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(TBT) Checklists: Easy to take for granted

Editor’s Note: This is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

Checklist

In any organization’s quality department there lives a nefarious, ever-present beast. It’s usually in paper form and comprises a list of seemingly innocuous phrases or sentences and to the far right is the “checkbox.” It’s easy to become disdainful of checklists, but the reality is they play an important role.

I’m sure we’ve all heard some of the complaints.

Often these checklists include things such as, “Are there any wall penetrations?” or “Do staff know where the closest fire extinguisher is?” These questions often can be grating to hospital administrative teams because it’s “one more thing” they have to worry about and it can be frustrating during surveys to be “caught” on things that “don’t matter” in the clinical realm.

I hear the reactions to such mundane questions all the time, “Yes, it’s important but we are more concerned with medication errors, fall rates, sentinel events. Who has time to check for escusions? Shouldn’t there be a weighting scheme to it all?”

The reality is that checklists are important, and they’re focused on patient safety and care. Escusion plates and wall penetrations exist for those unthinkable times when hospitals catch fire, a rare and devastating event. When fires occur, though, those safety measures limit the impact fire and smoke can have to the most vulnerable of populations. The same can be said about medication errors and sentinel events: they are rare and potentially devastating. The measures organizations take to prevent harm must be all-encompassing.

When being confronted with checkboxes, do not put them off as non-mission critical, or roll your eyes at the people who bring them to your attention. These are safety measures, clear and simple, that must be addressed with the same type of immediacy.

Moreover, the idea of checkboxes must become incorporated into the everyday fabric of hospital operations and not delegated to one person doing safety rounds once per quarter. Educate frontline leaders to remain abreast of their own areas or have them round on other departments to keep a fresh set of eyes on the organization. Have it be part of the expectation as opposed to being something extra you ask of your leadership team.

Healthcare isn’t easy; it takes a concentrated effort to remain diligent. Healthcare exists to take care of people at their most vulnerable, which means being vigilant about the checkboxes, too.

Editor’s note: Patrick Pianezza, MHA, has worked with the Studer Group and Johns Hopkins Hospital. In his most recent role, Pianezza’s work drove organizational performance in HCAHPS to an all-time hospital best in the 90th percentile. He can be reached at ppianezza@gmail.com.

CMS releases interpretive guidance on emergency preparedness

CMS unveiled interpretive guidance and survey procedures on its emergency preparedness rule. The emergency preparedness rule went into effect last November. The interpretive guidelines apply to all 17 provider and supplier types.

Read the full memo here. 

Joint Commission Updates on HAI-related National Patient Safety Goal on HAIs

The Joint Commission has revised several of its requirements for National Patient Safety Goal (NPSG) 7, which focuses on the issue of healthcare-associated infections (HAI). The revisions go into effect on January 1, 2018, and apply to hospitals, critical access hospitals (CAH), and nursing care centers (NCC).

NPSG 07.03.01: Multidrug-resistant organisms (MDRO)

•    NCCs are now expected to follow the MDRO NPSG.07.03.01. Nursing homes experience a high rate of MDROs such as methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). This was particularly concerning because nursing home patients were bringing MDROs to hospitals and vice versa.
•    The Joint Commission is adding a new infection, carbapenem-resistant enterobacteriaceae (CRE) to NPSG.07.03.01. This change applies to hospitals, CAH, and NCCs.

NPSG 07.04.01: Central line-associated bloodstream infections (CLABSI)

•    The EPs for the NPSG 07.04.01 have been reordered.
•    EP 11 was revised to specify the use of chlorhexidine for antiseptic skin preparation.
•    For both NPSG 07.03.01 and NPSG 07.04.01, facilities are now allowed to determine how frequently they need to re-educate staff and licensed independent practitioners on MDROs and CLABSIs.

CMS issues Legionella reduction memo

On June 2, CMS issued a new memo to surveyors on the importance of reducing cases of Legionella infections. Accredited facilities should double check their waterborne pathogens compliance, as surveyors will likely pay more attention to it in upcoming surveys.

Legionellosis is comprised of a sometimes fatal form of pneumonia called LD as well as Pontiac fever. The bacterium grows in the parts of hospital water systems that are continually wet and is spread through inhalation of aerosolized droplets of contaminated water. Legionellosis poses a particular risk to patients older than 50, who smoke or have chronic lung or immunosuppression conditions. Approximately 9% of reported legionellosis cases are fatal.

Badly maintained water systems have been linked to the 286% increase in legionellosis between 2000-2014. There were 5,000 cases of it reported to the Centers for Disease Control and Prevention (CDC) in 2014 alone. About 19% of outbreaks were associated with long-term care facilities and 15% with hospitals. Just a few items that can spread the contamination include:

•    Decorative fountains
•    Shower heads and hoses
•    Electronic and manual faucets
•    Hot and cold water storage tanks
•    Water heaters and filters
•    Pipes, valves, and fittings
•    Eyewash stations
•    Ice machines
•    Cooling towers
•    Medical devices (e.g., CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units)

“Healthcare facilities are expected to comply with CMS requirements to protect the health and safety of its patients,” the agency writes in its memo. “Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance with the CMS Conditions of Participation. Accrediting organizations will be surveying healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite noncompliance accordingly.”

The memo tells surveyors to review policies, procedures, and reports documenting water management implementation results to ensure facilities:

1.    Conduct a facility risk assessment to identify where Legionella and other waterborne pathogens could grow and spread in the facility water system.

2.    Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit. The program should include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.

3.    Specify testing protocols and acceptable ranges for control measures. Document the results of testing and corrective actions taken when control limits are not maintained.

The contents of this memo go into effect immediately.

Help us out with a survey!

Dear Accreditation Professional,

Your feedback is essential to us at HCPro. Please take just a few minutes to share your thoughts with us regarding your salary and job duties. We will compile the survey results in a special report to provide insight into the state of the profession. Simply click on the link below to begin the survey.

Begin Survey

If clicking on the link does not work, please cut and paste the URL below into the address bar of your browser: https://www.surveymonkey.com/r/MGWCMHX

All your answers are confidential and anonymous. Please fill out the survey before the deadline on July 15, 2017.

If you have questions related to this survey, please contact me at the email address below.

Thank you!

Sincerely,

Jay Kumar | jkumar@hcpro.com
Associate Product Manager, Accreditation and Safety
HCPro

TBT: Building a better self-reporting structure

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

Does your organization have a formalized process for debriefing after an adverse event? And if so, is it working? For many organizations, reporting of adverse events can be problematic, with challenges ranging from time management and inefficient processes to the age-old challenge of shame?reporting near misses and adverse events can be a challenge in an industry where everyone pursues the field to help, not hurt.

“Everyone wants to leave work happy and feel like they did a good job,” says Anngail Smith, VP of operations and risk management for CRG Medical, Inc., in Houston. “Someone once said that healthcare is the intersection of care and being able to hurt people. A client told me that healthcare is a courageous activity.”

Because healthcare rides along that fine line between safe care and risk of harm, the industry needs to build an environment where people are willing to report errors and near misses so that the industry as a whole can work on the problem without being afraid.

“I think the fear of hurting someone is always there,” says Douglas Dotan, president and CEO of CRG Medical. “The question is, are you willing to incorporate that into learning how to make your processes better?”

The pressures to report are staggering for providers, Dotan says. Personal liability, risks to reputation, job security, and even peer pressure can all come into play with the issue of reporting. But the industry needs physicians to speak up and identify hazards to patient safety, share their knowledge about near misses, and propose actions to improve the delivery of care. This requires a culture change to create an environment in which providers feel safe to talk about these things without putting themselves at risk.

“If there is something that really stresses caregivers out, we need to find a way to fix it, and we need to share that fix,” says Dotan. “That won’t happen if they’re afraid.”

This is not a new issue, Dotan points out. Donald Berwick’s Institute of Healthcare Improvement talked about these factors 15 years ago, Dotan notes, and yet most events which occur today have occurred in the past, and the latest reports state that the industry has well over 400,000 preventable deaths in healthcare every year.

“That’s about 1,000 deaths that occur every day from preventable medical errors,” says Dotan.

And the contributing factors leading up to these preventable errors occur all the time. The same situation may occur 200 or 300 times before a sentinel event occurs, leading to hundreds of thousands of dollars spent in litigation and reparations because it wasn’t prevented the first 300 times, Dotan says.

This comes down to continual process improvement, he says.

“What we’ve been working on is identifying those hazards and unsafe conditions and putting an easier way for people to communicate in place,” says Dotan. “You need to have a way of documenting and giving feedback. If I continuously give you information I think is important to act on and leadership doesn’t act on it, I will stop communicating that information. So when future problems arise, they will not be reported.”

An open communication system will help overcome the fear of reporting, Smith says.

“Are you good at your job? If you did it badly would you want to tell someone? We spend more time doing our jobs than anything else. For an inexperienced person, if they make a mistake, they might report it. ‘I am new at this; I will make mistakes,’ ” says Smith. “But if the experienced person makes a mistake, they’d think they would be embarrassed to talk about it.”

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Joint Commission issues another warning about improperly cleaned medical devices

For the second time in three years, The Joint Commission has released a Quick Safety issue on the topic of improperly sterilized or high-level disinfection (HLD) equipment and devices. The accreditor writes that despite bringing the problem to light in 2014, there’s an increase in cases of medical devices not being cleaned properly.

“Immediate threat to life (ITL) declarations related to improperly sterilized or high-level disinfected (HLD) equipment have increased significantly from 2013-2016,” wrote Lisa Waldowski, DNP, PNP, CIC, Joint Commission infection control specialist, in a blog post. “In 2016, 74% of all ITL declarations from The Joint Commission were related to improperly sterilized or HLD equipment. As reports of sterilization and HLD-related issues continue to be received by our Office of Quality and Patient Safety, our surveyors also are seeing it firsthand in hospitals, ambulatory care sites and other healthcare settings across the country.”

According to Quick Safety Issue 33, noncompliance with standard IC.02.02.01 (which deals with sterilization) has been on the rise since 2009 in Joint Commission-accredited hospitals, critical access hospitals, ambulatory centers, and office-based surgery facilities.

There are several risks tied to improper reprocessing such as infection and outbreaks, loss of accreditation, litigation, negative publicity, and lost revenue. A prime example of this occurred during the 2015-2016 outbreaks, when it was discovered that the design of the duodenoscopes could prevent them from being properly sterilized.

There are several factors that are causing this rise in noncompliance, according to The Joint Commission. These include:

•    The incorrect assumption that the risk of infection to patients is low or nonexistent
•    Staff either don’t know how to properly sterilize or HLD equipment or they knowingly chose not to follow proper procedures
•    Lack of leadership oversight and the belief that sterilization or HLD is a low priority
•    A culture that discourages the reporting of safety risks
•    No dedicated staff person to oversee the proper sterilization or HLD of equipment
•    Facility design or space issues prevent proper sterilization or HLD of equipment
•    Lack of monitoring or documentation of sterilization or HLD of equipment

“Healthcare organizations need to prioritize improving sterilization and HLD efforts year-round and well before a survey occurs to best protect patients,” says Waldowski. “Together, we can work to change news headlines from reporting on sterilization or HLD-related outbreaks to touting reductions in outbreaks through quality improvement efforts.”

CMS publishes new emergency preparedness Interpretive Guidelines

On June 2, CMS published its final rule for emergency preparedness guidelines and survey procedures. These rules affect all 17 providers and suppliers and the rules will be enforced starting November 15, 2017.

While the survey process will remain the same, the new rule creates compliance tags for emergency preparedness requirements. These tags will be similar to how K-tags are used to cite noncompliance with the Life Safety Code® (LSC).

The emergency preparedness tags will be called “E Tags” and are accessible to both health and safety surveyors and LSC surveyors. State survey agencies will have the discretion to decide which surveyor group will conduct the emergency preparedness surveys.

Joint Commission comments on proposed CMS transparency rule

The Joint Commission has made a public comment regarding CMS’ proposed rule to require accrediting organizations (AO) to make their survey reports publicly available. The Joint Commission is opposed to sharing private survey reports and thinks making the reports public will harm patient care.

Currently, AOs like The Joint Commission and DNV aren’t required to make their survey reports or plans of corrections (PoC) available to the public. Under the proposed rule, AOs would have to post these on their websites. 

“Access to survey reports and PoCs will enable health care consumers, in addition to Medicare beneficiaries, to make a more informed decision regarding where to receive health care thus encouraging health care providers to improve the quality of care and services they provide,” CMS wrote in the proposal memo. If you want to read and comment on the proposed rule, you can find a copy of the memo and commenting instructions here. CMS will accept comments until June 13.

In an open letter to CMS, Joint Commission President and CEO Mark R. Chassin, MD, FACP, MPP, MPH, wrote that while the accreditor is a strong supporter of transparency, it believes revealing all accreditation survey reports to the public is a bad idea. The crux of the issue is that the contents of those survey reports are meant as tools for hospitals to improve. It’s not the same as healthcare quality data, a distinction that may be lost on the public.

“As an organization whose mission is to support quality improvement and patient safety and inspire excellence, we believe the proposal will have significant detrimental consequences on our nation’s ability to continually improve the delivery of health care services,” he writes. “To be clear, this opposition is not one against transparency, but one of creating the right balance between useful, publicly available information and improving the quality and safety of healthcare.”

Some of the Joint Commission’s concerns are:

  • It’ll be harder to get AOs and healthcare organizations to collaborate on patient safety and continuous quality improvement.Having AOs release collected information would make providers less candid about their weaknesses and create an adverse dynamic that will ultimately, there will be increased patient harm and lower quality.
  • It will stunt AO’s efforts to create new standards or raise compliance standards for existing requirements.
  • Healthcare organizations will be incentivized to use AOs that report on the least number of Medicare-comparable standards. This will spur a race to the bottom on quality and may also cause a growth in the number of non-accredited facilities that’ll be surveyed at taxpayer expense and with fewer oversight visits.
  • The proposal will diminish the value of accreditation as a way to motivate healthcare organizations to excel.
  • The proposal will increase costs for AOs and healthcare organizations.

Joint Commission clarifies four LSC-related requirements

The Joint Commission issued clarifications on some of its 2012 Life Safety Code®-related (LSC) requirements. In particular, the clarifications are aimed at the standards for fire doors, fire drills, and emergency department occupancy.

 

  1. Emergency department (ED) occupancy classification: Some EDs meet the qualifications to be considered healthcare or ambulatory healthcare occupancies. The clarification explains how to tell the difference.
  2. Annual door inspection: Fire and smoke doors must receive their annual inspection and testing before July 5, 2017. Corridor doors that aren’t required to be fire doors or smoke door assemblies aren’t subject to the National Fire Protection Association annual inspection and testing requirements. However, they should be routinely inspected as part of facility maintenance.
  3. Rated fire door assembly installed in lesser rated or non-rated assembly: If a fire-rated door is used in a nonrated barrier assembly, the fire door must be maintained as a fire door unless any markers identifying it as a fire door have been removed.
  4. Fire drills and varying times: There can’t be a pattern for conducting fire drills. But drills conducted no closer than one hour apart would be acceptable.