RSSAuthor Archive for Brian Ward

Brian Ward is an Associate Editor at HCPro working on accreditation, patient safety, and quality news.

Featured Webcast: How to Establish an Antimicrobial Stewardship Program

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How to Establish an Antimicrobial Stewardship Program Webcast

Antimicrobial overuse is a major problem for hospitals. Overuse of antibiotics can lead to the development of multidrug-resistant organisms, unintended antibiotic toxicity, and Clostridium difficile infections. CMS and The Joint Commission have increased their emphasis on antimicrobial stewardship programs as a way to control this growing issue.

On Wednesday, May 18, from 1-2:30 p.m. Eastern, join expert speaker Jennifer Pisano, MD as she explains why antimicrobial stewardship programs (ASP) are important and how to establish a one for your facility. Utilizing her experience and successful track record, she will show attendees how her center has achieved a 95% acceptance rate by providers for stewardship recommendations.

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

  • Discuss the importance of antimicrobial stewardship and its relation to overall patient care (inside/outside the acute care setting)
  • Understand how to get an ASP started
  • Discuss ways to measure outcomes of an ASP
  • Outline the aspects of ASPs that are of interest to regulatory bodies

To sign up or learn more, visit the HCPro Marketplace.

Sponsored by:
Patient Safety & Quality Healthcare


Joint Commission rolls out changes to Denial of Accreditation decisions

The Joint Commission has set up a program for healthcare organizations that receive Preliminary Denial of Accreditation (PDA) decision PDA02. The decision is rendered when a facility has serious and widespread noncompliance issues. The accreditor says the new policies are to help organizations with a PDA02 improve themselves and get back up to standard.

The changes include:

  • Organizations must submit an acceptable Evidence of Standards Compliance (ESC) within 30 days and address the Requirements for Improvement (RFI) identified as the drivers of the PDA decision.
  • Upon approval of the ESC, the accreditor will conduct an on-site ESC survey.
  • If Condition-level findings are identified, a Medicare Deficiency Survey must be conducted within 45 days. The organization will have the option of combining this survey with the on-site ESC survey.
  • If the organization has a successful on-site ESC survey, the accreditation decision will change from PDA to Accreditation with Follow-up Survey (AFS).
  • Areas of risk and available Joint Commission resources will be reviewed in a conference call with leadership from The Joint Commission and the organization.
  • The organization’s leadership must participate in the Intracycle Monitoring (ICM) process, which occurs at 12 and 24 months.
  • The organization’s next triennial survey will occur in the earlier segment of the 18-to-33–month window.
  • If the organization’s next triennial survey results in a repeat PDA decision, the organization will receive a recommendation for Denial of Accreditation (DA) with the opportunity of an expedited appeal.

CMS adopts 2012 Life Safety Code®


In a highly-anticipated move expected to significantly affect the regulatory rules that hospitals and other healthcare facilities are held to, the Centers for Medicare & Medicaid Services (CMS) has officially adopted the 2012 edition of the Life Safety Code® (LSC).

CMS has confirmed that the final rule adopts updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the LSC as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code. The New Life Safety Code® Field Guide for Healthcare Facilities cover


Healthcare providers affected by this rule must comply with all regulations by July 4—60 days from the publication date of the rule in the Federal Register.

The adoption of the rule has long been anticipated, as the LSC, which governs fire safety regulations in U.S. hospitals, is updated every three years, and CMS has not formally adopted a new update since 2003, when it adopted the 2000 edition. As a result, CMS surveyors have been holding healthcare facilities to different standards to other regulatory agencies that have gradually adopted provisions of the new LSC in their survey requirements.

Some of the main changes required under the final rule include:

  • Healthcare facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years. after the rule’s effective date.
  • Healthcare facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than 10 hours.
  • The provisions offer long-term care facilities greater flexibility in what they can place in corridors. Currently, they cannot include benches or other seating areas because of fire code requirements limiting potential barriers to firefighters. Moving forward, LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms.
  • Fireplaces will be permitted in smoke compartments without a one-hour fire wall rating, which makes a facility more home-like for residents.
  • For ASCs, alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.

To get up to speed on the 2012 Life Safety Code®  check out the following resources from HCPro Marketplace:

Visit the Federal Register document to read the final rule in full, and view the CMS press release on the LSC here.

Physicians may now text medical orders

In 2011, The Joint Commission ruled that physicians and practitioners were forbidden from using text messaging to send patient care orders. Now the accreditor has reversed its ruling, and effective immediately hospital staff are allowed to send orders for care, treatment, and services via text. The change applies to all Joint Commission-accredited and certified organizations.

The Joint Commission had originally ruled against using text messaging in medicine because:

  1. Worries about private medical information being sent through unencrypted texting services
  2. A lack of a way to verify who was actually sending the text

However, technology has finally reached a point where the twin issues of verification and encryption for texts are no longer a problem. That said, organizations are still expected to comply with Medication Management standard MM.04.01.01 and there are restrictions on the type of texting program that can be used. The Joint Commission says that for a messaging service to be used, it must have:

  • A secure sign-on process
  • Encrypted messaging
  • Delivery and read receipts
  • Date and time stamp
  • Customized message retention time frames
  • Specified contact list for individuals authorized to receive and record order

Click here to read the full Accreditation Insider article on the new texting policies. 

Joint Commission updates look of Leading Practice Library

In mid-April, The Joint Commission updated its Leading Practice Library (LPL) to a more user-friendly interface. The LPL is full of real-life solutions to healthcare problems, all of which have been reviewed and approved by The Joint Commission. Users can browse the LPL by specific topics and all the documents are cross-referenced with Joint Commission manuals.

The changes include:

  • More refined search options including program, chapter, location, and organization size.
  • The ability to create your own personal library of “favorited” practices and documents.
  • A faster, simpler, and less technical submission process.
  • New help guides in both written and video formats.

The LPL is available to Joint Commission accredited or certified organizations for free on their secure extranet.

Joint Commission to delete 131 hospital program requirements

The Joint Commission announced plans to delete 131 standards and Elements of Performance from its hospital program requirements. The accreditor released a prepublication list of all the requirements, along with the rationale behind deleting each one. The deletions go into effect on July 1, 2016 and are part of an effort to improve the accreditation process.

Click here to see the list of all the hospital program standards that will be deleted. 

Joint Commission redesigns standards FAQs

After listening to feedback from clients and readers, the Joint Commission has updated its standards FAQ format. The accreditor uses its FAQs to clarify common patient safety and healthcare quality questions and the new design is intended to help users find important information quickly and easily.

The highest-rated FAQs will now be listed by chapter and there will only be one question and answer per FAQ. As part of the new changes, site users can now:

  • Filter search results by manual, chapter, or keyword.
  • See new and featured FAQs for two weeks.
  • Print out individual FAQs, or by chapter or manual.
  • Vote thumbs up or down on FAQs
  • Submit comments about individual FAQs

The Joint Commission encourages users to look at existing FAQs before sending in a question of their own, in case it’s already been answered.

Questions that CMS surveyors will now ask about CT services

CMS surveyors are no longer required to determine a facility’s compliance with Advanced Diagnostic Imaging (ADI) supplier requirements or hospital outpatient department requirements. Accrediting organizations like HFAP will still evaluate compliance on these requirements, though they won’t audit billings submitted by providers.

ADI suppliers and hospital outpatient areas with computed tomography (CT) services must meet safety requirements under NEMA Standard XR-29-2013. The ruling applies to hospitals and critical access hospitals and went into effect on January 1, 2016.

Although none of the standards have been changed, surveyors will now ask facilities:

  • Does the facility have outpatient areas providing CT services?
  • If yes, the surveyors will request the manufacturer’s certification of NEMA XR-29 compliance.

CMS has published a FAQ on this new policy and its impact on healthcare facilities. 

Joint Commission rebuts criticism of pain management standards

The Joint Commission released a defense of its pain management standards on April 18. The response came five days after the accreditor received a petition by the Physicians for Responsible Opioid Prescribing (PROP), which claimed the pain management standards were linked to excessive opioid prescriptions. The petition asked The Joint Commission to reexamine pain management standards PC.01.02.07, PC.01.02.01, and RI.01.01.01 and was signed by over 60 medical experts and nonprofit organizations.

“The Pain Management Standards 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,” according to PROP’s petition. It also said that opioid prescriptions rates and opioid addiction rates were linked, with more than 200,000 Americans dying due to prescription opioid overdoses since the pain management standards came into effect in 2001.

In a press release, The Joint Commission said that in the midst of the opioid epidemic, people are looking for someone to blame. The accreditor encouraged critics to look at the pain management standards along with their historical context to understand what they actually require facilities to do.

“The Joint Commission first established standards for pain assessment and treatment in 2001 in response to the national outcry about the widespread problem of undertreatment of pain,” the press release said. “The Joint Commission’s current standards require that organizations establish policies regarding pain assessment and treatment and conduct educational efforts to ensure compliance. The standards DO NOT require the use of drugs to manage a patient’s pain; and when a drug is appropriate, the standards do not specify which drug should be prescribed.”

The Joint Commission went on to rebut what it claims are five major misconceptions about its pain management standards, namely:

  1. The Joint Commission endorses pain as a vital sign
  2. The Joint Commission requires pain assessment for all patients.
  3. The Joint Commission requires that pain be treated until the pain scorereaches zero.
  4. The Joint Commission standards push doctors to prescribe opioids
  5. The Joint Commission pain standards caused a sharp rise in opioid prescriptions.

Read the Physicians for Responsible Opioid Prescribing letter to The Joint Commission here, along with the accreditor’s defense of its pain management standards.




Petitions ask Joint Commission and CMS to change pain management policies

More than 60 medical experts and nonprofit organizations sent petitions this week to The Joint Commission and CMS asking for changes in their respective pain management policies. The petitions say that making physicians routinely ask patients about their pain level encourages excessive prescriptions of opioids.

“Mandating routine pain assessments for all patients in all settings is unwarranted and can lead to overtreatment and overuse of opioid analgesics,” they wrote to The Joint Commission. “Healthcare professionals are capable of using their clinical judgment to determine when to assess patients for pain.”

Specifically, petitioners are asking for changes to The Joint Commission standards PC.01.02.07, PC.01.02.01, and RI.01.01.01 and for CMS to remove pain treatment questions from its Hospital Consumer Assessment of Healthcare Providers and Systems survey.

The petitions were headed by the Physicians for Responsible Opioid Prescribing and are co-signed by the heads of the National Center on Addiction and Substance Abuse, the National Women’s Health Network, the American Society of Addiction Medicine, and health commissioners from Vermont, Pennsylvania, Alaska, and Rhode Island.