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CMS withdraws proposal to have AOs post survey reports online

A proposal by CMS to have accrediting organizations (AOs) post the details of survey reports online was withdrawn by the agency, not because of negative comments — although there were plenty — but because, well, it might be prohibited under federal law.

CMS first made the proposal in April, tucking it into the latter pages of the always-long proposed on changes to the Inpatient Prospective Payment System (IPPS) for the upcoming fiscal year.

The proposal was to have AOs post final survey reports online within 90 days that the same information is available to the hospital or other health care organization, including details of all initial and recertification surveys at that provider in the prior three years, as well as the accepted plans of correction (PoCs).

AOs now post only whether an organization is accredited or not, and do not make details of findings public.

CMS argued its proposal was to promote transparency in health care, and noted that it posts its own  survey reports online. But critics responded that the CMS reports are made available in a hard-to-read spreadsheet and that the federal agency was responsible for far fewer surveys at health care organizations that were often surveyed only after a complaint (IJC 5/1/17).

In public comments to CMS concerning the proposal, The Joint Commission said that requiring survey details be made public would have “chilling effect” on efforts to raise standards of quality. Dr. Mark R. Chassin, president and CEO of The Joint Commission, wrote: “There will be a race to the bottom on quality as health care organizations seek out oversight bodies that will report on the least number of standards comparable to the Medicare requirements. This may also lead to a growth in non-accredited facilities that will then be surveyed at taxpayer expense and with fewer oversight visits.”

Other groups similarly weighed in against the proposal, and offered alternatives. In the end though, it was shot down because it might potentially be prohibited.

In the IPPS final rule published Aug. 2, CMS noted that its proposal included revising the federal regulations overseeing Medicare to incorporate the requirement for AOs to post report details publically.

“Section 1865(b) of the Act prohibits CMS from disclosing survey reports or compelling the AOs to disclose their reports themselves. The suggestion by CMS to have the AOs post their survey reports may appear as if CMS was attempting to circumvent the provision of section 1865(b) of the Act. Therefore, this provision is effectively being withdrawn.” — A.J. Plunkett (aplunkett@h3.group)

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Maintaining security during a Joint Commission survey

Facilities often have questions when surveyors come to visit. Some of the most frequently asked questions involve security and confidentiality, how to make sure surveyors see what they need to without violating hospital safety. In the July issue of Perspectives, The Joint Commission answered some of the most frequent questions.

Access to Computer Systems: Surveyors will sign security agreements with the facility in order to receive a user ID and password to access a computer system (for example, in order to review policies and medical records) if the facility requires it.

Confidentiality Agreements: If a facility wants surveyors to sign a confidentiality agreement, then that agreement has to be sent to the Joint Commission Central Office for review before the survey.

That said, asking surveyors or reviewers to sign an agreement is unnecessary, according to The Joint Commission. Accreditation and certification contracts, plus the Business Associate Agreement between The Joint Commission and the facility, already bind individual surveyors and reviewers to confidentiality.

Security Sign-In: If a facility requires visitors to sign into the building as part of the organization’s regular security process then surveyors will sign in too. In lieu of asking to copy a surveyor’s driver’s license, Joint Commission badge, or any other form of ID, facilities should refer to surveyors’ pictures and biographies on the Joint Commission Connect™ secure extranet site.

Videotaping Survey Activities: Videotaping or recording any part of a survey or review, including the exit conference is forbidden.

Joint Commission: Six EPs deleted for Critical Access Hospitals

Later this year The Joint Commission will delete six elements of performance (EPs) from the Distinct Part Unit (DPU) standards for Critical Access Hospitals. The accreditor says this will streamline the standards and the changes go into effect on September 24, 2017.

The deleted EPs are from the Medical Staff, Leadership, and Rights and Responsibilities of the Individual chapters. You can read all six standards at the Joint Commission website. Those with questions can contact Laura Smith, MA, Joint Commission project director at lsmith@jointcommission.org.

https://www.jointcommission.org/standards_information/prepublication_standards.aspx

The Focused Standards Assessment tool goes temporarily offline in July

The Focused Standards Assessment (FSA) tool on The Joint Commission’s Intracycle Monitoring (ICM) Profile will be taken offline from June 30, (5:00 PM Central Time) through  July 10 (9:00 PM CT)

The FSA is an interactive standards self-assessment tool for facilities that lists the standards applicable to each organization’s accredited programs and services. An extension due date will be set to Monday, July 24, 2017 for facilities with an ICM submission date between July 1 and July 10.

https://www.jointcommission.org/facts_about_the_intracycle_monitoring_process/

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.”

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.

First set of SAFER Matrix data is online

The Joint Commission released the first set of data collected from its new Survey Analysis for Evaluating Risk™ (SAFER™) scoring methodology this May. The SAFER matrix was first rolled out to psychiatric hospitals as part of their accreditation surveys. It has been since implemented for all Joint Commission-accredited programs.

The accreditor made a chart of the most frequently cited compliance challenges for deemed psychiatric hospitals between Aug. 1, 2016 to Feb. 17, 2017.

The Joint Commission writes that it plans to keep analyzing aggregate SAFER data going forward to:

  • Continuously improve consistency
  • Identify potential EPs for revision
  • Assist in identifying areas of high risk noted within each program

Joint Commission: Facilities now to receive email notifications about upcoming surveys/reviews

Starting March 6, The Joint Commission will send email notifications to organizations about upcoming surveys/review events. For each event, The Joint Commission will post the letter of introduction, the survey/review agenda, and surveyor/reviewer biographies and photos on organizations’ Joint Commission Connect extranet site. Afterwards, an email will be sent to the CEO and contact person for the accreditation team, letting them know this information is now up on the extranet to view. The main difference is how far in advance notifications are sent:

  • Announced events—30 days in advance, plus a second email the day of the event
  • Short-notice Events—7 business days in advance, plus a second email the day of event
  • Unannounced events (including all Medicare certification events)—Same day as the event

Additional information about the different types of events can be found in “The Accreditation Process” (ACC) chapter or “The Joint Commission Certification Process” chapter.

Joint Commission issues new Sentinel Event Alert about culture of safety

The Joint Commission today published its newest Sentinel Event Alert (SEA), which addresses the role of leadership in creating a culture of safety, namely that leaders’ first priority is being held accountable for the safety of patients and staff. Leaders are expected to find flaws and gaps in the care process and ensure that they are resolved.

The SEA comes with an infographic on the “11 Tenets of a Safety Culture.”