RSSAuthor Archive for Michelle Clarke

Michelle Clarke is a Managing Editor at HCPro working on accreditation and patient safety products.

We need your feedback on accreditation books!

Hi there,

We’re in the process of planning for 2016 and would love your feedback to ensure that we provide you with the information that is most useful for you. What are your biggest accreditation-related challenges and priorities?

Now is your chance to tell us what topics you would like covered in 2016 and beyond.

Click here for the survey. As always, your information will be kept confidential.

Everyone who completes the survey will be registered for chance to win $50 to be used at www.hcmarketplace.com.

Thanks!

Accreditation Q & A

From time to time, we’ll post a question and answer that will help you as you prepare for your next survey.

Question

Each hospital is required to have a formal process to evaluate whether a drug should be added to the formulary. This process should include specific criteria for evaluating each drug. What criteria are utilized in your institution?

Answer

Each institution may have a slightly different list. Make sure you have criteria and that it includes at least the following criteria that The Joint Commission recommends be included:

  • Indications for use
  • Effectiveness
  • Interactions with other drugs
  • Potential for error in its use or for abuse of the medication
  • Known adverse drug reactions
  • Any sentinel event information or sentinel event alert information
  • Cost

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Do you have a question you would like us to answer? Send an email to me at mclarke@hcpro.com and we’ll do our best to answer your question.

Editor’s Note: The above question and answer are from j-Mail 2016 Edition: Tools for Ongoing Joint Commission Survey Prep.

AAAHC acquires HFAP

The Accreditation Association for Ambulatory Health Care (AAAHC) acquired the Healthcare Facilities Accreditation Program (HFAP) from the American Osteopathic Association (AOA), HFAP announced on their website yesterday.

The acquisition has been approved by Centers for Medicare and Medicaid Services (CMS) and is the first time two organizations with deeming authority will transition to single ownership.

The management and operations of HFAP will fall under the direction of Accreditation Association for Hospitals and Health Systems (AAHHS), the accrediting arm of AAAHC.

Read the full release on HFAP’s website.

New name for Briefings on The Joint Commission

Briefings on The Joint Commission has a new name: Briefings on Accreditation and Quality!

For the last few years, in addition to covering the latest Joint Commission happenings, we’ve also included a broad focus on CMS compliance and quality improvement. We think our new name better reflects the quality content we strive to bring you each month. You’ll still be able to access prior issues of Briefings on The Joint Commission on our website.

The November issue should be in your inbox. You can view it here and if you haven’t had a chance to subscribe to the newsletter, click here for more information.

We’re excited about this change and hope you will be too. If there are any topics you would like to see covered in upcoming editions of Briefings on Accreditation and Quality, please email me at mclarke@hcpro.com.

 

New Sentinel Event Alert focuses on patient falls prevention

Sentinel Event Alert (SEA) #55, issued by The Joint Commission today, urges healthcare facilities to take action to prevent falls and fall-related injuries.

Falls are routinely in the top 10 sentinel events reported to The Joint Commission each year. The most common causes of falls or fall-related injuries, include poor patient assessment, lack of communication, failure to follow healthcare facility protocols and safety practices, and the absence of strong leadership, according to the SEA.

The Joint Commission recommends the following actions under the command of a strong leadership:

  • Raise awareness of the need to prevent falls
  • Create an interdisciplinary falls injury prevention team
  • Implement a standardized tool to assess possible fall risks
  • Develop patient-specific plans of care based on possible fall and injury risks
  • Create standardized practices and interventions for healthcare professionals and patients
  • Perform a root cause analysis after a fall

Read the SEA for further information on The Joint Commission’s recommendations to prevent falls and fall-related injuries.

Reducing the length of stay: Not yours, but somebody who visits but once in a three-year cycle…

Editor’s note: This post, written by my colleague Steve MacArthur, originally appeared on Mac’s Safety Space.

One of the most interesting parts of my job is helping folks through the actual Joint Commission survey process. Even as a somewhat distant observer, I can’t help but think that the average survey (in my experience) is about a day longer than it needs to be. Now, I recognize that some of that on-site time is dedicated to entering findings into the computer, so I get that. But there are certain parts of the process, like, oh I don’t know, the EC/EM interview session, that could be significantly reduced, if not dispensed with entirely. Seriously, once you’ve completed the survey of the actual environment, how much more information might you need to determine whether an organization has its act together?

At any rate, I suppose this rant is apropos of not very much, but the thought does occur to me from time to time. So I ask you: is there anybody out there who feels the length of the survey was just right or, heaven forbid, not long enough? As I’ve always maintained, TJC (or, for that matter any regulatory survey type—including consultants) tend to look their best when you see them in the rear view mirror as you drive off into the future. I know the process is intended to be helpful on some level, but somehow, the disruption never seems to result in a payoff worth the experience. But hey, that may just be me…

Any thoughts you’d like to share would be most appreciated.

Reduce clinical alarm fatigue with new HCPro webcast

The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commission created a new National Patient Safety Goal to address it. With so many device alarms going off, staff may tune them out and miss important warnings that can lead to adverse patient events.

In this webcast scheduled for Wednesday, October 14 at 1 p.m. Eastern, Deborah Whalen and Jim Piepenbrink of Boston Medical Center will explain how their facility successfully reduced alarm fatigue through process management, collaboration, and governance. Register today for “Clinical Alarm Management: Reduce Alarm Fatigue and Meet The Joint Commission’s National Patient Safety Goal” and get the knowledge you need to improve alarm management in your facility.

Visit here for more information.

Joint Commission launches leadership module on Physical Environment portal

The Joint Commission posted the leadership portion of the management of utility systems (EC.02.05.01) on its Physical Environment portal earlier this week. The first part of the module discussed the impact noncompliance of utility systems has on patient care safety.

The next modules to be released on the portal, in October and November, will cover maintenance of egress integrity (LS.02.01.20) and management of hazardous materials and waste risks (EC.02.02.01).

The Joint Commission and American Society for Healthcare Engineering (ASHE) launched the portal in July to provide hospitals with online resources and tools to comply with the most challenging Life Safety (LS) and Environment of Care (EC) standards.

Visit the Physical Environment Portal.

Joint Commission seeks comments on proposed changes to National Patient Safety Goal on Catheter-Associated Urinary Tract Infections

The Joint Commission is calling for comments on proposed changes to existing NPSG.07.06.01 on Catheter-Associated Urinary Tract Infections (CAUTI). The proposed changes including educating, patients and their families on the importance of preventing CAUTI. Additional proposed changes include requiring consistent documentation methods for indwelling catheter use.

The Joint Commission is also seeking comments on this NPSG for nursing care centers. This is a new NPSG for those facilities.

The comment period for both ends on October 14.

Read more about the proposed changes here.

Healthcare organizations urge CMS to suspend new sepsis management measure

Four major healthcare organizations have asked CMS to postpone implementation of the severe sepsis and septic shock management bundle measurement that is scheduled to go into effect October 1, 2015. The measure as currently written, calls for the use of broad spectrum antibiotics to treat severe sepsis and septic shock.

The group consisting of the American Health Association (AHA), America’s Essential Hospitals, AAMC, and the Federation of American Hospitals, is urging CMS to refine the measure so that it more closely aligns with the antimicrobial stewardship put forth by the CDC and the White House earlier this summer.

“By encouraging the use of broad spectrum antibiotics when more targeted ones will suffice, this measure promotes the overuse of the antibiotics that are our last line of defense against drug-resistant bacteria,” the group wrote in a letter to CMS.

Read the full letter here.