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Joint Commission leaders call for high reliability in hospitals

Too many hospitals and healthcare leaders currently experience serious safety failures as routine and inevitable parts of daily work, according to an article published last week in The Milbank Quarterly. In the article, authors Mark R. Chassin, MD, FACP, MPP, MPH, president and CEO of The Joint Commission; and Jerod M. Loeb, PhD, executive vice president for healthcare quality evaluation at The Joint Commission, urge hospitals to make the substantial changes necessary to achieve the ultimate goal of zero patient harm by adapting lessons from high-risk industries.

To prevent the harm that results from failures, which affects millions of Americans each year, Chassin and Loeb offer a framework for major changes involving leadership, safety culture and robust process improvement. The framework is designed to help hospitals make progress toward high reliability—defined as extremely high levels of safety maintained over long periods of time, and comparable to levels demonstrated by the commercial air travel and nuclear power industries, among others.

For more information, visit the Joint Commission’s website.

Standards proposed for new blood management certification program

The Joint Commission’s Laboratory Accreditation program announced earlier this month that it is developing a Patient Blood Management certification program for Joint Commission-accredited hospitals. The process of patient blood management involves bringing a patient-centered approach in the hospital to to the blood utilization activities as well as blood conservation.

For more information, visit here. 

CMS renews HFAP deeming authority

The Healthcare Facilities Accreditation Program (HFAP) has received its continued status as an accrediting organization for hospitals through CMS. The notification was posted in the August 28 Federal Register and goes into effect September 25, 2013.

Accrediting organizations must reapply for deeming authority at least every six years. This decision provides HFAP with deeming authority through September 25, 2019.

The decision can be seen here. 

Ten California hospitals fined for patient safety issues

The California Department of Public Health (CDPH) issued ten penalties this week to California hospitals–and fines totaling $675,000–after investigations found the facilities’ noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients.

The penalties range for lack of compliance for everything from telemetry monitoring to cardiac catheterization processes, respiratory care and general patient safety.

Find more on the CDPH site here. 

Patient dumping scandal may cost accreditation

The Joint Commission has issued preliminary denial of accreditation for Rawson-Neal Psychiatric Hospital, a mental health facility in downtown Las Vegas, over a patient dumping scandal.

State officials with the Nevada Department of Health and Human Services have expressed disappointment in The Joint Commission’s decision, stating: “We are disappointed by the Joint Commission’s decision to move for a Preliminary Denial of Accreditation, which appears to be based on outdated survey information and is not an accurate reflection of the hospital’s current practices and policies.”

For more on this story, click here.

CIHQ receives deemed status for acute care hospitals

The Center for Improvement in Healthcare Quality has announced that it is the latest organization to receive deemed status for acute care hospitals from CMS. This allows CIHQ’s hospital accreditation program to deem hospitals to be in compliance with CMS Conditions of Participation.

For more information on this announcement, visit CIHQ’s accreditation home page here.


Emergency Management standards revised

The Joint Commission has announced revisions to its Emergency Management standards intended to take into account leadership accountability for hospitals and critical access hospitals.

Based upon a field review conducted in 2012, these changes will go into effect as of January 1, 2014 and target leadership involvement and oversight as well as staff input.

For more on the revised standards, which will appear in the e-dition of the standards for both programs in November, visit The Joint Commission’s website.

Joint Commission announces alarm safety NPSG

The Joint Commission has announced the creation of a National Patient Safety Goal (NPSG.06.01.01) addressing growing concerns surrounding alarm safety.

The multi-phase implementation process for this new goal will begin January 1, 2014 with a second phase beginning Junuary 1, 2016.  

For specifics on the goal, including requirements and implementation expectations, visit The Joint Commission website. Our sister newsletter, Briefings on The Joint Commission, will have ongoing coverage of this new NPSG leading up to the implementation deadline as well.

AHAP Networking Call, June 19th

Hello, AHAP members. I wanted to let you know that we have set up a time for our next AHAP networking call and we’d love to invite everyone to attend. The call will take place June 19th at 3 PM EST (2 PM Central, 12 PM PST).

We have a great topic to discuss this quarter. Recently, Briefings on The Joint Commission interviewed Rachel Zastrow, MSN, RN, CCRN, and Six Sigma Black Belt about the work her organization has been doing to prevent drift. Her story is really intriguing and we’re very much looking forward to having her share it with you, as well as hearing about what your own organizations are working on in this area.

The dial-in information for all participants is below—feel free, as always, to invite any of your colleagues to listen in as well! I’d like to ask a favor of you—if you plan to attend, please email me at to let me know. This is simply so I can get a rough estimated headcount to ensure we are properly staffed as members dial in to the call. Anyone who emails ahead of time to confirm will receive an electronic copy of the BOJ article on drift in response.

Here is the dial-in information:

Participant Dial-In (Toll Free): 877-869-3841

Password: 370331

Looking forward to having you join us on the call!

A view from the podium

Our afternoon session at the 7th annual AHAP conference included a series of round table discussions, giving attendees a chance to speak in a smaller group with all of this year’s conference. Here’s a view from above: