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National Guidelines, Quality Measures Clearinghouses Shutting Down

If you or anyone at your hospital use the National Guidelines Clearinghouse or National Quality Measures Clearinghouse operated under the auspices of the Agency for Healthcare Research and Quality (AHRQ), download the information you need soon.

Both online clearinghouses will go dark after July 16 as federal funding runs out. Neither site is accepting new guidelines or quality measure sets in anticipation of shutting the databases down.

Announcements on each website note that that AHRQ has received “expressions of interest from stakeholders” that want to takeover maintenance of the databases, but AHRQ officials have declined to identify who those stakeholders are for now.

The clearinghouses were set up more than two decades ago as central sites to help hospitals, clinicians and others in health care find evidence-based information on which to set policy, create clinical treatment plans and objectively measure quality outcomes.

The guidelines and measures are submitted by various professional or academic health organization and must meet detailed criteria to be included in each database. As guidelines or measures are updated or become outdated, the information is removed.

AHRQ evaluating options

“AHRQ recognizes the importance of this resource and is evaluating potential options, including the participation of stakeholders who may wish to operate the Clearinghouse in the future,” stated Alison Hunt, MPH, with AHRQ’s Office of Communications, Media Division.

If public or private stakeholders are found to take over the clearinghouses, ARHQ still has not decided what role it will continue to play, Hunt said.

While the federal sites may go away, the information will still be available from each of the professional society, academy or other healthcare group that originated the material, notes Karen Schoelles MD, SM, FACP, director of ECRI Institute’s Penn Medicine Evidence-based Practice Center (EPC) and project director for both clearinghouses.

ECRI was the original contractor hired by AHRQ to set up and run the guidelines clearinghouse in 1987.

Besides having information in one place, one of the advantages in having each of the clearinghouses is that users could have some assurance that the information had been professionally vetted and was up-to-date.

Having evidence-based information to back a policy or best practice is one of the key mantras of both The Joint Commission and CMS.

Hospital leaders or others who need information about the validity of a particular set of guidelines or best practice can still seek out help from any of the Evidence-based Practice Centers (EPC) set up through AHRQ, says Schoelles. ECRI-Penn Medicine is one of 12 EPCs across North America.

EPC programs offer help

The EPCs develop evidence reports and technology assessments to assist public- and private-sector organizations, and “provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies and strategies,” according to a AHRQ research white paper released in December. Schoelles was a work group leader on the paper, A Framework for Conceptualizing Evidence Needs of Health Systems.

The paper sets out to determine the evidence needs of health systems to both guide future EPC programs and ultimately help organizations as they seek “evidence to inform decisions about acquiring new or emerging medical technologies; implementation or expansion of service offerings; and selection of governance, finance or delivery system models,” notes a summary.

As part of the group’s research it looked at information requests made at four large health institutions;  Kaiser Permanente Southern California, the Veterans Health Administration’s Evidence Synthesis Program, ECRI Institute’s Health Technology Assessment Information Service, and Penn Medicine Center for Evidence-based Practice.

“A wide range of clinical and administrative decision-makers requested evidence reviews, and the topics were similarly broad—ranging from evidence to guide clinical care; purchasing of medications and devices; procedural and non-procedural interventions; and processes of care,” according to the paper.

Highlighted throughout the requests was a need for trustworthiness of information, notes Schoelles.

If you are seeking to verify or evaluate information and are part of a larger health system, Schoelles suggests starting with the larger organization to see what help it can offer. Often health systems will evaluate a guidelines or best practice and then establish a policy or guidelines based on that information, or can share the evaluation throughout the system’s smaller organizations, she said.

ECRI, for instance, offers a variety of evaluation services. Some ECRI services are free to members, others are fee-based. ECRI Institute also is currently exploring ways to maintain a guideline repository, notes Schoelles.

Resources

This article was originally published in Inside The Joint Commission.

CMS’ severe sepsis bundle ISN’T a Joint Commission requirement

The April 17 issue of Annals of Internal Medicine (AIM) incorrectly stated The Joint Commission was considering creating a requirement for hospitals to implement CMS’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) to receive accreditation. This information is incorrect and AIM has published a correction.

Joint Commission Urges Hospitals to Protect Workers from Abuse

This story originally ran on HCPro’s OSHA Healthcare Advisor.

The Joint Commission is the latest healthcare heavy-hitter to call for better protection of healthcare workers, announcing on Tuesday the creation of Sentinel Event Alert 59, which addresses violence—physical and verbal—against healthcare workers.

About 75% of workplace assaults occur in healthcare and social service sector each year, and violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries.

The purpose of the new alert is to help hospitals and other healthcare organizations better recognize workplace violence directed by patients and visitors toward healthcare workers and better prepare healthcare staff to address workplace violence, both in real time and afterward, The Joint Commission wrote in this latest Sentinel Event Alert publication.

Sentinel Event Alert 59 has some overlap with Alerts 40 and 57—which were released in 2008 and 2017, respectively, and focused on the development and maintenance of safety culture—and therefore were not addressed in this alert.

Per the Occupational Safety and Health Administration (OSHA), about 75% of workplace assaults annually occurred in the healthcare and social service sector. Violence-related injuries are four times more likely to cause healthcare workers to take time off from work than other kinds of injuries, according to the Bureau of Labor Statistics (BLS).

The Joint Commission cites both of those facts in this Sentinel Event Alert publication and adds that Joint Commission data show 68 incidents of homicide, rape, or assault of hospital staff members over the past eight years—and that’s mostly only what hospitals voluntarily reported.

The Joint Commission is calling for each incident of violence or credible threat of violence to be reported to leadership, internal security, and—if necessary—law enforcement, and it also wants an incident report to be created. Under its Sentinel Event policy, The Joint Commission says that any rape, any assault that leads to death or harm, or any homicide of a patient, visitor, employee, licensed independent practitioner, or vendor on hospital property should be considered a sentinel event and requires a comprehensive systematic analysis.

Additionally, The accreditor says it’s up to the healthcare organization to specifically define unacceptable behavior and determine what is severe enough to warrant an investigation.

This Sentinel Event Alert, which you can download here along with other resources, comes on the heels of an emergency preparedness rule from CMS that recently went into effect and efforts from the National Fire Protection Association to fast-track its new standard for active shooter events and other violent incidents. OSHA is also considering a standard to help protect healthcare and social workers from violence.

Avoid Eyewash-Related Regulatory Compliance Issues

Eyewash stations continue to confuse and confound healthcare organizations (HCO). Not only can they pose infection control and safety issues for workers, they can be a point of contention between HCOs and surveyors, who often seem to work by different sets of rules.

During this 90-minute webinar on May 31, former hospital administrator and accreditation expert John R. Rosing, MHA, FACHE, will explain what regulators like CMS, The Joint Commission, and OSHA expect from an HCO’s eyewash stations. He will provide the steps personnel can take to keep staff safe and the organization in compliance with rules and regulations. Attendees will learn how to avoid eyewash-related regulatory compliance issues, how to perform a risk assessment to determine when an eyewash station is necessary, and what type of eyewash station they need.

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

  • Avoid eyewash-related regulatory compliance issues
  • Perform a risk assessment to determine when an eyewash station is needed
  • Identify what type of eyewash station is needed
  • Properly maintain eyewash stations

Presented on:
Thursday, May 31, 2018
1:00-2:30 p.m. ET

Presented by:
John R. Rosing, MHA, FACHE

Level of Program:

Intermediate

To register or get more information, please visit the event page at HCMarketplace.com.

The Joint Commission: Comments open on proposed suicide risk NPSG through May 7

Wishing you could weigh in on The Joint Commission’s expectations about suicide risk? You have your chance. Through May 7, The Joint Commission is accepting comment on proposed revisions to National Patient Safety Goal 15 on reducing the risk of patient self-harm.

The Joint Commission published the revisions on its Standards Field Reviews web page on March 26. The revisions, which will require hospitals to be more proactive in removing risks from the physical environment, include proposed changes to both the general Hospital and the Behavioral Health Care accreditations programs.

Under the Hospital Accreditation program, a revised Element of Performance (EP) 1 applies only to hospitals, whereas the rest of the now seven EPs — up from just three — will apply only to those patients in psychiatric hospitals or being treated for behavioral health problems in general hospitals, according to the field review information.

The other EPs for both programs outline expectations of conducting suicide assessment of patients, documenting a patient’s risk and the plan to deal with that patient’s suicidal ideation, the need for written policies and procedures and quality monitoring of the programs, among other things.

You can comment on the proposed revisions online or by mail. To read the full set of revisions, and for links and instructions on how to comment, go to the Field Reviews page, https://www.jointcommission.org/standards_information/field_reviews.aspx. — A.J. Plunkett (aplunkett@h3.group)

Lawmakers want more AO oversight

In a letter to CMS Administrator Seema Verma, the committee is asking for what could be reams of information from the agency about patient harm and incidents of misconduct at acute care hospitals. The committee has also asked for similar information from each of the four hospital accrediting organizations (AOs).

The committee was particularly concerned about information in a report to Congress published last summer that indicated AOs “conducting hospital surveys did not report 39% of ‘condition level’ deficiencies that were subsequently reported following validation surveys conducted by [CMS] State Survey Agencies no later than 60 days following the AO survey.”

“Although CMS has worked to strengthen its oversight of AOs, the committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the accrediting organization survey process,” wrote the committee leaders.

Noting that the Department of Health and Human Services, through CMS, must provide oversight of accrediting organizations, including CMS’ own survey agencies, “the Committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the AO survey process,” read the letter to Verma.

More coverage of this story will be in the May edition of Briefings on Accreditation and Quality

Joint Commission releases 2017 sentinel event stats

Unintended retention of a foreign body, patient falls, and wrong-site surgery top The Joint Commission’s full list of reported sentinel events for 2017.

Every year, The Joint Commission complies a list of all the sentinel events that hospitals reported to them. Since the list only comes from self-reported data, it tends to underrepresent the real frequency of these problems. However, it’s useful in identifying trends, causes, and outcomes of adverse events. The top 10 sentinel events in 2017 were:

  1. Unintended retention of a foreign body
  2. Falls
  3. Wrong patient, wrong site, wrong procedure
  4. Suicide
  5. Delays in treatment
  6. Other unanticipated events
  7. Criminal events
  8. Medication errors
  9. Operative/postoperative complication
  10. Self-inflicted injury

The only new addition to the list since 2016 is “self-inflicted injuries,” which replaced “perinatal death/injury.” While a few hopped up or down one on the list, for the most part, there wasn’t much change.

CMS Cites Baltimore Hospital for Abandoning Patient in January

A Baltimore hospital was cited by CMS in a report released this week for its actions in removing a mentally ill patient from its emergency room (ER) and leaving her at a bus stop wearing just a hospital gown. The Washington Post reports that the University of Maryland Medical Center (UMMC) was cited for failing to comply with the Emergency Medical Treatment and Labor Act (EMTALA).

The hospital came under fire in January after a bystander filmed the incident as the woman was left by security guards at a bus stop on a cold night. According to the Post, the patient was admitted to the hospital earlier that day after a fall from a motorized bike. She was cleared for discharge, but resisted and refused to dress, the report said. Security then dropped the patient off at a nearby bus stop, where the man who filmed the incident and then called for an ambulance. The woman was brought back to the hospital and then taken to a homeless shelter in a taxi without an exam, and it was not registered that she returned to the facility, the Post reports.

According to the Baltimore Sun, CMS found that UMMC violated a federal law that hospitals must protect and promote each patient’s rights. The hospital also was found to have violated the woman’s right to receive care in a safe setting, to be free from all forms of abuse or harassment, and her right to confidentiality of records because non-clinical staff were given access to or made aware of part of the patient’s medical history. CMS also found that UMMC failed to meet data collection and analysis standards and failed to perform quality improvement activities.

The Sun reports that the hospital has now begun to record every time patients visit the ER. It also conducts audits of the patient log each month, provides additional staff training on federal requirements, and keeps ER doors unlocked. The staff bylaws were updated to specify who can perform medical screenings.

In a statement reported by the Post, a UMMC spokesperson admitted that mistakes were made. “We take responsibility for the combination of circumstances in January that failed to compassionately meet our patient’s needs beyond the initial medical care provided. While our own thorough self-examination revealed some shortcomings, the regulatory assessment punctuates the necessity to more firmly demonstrate our unwavering commitment to safety quality, compassionate patient care.”

EMTALA, in general, requires hospitals to care for patients with emergent conditions, regardless of their ability to pay. Violations of EMTALA are often cited by CMS surveyors under patients’ rights or failure to do an adequate medical screening exam. In addition to potentially impacting a hospital’s accreditation or ability to bill Medicare, EMTALA violations can also come with a civil penalty, which can reach nearly $105,000 for each citation. The newspaper reports did not mention whether the hospital was fined in relation to the CMS findings.

Joint Commission changes for March 2018

Deleted: RI.01.01.01, EP 8

Effective immediately, The Joint Commission (TJC) has deleted element of performance (EP) 8 from Rights and Responsibilities of the Individual (RI) standard 01.01.01. While it’ll take some time to come out of the manual, surveyors can no longer survey for it. The EP said that a hospital must respect the patient’s right to pain management. The accreditor said that after reviewing its comprehensive pain assessment and management requirements, the EP was found to be irrelevant.

Revised: EC.02.03.05, EP 25

The point of this revision is to provide extra clarity on non-rated doors. TJC made the revision to make the Environment of Care (EC) chapter align with the Life Safety Code (LSC). This revision applies to ambulatory care, behavioral healthcare, critical access hospitals, home care, and hospitals. You can read the program-specific EPs here.

Revised: EC.02.05.01, EP 27

The purpose of this revision is to address environmental features of areas administering inhaled anesthetics. TJC made the revision to make the EC chapter align with the LSC. This revision applies to ambulatory care, critical access hospitals, hospitals, and office-based surgery practices. You can read the program-specific EPs here.

Joint Commission plans to make new suicide prevention standards

This December, The Joint Commission (TJC) convened the fourth meeting of a suicide prevention expert panel. The accreditor announced in the March edition of Perspectives that the recommendations they came up with went beyond what’s in the standards. So they intend to convert some of them into new Elements of Performance in National Patient Safety Goal 15.01.01. When they are finished updating the NPSG, it will be sent out for national field review, just like it normally would.

The first and second panels were published in November and centered on inpatient psychiatric units, general acute inpatient settings, and emergency departments. The third panel discussed other behavioral healthcare settings and had its recommendations published in January.