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Brian Ward

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

Lawmakers want more AO oversight

In a letter to CMS Administrator Seema Verma, the committee is asking for what could be reams of information from the agency about patient harm and incidents of misconduct at acute care hospitals. The committee has also asked for similar information from each of the four hospital accrediting organizations (AOs).

The committee was particularly concerned about information in a report to Congress published last summer that indicated AOs “conducting hospital surveys did not report 39% of ‘condition level’ deficiencies that were subsequently reported following validation surveys conducted by [CMS] State Survey Agencies no later than 60 days following the AO survey.”

“Although CMS has worked to strengthen its oversight of AOs, the committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the accrediting organization survey process,” wrote the committee leaders.

Noting that the Department of Health and Human Services, through CMS, must provide oversight of accrediting organizations, including CMS’ own survey agencies, “the Committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the AO survey process,” read the letter to Verma.

More coverage of this story will be in the May edition of Briefings on Accreditation and Quality

3 Ways to Knock C. diff Rates Down to Zero

For Necia Kimber, RN, CIC, MHA, infection control practitioner at Stillwater (Oklahoma) Medical Center, “one infection is too many.” Fortunately, when it comes to C. diff, Kimber has infection rates at the healthcare organization at just the right number: zero.

Thanks to a multifaceted approach, the 177-bed hospital with average daily census of 60 patients, has not seen a hospital-acquired case of C. diff since October 2017.

While the organization’s rates were not above the national average, Kimber still wanted to reduce the bioburden—particularly of C. diff, MRSA, VRE, and CRE—within the hospital.

“We didn’t have a high rate that made me say, ‘Oh, my goodness!’ It was just wanting to do overall good and making sure we were doing the best we could,” she says. “This is the hospital I’m going to bring my family to and I want to provide the best care for anybody who walks through that door.”

Here are three ways Kimber achieved lower infection rates at Stillwater Medical Center:

1. Education
Kimber spearheaded an antimicrobial stewardship program at the facility in 2017. There was also assessment of and education regarding ordering of C. diff testing.

“[As healthcare professionals], when you have a patient and you can’t find anything with normal testing, we tend to expound our testing,” she says. “Sometimes it would end up hurting us with pay-for-performance—if [the patient] tested positive for [C. diff, it] didn’t mean they were actually infected with it. They can just be colonized with it.”

The infection control team provided education on national standards for ordering C. diff testing, including testing only when patients were symptomatic of the infection. The IC team provided nurses and physicians with education on when to implement C. diff precautions with the intent that earlier intervention would prevent transmission.

2. Hand hygiene and cleanliness
Hand hygiene was a focus area for preventing the spread of infections at Stillwater.

“We do a program that’s a commitment to excellence,” she says. “Last year we did a huge push on hand hygiene.”

Each month, “secret shoppers” do direct observation on the units to assess issues regarding hand hygiene.

“What we check for is hand hygiene upon entering the room and upon leaving the room,” Kimber says.

To increase patients’ sense of safety, Kimber says she has reinforced hand hygiene practices with clinicians so that even if nurses or physicians have just cleaned their hands with alcohol foam or gel after exiting a room, they need to reapply it if they are going directly into a new room, even if they have not touched anything between rooms.

In addition, Stillwater Medical Center is using a bleach-based product to clean all rooms and equipment after a patient is discharged.

“We used to only [use bleach] on positive C. diff rooms,” Kimber explains. “Now we use it on all rooms because there are so many people who are carriers and not showing signs [of infection] until after they’ve been discharged.”

Kimber also educates environmental services staff on the “why” behind cleaning techniques.

“What we honed-in on is the actual cleaning of the area—friction and leaving the products on for the allotted time to disrupt the replication of cells and bacteria,” she says. “We’ve done a ton of education on how to clean, when to clean, and why to clean.”

3. Robots
While the campaign took place over a year, Kimber says it was the addition of pulsed xenon ultra-violet robots that drove C. diff rates down to zero.

“What we saw with our use of the UV robots, which we started in October 2017, was that for the last quarter of the year, our C. diff hospital onset cases have been zero,” she says. “I’ve been an infection control nurse for almost 18 years and I’d never seen a drop as dramatically as I had in C. diff after implementation of the UV robots.”

While the robots are not cheap, Kimber estimates that each machine costs about $100,000. Stillwater purchased six robots.

“You always worry about surgical-site infections, and you always worry about those infections that patients get in the hospital such as C. diff, MRSA, CRE, and VRE,” she says. “By national standards one C. diff infection is about $30,000 when you look at morbidity and length of stay. For surgical-site infection, if it’s a hip or a knee, you’re getting into the hundreds of thousands. So, for example, with surgical-site infections if you could just save one surgical-site infection—say a hip or a knee—you’ve already saved $100,000, so your ROI will be pretty quick in knocking your infection rates down.”

Kimber says she encourages infection control practitioners to talk with their colleagues about effective solutions for decreasing infections—whether it’s using education, technology, or something else.

“I recommend people do their own research and find out what’s best for their facility and what their actual needs are,” she says. “Infection control nurses have a pretty tight network, so talk to your colleagues and see what they’re doing in their hospitals. Talk to the ones that are the same size as you and bigger than you and see how you can glean information from that.”

Kimber says, “There were tons of things that went into [reducing hospital onset infections]. Having that rate down to zero for three months has been a huge accomplishment.”

Orignially published in HealthLeaders Media

Joint Commission releases 2017 sentinel event stats

Unintended retention of a foreign body, patient falls, and wrong-site surgery top The Joint Commission’s full list of reported sentinel events for 2017.

Every year, The Joint Commission complies a list of all the sentinel events that hospitals reported to them. Since the list only comes from self-reported data, it tends to underrepresent the real frequency of these problems. However, it’s useful in identifying trends, causes, and outcomes of adverse events. The top 10 sentinel events in 2017 were:

  1. Unintended retention of a foreign body
  2. Falls
  3. Wrong patient, wrong site, wrong procedure
  4. Suicide
  5. Delays in treatment
  6. Other unanticipated events
  7. Criminal events
  8. Medication errors
  9. Operative/postoperative complication
  10. Self-inflicted injury

The only new addition to the list since 2016 is “self-inflicted injuries,” which replaced “perinatal death/injury.” While a few hopped up or down one on the list, for the most part, there wasn’t much change.

CMS Cites Baltimore Hospital for Abandoning Patient in January

A Baltimore hospital was cited by CMS in a report released this week for its actions in removing a mentally ill patient from its emergency room (ER) and leaving her at a bus stop wearing just a hospital gown. The Washington Post reports that the University of Maryland Medical Center (UMMC) was cited for failing to comply with the Emergency Medical Treatment and Labor Act (EMTALA).

The hospital came under fire in January after a bystander filmed the incident as the woman was left by security guards at a bus stop on a cold night. According to the Post, the patient was admitted to the hospital earlier that day after a fall from a motorized bike. She was cleared for discharge, but resisted and refused to dress, the report said. Security then dropped the patient off at a nearby bus stop, where the man who filmed the incident and then called for an ambulance. The woman was brought back to the hospital and then taken to a homeless shelter in a taxi without an exam, and it was not registered that she returned to the facility, the Post reports.

According to the Baltimore Sun, CMS found that UMMC violated a federal law that hospitals must protect and promote each patient’s rights. The hospital also was found to have violated the woman’s right to receive care in a safe setting, to be free from all forms of abuse or harassment, and her right to confidentiality of records because non-clinical staff were given access to or made aware of part of the patient’s medical history. CMS also found that UMMC failed to meet data collection and analysis standards and failed to perform quality improvement activities.

The Sun reports that the hospital has now begun to record every time patients visit the ER. It also conducts audits of the patient log each month, provides additional staff training on federal requirements, and keeps ER doors unlocked. The staff bylaws were updated to specify who can perform medical screenings.

In a statement reported by the Post, a UMMC spokesperson admitted that mistakes were made. “We take responsibility for the combination of circumstances in January that failed to compassionately meet our patient’s needs beyond the initial medical care provided. While our own thorough self-examination revealed some shortcomings, the regulatory assessment punctuates the necessity to more firmly demonstrate our unwavering commitment to safety quality, compassionate patient care.”

EMTALA, in general, requires hospitals to care for patients with emergent conditions, regardless of their ability to pay. Violations of EMTALA are often cited by CMS surveyors under patients’ rights or failure to do an adequate medical screening exam. In addition to potentially impacting a hospital’s accreditation or ability to bill Medicare, EMTALA violations can also come with a civil penalty, which can reach nearly $105,000 for each citation. The newspaper reports did not mention whether the hospital was fined in relation to the CMS findings.

Webinar: How Vanderbilt University Medical Center Established a Hand Hygiene Program

Presented on: March 22, 2018, 1:00-2:30 p.m. EST
Presented by: Thomas R. Talbot, MD, MPH
Level of Program: Intermediate
Registration:  http://hcmarketplace.com/hand-hygiene-program

HCPro Webcast Icon

Summary: 
Hand hygiene is the top way to prevent the spread of healthcare-associated infections. It has also become a major focus of Joint Commission and CMS surveyors, so hospitals need to ensure their healthcare workers are complying with hand washing guidelines.

During this 90-minute webinar, Thomas R. Talbot, MD, MPH, will explain how he led a successful effort to establish a hand hygiene compliance program at Vanderbilt University Medical Center. Dr. Talbot will help attendees overcome barriers to hand hygiene compliance, set up a compliance program in their facility, and create a culture of safety that encourages increased accountability.


Who Should Listen?

  • Infection preventionists
  • Quality improvement personnel
  • Operational quality leaders
  • Safety directors
  • Patient safety professionals
  • Risk managers

Report: Six opportunities to improve patient safety

Over the next four years, $383.7 billion will be spent on adverse patient safety events in the United States and Western Europe. These events will have cumulatively affected 91.8 million patient admissions and caused 1.95 million deaths. Researchers at Frost & Sullivan analyzed 30 major patient safety concerns to find the areas where a change could make the most impact.

“Up to 17 percent of all hospitalizations are affected by one or more adverse events and around 15% of hospital expenditure is attributable to addressing them. The fact that 30 to 70 percent of these are potentially avoidable makes it imperative to prevent them from happening,” said Anuj Agarwal, Transformational Healthcare Senior Research Analyst at Frost & Sullivan in a press release.

Researchers boiled their list down to six areas that have the biggest opportunities for improvement:

  1. Medication safety: Ensuring patients get the right medicine at the right time and dosage is an ongoing challenge for providers. Even with new medication management approaches that have sprouted up, researchers say, there’s plenty of room for hospitals to step up on unifying health IT integration and value.
  2. Sepsis: Sepsis is the underlying cause in nearly 50,000 deaths each year, and one of multiple causes in more than 182,000 deaths each year. The condition is hard to diagnose and needs to be caught early.
  3.   Antibiotic resistance: Drug-resistant diseases have been a big worryin recent years. And 60% of U.S. hospitals don’t have an antibiotic stewardship program (ASP) that meets all seven components of the CDC’s stewardship guidelines. With research on new antibiotics still slow to develop, hospital need to improve their diagnostic capabilities, antibiotic stewardship, and infection-control strategies.
  4. Cybersecurity: Healthcare organizations are prime targets for computer viruses and hacking since they’re relatively easy targets with the resources to pay off hackers. Providers need to work fast to adopt new technologies such as blockchain to protect patients’ privacy.
  5.  Diagnostic safety: Researchers wrote that providers are reexamining diagnostic approaches to reduce errors. They also expect calls for improved diagnostics to drive interest in new lab management systems.
  6. Unnecessary ED admissions: People using the emergency room as their primary physician has placed a major burden on EDs. The study recommends investing more into remote monitoring and telehealth to fight this problem.

Joint Commission changes for March 2018

Deleted: RI.01.01.01, EP 8

Effective immediately, The Joint Commission (TJC) has deleted element of performance (EP) 8 from Rights and Responsibilities of the Individual (RI) standard 01.01.01. While it’ll take some time to come out of the manual, surveyors can no longer survey for it. The EP said that a hospital must respect the patient’s right to pain management. The accreditor said that after reviewing its comprehensive pain assessment and management requirements, the EP was found to be irrelevant.

Revised: EC.02.03.05, EP 25

The point of this revision is to provide extra clarity on non-rated doors. TJC made the revision to make the Environment of Care (EC) chapter align with the Life Safety Code (LSC). This revision applies to ambulatory care, behavioral healthcare, critical access hospitals, home care, and hospitals. You can read the program-specific EPs here.

Revised: EC.02.05.01, EP 27

The purpose of this revision is to address environmental features of areas administering inhaled anesthetics. TJC made the revision to make the EC chapter align with the LSC. This revision applies to ambulatory care, critical access hospitals, hospitals, and office-based surgery practices. You can read the program-specific EPs here.

Joint Commission plans to make new suicide prevention standards

This December, The Joint Commission (TJC) convened the fourth meeting of a suicide prevention expert panel. The accreditor announced in the March edition of Perspectives that the recommendations they came up with went beyond what’s in the standards. So they intend to convert some of them into new Elements of Performance in National Patient Safety Goal 15.01.01. When they are finished updating the NPSG, it will be sent out for national field review, just like it normally would.

The first and second panels were published in November and centered on inpatient psychiatric units, general acute inpatient settings, and emergency departments. The third panel discussed other behavioral healthcare settings and had its recommendations published in January.

Involving patients and representatives in care decisions

Involving patients in their care isn’t just polite, it’s a CMS requirement. Condition of Participation (CoP) §482.13(b)(2) says that patients have the right to make informed choices about their care and be involved in crafting their care plan. And CoP §482.13(a)(1) requires hospitals to take reasonable steps to decide who the patient’s designated surrogate is when the patient is unable to make the decision.

According to CMS, patients have the right to make informed choices about their care and be involved in crafting their care plan. Diana Topjian, a patient safety coach with Studer Group, says that when talking to patients about their care plan, it must be clear that they understand the risks and benefits of agreeing or declining to the treatment regimen.

“It’s incumbent upon us as providers to ensure we present the plan of care in such a way that the patient (and/or family) understand and clearly can follow the information we used in reaching those decisions,” Topjian says.

“I believe that this is a two-part process,” adds Erin Shipley, RN, MSN, a patient safety coach with Studer Group. “Not only continuing to involve the patient and family as much as possible in the planning around their plan of care and any preferences that they have, but also assessing for any changes to these wishes, and deliberate teach-back with the patient, to ensure that the knowledge and information taught and shared has been retained.  This also helps improve the engagement of the patient to understand any perceived or actual barriers the patient and family has with following the plan developed.”

Editor’s note: you can read more about this in Briefings on Accreditation and Quality. 

Like CMS, you should pay attention to sexual harassment

With all the recent focus on sexual harassment in the workplace, healthcare organizations shouldn’t expect to avoid scrutiny. Especially not from CMS or the press. Sexual harassment always has been an issue in healthcare, and it’s not hard to find examples. Like the California surgeon who slapped a nurse’s rear every morning while saying “I’m horny.” That behavior and the facility’s inaction led to a $168 million lawsuit, plus months of bad publicity.

“I suspect we’re going to see much more attention to this in healthcare, because it’s in the headlines,” says Kate Fenner, PhD, RN, managing director of Compass Clinical Consulting. “We know that we have some healthcare incidents that have gotten national attention. We know that CMS takes this seriously, Joint Commission takes this seriously. So healthcare organizations need to review their vows about how they provide a safe working environment for employees.”

The Joint Commission requires that its accredited facilities meet all applicable laws (Civil Rights Act of 1964, Title IX, for example, the recognition of sexual harassment as an infringement on civil rights for employees), and CMS is stringent about protecting patient rights (CMS Tag A-0145), including the right to receive care without harassment.

“Regulators and surveyors (CMS and The Joint Commission) pay careful attention to the news and trends in public interest,” Fenner says. “Allegations of improper conduct such as that recently lodged against a physician then practicing at a highly regarded medical center pique regulator interest and focus attention.”

Editor’s Note: You can learn more about sexual harassment in the April editions of Patient Safety Monitor Journal and Briefings on Accreditation and Quality.