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Joint Commission Critical Access Hospital Accreditation program receives CMS recognition

The Centers for Medicare and Medicaid Services (CMS) have granted deeming authority to The Joint Commission to accredit critical access hospitals, effective November 21, 2011.

Critical access hospitals are defined as having no more than 25 acute care beds and an annual average length of stay per patient of 96 hours. Critical access hospitals are are usually more than 35 miles from another hospital, and receive cost-based reimbursement from Medicare.

“The Joint Commission is pleased to once again receive this recognition for its accreditation of critical access hospitals, which are vital to the health of Americans, especially residents of rural areas,” Mark R. Chassin, MD, FACP, MPP, MPH, president, The Joint Commission, said in an official press release. “This public-private collaboration between CMS and The Joint Commission creates the necessary quality and safety oversight framework for these hospitals.”

For more information on this announcement, visit The Joint Commission’s homepage.

CMS proposes changes to CoPs to “cut red tape”

The Centers for Medicare and Medicaid Services (CMS) has announced proposed changes to the Conditions of Participation (CoPs) which are intended to save approximately $900 billion annually by removing, as CMS stated in its official press release, removing “unnecessary regulations,” MedPageToday reports.  

These proposed changes, should they be approved, would be the first major changes to the CoPs in over 20 years. The proposed changes include changes to the care planning process, allowing for interdisciplinary teams to work together to create a single plan of care for each patient (instead of separate plans of care for nursing, pharmacy, and physicians); as well as a change targeting hospital systems which would allow such systems to use a single governing board across all hospitals in the system rather than requiring a governing board for each hospital.

Other changes include alterations to authentication of verbal orders; reporting patient deaths involving soft, two-point restraints; and expanding the concept of “medical staff” to all practitioners who are granted hospital privileges.

The proposed rule can be found online here. It will be open for comment for 60 days.

HFAP appoints new director of accreditation services

The Healthcare Facilities Accreditation Program (HFAP) announced it has named a new director of accreditation services, Beverly Robbins, most recently acting as Chicago Medical Center’s director of nursing ambulatory care. This is the second major appointment in less than a month for the Chicago-based accrediting body, which also named Joseph L. Cappiello as their new chief operating officer recently as well.

In addition to her experience with Chicago Medical Center, Robbins served as the field director for the ambulatory care program for The Joint Commission from 2002 to 2010.

“I’m thrilled to have someone of Ms. Robins’ caliber join our organization,” Michael J. Zarski, CEO of HFAP, said in an official press release. “Healthcare delivery is evolving at breakneck speed, and so is the accreditation process. Bringing Beverly and Joe onboard–two seasoned accreditation experts–demonstrates HFAP’s commitment to staying at the front of that curve. Combining education with rigorous assessment, HFAP will continue to help hospitals meet swiftly evolving quality standards.”

For more information on this appointment, click here.

Study finds performance trends tied to Joint Commission accrediation

A recent study published in the Journals of Hospital Medicine found that hospitals accredited by The Joint Commission, examined in the study, tended to have better baseline performance in 2004 than non-accredited hospitals. Accredited hospitals had larger gains over time, and were significantly more likely to have high performance in 2008 on 13 out of 16 standardized clinical performance measures and all summary scores.

The study used performance data, obtained using publicly available CMS Hospital Compare data, for 2004 and 2008 from U.S. acute care and critical access hospitals,  augmented with Joint Commission performance data.

The study reported that while, in the early days of public reporting, Joint Commission-accredited hospitals already outperformed non-accredited hospitals on publicly reported quality measures, these differences became significantly more pronounced over 5 years of observation.

For more information on the study, click here.

Accreditation in fiction

One of AHAP’s members came across a very interesting link this week and thought it would be of interest to those of us working in the accreditation world. Physician George Beddingfield, MD, is in the process of self-publishing a novel with a distinct hospital accreditation angle.

In his blog, Dr. Beddingfield describes the book–the title of which, “Unannounced,” is a word that still causes a wave of anxiety among accreditation professionals–as a thriller in which a physician and an FBI agent work to unravel a terrorist plot.

The world of healthcare is more and more accessible to the public eye, and works of fiction quite frequently tie into some of our biggest challenges–infection control and medical errors, for example. Have you encountered any works of fiction that use accreditation themes to build tension and drama?

Enhanced certification alliance expands connection between Joint Commission and American Heart Association

In order to help organizations provide even better care through Certified Primary Stroke Centers and Heart Failure Programs across the country, The Joint Commission and the American Heart Association (AHA)/American Stroke Association (ASA) are enhancing their existing alliance.

The intent is to combine the scientific expertise provided by the AHA and ASA with the evaluation experience The Joint Commission brings to the table. According to an official press release, beginning February 1, 2012, these centers and programs will be able to use designated seals from The Joint Commission and American Heart Association/American Stroke Association to signify that they are providing the “next generation of stroke or heart failure care.”

For more information on this newly enhanced partnership, visit The Joint Commission’s website.

Study: Lower performing hospitals treat more minorities, poor patients

According to a new report by researchers at the Harvard School of Public Health, hospitals which scored lowest on certain quality and cost measures treat more than double the number of minority and poor patients compared to those hospitals which scored the highest.

The study, published in Health Affairs, compared quality and cost measures at roughly 3,200 hospitals with the proportion of minority and Medicaid patients the hospitals served.

“As the United States embarks on efforts to improve hospital care using value-based purchasing principles, we will need to help hospitals improve quality and efficiency simultaneously and to monitor the results of their efforts, so that we do not inadvertently worsen disparities in care,” the study concludes.

To view the report, visit the Health Affairs website.

MAP announces finalized strategy for aligning quality measures

The Measures Application Partnership (MAP) released its final strategy this month to align public and private efforts for the reduction of healthcare-acquired conditions (HAI) and readmissions.

MAP is a public-private partnership convened by the National Quality Forum (NQF) to provide input to the Department of Health and Human Services on selecting and aligning performance measures for public reporting and performance-based payment programs.

The organization’s recommendations include:

  • creating and maintaining a national core set of safety measures that are applicable to all patients
  • collecting data elements to calculate the measures
  • coordinating public and private efforts and incentive structures.

The group also issued its final strategy for aligning physician performance measurement across federal programs. More information on both the organization and these strategies can be found on the NQF website.

First Disease-Specific Care certifications for nursing homes issued by Joint Commission

The Joint Commission has announced that to Illinois nursing homes have become the first facilities accredited under the organization’s new Disease-Specific Care Certification for Nursing Homes.

Claremont Rehabilitation and Living Center of Buffalo Grove and Forest Villa Nursing Care in Niles became the first organizations to become certified under this program.

The Joint Commission’s Disease-Specific Care Certification Program evaluates organizations for delivery of clinical care, program management and improvement, and clinical information management.

For more information on this announcement, visit The Joint Commission’s website.

Joint Commission releases R3 report looking at CAUTI

The Joint Commission has just released a new R3 report examining the 2012 National Patient Safety Goal (NPSG) related to catheter-associated urinary tract infections, or CAUTI.

CAUTI is the leading healthcare-associated infection, with roughly 450,000 cases reported in hospitals every year. The Joint Commission added a new NPSG, going into effect January 1, 2012, to require hospitals to minimize the risks fo CAUTI through better processes and practices.

For more information on the R3 report, visit The Joint Commission’s website.