The analysis found that missing data was the biggest cause of discrepancies. Some examples of missing data are:
• Missing data on medication route
• Use of wrong template ID
• Diagnosis Active is missing, which puts the case in denominator
The Joint Commission also unveiled its Core Measure Solution Exchange®,which allows hospitals to share how they implemented the eCQMs. Users can post about the implementation issues they’ve had, challenges they’ve faced, and solutions they’ve come up with. They can learn from other facilities about the problems and solutions they came up with as well.
The Exchange is free and is part of your facility’s Joint Commission Connect extranet.
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During your next Joint Commission survey, be prepared to answer three new questions before even starting your building tour. Jim Kendig, the Joint Commission’s field director for surveyor management and development, told the American Society for Healthcare Engineering (ASHE) that the questions are intended to spur conversations among surveyors and healthcare facility managers about common areas for findings.
The three new questions are:
1. What type of fire-stopping is used in the facility?
2. What is the organization’s policy regarding accessing interstitial spaces and ceiling panel removal?
3. Which materials are used (e.g., glutaraldehyde, ortho-phthalaldehyde, peracetic acid) for high-level disinfection or sterilization?
“They’re pretty straight forward—there’s no hidden agenda here,” Kendig said. “We’re just trying to get some information before we start the building tour.”
The Joint Commission and the Centers for Disease Control and Prevention (CDC) are working on a new initiative to improve infection control in ambulatory care settings. The Adaptation and Dissemination Outpatient Infection PrevenTion (ADOPT) project will promote existing CDC infection prevention (IP) guidance while also making updates and alterations. The collaboration will involve:
• Evaluating organizations’ infection prevention and control guidelines and materials to find gaps between what’s done in practice and what’s in the CDC materials.
• Finding new ways and opportunities to raise awareness of IP guidance.
• Adapting model infection control plans for outpatient-focused professional organizations.
• Developing new ways of disseminating these materials and models to healthcare organizations to increase their reach, uptake, and adoption in outpatient settings.
There are 12 outpatient-focused professional organizations and 11 ambulatory healthcare systems participating in ADOPT. Other healthcare organizations or state health departments interested in learning more can reach out to Barbara Braun, PhD, at email@example.com.
For examples of CDC ambulatory-focused infection prevention and control guidance, check out the following links:
• CDC Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care
• CDC Outpatient Settings Policy Options for Improving Infection Prevention
• CDC Basic Infection Control and Prevention Plan for Outpatient Oncology Settings
• The CDC One and Only Campaign
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Are you wondering how you’ll ever be prepared for the CMS’ updated Electronic Clinical Quality Measures (eCQM) due for release February 28, 2017? Don’t worry, you don’t have to face it alone.
The Joint Commission recently unveiled its Core Measure Solution Exchange®, which allows hospitals to share how they implemented the eCQMs. Users can post about the implementation issues they’ve had, challenges they’ve faced, and solutions they’ve come up with. They can learn from other facilities about the problems and solutions they came up with as well.
The Exchange is free and is part of your facility’s Joint Commission Connect extranet. There is already an eCQM solution posted by Wooster Community Hospital for viewing.
Over the next couple of months, several Joint Commission programs, standards, and updates will go into effect. Here is a brief overview of some of the bigger changes and the months they’ll go into effect.
• Elimination of Plans for Improvement (PFI)—After August 1, all PFIs will be replaced by Requirements for Improvement (RFI) issued by the surveyor.
• Updated diagnostic imaging standards—The accreditor published a checklist to help healthcare organizations prepare for new standards.
• 2012 Life Safety Code® (LSC)—CMS and The Joint Commission will begin surveying hospitals on the 2012 LSC on November 1. HFAP has published itsprepublication standards for LSC surveys as well.
• Antibiotic stewardship programs (ASP)—On January 1, ASPs will be mandatory in CMS- and Joint Commission-accredited facilities.
• Survey Analysis for Evaluating Risk (SAFER) matrix—As of January 1, the SAFER matrix will replace the current Category A and C scoring methodology.
• Catheter-associated urinary tract infections (CAUTI) National Patient Safety Goal (NPSG)—On January 1, The Joint Commission’s newest NPSG will go into effect, with facilities expected to drastically cut the rate of CAUTIs.
• Updated Integrated Care (ICC) program standards—Effective as of January 1 for Joint Commission-accredited facilities
• Updated advanced heart failure certification—Effective as of January 7 for Joint Commission-accredited facilities
The Joint Commission has updated and released its Integrated Care (ICC) Program standards, which will go into effect on January 1, 2017. The standards are aimed at improving key ICC processes and promoting the use of common patient risk screening criteria. The standards also try to eliminate duplicative care coordination and case management efforts.
There have been several changes to the accreditation process this year, with more to come in 2017. The Joint Commission has released notes on all changes that went into effect on August 1, such as the elimination of Plans for Improvement. The changes can be viewed in the 2016 Survey Activity Guide.
The Joint Commission, American Hospital Association, and the Federation of American Hospitals sent out a survey to 886 hospitals this March asking for feedback on the Electronic Clinical Quality Measures (eCQM). The eCQMs, which deal with data from electronic health records and health information technology system, are due for release on February 28, 2017. This July, the organizations heard back from 319 hospitals and released the survey results:
• 86% of hospitals say they plan on submitting eCQMs to CMS by the February 2017 deadline.
• While 76% of hospitals say they have the skill level and knowledge to implement eCQMs, only 64% can afford health IT support. Many said they’ll have to change electronic health record vendors to stay compliant.
• More than 85% have never successfully submitted eCQM patient level data to CMS.
• 58% haven’t or don’t know if they can generate a Quality Reporting Document Architecture [QRDA] 1 document.
• 79% haven’t or don’t know if they’ve ever successfully generated a QRDA1 doc.
• Surveyed hospitals asked The Joint Commission for more forums, webinars, and a comprehensive library of eCQM resources to help with the transition.
The Joint Commission’s Pioneers in Quality program is using these results to determine the best way to help facilities comply with the eCQMs. The Joint Commission plans to follow up with a second survey on the eCQMs this fall. Click here to see the full survey results.
In the wake of a CMS ruling that will make antibiotic stewardship programs (ASP) mandatory, The Joint Commission recently announced that it will roll out a similar standard. Effective January 1, 2017, the new Medication Management standard requires facilities to create an effective ASP. The standard applies to:
The Joint Commission released the standard a month after attending the White House Forum on Antibiotic Stewardship, which focused on implementing changes over the next five years to slow the emergence of antibiotic-resistant bacteria, detect resistant strains, promote stewardship of existing antibiotics, and prevent the spread of resistant infections. Representatives from 150 retailers, food organizations, healthcare organizations, and animal health organizations were in attendance.
Only 40% of U.S. hospitals have an antibiotic stewardship program and an estimated 30% to 50% of prescribed antibiotics are unnecessary or inappropriate. In the U.S., drug-resistant diseases cause 23,000 deaths and 2 million illnesses each year. That number is expected to increase exponentially in the upcoming decades.
As of August 1, The Joint Commission will no longer accept hospital Plans for Improvement for life safety deficiencies identified by surveyors, the accreditor announced today. Hospitals will now have 60 days to fix any and all life safety deficiencies, unless they receive a waiver from a CMS regional office for additional time. The change was announced at the American Society of Healthcare Engineering (ASHE) annual conference by George Mills, director of engineering for The Joint Commission, according to an ASHE advisory alert. The change comes at the request of CMS, which had asked The Joint Commission to revise its Statements of Conditions process. Visit here for more information on the changes.