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Brian Ward

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

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.

Joint Commission: screening for violence

In the October edition of Perspectives, The Joint Commission reiterated the need to screen patients for potential risks to themselves or others. This is part of a long-standing and ongoing effort to change the sky-high rates of workplace violence in healthcare.

More than 70% of the 23,000 significant injuries resulting from workplace assault in 2013 happened in healthcare and social service settings, according to the Bureau of Labor Statistics. The settings with the highest rates of workplace violence are emergency departments, behavioral healthcare settings, extended care facilities, and inpatient psychiatric units.

After reviewing 145 sentinel events between 2013 and 2015, The Joint Commission wrote that a common cause of violence was an inadequate behavioral health assessment of patients to identify aggressive tendencies. Sometimes, these assessments weren’t done at all, and the results ranged from assault to rape and even death.

“In order to accurately assess the needs of an individual for care planning, it is important to collect data about the individual’s past emotional and behavioral functioning, to assess his/her current needs and goals, and to analyze the data collected in order to develop a plan of care, treatment, or services that effectively addresses the risk of harm to self or others,” The Joint Commission writes. “These steps are also important to determine if there is a need to collect additional information.”

This includes checking to see if the patient has a history of violent behavior. If so, is there anything in their record that could determine if they’ll repeat their actions?

“If there is a history of aggression, or if the individual is admitted in an agitated state, staff should be alerted and the preliminary plan of care, treatment, or services should address the interventions required to maintain the safety of the individual and others,” “…the Perspectives article continued. “Interventions in the preliminary plan of care would likely include close supervision and monitoring of the individual, individualized de-escalation strategies, and adjustments to the environment of care as needed.”

Here are some other free resources and training on workplace violence prevention:

1.    Workplace Violence Prevention Resources for Health Care Portal (www.jointcommission.org/workplace_violence.aspx)    
2.    OSHA’s Guidelines for Preventing Workplace Violence in Healthcare and Social Services (www.osha.gov/Publications/osha3148.pdf)
3.    OSHA’s Preventing Workplace Violence: A Road Map for Healthcare Facilities (www.osha.gov/Publications/OSHA3827.pdf)
4.    The Center for Health Design’s Safety Risk Assessment Toolkit
(www.goo.gl/eH9IbG)
5.    The CDC’s Workplace Violence Prevention for Nurses course (www.cdc.gov/niosh/topics/violence/training_nurses.html)
6.    The Emergency Nurses Association’s Workplace Violence Toolkit
(www.goo.gl/0GXblW)
7.    ASIS International’s Managing Disruptive Behavior and Workplace Violence in Healthcare
(www.goo.gl/MDGsrf)

Joint Commission updates EM standards to match CMS

In response to CMS’ final emergency preparedness rule issued earlier this month, The Joint Commission announced revisions to its emergency management (EM) standards. CMS is expected to approve the updated standards before they go into effect on November 15.

Accredited organizations can access the proposed drafts on their Joint Commission Connect™ extranet site, with more information on the way.

The Joint Commission’s standards come with new Elements of Performance on the following topics:

•    Continuity of operations and succession plans
•    Documentation of collaboration with local, tribal, regional, state and federal emergency management officials
•    Contact information on volunteers and tribal groups
•    Annual training of all new or existing staff, contractors, and volunteers
•    Integrated healthcare systems
•    Transplant hospitals

Several of the new requirements merely provide more specifics on what The Joint Commission already expects. This includes including documentation for existing practices and annual training for staff.

CMS first announced the emergency preparedness CoPs in September 2016, compelling hospitals to communicate and coordinate their emergency plans with other hospitals and government agencies.

They also require regular emergency preparedness training with staff and disaster contingency planning. CMS published the final version of the new Appendix Z of Medicare’s State Operations Manual online, and state surveyors will use newly created E-tags to score deficiencies and expectations set in it.

 

HFAP revises emergency management standards

HFAP has revised its Emergency Management standards in our Acute Care, Critical Access, and Ambulatory Surgical Center manuals to be in compliance with “Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, Final Rule.” The chapter is the only change to the manuals.

The updated requirements include the need for:

  1. A written Emergency Operations Plan (EOP)
  2. Conducting a Hazards Vulnerability Analysis (HVA)
  3. Policies and procedures that address evacuation, staff responsibilities, transportation, communication, use of volunteers, and more
  4. Emergency testing (disaster drills) and evaluation twice per year

Acute Care Hospitals, Critical Access Hospitals, and Ambulatory Surgical Centers must implement and be in full compliance by November 15, 2017. This is the same date that The Joint Commission and CMS’ emergency requirements will go into effect.