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Brian Ward

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

Joint Commission deletes ORYX standard

The Joint Commission will delete performance improvement standard PI.02.01.03 and its single element of performance on January 1, 2018. The standard had required facilities to receive a composite performance rate of 85% or higher on the ORYX accountability measures.

The accreditor announced that it was deleting the standard because it wasn’t possible for facilities to accurately calculate their composite rates.

So many chart-based measures were retired to maintain alignment with CMS that there weren’t enough left relevant to this requirement. Also, since hospitals can submit data in several different ways, it threw off the composite rate calculations.

https://www.jointcommission.org/assets/1/18/Baking_Deletion_Prepublication.pdf

The measure had been suspended since 2015.

Crucial accreditation deadlines on the horizon for pain management and emergency preparedness

Time is running out to meet the new emergency management (EM) Conditions of Participation (CoP) and The Joint Commission’s revised pain management standards. The EM Interpretive Guidelines go into effect on November 15 while the pain management standards go into effect January 1.

Emergency management

The new EM CoPs fill gaps CMS’ previous regulations by compelling hospitals to communicate and coordinate their emergency plans with other healthcare organizations and government agencies. They also require regular emergency preparedness training with staff and disaster contingency planning.

Steve MacArthur, a safety consultant at The Greeley Company, pointed out that a lot of the new requirements include things that hospitals should have already been doing.

“While this rule is new to the ‘marketplace,’ there are really no new concepts contained therein,” he says. “This may provide some guidance for CMS surveyors as they drill down on organizational preparedness activities. But none of this is groundbreaking or in any way representative of a change in how hospitals have done, and will continue to do, business. [It’s] just another set of official ‘eyes’ looking through the compliance microscope.”

Pain management

The Joint Commission prepublished its new pain management standards back in June. The accreditor said it used the revision to address disparities between its standards and what the literature recommended. Some of the changes include:

•    Enabling clinician access to prescription drug monitoring program databases

•    Performance improvement activities focusing on pain assessment and management to increase the safety and quality for patients

•    Identifying the leader or leadership team responsible for pain management and safe opioid prescribing

•    Involving patients in developing their treatment plans and setting realistic expectations and measurable goals

•    Identifying and monitoring high-risk patients as a way to promote safe opioid use

Facilities should assign teams to research best practices in pain management, get the medical staff working on revising protocols and deter¬mining how to gather data on pain management effectiveness, and alert your information technology and electronic health records experts that they will be needed.

The annual fire and smoke door testing requirements will also be due by January 2018.

Solar Eclipse: Prepare for eye injuries

Healthcare providers should be on the lookout (no pun intended) for patients complaining of eye trouble over the next few days. 

Monday, August 21, a total solar eclipse will occur over the continental United States, the first one to do so since 1918. Over 12 million of people will be able to see the sun completely blocked out by the moon, with more able to see a partial eclipse.

While there have been plenty of PSAs and warnings about not looking directly at the sun (even when it’s partially obscured) healthcare organizations should be ready to deal with patients coming in complaining of eye pain or damaged vision.

New may not be better: hospital returns to paper and happier docs

The Illinois Pain Institute (IPI) was having trouble with its electronic health records (EHR). So they got rid of them and went back to paper. And they aren’t planning on going back anytime soon.

Two years ago, all 70 members of the IPI voted unanimously to get rid of its EHR saying it was slowing down care and alienating patients.

“We felt the level of patient care was not enhanced by an electronic health record. We saw it was inefficient and added nonproductive work to physicians’ time,” John Prunskis, MD, IPI founder and co-medical director told Becker’s Hospital Review. 

Since the switch, IPI has reported greater ease communicating information between hospital systems, less time spent on data entry, happier patients and staff.

“The EHR hinders data exchange,” he says. “One EHR doesn’t talk to another EHR, and there’s many reasons for that. The other thing is when you dictate a paper note with the relevant clinical findings and history, it’s rather succinct, but with the EHR, there’s a problem. The EHR is pages and pages of mind-numbing text, where important labs and information can be lost. Before, a note might be a half-page long, but now it can be five, six pages long, and doctors frequently can’t find what’s relevant through the reams of text and clutter.”

The IPI’s feelings are echoed by many physicians, according to the Mayo Clinic, which in 2016 found in EHR usage reduces physician satisfaction and increases burnout. Another study from the same year found that for every hour physicians spend with patients, they spend two hours interfacing with their EHR.

“Electronic health records hold great promise for enhancing coordination of care and improving quality of care,” said Tait Shanafelt, MD, Mayo Clinic physician and lead author of the study, in a statement. “In their current form and implementation, however, they have had a number of unintended negative consequences including reducing efficiency, increasing clerical burden and increasing the risk of burnout for physicians.”

 

Fire and smoke: CMS clarifies which doors must be inspected annually

After pushback, federal officials backed away from their claim that smoke barrier doors must be inspected and tested annually.

More than three weeks after a well-publicized compliance deadline passed, CMS announced Friday that the deadline would be pushed back nearly six months, giving facilities until New Year’s Day 2018 to comply with an annual testing requirement for certain doors.

David Wright, director of the CMS Survey and Certification Group, made the announcement in a memo to state survey agency directors. He acknowledged that there had been a fair amount of confusion concerning the change, and he offered some pretty consequential clarifications that could affect whether the new requirement applies to your facility at all.

“[C]onsidering the level of reported misunderstanding of this requirement, CMS has extended the compliance date for this requirement by six months,” Wright wrote.

Within the National Fire Protection Association’s (NFPA) 2012 Life Safety Code® (LSC), which CMS adopted last year, there is a requirement that fire doors and smoke barrier doors be tested annually. Officials with CMS had taken the position that the new requirement applies to healthcare occupancies; that position, however, was met with pushback.

A petition objecting to the CMS position was discussed at length in June by members of the NFPA Healthcare Interpretations Task Force (HITF), says Brad Keyes, CHSP, owner of Keyes Life Safety Compliance. That petition objected to the notion that the LSC specifically requires annual inspections of smoke barrier doors in healthcare occupancies.

“The HITF members did discuss the issue and agreed that healthcare occupancies were exempt from complying with section 7.2.1.15.2 … because the healthcare occupancies did not specifically require compliance with that section,” Keyes says in an email.

The committee decided to table its decision on the matter to give CMS an opportunity to review its position, as it did, Keyes says.

“I am pleased that the system worked in favor for the many hospitals that are certified by the Federal agency,” he adds.

Although the LSC does include provisions requiring annual inspections of smoke barrier doors and fire doors alike, section 7.2.1.15.1 states that these standards apply only where required by Chapters 11–43. Since the chapters governing healthcare occupancies make no direct reference to Section 7.2.1.15.1, the door inspection provisions do not apply to healthcare occupancies, Wright acknowledged in his memo.

Based on that conclusion, Wright spells out a few key takeaways:

  1. Fire doors. In healthcare occupancies, all fire door assemblies must be inspected and tested annually in healthcare occupancies, based on section 8.3.3.1 of the 2012 LSC, which applies to all occupancies.
  2. Smoke barrier doors. Non-rated doors (including smoke barrier doors and corridor doors to patient care rooms) aren’t subject to the annual inspection and testing requirements, but they “should be routinely inspected as part of the facility maintenance program.”
  3. Deadline. The compliance deadline has been pushed back from July 6, 2017, to January 1, 2018.
  4. Citations. Any LSC deficiencies related to annual fire door inspections should be cited under K211—Means of Egress—General.

But what if a healthcare organization was already cited at some point during the three-week gap between the original compliance date and the clarifying memo (July 6–28) for a failure to conduct an annual test of its smoke doors? Multiple CMS representatives did not respond to requests for an answer. Keyes says CMS has been a stickler in the past, holding that a finding cannot be removed once it is written on a survey report.

“There was an accreditation organization [AO] that used to allow findings to be removed from their survey report if the hospital could demonstrate compliance at the time of the survey,” Keyes says. “CMS has said that the AOs may no longer remove findings, even if the hospital was compliant at the time of the survey.”

The Joint Commission stated in the July edition of Perspectives that it requires annual testing for fire door and smoke door assemblies alike, despite acknowledging that the healthcare occupancy chapters don’t cite section 7.2.1.15 specifically. (To support the requirement, The Joint Commission noted that Section 18/19.2.2.2.1 references section 7.2.1, and cited a belief that the annual tests are beneficial.)

Keyes adds a word of caution: “The AOs are not locked into complying with everything CMS says or does. The AOs may have standards that exceed what CMS requires.”

That means the guidance in Wright’s memo might not trickle down to the AOs and state agencies that conduct surveys at your facilities, especially considering how widely advertised the original compliance date has been.

“So, I suspect many of the AOs will keep the start date at July 5, 2017, since they are already enforcing that,” Keyes says.

With that in mind, he recommends that all healthcare facilities have their fire doors tested as soon as possible, rather than waiting until the new deadline—because another authority having jurisdiction might keep to the stricter timeline.

Joint Commission revises Medication Management EPs

The Joint Commission has revised Medication Management elements of performance (EP) for several of its programs. The changes will go into effect on January 1, 2018 and will impact hospitals, ambulatory care, behavioral care, home care, nursing care centers, critical access hospitals, and office-based practices accredited by The Joint Commission. The revisions will require organizations to:

•    Record the date and time of any medication administered in the patient’s clinical record.
•    Implement a policy to provide emergency backup for essential medication dispensing equipment and for essential refrigeration for medications.
•    Have a written policy addressing the control of medications between when they are received by a provider and given to a patient. Those policies should now include what to do for the “wasting of medications.”
•    Implement a policy describing the types of medication overrides for automatic dispensing cabinets that will be reviewed for appropriateness and the frequency.

The revisions vary depending on the program.

AAMI takes action on medical cart fires

Last year, the Food and Drug Administration (FDA) released a report warning that mobile medical carts have been overheating, igniting, smoking, burning, or exploding. This July, the Association for the Advancement of Medical Instrumentation (AAMI) responded by convening a group of experts to talk about this new fire hazard.Explosion

Similar to the infamous Samsung Galaxy 8, the fires are caused by carts’ lithium batteries and are extremely hard to extinguish. In some cases, firefighters have had to bury medical carts to put out the flames.

“Surely, we’re not going to wait until there’s a patient incident to do something,” said Ram Dhurjaty, president of Dhurjaty Electronics Consulting, during the AAMI meeting.

A 2016 FDA survey revealed that half of hospital respondents have experienced a cart battery or electrical-related problem during the previous two years. In response, the agency put out a letter to healthcare professionals about the dangers. 

“We’ve learned that for most medical cart fires, the products in question met all applicable battery safety standards, including cell-level, pack-level, and product-level standards, and we believe a majority of these were legitimate certified products,” Pete Segar, CEO of medical cart manufacturer Ergotron, told HFAP. “There is good reason to believe that incidents of lithium battery fires will continue. We need to take action to reduce the likelihood of fires that could cause serious safety events in a healthcare setting.”

“Current industry standards have not been adequate,” he continued. “Most likely because the failures are caused by low likelihood contamination or defects that are not present in the nominal designs tested during the certification process. Developing new standards would be influential in driving innovations that could have a major impact on improving safety.”

In response, the AAMI has created three priorities and work groups to help hospitals with this problem.

1.    “Conduct failure analyses for high-capacity batteries in the health care setting and develop a feedback loop with device and battery manufacturers so this information can be incorporated into future designs.”
2.    “Develop new or update existing battery design standards to reflect the best practices found in UL’s Safety Issues for Lithium-Ion Batteries, AdvaMed’s Successful Practices for Battery-Powered Medical Devices, and other published documents.”
3.    “Train health care technology management professionals about safe battery management practices.”

Those interested in joining AAMI’s workgroups should contact Joe Lewelling, AAMI’s vice president of emerging technologies and health IT, at jlewelling@aami.org.

CMS withdraws proposal to have AOs post survey reports online

A proposal by CMS to have accrediting organizations (AOs) post the details of survey reports online was withdrawn by the agency, not because of negative comments — although there were plenty — but because, well, it might be prohibited under federal law.

CMS first made the proposal in April, tucking it into the latter pages of the always-long proposed on changes to the Inpatient Prospective Payment System (IPPS) for the upcoming fiscal year.

The proposal was to have AOs post final survey reports online within 90 days that the same information is available to the hospital or other health care organization, including details of all initial and recertification surveys at that provider in the prior three years, as well as the accepted plans of correction (PoCs).

AOs now post only whether an organization is accredited or not, and do not make details of findings public.

CMS argued its proposal was to promote transparency in health care, and noted that it posts its own  survey reports online. But critics responded that the CMS reports are made available in a hard-to-read spreadsheet and that the federal agency was responsible for far fewer surveys at health care organizations that were often surveyed only after a complaint (IJC 5/1/17).

In public comments to CMS concerning the proposal, The Joint Commission said that requiring survey details be made public would have “chilling effect” on efforts to raise standards of quality. Dr. Mark R. Chassin, president and CEO of The Joint Commission, wrote: “There will be a race to the bottom on quality as health care organizations seek out oversight bodies that will report on the least number of standards comparable to the Medicare requirements. This may also lead to a growth in non-accredited facilities that will then be surveyed at taxpayer expense and with fewer oversight visits.”

Other groups similarly weighed in against the proposal, and offered alternatives. In the end though, it was shot down because it might potentially be prohibited.

In the IPPS final rule published Aug. 2, CMS noted that its proposal included revising the federal regulations overseeing Medicare to incorporate the requirement for AOs to post report details publically.

“Section 1865(b) of the Act prohibits CMS from disclosing survey reports or compelling the AOs to disclose their reports themselves. The suggestion by CMS to have the AOs post their survey reports may appear as if CMS was attempting to circumvent the provision of section 1865(b) of the Act. Therefore, this provision is effectively being withdrawn.” — A.J. Plunkett (aplunkett@h3.group)

Resource:

Policies for the Use of Personal Mobile Devices in Surgical Suites

Written by Anne V. Irving, MA, FACHE, CPHRM, DFASHRM and published in PSQH 

cellphone

When is it okay to text and operate?

Human factors studies indicate that distractions and multitasking increase the likelihood of error (Feil, 2013; Wiegmann, ElBardissi, Dearani, Daly, & Sundt, 2007). Allowing personnel to bring their cell phones, smartphones, or other mobile devices into a surgical suite introduces a new distraction into an already complex, noisy, high-stakes environment. Rather than assume that perioperative personnel will always use their best judgment, health systems should adopt formal, written policies, procedures, or guidelines for the use of personal devices in order to provide:

  • Clarity regarding specific performance expectations
  • A basis for enforcement, if instances of noncompliance are reported
  • A clear message that patient safety is the highest priority at all times

Several perioperative professional associations have weighed in on the use of personal mobile devices, including the Association of periOperative Registered Nurses, the American Association of Orthopaedic Surgeons, and the American Association of Nurse Anesthetists. See the appendix for the American College of Surgeons’ statement on the use of cell phones in the operating room and links to policies of other organizations.

Choosing a risk mitigation strategy

Healthcare leaders who decide to limit use of personal mobile devices during work hours must balance multiple considerations: patient safety, the impact on workflows in the organization, and the potential effect on employees and affiliated providers. Policies to control the use of personal devices can be perceived as positioned at various points on the risk mitigation continuum (Figure 1).

Option A

Choosing not to develop a formal policy regarding the use of personal devices (Option A) offers little, if any, risk mitigation. With no guidelines to follow, some staff members may feel compelled to look at or use their mobile device when engaged in direct patient care that requires their full attention. Such mental distractions increase the likelihood of medical errors. [more]

Celebrating World Hepatitis Day 2017

July 28 is World Hepatitis Day, and the World Health Organization (WHO) and the Joint Commission have reaffirmed their commitment to eradicating Hepatitis B and C by 2030.

The WHO says there’s promising data coming out of the 28 countries that represent 70% of the global hepatitis burden. Nearly all of those countries have established high-level national hepatitis elimination committees (with plans and targets in place) and over half have allocated dedicated funding for hepatitis programs and education. The organization also added a new generic treatment to its list of Hep C medicines to increase access to therapy this week.

“It is encouraging to see countries turning commitment into action to tackle hepatitis,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General in a public statement. “Identifying interventions that have a high impact is a key step towards eliminating this devastating disease. Many countries have succeeded in scaling-up the hepatitis B vaccination. Now we need to push harder to increase access to diagnosis and treatment.”

Viral hepatitis affected 325 million people worldwide in 2015 and caused 1.34 million deaths—more those people killed by HIV deaths. Of cases worldwide, 257 million were of Hep B and 71 million were Hep C, which are the two main killers of the five types of hepatitis. And while Hep C can be cured, only 7% of those infected have access to treatment.

“If you’ve been paying attention to health news, you’ve probably heard that everyone, especially Baby Boomers, should be screened for Hepatitis C,” Lisa Waldowski, DNP, PNP, CIC, Joint Commission infection control specialist wrote in a press release. “Testing for the disease, which produces few, if any symptoms, leads to treatment and, eventually, eradication of the Hep C virus that was transmitted at its highest rates from 1960 to 1980.”

The promotion of blood safety and infection control are also key factors in reducing both Hep B and C transmission. However, a 2016 study found that only 17.4% of U.S. nurses follow all the standard blood-borne disease precautions. http://goo.gl/jn7i2y The study also found that many nurses had several misconceptions about Hep C including:

  • 26% incorrectly believed Hep C is commonly spread through sexual activity (it’s spread primarily through blood)
  • 14% incorrectly think most Hep C victims will die prematurely
  • 12% didn’t know that people can have Hep C antibodies without currently being infected
  • 11% didn’t know that there’re multiple Hep C genotypes

“The national response towards hepatitis elimination is gaining momentum. However, at best one in ten people who are living with hepatitis know they are infected and can access treatment. This is unacceptable,” said Dr Gottfried Hirnschall, WHO’s Director of the HIV Department and Global Hepatitis Programme. “For hepatitis elimination to become a reality, countries need to accelerate their efforts and increase investments in life-saving care. There is simply no reason why many millions of people still have not been tested for hepatitis and cannot access the treatment for which they are in dire need.”

The Joint Commission has made a list of several resources about hepatitis, and the WHO press release came with a list of injection safety tools and resources.