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Crucial accreditation deadlines on the horizon for pain management and emergency preparedness

Time is running out to meet the new emergency management (EM) Conditions of Participation (CoP) and The Joint Commission’s revised pain management standards. The EM Interpretive Guidelines go into effect on November 15 while the pain management standards go into effect January 1.

Emergency management

The new EM CoPs fill gaps CMS’ previous regulations by compelling hospitals to communicate and coordinate their emergency plans with other healthcare organizations and government agencies. They also require regular emergency preparedness training with staff and disaster contingency planning.

Steve MacArthur, a safety consultant at The Greeley Company, pointed out that a lot of the new requirements include things that hospitals should have already been doing.

“While this rule is new to the ‘marketplace,’ there are really no new concepts contained therein,” he says. “This may provide some guidance for CMS surveyors as they drill down on organizational preparedness activities. But none of this is groundbreaking or in any way representative of a change in how hospitals have done, and will continue to do, business. [It’s] just another set of official ‘eyes’ looking through the compliance microscope.”

Pain management

The Joint Commission prepublished its new pain management standards back in June. The accreditor said it used the revision to address disparities between its standards and what the literature recommended. Some of the changes include:

•    Enabling clinician access to prescription drug monitoring program databases

•    Performance improvement activities focusing on pain assessment and management to increase the safety and quality for patients

•    Identifying the leader or leadership team responsible for pain management and safe opioid prescribing

•    Involving patients in developing their treatment plans and setting realistic expectations and measurable goals

•    Identifying and monitoring high-risk patients as a way to promote safe opioid use

Facilities should assign teams to research best practices in pain management, get the medical staff working on revising protocols and deter¬mining how to gather data on pain management effectiveness, and alert your information technology and electronic health records experts that they will be needed.

The annual fire and smoke door testing requirements will also be due by January 2018.

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)

Resource:

Joint Commission to check for FDA powdered glove compliance

The Joint Commission surveyors will now check to see if hospitals are compliant with the Food and Drug Administration’s (FDA) ban on powdered medical gloves. The ban went into effect in January, with the administration citing the powder’s potential to cause severe airway and wound inflammation, granulomas, and post-surgical adhesions in the tissue between internal organs. Powdered latex gloves also carry the risk of allergic reaction in patients. The Joint Commission will now issue citations on the powdered glove ban under LD 04.01.01, element of performance 2.

“This ban is about protecting patients and healthcare professionals from a danger they might not even be aware of,” said Jeffrey Shuren, MD, director of FDA’s Center for Devices and Radiological Health, in a press release. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”

To learn more about the FDA’s decision, read our previous coverage on the ban.

Featured Webcast- “CMS Surveys: Preparing With Confidence”

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. 

Why: This webinar will teach you how to:

  • 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. 

For more details on how to join the webcast, please visit our website.  

 

 

Joint Commission identifies top five most-cited standards first half of 2015

The Joint Commission released the top five standards most cited during the first half of 2015, yesterday. There aren’t any surprises in the list, but there has been a slight change in the order of the standards with infection control creeping into the second spot.

The top five trouble spots:

  • EC.02.06.01 (maintenance of a safe environment), 59%
  • IC.02.02.01 (reduction of infection risk from equipment, devices, and supplies), 54%
  • EC.02.05.01 (management of utility system risks), 53%
  • LS.02.01.20 (maintenance of egress integrity), 50%
  • RC.01.01.01 (maintenance of accurate, complete medical records for all patients), 48%

View the full table here.

Read about the top 10 most-cited standards in Briefings of The Joint Commission.

I saw Mommy kissing the senior engineer…

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, wrote about recent mid-term release of The Joint Commission’s Survey Activity Guide.

Late last week, The Joint Commission provided information regarding the mid-term edition of this year’s Survey Activity Guide (SAG—and no, I will not make any gratuitous remarks about that particular acronymic confluence…), which includes “new description for Facility Orientation-Life Safety Surveyor and minor revisions to Environment of Care Session and Life Safety Building Tour for hospitals and critical access hospitals.”

While the minor revisions to the Environment of Care session and Life Safety building tour are indeed just that (with one exception that you already know about—more in a moment), it appears that Santa Mills has left us a nice little package under the Christmas in July tree: a new Life Safety and Environment of Care Document List and Review Tool (just think, kids—now you can survey like a real surveyor!). While I jest a wee bit (jester that I am), I do think that this is a pretty useful thing for the good folks in Chicago to be sharing. I think you’ll find the tool may give you a sense of “what” they’re looking for in terms of documentation; it also contains a nifty little typographical error. Let’s see who has the eagle eyes out there in radioland…

The one change that is a little more than minor (if only for its far-reaching consequences in surveys the past 18 months) is the instruction for surveyors to assess operating rooms for proper pressure relationships.

Continue reading this post at Mac’s Safety Space.

Briefings on The Joint Commission feedback survey

I know, I know, we just had a survey, but we really like surveys here. They give us an opportunity to find out what’s happening in the accreditation field and then share it with the rest of you.

They also give us a chance to ask you, our readers, what you like or dislike (gasp) about some of our products. In this case, we would like your thoughts on the Briefings on The Joint Commission newsletter.

The survey is quick and should only take about five minutes of your time.

Click on the link to take the survey.

Don’t forget to take the salary survey!

Thanks to everyone that has already taken the salary survey.  If you’ve been meaning to take the survey, now’s your chance as we’ll be closing the survey in a few days.

Stay tuned to the blog and Briefings on The Joint Commission for the results.

You can take the survey here.

Q&A: The mechanics of a clarification

Q: Do you have any advice on how to format evidence for a clarification or choosing a sampling method to submit to The Joint Commission?

A: Note the following excerpted example that uses an audit submitted for a clarification by a client. It is very clear how the medical records were sampled during the audit process and it leaves no doubt as to potential bias or skewing of the data or the validity of the outcome. Of course, the data would also be submitted to support the claim. This submission leaves a perception of confidence in the organization’s ability to correctly assess and support its claim of compliance.

Sampling method: The hospital discharged more than 2,000 patients in the 30 days preceding the survey; a sample of 70 medical records was anticipated. A list of the 2,443 patients admitted on or after January 6, 2011 (30 days prior to the beginning of the survey), and discharged on or before February 4, 2011 (the day before the survey), was prepared. Every 80th patient on the list was selected for review. Nine of these records were arbitrarily omitted from the sample prior to the review, leaving 71 records in the final sample.

Calculation: The organization’s policy titled “Consents, Policy 440-34” adopted by the medical staff in June 1999 and last modified in September 2009 requires that the provider performing a high-risk procedure document informed consent either by signing the consent form or by documenting informed consent in the medical record. The policy also requires that the name of the person performing the procedure be recorded on the consent form.

The denominator for this calculation was the number of times informed consent was required by hospital policy. The numerator was the number of such occurrences where a) informed consent was documented as required by hospital policy and b) the name of the person performing the procedure was on the consent form.

Outcome: Overall performance within this sample was 97%, leading to a score of full compliance for this EP.

We respectfully request that this finding be removed based on the evidence presented.

This is an excerpt from The Joint Commission Survey Coordinator’s Handbook, 13th edition.

Editor’s Note: Do you have a question about clarifying RFIs, policy management, or survey-prep for our experts? E-mail your queries to Jaclyn Zagami at jzagami@hcpro.com and receive one-on-one advice from our experienced advisory board. Submit a question and our credible sources will provide you with a timely answer.

Practice, practice, practice

Organizations that have practiced for the live on-site event always do better for the real thing. Everything from notification of the survey to the process of escorting surveyors to the survey room is much smoother and more organized. The advantage of practicing live is that it provides you with an overview of how well your plan is implemented. It allows you to modify your plan. You can never practice enough. Familiarity can only lead to a higher level of consciousness and ease for the staff.

Schedule practice sessions for the interview-type group sessions. Amazingly, it is not unusual for staff members to attend mock survey sessions and seem totally unprepared. As a  group, discuss your vulnerabilities and determine how they will be addressed. There is no excuse for not being able to address your data. Determine who is in the best position to respond to a specific issue, but avoid having a single person answering all the questions. This  gives you the advantage of having your staff well versed in the findings while the surveyors need to probe.

Tip for success: During the practice session, determine which specific issue each leader will address. Also, decide what examples you would like to highlight during this session in your responses. You probably have many good stories to tell regarding PI and patient care quality, and you should plan to highlight them during the interview when the time is right. You want to leave surveyors with a sense of confidence that you have good oversight of the care delivered in your facility.

Editor’s note: This blog post is an excerpt from The Joint Commission Survey Coordinator’s Handbook, Thirteenth Edition, by Jean S. Clark, RHIA, CSHA, and Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA