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Editor’s Choice: Live accreditation training with Jean Clark

When: June 1-3, 2015

Where: Boston area

Are you in the New England Area? Jean Clark, RHIA, CSHA, is leading a two-and-a-half day boot camp in June and if you haven’t attended one of our boot camps yet, you won’t want to miss this experience.

The boot camp provides survey coordinators and accreditation professionals with best practices for survey prep, training, and overall management, focusing on CMS and Joint Commission requirements.

At the end of the boot camp, you’ll have learned:

  • Where to find resources to assist your survey prep and accreditation knowledge
  • How to interpret accreditation standards and regulations and measure your organization’s compliance
  • How to identify organizational weaknesses so you can fix them before accreditors arrive and therefore improve your survey results

I will be attending this boot camp and I’m looking forward to Jean’s practical and insightful teaching as well as meeting some of you!

Please feel free to send me an email if you would like to connect during the boot camp.

Sign up for the boot camp here.

The Joint Commission has revised accreditation policies concerning facilities that discontinue services

The policies deal with facilities that have closed as a result of disaster and facilities that no longer have patients.

A facility closed as a result of a disaster will retain accreditation for 30 days. After that time, if the facility reopens, The Joint Commission will conduct either an extension survey (up to 90 days) or a full site survey (after 90 days to six months).

If a facility has no patients, it will retain accreditation for 60 days. If it does not have patients for up to six months, it can retain accreditation but only if it applies for an extension survey.

In both cases, if services or patient care do not resume after a six month period, the facilities will lose accreditation. They will need to reapply for accreditation if they resume services.

The policies are effective immediately and can be read in full here.

Advisory panel determines endoscopes unsafe

A federal advisory panel deemed the endoscopes linked to the carbapenem-resistant Enterobacteriaceae (CRE) outbreak earlier this year in two Los Angeles area hospitals, but did not call for the discontinuation of their use, according to a recent report in the L.A. Times.

In spite of the risks associated with the endoscopes, the panel said they should remain available as there is currently not a suitable replacement.

The panel also took both the FDA and Olympus Corp., the manufacturer of the scopes, to task for not providing suitable safety measures to prevent the contamination.

Read the full article at the L.A. Times.

Physicians urged to take more active leadership role to improve quality and patient safety

Earlier this week, an article appeared in The Journal of the American Medical Association (JAMA) released an article calling on physicians to work together and take a more active leadership role in the hopes that the action will help improve quality and patient safety.

This request doesn’t mean that the authors think physicians don’t work together, rather they’re saying that our current health care system is complicated for a single physician to be able to achieve higher levels of quality and safety on their own.

Traditionally, physicians and healthcare systems are judged on their compliance by identifying areas that need improvement or correction altogether.  The article suggests that physicians, healthcare providers, and accrediting bodies should go one step further and develop programs that identify excellence within healthcare systems.

The authors issue three challenges to achieve this goal:

  • No harm for either patient or healthcare worker
  • Healthcare systems should employ methods and management that have been successful, such as Lean, Six Sigma
  • Accrediting and certifying bodies should develop programs identifying excellence in both healthcare workers and systems

Read the full article here.

What do you think about this proposal? Is this something that has already been implemented within your healthcare system or something you’re currently working towards? We would like to hear your thoughts. Please leave a note in the comments or email me directly at

The Joint Commission updates several standards for hospitals

In order to align with CMS’ Conditions of Participation, The Joint Commission has updated eight standards for hospitals and one standard for critical access hospitals. The majority of the updates apply to hospitals with swing beds.

The following standards have been updated:

  • Standard MS.01.01.01
  • Standard PC.02.02.01
  • Standard PC.04.01.03
  • Standard PC.04.01.07
  • Standard RC.02.04.01
  • Standard RI.01.01.01
  • Standard RI.01.06.03
  • Standard RI.01.07.07
  • Standard MS.01.01.01

The updates go into effect July 1, 2015.

Plans to increase hospital infection reporting

The Centers for Medicare & Medicaid Services (CMS) plans to expand reporting of certain hospital-acquired infections (HAIs) beyond ICUs in an effort to reduce confusion among providers, HealthLeaders Media reported on Friday.

A two-pronged federal effort launching this year seeks to more accurately collect HAI rates.

The new, more specific definitions of infections seek to reduce confusion among providers, health officials say. The aims are first to assure clinicians report beyond the ICU to general med-surg patients, and second, to prevent hospitals’ from subjectively interpreting what qualifies as a reportable infection.

In the first effort, CMS plans to expand reporting of central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) to all medical and surgical beds throughout a hospital, with reports starting Jan. 1, 2015.

In the second effort, the CDC has refined the definitions of what constitutes a CLABSI and a CAUTI in several ways to ensure clinicians consistently report the same thing, eliminating interpretive variation.

Read the full article at

Editor’s choice: j-Mail 2016 Edition: Tools for Ongoing Joint Commission Survey Prep

Hot off the virtual presses! j-Mail 2016 Edition: Tools for Ongoing Joint Commission Survey Prep is a ready-made tools library that allows you to download, customize if needed, and start using the tools and training today.

This new edition is a quick and easy way to train your staff, featuring ready-made emails and compliance questions with varying levels of difficulty that can emailed, posted on bulletin boards, or included in newsletters.

j-Mail is a “no-prep needed” electronic tool that addresses all levels of training and allows for customization. This latest editions puts forth the same tried and true question-and-answer format as found in earlier editions.

For more information or to order a copy, click here.

CMS announces Physician Quality Reporting Programs Strategic Vision

When CMS shared the findings of the 2015 Physician Quality Reporting System (PQRS) payment system, they also released the publication of the Physician Quality Reporting Programs Strategic Vision, or “Strategic Vision”.

The Strategic Vision is part of a long-term quality measurement plan for healthcare providers and public reporting programs and how those can be enhanced to support better decision-making from physicians, consumers, and everyone involved in healthcare.

For more information about the plan, click here.

CMS updates eCQMs for 2016 reporting

Last Friday, CMS posted the annual update for the 2014 electronic clinic quality measure (eCQMs) for eligible hospitals and professionals. Providers should use these measures to report 2016 quality data for CMS reporting programs, including the Physician Quality Reporting System (PQRS), Inpatient Quality Reporting Program (IQR), and the EHR Incentive Programs.

CMS updated 29 measures for eligible hospitals and 64 measures for eligible professionals.

Read the updated measures here.

Don’t forget to take the salary survey!

Thanks to everyone that has already taken the salary survey.  If you’ve been meaning to take the survey, now’s your chance as we’ll be closing the survey in a few days.

Stay tuned to the blog and Briefings on The Joint Commission for the results.

You can take the survey here.