed while the catheter was still in place said it was causing them pain or discomfort.
  • One in four patients reported the catheter had caused bladder spasms or a sense of urgency about urinating.
  • 10% said the catheter led to blood in their urine.
  • Nearly 40% of patients interviewed while a catheter was still in place, said it restricted their daily activities
  • About 20% who had their catheters removed said they experienced urine leakage, or difficulty starting or stopping urination.

“While there has been appropriate attention paid to the infectious harms of indwelling urethral catheters over the past several decades, recently we have better appreciated the extent of non-infectious harms that are caused by these devices,” says Saint.

Story first appeared in PSQH.

Study: CMS Penalties for Hospital-Acquired Conditions Have Little Impact

A study published in Infection Control & Hospital Epidemiology found that hospitals may have dodged financial penalties by billing hospital-acquired conditions (HAC) as present at the time of the patient’s admission. The findings showed that a CMS policy to penalize hospitals for preventable complications had minimal impact on the reduction of hospital-associated infections.

The targeted billing codes were rarely used by hospitals, and the study found that when hospitals billed for HACs during a patient’s stay, it infrequently affected the diagnosis-related group assignment, impacting hospital reimbursement.

“With this policy, CMS was hoping to see more attention paid to improving quality care, but it appears that the original HAC policy mostly led to changes in coding practices,” said study lead author Michael S. Calderwood, MD, MPH, regional hospital epidemiologist at Dartmouth-Hitchcock Medical Center, in a release. “It’s worth further investigation to determine whether Medicare reimbursement codes are being incorrectly used, or if there is now a greater effort to document conditions at the time of the patient’s admission.”

Ten years ago, CMS’ Hospital Inpatient Prospective Payment System stopped reimbursing hospitals for HACs not present on admission (POA), with the hopes of encouraging hospitals to improve their infection prevention practices.

The researchers analyzed more than 65 million Medicare fee-for-service hospitalizations from 2007 to 2011 in acute care facilities, specifically examining documentation for central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) and whether the codes for those HACs were submitted as POA (which aren’t counted as preventable complications).

The study found that CLABSI and CAUTI affected 0.23% and 0.06% of hospitalizations, respectively, and in the three years immediately after the 2008 CMS policy took effect, 82% of CLABSI codes and 91% of CAUTI codes were marked as POA. This was a significant increase compared with before the HAC policy was implemented.

Diagnosis coding for CAUTI and CLABSI that was not POA from 2007 to 2011 dropped dramatically. In 2007, hospitals discharged 6,172 patients with a CAUTI diagnosis code, 99.8% of whom were marked not POA; comparatively, in 2011 when 6,448 patients were coded as having a CAUTI, just 10.7% of them had the no POA designation.

First published in PSQH

CMS Reverses Plan to Cut Reporting of HAIs

The Centers for Medicare & Medicaid Services (CMS) has decided not to carry out a proposal to remove public reporting of hospital-acquired infections (HAI), medical errors, and injuries. Instead, CMS will publish the information on the Hospital Compare site and in a database.

After the plan was announced in June, there were complaints from patient safety advocates. A new rule, published last week, restores reporting of data through the Inpatient Quality Reporting Program, including infection rates of Clostridium difficile, Methicillin-resistant Staphylococcus aureus, and post-surgery sepsis.

The Trump administration had initially agreed to remove the reporting measures at the request of the American Hospital Association, which argued that they unfairly penalize hospitals for safety problems.

Survey: 36% of facilities struggle to meet TJC MRI standards

new survey found that 36% of medical resonance imaging (MRI) providers do not comply with The Joint Commission’s (TJC) standards for diagnostic imaging services, which were released in 2015.

The standards, which are in effect for hospital and ambulatory care programs, require that MRI facilities should collect data on incidents where ferromagnetic objects unintentionally entered the MRI scanner room and injuries resulting from the presence of ferromagnetic objects in the scanner room. Ferromagnetic objects, which include oxygen tanks and wheelchairs, can become dangerous when brought into an MRI room; the MRI’s strong magnetic field can pull objects at high speed toward the machine, which can lead to injuries and occasionally deaths.

Conducted by MRI safety firm Metrasens, the survey of 162 MRI professionals highlights ongoing issues with safety in those facilities. “The Joint Commission’s Revised Requirements for Diagnostic Imaging Services state that hospitals must manage safety risks in the MRI environment, but these survey results suggest that there is still room for improvement,” said Tobias Gilk, a Metrasens consultant, in a release.

TJC’s standards also cover equipment testing and maintenance, annual education for staff, minimum qualifications for medical physicists, and managing MRI safety risks.

CMS Revises Memo on Requirements to Reduce Risk of Legionella Infection

Be prepared for renewed interest in your water management program and especially how it is designed to prevent the spread of Legionella infection. CMS just updated its memo from last year on requirements to reduce the risk of Legionnaire’s disease, in part to clarify expectations for hospitals and nursing homes (NH).

While there are no new expectations for hospitals or critical access hospitals (CAH), be aware it does add a specific statement that “facilities must have water management plans” as well as a new note that testing for waterborne pathogens is left “to the discretion of the provider,” according to the letter to CMS’ Quality, Safety and Oversight (QSO) group, formerly the Survey & Certification (S&C) group.

“The terms ‘plans’ and ‘policies’ are sometimes confusing to hospitals,” warns Kurt Patton, the former director of accreditation services for The Joint Commission (TJC) and founder of Patton Healthcare Consulting, now in Naperville, Ill.

“TJC already requires a utilities management plan and water is a component of that. The unknown will be if CMS surveyors say they don’t want to look at a utilities plan, they want to look at a water management plan,” explains Patton. “At a minimum, I would suggest accredited hospitals have a table of contents and a subject header for ‘Water Management Plan’ inside their overall utilities plan.”

The memo, QSO 17-30-Hospitals/CAHs/NHs, was published July 6 and supersedes the former S&C 17-30-Hospitals/CAHs/NHs, issued in June 2017, and it adds more specific expectations for long-term care (LTC) facilities. [more]

New CMS guidance on ligature risk says Joint Commission recommendations set the bar

Expect CMS surveyors to be referring to recommendations set out by The Joint Commission last fall when looking for ligature risk and other environmental hazards in the push to make hospitals and psychiatric units safer for patients at-risk of self-harm.

For now, assess your hospital’s environmental compliance against those Joint Commission recommendations, regardless of what organization you might use for accreditation, and be prepared to provide one-to-one observation of at-risk patients if you cannot provide a ligature-resistant environment, says one safety consultant.

In a new memo to its state survey agencies, CMS said it would use those Joint Commission recommendations — drawn from a task force convened by the accreditor that included several CMS experts in suicide prevention — as the federal agency goes forward with clarifying and updating interpretive guidelines for its surveyors.

The memo QSO: 18-21-All Hospitals, “CMS clarification of Psychiatric Environmental Risks,” from the Quality, Safety & Oversight Group (QSO), formerly known as the Survey and Certification Group, is dated July 20, although it was not posted online until Aug. 1.

CMS says Joint Commission panel good enough

In earlier communications, CMS had indicated it would convene its own group of experts to update its guidance to increase focus on ligature as well as other physical risks covered under the Condition of Participation (CoP) for patient rights to care in a safe setting.

However, since participating in the The Joint Commission panel, CMS officials now think its own panel would be redundant. “CMS felt that to repeat the work of TJC Suicide Panel (in which CMS participated) would not provide any substantive additional gains and would not be a productive use of the time and expertise of the participants,” according to the newest memo.

CMS is still working to revise the interpretive guidelines for its surveyors but referred regional offices for now to expectations set out in its Dec. 8 memo on clarifying ligature risk, S&C 18-06-Hospitals (ECL 1/1/18). That memo carried extensive guidance, including an initial update to parts of the interpretive guidelines found in Medicare’s State Operations Manual, Appendix A (SOMA).

Expect more changes in the future, though. In the most recent memo, CMS said it would continue to work on updates to Appendix A as well as Appendix AA, guidelines for surveyors at Psychiatric Hospitals, “which will incorporate the standards that were recommended via the collaborative work of the The Joint Commission Suicide Panel Special Report: Suicide Prevention in Health Care Settings.” The memo provided an online link to the November The Joint Commission recommendations.

Written by A.J. Plunkett