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Brian Ward

Brian Ward is an Associate Editor at HCPro working on accreditation news.

Webinar: Suicide Prevention in Hospitals: Reduce Risk and Comply With Joint Commission Requirements

Presented on: Tuesday, November 21, 2017, 1:00-2:30 p.m. EST
Speaker: Ernest E. Allen, ARM, CSP, CPHRM, CHFM
Program Level: Intermediate 
Registration: http://hcmarketplace.com/suicide-prevention-in-hospitals

Summary:  Hospitals are continually working to reduce the risk of patient suicide in their facilities, but the problem persists. The Joint Commission has placed particular emphasis on reducing suicide risk, including a National Patient Safety Goal and a recent Sentinel Event Alert.

In this webinar, former Joint Commission surveyor Ernest E. Allen, ARM, CSP, CPHRM, CHFM, will explain how hospitals can identify and reduce suicide risks and improve compliance with Joint Commission requirements.

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

  • Identify suicide risks in hospitals
  • Be able to reference applicable Joint Commission standards and Sentinel Event Alerts
  •  Learn prevention methods to help lower suicide risk

USP deadline on hazardous drug handling postponed until 2019

The U.S. Pharmacopeial Convention (USP) has announced it intends to push back the compliance deadline for USP Chapter <800> “Hazardous Drugs; Handling in Healthcare Settings” from July 1, 2018, to December 1, 2019.

USP <800> applies from the moment a hazardous drug is received at the loading dock all the way through to the medicine’s disposal. Its standards apply to anyone who comes into contact with hazardous drugs: nurses, physicians, pharmacists, pharmacy technicians, loading dock personnel, etc.

“USP encourages early adoption and implementation of General Chapter <800> to help ensure a safe environment and protection of healthcare practitioners and others when handling hazardous drugs. We will continue to support our stake-holders through education and outreach,” the organization wrote in a press release.

Thoughts about all that documentation the CoPs require? CMS wants to know

Have thoughts about the paperwork you have to generate because of Medicare’s Conditions of Participation (CoP)? Or rather, do you have thoughts you’d like to share with the public, as well as the Department of Health and Human Services (HHS)?

Now’s your chance. CMS has posted a call for comments on the paperwork required under the regulations that govern almost every aspect of operations at hospitals nationwide that also want the ability to bill Medicare for their services.

The call for public comment is periodic request, mandated in turn by the Paperwork Reduction Act of 1995. (So yes, it’s a regulatorily required chance to comment on extraneous regulations.)

And it’s one of many CMS puts out through the year. This particular request, according to the formal notice placed in the Federal Register Nov. 13, concerns the regular collection of information “needed to implement the Medicare and Medicaid Conditions of Participation (CoP) for 4,890 accredited and non-accredited hospitals and an additional 101 critical access hospitals (CAHs) that have distinct part psychiatric or rehabilitation units (DPUs). CAHs that have DPUs must comply with all of the hospital CoPs on these units. Thus, this package reflects the burden for a total of 4,991 hospitals (that is, 4,890 accredited/non-accredited hospitals and 101 CAHs which include 81 CAHs that have psychiatric DPUs and 20 CAHs that have rehabilitation DPUs).”

Translated, that’s most of the hospitals in the nation, minus the 1,183 CAHs without distinct part psychiatric or rehabilitation units. They operate under a separate set of CoP, according to the notice.

“The CoPs and accompanying regulatory requirements are used by our surveyors as a basis for determining whether a hospital qualifies for a provider agreement under Medicare and Medicaid. CMS and the health care industry believe that the availability to the facility of the type of records and general content of records is standard medical practice and is necessary to ensure the well-being and safety of patients and professional treatment accountability,” according to the notice.

CMS estimates that the paperwork required to meet the CoPs of the combined 4,991 respondents generates 1,342,424 responses a year, requiring a total of 18,840,617 hours a year.

That’s about 3,775 hours per hospital. Or 72 hours a week. Or basically two full-time positions a year.

(You might not want to ask one of those people to generate the report to send to Medicare, if you do decide to submit a comment.

Or you might.)

Comments must be received by Jan. 12, 2018.

After the notice is published on Nov. 13, to comment electronically — no physical paperwork needs to be generated! — go to www.regulations.gov, search for “2017-24524,” hit the button that says “COMMENT NOW” and follow the instructions.

Note the warning that the comments will be made public.

Or you can send comments by regular mail: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier/OMB Control Number 2017-24524, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

To read the request of information first, go to https://www.gpo.gov/fdsys/pkg/FR-2017-11-07/pdf/2017-24134.pdf 

— Written by A.J. Plunkett (aplunkett@h3.group)

Joint Commission announces four survey focus areas

Representatives from The Joint Commission, URAC, DNV-GL, the Healthcare Facilities Accreditation Program (HFAP), and National Committee for Quality Assurance (NCQA) took the stage at the 2017 NAMSS Educational Conference & Exhibition to share what they have learned from this year’s accreditation surveys and to tell audience members about relevant standards changes

The Joint Commission announced four areas of focus:

1.    The SAFER Matrix: Implemented in January 2017, the SAFER Matrix has nine boxes that measure the likelihood to harm a patient on one axis and scope of occurrence (limited, pattern, widespread) on the other.

2.    Antimicrobial stewardship: The CDC reported that 20% to 50% of antibiotics were prescribed unnecessarily or inappropriately annually. Medical staffs must reduce their antimicrobial use and have a medical staff process to demonstrate an effective use of antibiotics or antimicrobials in their organizations.

3.    Ligature risks for behavioral healthcare units: Due to the increasing rise of inpatient suicides (1,200 to 1,500 each year), 70% of which are by hanging, ligature risks are no longer acceptable in areas specified for the treatment of behavioral healthcare patients with suicide risk.

4.    Culture of safety:Leaders must ensure a culture of safety and identify areas to improve culture of safety. Staff must be comfortable and able to report issues of safety to leadership. This is already a culture of safety standard in the Leadership chapter and the accreditor will unveil a related standard in the Medical Staff chapter in 2018.

According to Louis Goolsby, MD, FACOG, FACHE, the most common citations from the Medical Staff chapter still come from MS.01.01.01, specifically EP3 (specific requirements and associated details are included in the medical staff bylaws) and EP5 (the medical staff complies with the medical staff bylaws). Another common citation is MS.03.01.01 (practitioners only practice within their scope of privileges).

Editor’s note: 
The following article was originally published on the Credentialing Resource Center, October 24, 2017.

West Virginia cities sue Joint Commission over alleged role in opioid crisis

Four West Virginia cities and towns filed a class-action lawsuit against The Joint Commission and Joint Commission Resources on November 2, claiming the accreditor “grossly misrepresented the addictive qualities of opioids” in their pain management standards. The town of Ceredo and cities of Charleston, Huntington, and Kenova claim that those standards forced hospitals to prescribe unsafe amounts of painkillers, fueling addiction and deaths in the state. [Is there any dollar amount named in the lawsuit? What is it asking for?]

“This lawsuit is a critical move toward eliminating the source of opioid addiction and holding one of the most culpable parties responsible,” said Huntington Mayor Steve Williams. “For too long, [The Joint Commission] has operated in concert with opioid producers to establish pain management guidelines that feature the use of opioids virtually without restriction. The [commission’s] standards are based on bad science, if they are based on any science at all.”

West Virginia has the highest drug overdose death rate in the nation, with 41.5 deaths per 100,000 in 2015. Huntington and Cabell County had the highest overdose fatality rate in the state last year.

The lawsuit claims that the pharmaceutical companies like Purdue Pharma (the makers of OxyContin) worked with The Joint Commission to create the pain management standards. These companies stood to gain from the overuse of their drugs, the lawsuit claims.

The Joint Commission accredits at least 10 hospitals and healthcare facilities in Charleston and Huntington, and other cities and towns are expected to join the federal lawsuit.

The Joint Commission updated its pain management standards in June to reduce over prescriptions, which will take effect on January 1. However, the lawsuit says the accreditor waited too long to make those changes.

This isn’t the first time that The Joint Commission has come under fire either. In 2016 more than 60 medical experts and nonprofit organizations signed petitions asking the commission to change its standards. Claiming they “foster dangerous pain control practices, the endpoint of which is often the inappropriate provision of opioids with disastrous adverse consequences for individuals, families, and communities.”

How to deal with unclear infection prevention guidelines

Written by Tinker Ready at HealthLeaders Media

A team of physicians from the University of Iowa Hospitals and Clinics has put forward a strategy that aims to standardize infection prevention guidelines for procedures performed outside the operating room. The team contends that for most procedures, from skin biopsies to chest tube insertions, there is no authoritative guidance on infection prevention.

Writing in the American Journal of Infection Control, it also notes that there is little published evidence for existing practices.

The strategy emerged from a hospital epidemiology leadership meeting, says Vincent Masse, MD, the study’s lead author.

They discussed a scenario whereby an interventional radiologist had been asked to wear a surgical hat and a mask while doing a fine needle aspiration. The radiologist had not worn the protection in 20 years of doing the procedure.

So the clinician asked what the hospitals policy was.

“Not only were we unable to provide evidence to support this practice, but we also had no comprehensive policy regarding infection prevention practices for medical procedures performed outside an operating room,” the authors write.

Masse and his fellow researchers looked at what kind of research had been done.

“We realized that there is very little data for most procedures and there is no simple model to follow,” he said.

Little Guidance

The researchers reviewed the available literature: textbooks, technical notes, and practice guides, but described them as unhelpful.

The Spaulding Classification guides the disinfection of devices and equipment, but does not go far enough, in the eyes of the study authors. “It would be nice if there were a similar model for outside-the-OR procedures,” says Masse.

“Most of these sources referred, at some point, to ‘your local policy’,” they write.

[more]

Joint Commission releases updated Patient Blood Management Certification standards

The new standards were updated to meet the AABB’s guidelines and will go into effect on January 1, 2018.

The Joint Commission’s Patient Blood Management Certification program was developed with the AABB, an international association focusing on cellular therapies, transfusion medicine, and blood management. The certification is based on the AABB’s Standards for a Blood Management Program and is aimed at educating hospitals on the benefits of an evidence-based, multidisciplinary approach to the transfusion decision-making process.

 

What books should we write in 2018?

Hello!

It’s book season at HCPro (also Halloween/Thanksgiving/sweater season) and we need your help!

This is the time when we come up with possible book ideas for 2018. But of course, we don’t want to write about something readers aren’t interested in, and want to hear your thoughts.

We need your feedback to get these books into production, so please share your thoughts by taking this short survey https://www.surveymonkey.com/r/66K3C7J 

And if you have other book ideas, we’re always open to suggestions!

Thanks

Brian Ward

Associate Editor, Briefings on Accreditation and Quality 

 

Seeking nominees for The Platinum Awards

The Platinum Awards sets the standard for recognizing professionals and organizations who demonstrate success in the overarching healthcare continuum.

Like no other awards program in the industry, the Platinum Awards brings professionals and organizations together to highlight their work, be publicly recognized, celebrate successes and collectively recognize that working as a team can ensure a safe, quality and sustainable healthcare system.

Another delay of CMS hospital star ratings system

CMS will delay an update to its controversial hospital star rating system for the second time in four months. The update was expected to launch this month and the new setback means the tool might not be available to the public until 2018.

CMS told reporters that it needed more time “to continue its examination of potential changes to the Star Rating methodology based on public feedback.” Until CMS releases the update, the ratings from December 2016 will remain on the Hospital Compare website.

The star ratings are intended to provide patients with more transparency on hospital quality, and are based on seven different latent variable models. Hospital scores are calculated using 57 quality measures broken up into seven categories:
•    Mortality
•    Patient experience
•    Readmissions
•    Safety of care
•    Care effectiveness
•    Care timeliness
•    Efficient use of medical imaging

However, since the day it was proposed many hospitals and healthcare organizations have argued against the five-star system. Some argued it unfairly penalized hospitals with poorer or sicker patients, that the methodology it uses is flawed, and that patients’ perceptions aren’t the same as quality.