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Healthcare organizations urge CMS to suspend new sepsis management measure

Four major healthcare organizations have asked CMS to postpone implementation of the severe sepsis and septic shock management bundle measurement that is scheduled to go into effect October 1, 2015. The measure as currently written, calls for the use of broad spectrum antibiotics to treat severe sepsis and septic shock.

The group consisting of the American Health Association (AHA), America’s Essential Hospitals, AAMC, and the Federation of American Hospitals, is urging CMS to refine the measure so that it more closely aligns with the antimicrobial stewardship put forth by the CDC and the White House earlier this summer.

“By encouraging the use of broad spectrum antibiotics when more targeted ones will suffice, this measure promotes the overuse of the antibiotics that are our last line of defense against drug-resistant bacteria,” the group wrote in a letter to CMS.

Read the full letter here.

Joint Commission identifies top five most-cited standards first half of 2015

The Joint Commission released the top five standards most cited during the first half of 2015, yesterday. There aren’t any surprises in the list, but there has been a slight change in the order of the standards with infection control creeping into the second spot.

The top five trouble spots:

  • EC.02.06.01 (maintenance of a safe environment), 59%
  • IC.02.02.01 (reduction of infection risk from equipment, devices, and supplies), 54%
  • EC.02.05.01 (management of utility system risks), 53%
  • LS.02.01.20 (maintenance of egress integrity), 50%
  • RC.01.01.01 (maintenance of accurate, complete medical records for all patients), 48%

View the full table here.

Read about the top 10 most-cited standards in Briefings of The Joint Commission.

Try not to breathe

Editor’s note: This post, written by my colleague Steve MacArthur, originally appeared on Mac’s Safety Space

I know that we’ve visited (and revisited) this topic once or twice over the last little while, but it continues to be (at least in my mind’s eye), the most significant vulnerability for every healthcare organization that uses The Joint Commission (TJC) for accreditation services: the management of temperature, humidity, and air pressure relationships (THAPR—How’s that for an acronym? It’s pronounced “thapper” or, if you’re from Boston, “thappah”) in the care environment. Folks continue to be cited for issues in this regard; other folks are jumping on board (a little late, but better than never) but are in the closing section of their survey window; and others still have not quite grasped the importance of having a stranglehold (if you will) on those areas for which there are THAPR requirements. Those of you who’ve accompanied me in the blogosphere for a while know that I do not do a lot of product marketing (even my own product), but I will encourage you once again: if you do not have a copy of ASHRAE 170—2008 Standard for Ventilation of Health Care Facilities, you are not in possession of what may be (at least at the moment) the single most important slab of information in the physical environment pantheon (yes, we will always have a place in our hearts for the 2000 edition of NFPA 101 Life Safety Code®; probably for too long, based on the ever-so-slow-to-adopt new things track for the 2012 edition).

While I’m not suggesting that you memorize ASHRAE 170 (it is fairly brief and those of you with eidetic memories probably won’t be able to keep yourselves from doing so), I am suggesting that you need to go to the table on pages 9-11 and start identifying the areas in your organization that have specific requirements and start figuring out where you stand in relation to those requirements, and perhaps more importantly, come to some sort of sense as to how reliably your systems can support those requirements. And you really need to go through the entire table; TJC certainly is. Just last week, I heard of pressurization issues in lab and pharmacy areas (labs are to be under negative pressure; pharmacies under positive) that added up to condition-level survey results.

Make sure you know where you have sterile storage in your organization; sterile storage areas are to be under positive pressure and should be monitored for temperature and humidity. But the reality of the situation is that you have sterile supplies in locations throughout your organization, so you have to define what does and what does not represent sterile storage (my best advice is to coordinate with your infection control and surgical folks on this one—it’s beginning to look a lot like a risk assessment—everywhere you go!). That way, you have a solid foundation for determining what needs to be managed from an environmental standpoint; it’s the only thing that will keep you out of the hottest water during survey.

Two final thoughts before signing off for this week; make sure that routine bronchoscopies are being performed under negative pressure (urgent or emergency bronchoscopies may not have quick enough access to the appropriate environment, so make sure that folks know what protective measures need to be considered to protect themselves and the patient when they’re aerosolizing potential bugs). There are still instances in which this is being cited during survey, so I think my best advice is to go and check with your respiratory therapy folks, as well as the folks in surgery, critical care, infection control, etc., and ask the question: Are bronchoscopy procedures being performed, and if so, where are they being performed? Then you can start walking it back to a point where you can be assured that they are being done in an appropriate environment.

The last thing is a brief reminder that the process for the survey of the physical environment (again, as it is currently being administered) involves all of the survey team – when it comes down to this are of concern, there is no more “clinical” versus “non-clinical”; everything that occurs within the four walls of your organization are patient care activities, direct or indirect (you may have noticed TJC has been splitting its performance elements using that very same language). Coordination of the various hospital services, etc., has never been more heavily scrutinized and never been found more wanting during survey. There is a paradigm shift afoot, my friends, and we need to get on the good foot.

Accreditation Q & A: How and what should the HVA be used for?

Question: How and what should the HVA be used for?

Answer: (Answers may vary).  To understand your level of preparedness for the emergency events most likely to occur at your facility; to communicate your concerns and weaknesses to community response agencies; to define your focus for improvement so you can improve your preparedness and mitigate your vulnerabilities.

Do you have a question you would like us to answer? Send an email to me at and we’ll do our best to answer your question.

Editor’s Note: The above question and answer are from j-Mail 2016 Edition: Tools for Ongoing Joint Commission Survey Prep.

Editor’s Choice: Active Shooters in Healthcare Facilities: Your Prevention and Response Plan

September 23, 2015

1:00-2:30 pm EST

Presented by:
Lisa Pryse Terry, CHPA, CPP

Christian M. Lanphere, PhD, FP-C, NRP, CEM

Active shooters and armed violence represent a rapidly growing issue in America’s hospitals and healthcare facilities. These incidents occur on a near-weekly basis, which means it is time to face the fact that they can also happen in your facility.

Don’t wait until it’s too late to develop an emergency response plan! Join HCPro for a live webcast presented by healthcare safety experts Lisa Pryse Terry, CHPA, CPP, and Christian M. Lanphere, PhD, FP-C, NRP, CEM. They will teach participants how to lessen the risk of a violent confrontation and how to prepare facility staff in the event an armed intruder comes through their doors.

For more information and to register for the webcast, click here.

Active hospital boards linked to better clinical outcomes

Editor’s note: This article was written by my colleague Janet Boivin, RN, for HealthLeaders Media.

Hospitals with boards and management practices that actively monitor quality and patient safety, as well as budgets and finances, have higher quality outcomes, researchers find.

Hospital boards that place quality and patient safety higher on their agenda somehow improve the performance of front-line management and clinical quality outcomes, a recent study has found.

“Conceptually, everybody understands that good leadership at the board level matters,” says Thomas Tsai, MD, a surgical resident at Brigham and Women’s Hospital and research associate at the Harvard T.H. Chan School of Public Health and the lead author of the study published in the August 4 issue of Health Affairs.

“But this is one of the first papers to empirically show the connection between hospital board and management practices. We also demonstrate that both hospital boards and management practices are then, in turn, related to the clinical quality of a hospital.”

Exactly how hospital boards impact clinical performance is unclear and needs to be further investigated, Tsai says.

Read the full article at

Joint Commission clarifies LS, EC survey process

The Joint Commission has clarified its expectations for the Life Safety (LS) and Environment of Care (EC) portions of its accreditation surveys, according to an article in the August issue of The Joint Commission Perspectives. The accreditor now requires hospitals to have staff available to assist the Life Safety Code® surveyor with document review.

The Joint Commission’s Survey Activity guide has been updated to include an LS and EC document list and review tool, which lists documents the Life Safety Code surveyor will review. The Joint Commission has also revised its sample LS survey agenda to include more detail on what the surveyor will do.

Read the Joint Commission’s revised LS and EC document list and review tool.

Join our accreditation book review group

HCPro is seeking enthusiastic accreditation professionals to join an ad-hoc group interested in reading and reviewing prepublication drafts of books and training materials in your areas of interest and expertise.

Our editors will send you periodic emails listing upcoming projects available for outside review. If you’re interested, just let us know. We’ll send reviewing guidelines and give you an idea of our time frame. If it works for you, we’ll send the draft chapters as they’re available, and a printed copy of the book when it’s complete. In addition, you will be recognized as a reviewer inside the printed book.

Please have a minimum of three years of accreditation experience and be in an educational, supervisory, or leadership role within your organization.

For more information or to sign up as a reviewer, please send an email including your areas of interest and expertise to Michelle Clarke at

FDA urges hospitals to discontinue use of Hospira Symbiq infusion pumps

The FDA issued a safety communication on Friday urging all healthcare facilities to stop using the Hospira Symbiq infusion systems due to potential cybersecurity vulnerabilities. The system may be accessed or “hacked” from outside the hospital’s network. The infusion system is a computerized pump designed for continuous delivery of general infusion therapy for a broad patient population.

“We strongly encourage that healthcare facilities transition to alternative infusion systems, and discontinue use of these pumps,” the FDA says in the report. Both the FDA and the U.S. Department of Homeland Security are aware of vulnerabilities, but as of yet, there have been no reported breaches in security.

Read the safety communication to learn more and for tips on how to disable the system from your network.

Underwear, Tattoos, and Patient Safety

Editor’s note: I thought this article written by my colleague Lena J. Weiner for HealthLeaders Media, was interesting. Please share your thoughts in the comment section below, I’m interested to hear your opinions on this topic.

As one healthcare system lays down the law with strict rules around employee dress — to the point of mandating underwear–it’s worth asking what dress codes are really for.

And is it time to relax them?

Between the influx of new residents straight out of med school and rising summer temperatures, employees mya be baring more than they normally would (or perhaps should). What’s the appropriate dress code policy for your organization?

Earlier this month, Akron, OH-based Summa Health System enacted a particularly restrictive dress code that not only bans visible tattoos and body piercings–which are standards strictures in dress codes–but also lists acceptable hair colors, stipulates that men’s beards be kept shorter than half-inch, requires female employees to wear hosiery with dresses or skirts, and insists that all employees must wear underwear, and that “the color, design, and style [of these garments] not be visible through clothing.”

The policy has drawn objections from some employees and garnered local attention.

Summa Health’s spokesperson, Mike Bernstein, declined my request for an interview, but he sent a statement saying that his organization “[has] a thorough dress code policy in place that is reviewed on a regular basis and updated as needed,” and that “the specific requirements of the policy are designed with the best interests and safety of our patients in mind as well as to ensure the image we portray as an organization is characteristc of our outstanding reputation in the community.” He says the new dress code is representative of the feedback the organization has received from patients.

Decoding the Dress Code

Jennifer Henly, institutional board member at the National Association for Health Care Recruitment and vice president of client services for NAS Recruitment Innovation says that dress codes help organizations convey a desired impression. “I think staff dress codes are really to promote a consistent, professional image throughout the organization,” she says, adding that she believes that most healthcare workers are comfortable with most dress codes.

“Healthcare professionals are there to help their patients feel safe and comfortable, and to provide them care. I think they’ll honor any particular guidelines that are in place.”

But rules regarding employee dress are a contentious topic for some healthcare workers.

Read the full article at