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Joint Commission announces new lab standards in 2011

Updated and revised laboratory standards have been announced by the Joint Commission, to go into effect July 1, 2011.

Organizations will be able to get a look at these standards beginning January 2011 through The Joint Commission’s official webiste. The intent of the standards revisions, according to an official Joint Commission statement, is to add dept to both the standards and elements of performance while allowing healthcare organizations enough flexibility to tailor their own policies and procedures to their unique needs.

To view the official announcement, click here.

2011 CMS CLASBI reporting requirements announced

The Joint Commission has issued a notification to its accredited hospitals regarding new reporting requirements for healthcare-associated infection (HAI) data for those Inpatient Prospective Payment System (IPPS) hospitals participating in CMS Hospital Inpatient Quality Reporting Program.  Effective Jan. 1, 2011, these hospitals, in order to qualify for their full annual payment, will need to submit this data through the CDC’s national Healthcare Safety Network.

Specifically, these hospitals must report data collected on central line-associated bloodstream infections (CLASBI) for intensive care and neonatal intensive care units. According to The Joint Commission’s notice, those facilities reporting data for the first quarter must submit their findings no later than August 15, 2011.

For more information and instructions, visit the CDC’s website here.

Field review for proposed VAP/CAUTI NPSGs

The Joint Commission has opened 2012 National Patient Safety Goals (NSPG) for ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI) for hospitals and long-term care organizations.

Comments will be accepted through Jan. 27, 2011. For more information on this field review and to read the proposed standards, visit The Joint Commission’s Web site.

Joint Commission announces revisions to medication reconciliation goal

Medication reconciliation has received a facelift: revisions to the medication reconciliation National Patient Safety Goal (NPSG) have been approved for implementation as of July 1, 2011. The Goal, NPSG.03.06.01 (formerly NPSG.08.01.01) has been altered based on feedback The Joint Commission has gathered that indicated the Goal was too prescriptive and detailed to be implemented effectively.

The changes effect the ambulatory, behavioral health care, critical access hospital, home care, hospital, long term care, and office-based surgery accreditation programs.

Intent to update or improve medication reconcilation requirements began in at the beginning of 2009, when The Joint Commission announced it would begin an analysis and review of the NPSG, and would not include medication reconciliation findings into survey results.

Medication reconciliation remains under the National Patient Safety Goal chapter of the Comprehensive Accreditation Manual, but has been moved under a new number (NPSG.03.06.01).

For more information, visit The Joint Commission’s Web site.

New Benchmarking Survey!

Hello, AHAP Members,

I wanted to let you know we’ve launched the latest AHAP Benchmarking Survey. This time, we’re looking into Medical Staff and Credentialing Challenges.

This survey is exclusively for AHAP members and should take just a few minutes to participate in. We hope you’ll take the time to participate. The results will be shared in a special report after the survey has closed.

As always, we’ve included in this survey several questions to help us improve the association and it’s content offerings—please take a moment or two to let us know how we’re doing and how we can better serve your needs as accreditation specialists.

The survey can be found here.  If this link does not work, copy and paste the following URL into your browser to go directly to the survey:

Thank you for participating. We look forward to sharing the results. As always, these surveys are completely anonymous.

On-site surveys and annual fees to see small cost increase

The Joint Commission Board of Commissioners have voted an increase to on-site surveys and annual fees averaging approximately 1% across most of the organization’s programs, effective Jan. 1., 2011. Some areas will see higher increases. This action is in response to an analysis of the existing fee structure, in which The Joint Commission determined that a slight increase in price was necessary to cover operating costs.

The office-based surgery program will not receive an increase in 2011. This program has experienced price increases when other programs remained static. In fact, there were no across the board fee increases in either 2009 or 2010.

Changes in volume or scope may impact overall fees or costs as well. Final pricing for 2011 will be posted by The Joint Commission to its extranet site on Dec. 15, 2010. For more information, visit The Joint Commission’s Web site.

Joint Commission updates public information policy

In a recent announcement on their Web site, The Joint Commission has updated the language of its public information policy.

The Board of Commissioners approved changes to the language of this policy. According to this updated language, The Joint Commission will not discuss patient identifiable information without authorization by the patient. This is consistent with the organization’s business associate oblications.

This does not include situations “pursuant to a court order, or as otherwise authorized by law,” official language states.

For more information, see The Joint Commission Web site.

Joint Commission updates policy on ceasing services

The Joint Commission has announced a new policy, effective January 1, 2011, for organizations that cease services or go through a period of time when they do not treat patients. While this is an event that does not happen often, facilities can potentially cease to provide treatment and services for a period of time. This new policy is in alignment with The Joint Commission’s procedures for organizations which undergo a disaster.

The policy addresses this issue in three tiers, from up to 60 days without patients to over six months. For more information on these tiers, visit The Joint Commission’s Web site.

ED directors report inadequate emergency surgery coverage

The majority of ED directors participating in a survey reported inadequate staff coverage for emergency surgery, according to the December edition of Academic Emergency Medicine. One quarter reported a loss or downgrade of their hospitals’ trauma center designation.

Neurosurgical and hand surgery coverage were most lacking, and teaching hospitals overall had more coverage than non-teaching hospitals.

“Twenty-one percent of emergency department deaths and permanent injury can be linked to shortages in specialty physician care. Transferring patients significant distances to an available specialist is sometimes the only option, but it can create a dangerous delay in care,” said the lead study author Mitesh Rao, MD, MHS, of the department of emergency medicine at Yale University in New Haven, Conn., and clinical scholar with the Robert Wood Johnson Foundation, in an American College of Emergency Physicians press release.

Joint Commission reduces full survey timeframe from 39 to 36 months

The Joint Commission will reduce the timeframe for surveys by three months. This new rule will go into effect January 1, 2011. Previously, hospitals could expect a survey within 18-39 months of The Joint Commission’s previous visit; that time frame will nwo be between 18-36 months.

The change comes as part of The Joint Commission’s offers to align with CMS requirements; CMS requires home healthcare agencies, advanced diagnostic imaging facilities, and providers of durable medical equipment, prosthetics, orthodontics, and supplies to be surveyed within 36 months. The Joint Commission, for consistency’s sake, is making this change across most of its accreditation programs.

Laboratory accreditation surveys will continue to be conducted in a 24-month timeframe as previously conducted. For more information, visit The Joint Commission’s Web site.