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Brian Driscoll

Brian Driscoll is Director of the Association for Healthcare Accreditation Professionals and Executive Editor of the Accreditation/Patient Safety group at HCPro, Inc.

Exclusive panel discussion on the options for healthcare accreditation

Our 2009 conference will include a special session featuring executives from The Joint Commission, DNV Healthcare Inc., and the Healthcare Facilities Accreditation Program.

Speakers will include Ann Scott Blouin, PhD, RN, Executive Vice President in the Division of Accreditation and Certification Operations at The Joint Commission, Patrick Horine, Executive Vice President of Accreditation Services at DNV Healthcare Inc., Rebecca Wise, Chief Operating Officer at DNV Healthcare Inc., and George A. Reuther, Chief Operation Officer at the Healthcare Facilities Accreditation Program.

Each organization will have 15 minutes to present, followed by 45 minutes of Q&A. Join us for what will undoubtedly be an interesting discussion on how all three organizations are changing accreditation in healthcare.

Congrats to our most recent CSHAs!

Congratulations to Emily Alvarez, Melinda Smith-Vaughn, Amy Boykin, Barbara Meacomes, and Cassie Seiler–our most recent Certified Specialists in Healthcare Accreditation!

The CSHA certification program is still new, and we’ve already had over 50 people take the exam. Congratulations to all who have passed!

TJC, DNV, and HFAP all to speak at conference

We’ve now confirmed speakers from The Joint Commission, DNV Healthcare, and HFAP for the May 2009 conference. Should be a great conference!

Working group call on critical test results

In case you missed them, we’ve posted our October 16 and October 28 calls on critical test results. Listen to them now by clicking here

Joining us on the calls was Gayla J. Jackson, RN, BSN. Gayla is a member of the AHAP advisory board and nurse manager at Mount Auburn Hospital in Cambridge, MA. She has 26 years of experience in acute care and was one of the 17 advisory committee participants chosen to work on a three-year federal grant from the Agency for Healthcare Research and Quality (AHRQ). The AHRQ provided funding to The Massachusetts Coalition for the Prevention of Medical Errors along with the Massachusetts Hospital Association for the purpose of identifying, choosing, and implementing two patient safety initiatives, one of which was communicating critical test results.

I hope you all found these calls useful. And look for Gayla at the 3rd annual AHAP conference in May. She will be joining us in Las Vegas for the second year in a row.

Speakers for 3rd Annual AHAP conference

Just wanted to follow up on Matt’s posting and offer some details on our 2009 conference. We’ve already confirmed the following speakers and topics:

Tracers: Jodi L. Eisenberg, MHA, CPMSM, CPHQ, CSHA, chair of the AHAP advisory board and program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago, and Jean Clark, RHIA, CSHA, member of the AHAP advisory board and service line director for health information management at Roper St. Francis Healthcare in Charleston, SC
Making the NPSGs come to life: Patricia Pejakovich, RN, BSN, MPA, CPHQ, CSHA, and WendySue Woods, RN, MHSA, CSHA, senior consultants with The Greeley Company, a division of HCPro
Leadership standards: Ken Rohde, senior consultant with The Greeley Company, a division of HCPro
Joint Commission alternatives: Patrick Horine, executive vice president of accreditation at DNV Healthcare, Inc. (we’ve also invited representatives from The Joint Commission and HFAP)
Critical test results 2.0: Gayla Jackson, RN, BSN, member of the AHAP advisory board and a practicing nurse manager at Mount Auburn Hospital in Cambridge, MA
Scoring: Kurt Patton, MS, president of Patton Healthcare Consulting, LLC, and former executive director of accreditation services for The Joint Commission
Survey readiness: Lisa Eddy, RN, CPHQ, CSHA, senior consultant for The Greeley Company, a division of HCPro
Suicide risk assessment: Sharon Chaput RN, CSHA, member of the AHAP advisory board and director of regulatory and quality management at Brattleboro Retreat in Brattleboro, VT
As Matt mentioned, we will be providing more details on the conference, which will take place May 14-15 in Las Vegas. Make sure to keep an eye on this blog in the comings days and weeks.
And, as always, you can sign up for the conference here.
Hope to see you all in Vegas!

2008 Survey Coordinator Salary Survey

Just wanted to let everyone know that we launched the second annual salary survey yesterday, and we have already had a lot of interest.

This is a great chance to see where you stand compared to others when it comes to salary, raises, bonuses, and overall responsibilities. Following completion of the survey, we will send out a full electronic report, detailing the results of the survey and comparing them to last year’s results.

This survey is for AHAP members only, so watch your e-mail for instructions on how to participate.

All responses will remain anonymous. Help us get you the information you want. Take advantage of this opportunity to see how you compare to your peers and take this short, 15-question survey.

To help us compile the most accurate data possible, please complete the survey only if your primary responsibilities include managing your organization’s Joint Commission and/or CMS survey preparation and your organization is located in the United States.

Thanks!

News from Executive Briefings: "D"s Will Not Change

Just wanted to share this posting from Bud Pate, REHS, Vice President of Content and Development for The Greeley Company. Bud is currently attending Executive Briefings in Los Angeles.

Although there may be some errors, the “D”s [indicating that documentation is required] for the new standards will remain as written in the current version of the manual according to Dr. Robert Wise, Vice President for the Division of Standards and Survey Methods for the Joint Commission. Although he acknowledges that there may be errors, Dr. Wise committed that, until they change, documentation is not required unless there is a Circle D logo in the accreditation manual.

Stay tuned for more.

Matt Phillion, Senior Managing Editor of Briefings on The Joint Commission, will be reporting back from the New York Executive Briefings.

An Inside Look at Successful RFI Clarification

Just wanted to share this white paper from Lisa Eddy, RN, CPHQ, CSHA, Senior Consultant for The Greeley Company, a division of HCPro, Inc. Those of you who participated in our working group calls on suicide risk assessment should be familiar with Lisa. Hope you find this white paper useful.

Go to http://www.hcpro.com/content/217282.pdf to download a PDF of the white paper.

Brian Driscoll
AHAP Director

Distinguish Between Medical and Behavioral Restraint

From Bud Pate, REHS, Vice President of Content and Development for The Greeley Company:

Surveyors commonly misapply the behavioral health rules to medical restraint. In fairness, the Joint Commission standards and CMS regulations are a more than a little confusing, even when you study them carefully. But the rules for behavioral health restraint are vastly different than those for medical restraint, so your definition should be crystal clear.

Regardless of the location, behavioral health restraint rules should only be applied to address violently aggressive or self disruptive behavior. We recommend that your policy clearly apply the medical restraint rules to the following situations:

– a patient who is in the critical care unit after a suicide attempt and is being restrained to avoind accidental extubation due to twitching or trying to sit up in bed;

– a patient experiencing involuntary thrashing during acute withdrawal syndrome;

– a confused patient who is interfering with nursing care.

“But wait,” you say, “we should use the behavioral health care rules because we are caring for patients with clear emotional disorders.” Or you may say “The confused patient is trying to hurt the nurse, shouldn’t the behavioral health rules apply?”

But remember, all restraint (medical and behavioral) is implemented to address behavior. And if you truly believed the behavioral health care rules applied you would already be staffing these situations with psychiatric nurses. Ask yourself, “would a debriefing be helpful to see how a future episode would be avoided?” I don’t think so.

There will certainly be those who object to this position. If you are one of them, then I encourage you to fully (and I mean fully) implement all the behavioral health care rules to these situations, including: continuous observation, 15 minutes assessments by a staff member with psychiatric training, post-restraint debriefing with the patient, and all the other very restrictive rules. If you don’t feel these measures are clinically necessary, then you agree with me: these are not behavioral health restraint. So define them as medical restraint in your policy.

Remember: we can debate the fine points of a policy with regulators all day long without reaching an adverse conclusion. However, you will definitely be guilty of an infraction if you violate your own policy. In other words: say what you do and do what you say.

Restraint benchmarking survey

Hello, all. I just wanted to share with you some results from our recent benchmarking survey:

Managing the use of restraints and complying with related requirements continue to be major challenges for accreditation professionals throughout the country. And one of the biggest areas of concern is the use of medication restraints, according to AHAP’s most recent benchmarking survey.

According to the members-only survey, conducted in June and July 2008, 46% of accreditation professionals find medication restraints the most troublesome under CMS’ updated restraint Interpretive Guidelines (24% listed soft limb restraints as most troublesome, while 17% listed “other,” 7% listed zippered comforter restraints, and 6% listed low bed restraints).

The number for medication restraints seems high, says Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, CSHA, member of the AHAP advisory board, healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor. “Perhaps the organizations need to review their definitions of chemical restraint,” she says. “They may, in fact, not be following the CMS/Joint Commission definition—theinappropriateuse of a sedating psychotropic drug to manage or control behavior. To give a medication may in fact be medical management of the patient’s condition and not inappropriate use.”

When asked how they used medication restraints, 51% of survey respondents said they use them to de-escalate aggressive, destructive behavior. Thirty-seven said they use medication restraints to manage behavior, 25% said they use them for other purposes, and 7% said they use them to restrict freedom of movement.

Hope you found this useful. Go to http://www.accreditationprofessional.com/benchmarking_survey.cfm?topic=WS_AHP_QBS to download the full 11-page report, as well as other benchmarking reports from this year.