RSSAll Entries in the "Accreditation" Category

Cost of sepsis readmissions exceeds $16,000 per patient

By Christopher Cheney, HealthLeaders Media 

The annual estimated cost of sepsis readmissions is about half the annual cost of all four of the conditions in Medicare’s Hospital Readmissions Reduction Program, recent research shows.

“In our study, the estimated annual cost of sepsis readmissions amounted to more than $3.5 billion within the United States. When compared to $7.0 billion for the four conditions (AMI, CHF, COPD and pneumonia) targeted by the Hospital Readmissions Reduction Program (HRRP), this accounts for a significant under-recognized burden on the U.S. healthcare system,” the researchers wrote in the journal CHEST.

Sepsis is the body’s extreme reaction to an infection, which can result in life-threatening symptoms such as multiple organ failure. Annually, more than 1.5 million people get sepsis in the United States, with about 250,000 fatalities.

The economic impact of sepsis on a national scale is significant, the CHEST researchers found in their study, which featured more than 1 million index admissions.

  • The annual cost of index admissions for sepsis was estimated at more than $23.3 billion
  • The mean cost per sepsis readmission within 30 days of discharge was $16,852
  • 30-day readmissions after an index admission for sepsis accounted for 13% of all sepsis-related hospitalization costs

The lead author of the CHEST research, Shruti Gadre, MD, told HealthLeadersthat sepsis readmissions are likely expensive because of intensive care unit treatment, antibiotics administration, and invasive procedures.

Sepsis readmissions are expensive relative to the HRRP conditions most likely because of the acuity of sepsis patients, said Gadre, a member of the Department of Pulmonary, Allergy and Critical Care Medicine at Cleveland Clinic’s Respiratory Institute.

“The hypothesis is that sepsis patients are sicker when they get readmitted to the hospital. They require ICU-level care and may have multi-organ involvement compared with patients with AMI, heart failure, COPD, and pneumonia, which may lead to higher costs.”

Anticipating readmissions

For patients who had an index sepsis admission, 17.5% were readmitted within 30 days. Gadre and her research team identified predictors of sepsis readmissions.

  • Infection was the most common cause for 30-day readmissions, accounting for 42.16% readmitted patients.
  • Sepsis accounted for 22.86% of readmissions.

The other most common causes for sepsis readmissions were gastrointestinal (9.60%), cardiovascular (8.73%), pulmonary (7.82%), and renal (4.99%) conditions.

“Our findings serve to create awareness among clinicians, administrators and policy makers alike regarding patient populations that are vulnerable to sepsis readmission and thus increased utilization of resources. Although it may be necessary to readmit some patients, the striking rate of readmission demands efforts to further clarify the determinants of readmission and develop strategies in terms of quality of care and care transitions to prevent this adverse outcome,” the research team wrote.

CMS Warns Detroit Hospital to Improve IC Issues or Lose Funding

The Centers for Medicare and Medicaid Services (CMS) has given Detroit Medical Center’s (DMC) Harper University Hospital until mid-April to correct its infection control problems or lose its federal funding, according to a story in The Detroit News.

The hospital was notified in January of the deadline to pass an inspection. Failure to do so could result in Harper losing the funding that provides 85% of its inpatient revenue, according to the story. The Michigan Department of Licensing and Regulatory Affairs conducted inspections in December on behalf of CMS after three cardiologists and a physician at DMC Heart Hospital claimed that they were terminated from management roles in retaliation for complaints they made about infection control issues. Heart Hospital shares many of Harper’s facilities and services. The inspection found flying insects in an intensive care unit, improperly attired surgical personnel, and problems with sterile processing of surgical instruments, the News reported.

Two of the cardiologists, Dr. Mahir Elder and Dr. Amir Kaki, filed a lawsuit this week in Detroit’s U.S. District Court, saying they were fired after complaining about dirty surgical instruments and other problems at DMC hospitals.

“Any suggestion that these leadership transitions were made for reasons other than violations of our Standards of Conduct is false,” DMC said in a statement released in response to the lawsuit.

Other DMC hospitals have come under recent scrutiny. Inspectors found that staff cuts at Detroit Receiving Hospital led to the discontinuation of surveillance of most surgical site infections. Meanwhile, Sinai-Grace Hospital, which also faces Medicare termination on August 31 if it doesn’t pass an inspection, was under threat of termination in 2018 because of building and nursing quality problems. Sinai-Grace recovered its deemed status in September but was inspected again in January after a November power outage left the hospital unable to treat a heart attack patient, who later died after being transferred to another hospital.

Once Again, Safety Issues Top List of Most-Cited TJC Standards

Hospitals continued to struggle with safety issues in 2018, according to The Joint Commission’s latest list of most challenging standards. Released in the April issue of Perspectives, the list covers the top Joint Commission requirements that surveyors found to be noncompliant most often during 2018.

For accredited hospitals, the most-cited standards were as follows:

  • 02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage).
  • 02.05.01—The hospital manages risks associated with its utility systems (78.7%).
  • 02.06.01—The hospital establishes and maintains a safe, functional environment (73.9%).
  • 02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%).
  • 02.02.01—The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70,9%)
  • 02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%).
  • 02.01.20—The hospital maintains the integrity of the means of egress (67.4%).
  • 02.05.05—The hospital inspects, tests, and maintains utility systems (64.7%).
  • 02.02.01—The hospital manages risks related to hazardous materials and waste (62.3%).
  • 02.05.09—The hospital inspects, tests, and maintains medical gas and vacuum systems (62.1%).

The March 27 issue of Joint Commission Online also includes highlights of the accreditor’s findings for its various accreditation settings.

Access the new AQCC portal in May

Good news! We will be launching the new Accreditation and Quality Compliance  (AQCC) portal this May . Be on the lookout for emails with information about how to set up your login and password info as well as the URL for this new one-stop-shop accreditation solution center.

Please be sure that we have your email address on file so that you don’t miss any of these important announcements. To double check the email we have on file call customer care at: 1-800-650-6787.

Along with free content, the new AQCC portal contains two membership levels—Basic and Platinum.

If you currently subscribe to a single newsletter, Briefings on Accreditation and Quality, Patient Safety Monitor Journal, or Insider the Joint Commission be added as a Basic Member, which includes:

  • Newsletter archives for BOAQ, PSMJ, and IJC
  • The Accreditation Encyclopedia
  • Sample Forms
  • Customizable Survey Tools
  • Online Forums

If you currently subscribe to two or more of these newsletters you’ll receive Platinum Member benefits. This includes all the benefits of a Basic Member, plus:

  • The CMS Compliance Crosswalk
  • The Patient Safety Standards Crosswalk
  • The Mock Tracer Toolkit
  • The Survey Training Essentials Toolkit
  • E-library of best-selling books on accreditation, safety and quality
  • And More!

If you have more questions, please feel free to email me at, with the subject line “AQCC Questions.”


Learning from a ransomware attack on your hospital

By Philip Betbeze

It’s breach season.

That’s what Ron Pelletier, founding partner of Pondurance, a cybersecurity company based in Indianapolis, calls February through April. Partly, that’s because it’s also tax season, when a lot of financial information is being sent and received via the internet. Bad actors often spend the latter part of the previous year “weaponizing” their tools and doing reconnaissance. Then they look for vulnerabilities.

For Hancock Health in Greenfield, Indiana, just outside Indianapolis, breach season started a little early. About 9:30 p.m. on the night of January 11, 2018, Steve Long, its president and CEO, got a call from the health system’s IT staff, telling him a computer in the lab was infected with ransomware. In an abundance of caution, the IT staff had turned everything off that was connected to the internet.

They were too late.

The attack from a criminal syndicate in Eastern Europe was initiated through the emergency backup facility used by the 71-staffed-bed hospital many miles away, and it had infected many, if not all its servers. The SamSam ransomware did not affect patient life-support systems.

Unlike ransomware programs that depend on phishing tactics to trick employees to open an infected email, the SamSam attack is more sophisticated. The criminals found a vulnerable port set up by one of the hospital’s vendors, then located a password to gain entry into the system, Long says. They infected data files associated with the hospitals’ most critical information systems.

“It was a port you had to log into but it was exposed to the internet,” Long says.

Long hopes by sharing his story that other healthcare organizations will avoid the disruptions that Hancock Regional experienced. He’s even written a publicly accessible blog about it.

From a forensics investigation done later, it appears the criminals made attempts at a “brute force” attack, in which they ran through tens of thousands of potential password combinations to gain entry.

“That did not work, but at some point, they found a login and password from a vendor who was working with our IT systems,” says Long. “We probably will never know exactly how they got a login and password. We’re told all the time we should be prepared for such things. We had hired a company that was supposed to track this, and had anti-malware and antivirus software we thought was good.”

In short, Long says, Hancock Health probably had a false sense of security about its network.

Long decided to pay the ransom price of four bitcoin, about $50,000 at the time, to begin the recovery process. After about 70 hours offline, and little sleep for the IT staff, communication systems were restored, network file servers were brought back online, and the electronic medical record system was restored.

Long and his staff emerged scarred, but smarter. He says other CEOs should learn at least four lessons from his headaches:

1. Remote Desktop Protocol ports need multifactor authentication

The vulnerability the criminals took advantage of at Hancock is a common port associated with Windows that has plenty of legitimate uses, says Pelletier, such as remote system maintenance, but ports like that are often exploited.

“With this particular port, if clients have a business case that it needs to be open we advise multifactor authentication, including a password, a biometric, and a PIN, randomly generated,” he says.

2. You’re more vulnerable than you think

“In terms of readiness, we had systems in place, had a company that was supposedly monitoring us, and we had cyberinsurance,” says Long.

Hancock didn’t use the cheapest vendors, but not the most expensive, either.

“When you’re the [CEO], IT is the thing you always feel like you put so much money into,” he says. “What we’ve also learned is you could have the best of everything, and you’re not 100% safe. There is a balance.”

3. It takes humans to counter humans

Software can’t fully do the job. It takes humans to offer a dynamic defense to the ingenuity of a hardworking criminal enterprise.

“A lot of organizations buy into what vendors say about their tool but there are vulnerabilities we don’t know about and someone might be harvesting that,” says Pelletier. “Bad actors leave evidence of their attempts that can show something is going on, but it takes a human to do the analysis.”

“In cyber terms, if you are targeted, then with enough time, effort, and resources, they will likely be successful, but It takes time and resources and money,” says Pelletier. “If you make yourself a hard target, they’ll move to someone else who is more vulnerable.”

4. Don’t underestimate the criminals

Cybercriminals carefully calibrate the ransom they ask for based on your organization’s ability to pay, Pelletier says.

“They want to get paid and that’s why the [ransom] dollar amounts, relatively speaking, are low,” Pelletier says.

He says you can restore from a backup rather than pay the ransom, but the likelihood of being able to recover completely may be questionable.

Adds Long: “They force you down a path. We needed to get up quickly, and we had some question about whether our backups were viable,” he says. “I agree with every reason not to pay, but until you are faced with the decision, it’s easy to say lots of things. For us it made the most sense to get the decryption keys.”

Long says such things can happen to anyone. You have to plan for the worst.

“I never imagined I would be sitting there on a Thursday night having shut down all our computers,” Long says. “We want others to learn from this and we believe we can be, for lack of a better word, a beacon.”

Challenges of antibiotic stewardship in the ICU

By Christopher Cheney, HealthLeaders Media

Antibiotic stewardship in the intensive care unit setting poses unique challenges to intensivists and other ICU clinicians, recent research indicates.

Appropriate prescribing of antibiotics by healthcare providers is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.

Research co-author Richard Wunderink, MD, FCCP, of Northwestern University Feinberg School of Medicine in Chicago, told HealthLeaders that there are three primary unique aspects of antibiotics stewardship in the ICU.

  • Severity and acuity of illness requires early administration of antibiotics
  • Diagnostic uncertainty in a patient who presents with multiple potential sites of infection prompts multiple potential antibiotic treatment regimens
  • There is a tendency for patients with risk factors for multidrug-resistant, extensively drug-resistant, and pan-drug-resistant infections to require transfer to the ICU

As a result of these challenges, ICU clinicians often deal with the negative impact of excess antibiotic therapy, Wunderink and his co-authors wrote in the journal CHEST. [more]

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

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.”