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TJC, Others respond to CMS concerns about AO consulting, conflicts of interest

By A.J. Plunkett

With less than four days to go before the February 19 public comment deadline, so far only The Joint Commission (TJC) and the Center for Improvement in Healthcare Quality (CIHQ) are among the hospital accrediting organizations (AO) to formally respond to CMS’ concerns about conflict of interest.

CMS published a request for information in mid-December, asking the public to weigh in on whether AOs that also offer consulting services have, or at least create, a public perception of conflict of interest. The request was made ahead of potential new regulations, according to CMS.

As of February 8, CMS has posted only about 80 comments from people or organizations responding to the request. Many of the comments said that TJC and other AOs keep sufficient firewalls to avoid conflicts of interest and expressed concern that more regulation would make hospitals and other healthcare facilities less safe.

“Why do you continue to make things more difficult for facilities to meet compliance standards? This would have a negative impact on facilities to maintain regulation. Facilities are having a difficult time to maintain compliance with the ever decreasing amount the health care facilities are reimbursed for services,” said one member of the public.

However, another public commenter said that she was against the practice of AOs “providing consulting as I have personally seen questionable interactions, both overt and implied.” That included one hospital system that was encouraged to use a product from an AO affiliate to improve survey scores, and the cross-marketing of services across the AO platforms.

TJC provided a 14-page response to CMS’ request for information, noting that TJC and its affiliates, Joint Commission Resources (JCR) and the Joint Commission Center for Transforming Healthcare, are all not-for-profit companies with separate organizations and boards of directors. The comment was introduced by a letter from Margaret VanAmringe, MHS, executive vice president of Public Policy and Government Relations.

The response provides a history of its efforts to avoid conflicts of interest, outlining the creation of an organizational and cultural firewall decades ago that prohibits and prevents consultants from JCR and surveyors from TJC communicating about clients.

“The structures and processes implemented and monitored by The Joint Commission and JCR to prevent any sharing of confidential consulting information with Joint Commission accreditation personnel are necessary for preventing any real or perceived conflict with the provision of consulting services. Firewall Policies and Procedures have been tested by independent, external auditors and by the Government Accountability Office (GAO),” wrote TJC in its comment.

While the firewall policy has evolved along with TJC and JCR over the years, the commission’s response noted that “what has never changed is the core principle addressed by the policy – to protect the integrity of The Joint Commission accreditation process. The policy was tested by GAO investigators in 2006, with a final report issued December 2006 that concluded:

‘Despite The Joint Commission’s control over JCR, the two organizations have taken steps designed to protect facility-specific information. In 1987, the organizations created a Firewall—policies designed to establish a barrier between the organizations to prevent improper sharing of this information. For example, the Firewall is intended to prevent JCR from sharing the names of hospital clients with The Joint Commission. Beginning in 2003, both organizations began taking steps intended to strengthen this Firewall, such as enhancing monitoring of compliance.

Ensuring the independence of The Joint Commission’s accreditation process is vitally important. To prevent the improper sharing of facility-specific information, it would be prudent for The Joint Commission and JCR to continue to assess the Firewall and other related mechanisms.’”

TJC also offered a point-by-point rebuttal to specific concerns CMS outlined in its request for information.

CIHQ, meanwhile, kept its comments to just over one page, in a letter written by Richard Curtis, the Texas-based AO’s chief executive officer. CIHQ was formally approved as an AO in 2013 following the extended CMS application process.

Like TJC, Curtis noted that CMS already requires AOs to demonstrate that they have sufficient protections against conflicts of interest as part of that initial and renewal applications. “CIHQ respectfully questions why additional rules would be required,” wrote Curtis.

And like other commenters, Curtis said more regulations could hurt healthcare organizations trying to comply with standards and improve patient safety.

“Some AOs – including CIHQ – offer a variety of support services to their accredited providers to help them understand standards and regulations, and provide tools to help them develop compliant processes. These take the form of standards interpretation, education programs, template policies, and documentation tools. These services do not assess a provider’s compliance, but rather provide information to the provider to help them comply. We are concerned that an overly expansive definition of what constitutes consulting would rob providers of vital sources of assistance that do not pose a conflict of interest.”

CMS will continue to take comments until February 19. Note that comments may be made public.

Comments should refer to file code CMS-3367-NC. CMS will not accept fax copies of comments. They can be submitted electronically by following the “submit a comment” instructions on, by regular mail or by overnight express mail.

To find out more about what information CMS hopes to learn, and specifics on how to comment, read the rule at

2019 Accreditation Salary Survey

Wonder how your salary holds up to others in your field? Did you get a raise? Did other people get a bonus but not you? How many hats do your colleagues wear?

Take our “2019 Accreditation Professional Salary Survey” and we’ll compile the results for you and your colleagues around the country so you can know where you stand in the challenging field of healthcare accreditation.

To take the survey, go to

Remember, all responses are anonymous.

Thank you!

Brian T. Ward

Joint Commission: How to improve patient depression screening and treatment

A new study published in The Joint Commission Journal on Quality and Patient Safety showcases four ways to improve screening and treatment of patients for depression. Depression is the leading cause of disability and 16.2 million Americans experienced a major depressive episode in 2016.  The condition often goes untreated in certain demographics such as minorities, refugees, and immigrants.

The study, “Not Missing the Opportunity: Improving Depression Screening and Follow-Up in a Multicultural Community,” was conducted by Ann M. Schaeffer, DNP, CNM, and Diana Jolles, PhD, CNM, at the Harrisonburg Community Health Center (HCHC) in Virginia. Their goal was to improve their Screening, Brief Intervention, and Referral to Treatment (SBIRT) method for identifying and treating depression.

Evidence-based guidelines recommend facilities screen for depression diagnosis, treatment and follow-up. However, they explain that only seven states report depression screening and follow-up data and the condition is the fourth least-reported measure on the Medicaid Adult Core Set.

“The project demonstrated the feasibility of using rapid-cycle improvement to improve depression screening and follow-up within a multicultural community health center,” the authors noted. “This project also brought attention to a chronic condition with long-standing implications for individual and community health that too often go unidentified and therefore unaddressed.”

The study looked at the impact of four core interventions:

  • Using written standardized screening tools in six languages
  • Using the Option Grid™, a standardized tool to help clients who screen positive for depression to share what matters most to them
  • Using a “right care” tracking log to help providers document follow-up phone calls and visits for at-risk patients
  • Conducting team meetings and in-services to support capacity building

By the end of the study:

  • The use of evidence-based care increased to 71.4 %
  • Compliance with follow-up policies increased from 33.3% to 60%
  • Screenings done in the patient’s preferred language increased to 85.2%
  • Identifying at-risk patients using a patient health questionnaire increased 45.5%

Improving depression care can also be useful in suicide prevention—a major goal of The Joint Commission this year.

(Webinar) Accreditation 101: A Beginner’s Guide to Hospital Surveys

Webinar Date: Tuesday,February 19 2019 |1:00-2:30 p.m. EST

Presented by: Heather Forbes, BSN, RN, CEN, CPhT


Summary: Accreditation is a complex topic with multiple branches, specialties, and nuances. New accreditation specialists often come from disparate backgrounds, with huge variations in the type and amount of training (if any) they had before accepting their new role. There’s a steep learning curve involved, with countless terms, organizations, and processes to understand and no clear method to go about it.

“Accreditation 101” provides a road map for the new specialist’s education and orientation, with plenty of guidance along the way. In this 90-minute webinar, accreditation expert Heather Forbes, BSN, RN, CEN, CPhT, covers survey preparation, responding to findings, maintaining compliance, and the role of the accreditation specialist.

Conducted in clear, accessible terms, this webinar is open to anyone wanting to learn more about the accreditation process—hospital leaders, quality officers, facility directors, and nurse leaders.

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

  • Establish a solid foundational knowledge of healthcare accreditation
  • Understand how to prepare for an accreditation survey and respond to findings
  • List the role and responsibilities of an accreditation specialist
  • Understand the differences between accrediting organizations such as The Joint Commission, HFAP, and DNV
  • Maintain survey readiness and compliance
  • Know key accreditation terms

Why Auditing Catheter Dislodgement is a Patient Safety Must

By Christopher Cheney

Dislodgement of venous access devices such as catheters is widespread and underreported, a survey of 1,500 clinicians shows.

There are several negative impacts from dislodgement of peripheral and central catheters including interrupted treatment, supply waste with catheter replacement, phlebitis, and infection.

Dislodgement is a significant source of wasteful spending at health systems and hospitals, the author of the survey, Nancy Morneau, RN, PhD, of Hartwell Georgia-based PICC Excellence Inc., told HealthLeaders last week.

“Accidental dislodgement may be a much bigger problem than central line associated blood stream infections. It contributes to the increasing cost of healthcare. When we look at the estimates of dislodged catheters, there are more than five million incidents. If you put dollars and cents to that, it’s more than a billion dollars that is lost every year,” she said.

The survey found high rates of catheter dislodgement.


  • 68% of clinicians surveyed said accidental dislodgement occurred often, daily, or multiple times daily
  • 96% said peripheral intravenous catheters were the most commonly dislodged vascular access device
  • The top three reasons for dislodgement were confused patient (80%), patients removing catheters (74%), and loose IV catheter tape or securement (65%)

Audits essential step

Auditing incidences of catheter dislodgement and other vascular access device failures is crucial to managing care, Morneau said.

“With value-based purchasing and pay-for-performance, everyone is on alert to reduce complications with these devices whether they are peripheral or central. By auditing complications—specifically dislodgement—we can identify causes and incidents. Then you can look to the solutions.”

Documentation is a key element of auditing.

The electronic medical record should account for discontinuation of vascular access devices for a patient including dislodgement, Morneau said.

“The EMR should have appropriate choices that include dislodgement and whether it was associated with securement, the dressing, or a patient dislodgement or a staff dislodgement. Looking at the reasons helps us to reach what the solutions may be.”

Health systems and hospitals also should encourage reporting of catheter dislodgements, she said.

“Hospitals can stress compliance with documentation and work on electronic medical record documentation in order to provide clear choices that are consistent with the reasons for catheter failure with dislodgement. Making a more accurate notation is one of the best ways hospitals can move forward with managing dislodgement.”

Auditing is foundational to improving vascular access device care, Morneau said. “Audit can help you achieve two key results: increasing education and helping to recognize where there are safety issues.”

CMS examines possible Conflicts of Interests in Accreditation Organizations

By John Commons 

Federal regulators are asking for public comment and cite ‘disparity rates’ between state audits and AO reviews of healthcare facilities.

The Centers for Medicare & Medicaid Services is asking questions about potential conflicts of interest between Medicare accrediting organizations and the healthcare facilities they monitor.

“We are concerned that the practice of offering both accrediting and consulting services–and the financial relationships involved in this work–may undermine the integrity of accrediting organizations and erode the public’s trust,” CMS Administrator Seema Verma said in a media release.

“Our data shows that state-level audits of healthcare facilities are uncovering serious issues that AOs have missed, leading to high ‘disparity rates’ between the two reviews,” Verma said.

“We are taking action across-the-board to ensure the quality and safety of patient care through strengthened CMS oversight of AOs, and today’s RFI is a critical component of that effort.”

The query likely will include an examination of The Joint Commission, the nation’s largest hospital accrediting organization. In a media statement, The Joint Commission said it is reviewing CMS’s requests for comment, but said it is confident in the integrity of the “firewall” between its consulting and accrediting divisions.

“The Joint Commission recognizes the importance of assuring the integrity of the accreditation process, which we accomplish by prohibiting any sharing of information about consulting services for individual organizations with anyone involved in accreditation,” the statement read.

“The Joint Commission as an accrediting organization and Joint Commission Resources, Inc. as a provider of education and consulting services are two separate organizations. The Joint Commission enterprise has long-standing firewall policies, practices and procedures in place that assure that this goal is achieved,” the statement read.

TJC anticoagulant NPSG updated

The Joint Commission (TJC) announced revisions to its anticoagulant therapy National Patient Safety Goal (NPSG) on December 7. NPSG 03.05.01 has eight new Elements of Performance (EPs).

All the changes are listed in R3 Report 19 and will take effect on July 1, 2019. The update applies to all TJC accredited hospitals, critical access hospitals, nursing care centers, and medical centers accredited under the ambulatory health care program.

The update requires impacted facilities too:

  • Have evidence-based protocols for starting, continuing, reversing, and testing anticoagulant treatment.
  • Establish processes for responding to adverse drug events
  • Educate patients and their families on anticoagulant treatment
  • Use programmable IV pumps when administering heparin
  • Use pre-measured products to limit dosing errors

More on this topic will be in future editions of Briefings on Accreditation and Quality

Joint Commission Revises Suicide Prevention National Patient Safety Goal

The Joint Commission (TJC) this week announced revisions to its suicide prevention National Patient Safety Goal (NPSG) to improve quality and safety of care for patients treated for behavioral health conditions and who are identified as high-risk for suicide.

Effective July 1, 2019, NPSG.15.01.01 (Reduce the risk for suicide) is applicable to all Joint Commission-accredited hospitals and behavioral healthcare organizations. The revised requirements are based on more than a year of research, public field review, and analysis with multiple panels convened by TJC and representing provider organizations, suicide prevention experts, behavioral facility design experts, and other key stakeholders.

The requirements are detailed in a new R3 Report published by TJC. The NPSG encompasses seven elements of performance (EP) that TJC will use to review hospitals and behavioral healthcare organizations during accreditation surveys. This is an increase over the three EPs in the current version of NPSG.15.01.01 (Identify individuals at risk for suicide).

“The science of suicide prevention has really advanced over the past few years, including better tools for screening, assessment of suicidal ideation, identification of environmental hazards in health care facilities, and methods to prevent suicide after discharge,” said David W. Baker, MD, MPH, FACP, executive vice president, TJC’s Division of Health Care Quality Evaluation, in a release. “We had not updated the NPSG since its original release in 2007. This revised version and the accompanying resource compendium will more robustly support health care organizations in preventing suicide among patients in their care.”

The new and revised requirements cover:

  • Environmental risk assessment and action to minimize suicide risk
  • Use of a validated screening tool to assess at-risk patients
  • Evidence-based process for conducting suicide risk assessments of patients screened positive for suicidal ideation
  • Documentation of patients’ risk and the plan to mitigate
  • Written policies and procedures addressing care of at-risk patients and evidence staff are following them
  • Policies and procedures for counseling and follow-up care for at-risk patients at discharge
  • Monitoring of implementation and effectiveness, with action taken as needed to improve compliance

Before the Plane Crash

In January 2009, all eyes were focused on the Hudson River after a plane flying out of New York’s LaGuardia Airport struck a flock of geese and crash landed in the river. Thanks to fast acting by the pilots, all 155 passengers survived, with few major injuries, in the disaster dubbed “the Miracle on the Hudson.” However, trouble emerged in the aftermath when people tried to find out which hospital their loved ones had been sent to.

“Some of the patients went to New York and some went to New Jersey. And because of HIPAA laws, it was very difficult for airline authorities to get the names of who was where,” says Sharon Carlson, RN, director of Emergency Preparedness at Sharp HealthCare in San Diego, CA. “As a family member you can imagine your terror knowing that your loved one was in a plane crash and not knowing where they are. That’s a big issue we always have, reunifying people after a disaster.”

“Because of [the Miracle on the Hudson] we decided in San Diego that we needed to make relationships before an event happens,” she adds. “Get to know each other, work together, know each other by first name, know each other’s number.”

Using the lessons learned from the Hudson, Carlson and her health system joined a disaster partnership with their local airport, San Diego International (SAN.) The airport has been growing steadily over the past decade, with over 22 million people flying in and out of it in 2017. The airport partnership was started originally in 2010 by UC San Diego Health system.

The transportation administration requires SAN to conduct major disaster drills periodically. As part of the partnership, Sharp Healthcare is included in those drills, Carlson says. They practice their communication process once a year to ensure everybody is on the same page and that there’s been no changes in the contact information.

“We have a partnership with the airports, so they know who to contact at our hospitals,” she says. “And we’ve sent it through our compliance and legal departments, they know what kind of information we can give them.”

In the event of a plane crash or disaster, airport staff have a list of hospital contacts so they can reach out, then read names off the plane’s manifest and the hospital will be able to tell them which people on the list are there or not.

“We don’t give out conditions, injuries, or illnesses,” she says. “We just say if they’re here or not. Because the airline is wanting to tell the family members ‘ok, go over here, your loved one is at this hospital.’”

WEBINAR – Preliminary Denial of Accreditation: Actions, Recovery, and Prevention

Presented on: Wednesday, December 12, 2018 |1:00-2:30 p.m. EST

Presented by: Kurt A Patton, MS, RPh.\


When the Joint Commission hands out a Preliminary Denial of Accreditation (PDA) decision, you have a small window to set things right. If you can’t get your hospital to band together to fix the problem, a PDA can cost you your accreditation, reputation, and ability to treat patients. And that’s before CMS gets involved.

Join former Joint Commission surveyor Kurt Patton, MS, RPh, this August as he reviews how you might get a PDA, what you can do about it, and what surveyors will expect during their follow-up.

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

  • Contest a PDA decision
  • Develop a corrective action plan in less than 10 days
  • Focus and prepare for the 60-day PDA follow-up survey
  • Get organized and keep staff and leaders accountable for deadlines
  • Prioritize the most difficult performance-based findings in preparation for the 60-day follow-up survey


  • What to do if you think an “immediate threat” or “immediate jeopardy” situation is pending
  • What to do if your report is posted and you are surprised to learn it is PDA
  • How to develop a strategy to dig your way out of this situation
  • How to do a corrective action plan in contrast with an Evidence of Standards Compliance (ESC)
  • How to prepare for the most difficult survey you’ve ever experienced: the 60-day PDA follow-up survey
  • Live Q&A