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New name for Briefings on The Joint Commission

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.

The November issue should be in your inbox. You can view it here and if you haven’t had a chance to subscribe to the newsletter, click here for more information.

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


Healthcare organizations urge CMS to suspend new sepsis management measure

Four major healthcare organizations have asked CMS to postpone implementation of the severe sepsis and septic shock management bundle measurement that is scheduled to go into effect October 1, 2015. The measure as currently written, calls for the use of broad spectrum antibiotics to treat severe sepsis and septic shock.

The group consisting of the American Health Association (AHA), America’s Essential Hospitals, AAMC, and the Federation of American Hospitals, is urging CMS to refine the measure so that it more closely aligns with the antimicrobial stewardship put forth by the CDC and the White House earlier this summer.

“By encouraging the use of broad spectrum antibiotics when more targeted ones will suffice, this measure promotes the overuse of the antibiotics that are our last line of defense against drug-resistant bacteria,” the group wrote in a letter to CMS.

Read the full letter here.

CMS announces Physician Quality Reporting Programs Strategic Vision

When CMS shared the findings of the 2015 Physician Quality Reporting System (PQRS) payment system, they also released the publication of the Physician Quality Reporting Programs Strategic Vision, or “Strategic Vision”.

The Strategic Vision is part of a long-term quality measurement plan for healthcare providers and public reporting programs and how those can be enhanced to support better decision-making from physicians, consumers, and everyone involved in healthcare.

For more information about the plan, click here.

CMS updates eCQMs for 2016 reporting

Last Friday, CMS posted the annual update for the 2014 electronic clinic quality measure (eCQMs) for eligible hospitals and professionals. Providers should use these measures to report 2016 quality data for CMS reporting programs, including the Physician Quality Reporting System (PQRS), Inpatient Quality Reporting Program (IQR), and the EHR Incentive Programs.

CMS updated 29 measures for eligible hospitals and 64 measures for eligible professionals.

Read the updated measures here.

CMS announces five-star rating for Hospital Compare

Yesterday, CMS officially unveiled the star ratings on its Hospital Compare website in an effort to make it easier for consumers to choose a hospital and understand the quality of care each delivers.

After the new rating system went into effect, only 251 out of approximately 3,300 hospitals have all five stars. The Hospital Compare site notes that a hospital with a one-star rating doesn’t indicate a consumer will receive poor care and encourages consumers to consider multiple factors when choosing hospitals, rather than focusing solely on the star rating.

CMS levies heavy fines on Medicare Advantage plans

The CMS has fined 12 Medicare Advantage plans nearly $4 million in civil money penalties (CMP) since the beginning of the year. Nearly all of the plans were cited for failing to comply with contract requirements, such as incorrect prescription information or coverage disputes.

CMPs are the lowest enforcement penalty the CMS orders, although the financial penalties can be steep. Penalties issued so far range from approximately $21,000 to $1 million. The highest penalty is plan termination.

Additionally, CMS ordered one plan to suspend enrollment and three plans were released from sanctions after correcting deficiencies.

CMS to add five-star rating to Hospital Compare website

The Centers for Medicare & Medicaid Services (CMS) will add the five-star quality rating to its Hospital Compare website later this month. The five-star quality rating is already used on the Nursing Home Compare and Physician Compare sites.

CMS will add twelve HCAHPS Star Ratings to the Hospital Compare; one for each of the 11 publicly reported measures, plus an overall Summary Star Rating that represents a weighted average of the individual HCAHPS Star Ratings.

According to CMS, the star ratings will make it easier for consumers to use the information on the Compare websites and spotlight excellence in healthcare quality.

CMS releases final hospital/CAH CoPs

Last week, the Centers for Medicare and Medicaid Services (CMS) posted the final rule reforming the Hospital/CAH CoPs. This rule is available on display copy only and will publish officially to the Federal Register on May 16th.  The DC office is in the process of completing a thorough review of the final rule and will pull a team together to discuss the provisions, and will provide a comparative analysis of the final provisions to the comments that Joint Commission submitted.

A quick review of the final rule can be found here.

HHS seeks to reduce preterm births with $40m grant incentive

Last week the Department of Health and Human Services (HHS) launched a $40 million effort to reduce preterm births and ensure more babies are born healthy. Through a program called the Strong Start initiative, the Centers for Medicare and Medicaid Services (CMS) will seek to reduce preterm births by awarding grants to hospitals, healthcare providers, and community coalitions to improve prenatal care, test new methods to reverse the trend, and reduce early elective deliveries.

According to HHS, about 10 percent of all deliveries are scheduled—either as induced or Cesarean-section— before 39 weeks and are not medically indicated.

Testing for early induction of labor is addressed in the Joint Commission’s latest National Patient Safety Goal aimed at minimizing overuse of tests, treatments, and procedures in hopes to prevent harm and reduce waste. The idea is that if evidence shows no benefit, you are exposing a patient to only potential harm by giving an unnecessary test or treatment.

In fact, evidence shows the opposite. The American College of Obstetricians and Gynecologists says preterm babies (those born before 39 weeks) are at an increased risk of significant complications such as low birth weight, lung disorders, feeding problems, and blood infections, as well as long-term health problems, and an article released by Kaiser Health News said Medicaid spends $20,000 a year on babies born premature in their first year, almost 10 times that of infants born at full term.

A report by HealthLeader’s Media says reducing early elective births could save $1 billion annually, and according to a survey by The Leapfrog Group, of the 757 hospitals that volunteer to report data on obstetric care quality, too many have obstetricians who still schedule potentially harmful elective Cesareans and inductions too early rather than supporting unprompted deliveries.

To learn more about the effort to reduce preterm births, visit the CMS Innovation website.

HHS encourages equal visitation and representation rights

The Department of Health and Human Services (HHS) issued a press release this week to give added support to The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COP) rules released in November of last year giving patients the right to choose their own visitors during a hospital stay.

The guidance given by the HHS emphasizes that hospitals should respect patients’ wishes concerning their representatives (whether expressed in writing, orally, or through other evidence unless prohibited by state law) in an effort to make it easier for family members, including a same-sex domestic partner, to make informed care decisions for loved ones who are incapacitated.

The CMS also sent a letter this week to State Survey Agencies (SSAs), highlighting the equal visitation and representation rights requirements and directing SSAs to be aware of the guidance when surveying for hospitals’ compliance with CoPs.

Read the full press release here.