In a highly-anticipated move expected to significantly affect the regulatory rules that hospitals and other healthcare facilities are held to, the Centers for Medicare & Medicaid Services (CMS) has officially adopted the 2012 edition of the Life Safety Code® (LSC).
CMS has confirmed that the final rule adopts updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the LSC as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code.
Healthcare providers affected by this rule must comply with all regulations by July 4—60 days from the publication date of the rule in the Federal Register.
The adoption of the rule has long been anticipated, as the LSC, which governs fire safety regulations in U.S. hospitals, is updated every three years, and CMS has not formally adopted a new update since 2003, when it adopted the 2000 edition. As a result, CMS surveyors have been holding healthcare facilities to different standards to other regulatory agencies that have gradually adopted provisions of the new LSC in their survey requirements.
Some of the main changes required under the final rule include:
- Healthcare facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years. after the rule’s effective date.
- Healthcare facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than 10 hours.
- The provisions offer long-term care facilities greater flexibility in what they can place in corridors. Currently, they cannot include benches or other seating areas because of fire code requirements limiting potential barriers to firefighters. Moving forward, LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms.
- Fireplaces will be permitted in smoke compartments without a one-hour fire wall rating, which makes a facility more home-like for residents.
- For ASCs, alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.
To get up to speed on the 2012 Life Safety Code® check out the following resources from HCPro Marketplace:
- The New Life Safety Code®: How to Prepare in Advance
- The New Life Safety Code® Workbook and Study Guide for Healthcare Facilities
- The New Life Safety Code® Field Guide for Healthcare Facilities
CMS surveyors are no longer required to determine a facility’s compliance with Advanced Diagnostic Imaging (ADI) supplier requirements or hospital outpatient department requirements. Accrediting organizations like HFAP will still evaluate compliance on these requirements, though they won’t audit billings submitted by providers.
ADI suppliers and hospital outpatient areas with computed tomography (CT) services must meet safety requirements under NEMA Standard XR-29-2013. The ruling applies to hospitals and critical access hospitals and went into effect on January 1, 2016.
Although none of the standards have been changed, surveyors will now ask facilities:
- Does the facility have outpatient areas providing CT services?
- If yes, the surveyors will request the manufacturer’s certification of NEMA XR-29 compliance.
More than 60 medical experts and nonprofit organizations sent petitions this week to The Joint Commission and CMS asking for changes in their respective pain management policies. The petitions say that making physicians routinely ask patients about their pain level encourages excessive prescriptions of opioids.
“Mandating routine pain assessments for all patients in all settings is unwarranted and can lead to overtreatment and overuse of opioid analgesics,” they wrote to The Joint Commission. “Healthcare professionals are capable of using their clinical judgment to determine when to assess patients for pain.”
Specifically, petitioners are asking for changes to The Joint Commission standards PC.01.02.07, PC.01.02.01, and RI.01.01.01 and for CMS to remove pain treatment questions from its Hospital Consumer Assessment of Healthcare Providers and Systems survey.
The petitions were headed by the Physicians for Responsible Opioid Prescribing and are co-signed by the heads of the National Center on Addiction and Substance Abuse, the National Women’s Health Network, the American Society of Addiction Medicine, and health commissioners from Vermont, Pennsylvania, Alaska, and Rhode Island.
This month, CMS plans to add a new “five-star” hospital rating system to its Hospital Compare website. Under the system, hospitals would receive more stars for better compliance with a set of 62 measures that focus on mortality, safety, hospital readmissions, and the timeliness and effectiveness of care.
The plan has come under fire, however, with many saying the rating system is too simplified to show true quality and puts too much emphasis on patient satisfaction. So far, 60 senators, two congressmen, and the American Hospital Association (AHA) have sent or published letters to criticizing the rating system.
“While the AHA supports the concept of providing an easier way for patients and communities to understand quality data, we are concerned that an overall hospital star rating oversimplifies the complexity of delivering high-quality care,” the organization wrote in a press release. “This is especially true because the measures in the [inpatient quality reporting program] and [outpatient quality reporting program] were not chosen with the intention of creating a single score reflecting all aspects of quality.”
Using the rating system to look at past data, CMS said that out of 3,647 hospitals, 142 would get one star, about 1,881 would get three stars, and 87 would get five.
Update: CMS has announced it will delay the release of the five star rating system until July.
A study published in Health Affairs found that the time lost reporting on quality measures costs medical practices around $15.4 billion annually. The time spent reporting on quality costs practices around $40,069 per physician each year, with 80% of practices saying that time spent on quality reporting has increased over the last three years.
The study compared 1,000 practices across four specialties: cardiology, orthopedics, primary care, and multispecialty. Researchers found that a single physician generates about 15.1 hours’ worth of quality data per week. Physicians typically spent 2.6 hours doing quality measure reporting, with the rest falling to staff. A majority of the work was data entry. How much time a physician personally spent each week on quality measures varied between primary care physicians (3.9 hours), multispecialty physicians (3.0 hours), cardiologists (1.7 hours), and orthopedists (1.1 hours).
“There is much to gain from quality measurement, but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures,” the authors wrote.
Most healthcare insurers have their own unique quality measure sets and reporting methods. However, this is expected to change with the recent CMS announcement of new nationally accepted core quality measures, which are currently being phased in by CMS and 70% of private insurers.
CMS and a consortium of health organizations and insurers on February 16 revealed a new agreement to create a nationally accepted set of quality measures for hospitals and physicians. The agency said the new measure sets will improve consumer decision-making, value-based payment and purchasing, reduce the variability in measure selection, and decrease the collection burden and cost for providers.
“In the U.S. healthcare system, where we are moving to measure and pay for quality, patients and care providers deserve a uniform approach to measure quality,” acting CMS Administrator Andy Slavitt said in a news release. “This agreement today will reduce unnecessary burden for physicians and accelerate the country’s movement to better quality.”
CMS has been working with members of the Core Quality Measures Collaborative (CQMC) on the seven measure sets, with links to the new measures included below:
- Accountable Care Organizations (ACO), Patient Centered Medical Homes (PCMH), and Primary Care
- HIV and Hepatitis C
- Medical Oncology
- Obstetrics and Gynecology
CMS says the promotion of evidence-based measurement will help patients, consumers, and physicians. Some of the CQMC members now recognizing the new measures include:
- America’s Health Insurance Plans, Inc.
- BlueCross BlueShield Association;
- Kaiser Permanente
- The American Academy of Family Physicians
- The American Medical Association
- The National Partnership for Women and Families
- The National Quality Forum
- United Health Insurance
When: 1:00–2:30 p.m. EST, Wednesday, February 24, 2016
What: CMS has increased the frequency of its hospital surveys, and many healthcare facilities are finding themselves unprepared for the bump in federal scrutiny. This webcast will arm attendees with the preparatory steps and strategies needed to survive a CMS survey. Attendees will also examine a real-life case study for specific examples of survey citations and how to respond to them.
- Utilize a compliance plan to develop an organization-specific, comprehensive approach to accreditation and compliance readiness
- Identify at least three sources of information to review changes in the Conditions of Participation/survey process
- Implement a gap analysis of your organization’s compliance readiness
Who: Victoria Fennel, PhD, RN-BC, CPHQ, is the director of accreditation and clinical compliance for Compass Clinical Consulting and has 20 years of healthcare leadership experience. She has spent the majority of her career in nursing leadership roles and brings expertise in evidence-based practice, nursing education, quality management, performance improvement, accreditation, risk management, patient safety, and patient-centered care.
Julie Campbell, MHA, BSN, NE-BC, HACP, is the Baylor Scott & White Health North Texas Division vice president and has than 25 years of nursing leadership experience. Campbell assists in survey preparation, development of corporate policies and procedures, communications on revisions to regulations/standards, and recommendations of regulatory changes to various system councils to maintain continuous readiness.
There’s still time to join the December webcast on CMS and Joint Commission hot spots for 2016.
Join Bud Pate, REHS, and Lisa Eddy, RN, CPHQ, on Wednesday, December 16 at 1 p.m. ET as they examine current survey focuses and point out where CMS and The Joint Commission will concentrate their efforts during your next survey.
In just 90 minutes, find out how to prepare for your next accreditation survey and comply with the most troublesome CMS and Joint Commission requirements. Pate and Eddy will provide strategies for preparing your staff for survey and give you valuable tips about what surveyors will expect when they arrive at your facility.
For more information and to register for the webcast, call HCPro customer service at 800-650-6787 or visit the HCPro Marketplace.
CMS is asking Medicare patients or their family members to help them develop a new patient-satisfaction survey of long-term, acute-care facilities. The comments will help CMS decide what sorts of information the survey will need to collect. Some of the suggested topics areas include:
• Communication with providers
• Mechanical ventilation
• Therapy services
• Wound care
• Pain management/control or non-pain symptom management
• Rehabilitation services
• Medical and nursing care
• Interdisciplinary team goal setting and care planning
• Family training
• Discharge planning
The survey will also be used in Medicare’s quality reporting program, meaning facilities that fail to deliver data could get a 2% reduction in their payment updates. CMS is accepting comments until 5 p.m. on Jan. 19.
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.
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 firstname.lastname@example.org.