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Physicians urged to take more active leadership role to improve quality and patient safety

Earlier this week, an article appeared in The Journal of the American Medical Association (JAMA) released an article calling on physicians to work together and take a more active leadership role in the hopes that the action will help improve quality and patient safety.

This request doesn’t mean that the authors think physicians don’t work together, rather they’re saying that our current health care system is complicated for a single physician to be able to achieve higher levels of quality and safety on their own.

Traditionally, physicians and healthcare systems are judged on their compliance by identifying areas that need improvement or correction altogether.  The article suggests that physicians, healthcare providers, and accrediting bodies should go one step further and develop programs that identify excellence within healthcare systems.

The authors issue three challenges to achieve this goal:

  • No harm for either patient or healthcare worker
  • Healthcare systems should employ methods and management that have been successful, such as Lean, Six Sigma
  • Accrediting and certifying bodies should develop programs identifying excellence in both healthcare workers and systems

Read the full article here.

What do you think about this proposal? Is this something that has already been implemented within your healthcare system or something you’re currently working towards? We would like to hear your thoughts. Please leave a note in the comments or email me directly at

The Joint Commission updates several standards for hospitals

In order to align with CMS’ Conditions of Participation, The Joint Commission has updated eight standards for hospitals and one standard for critical access hospitals. The majority of the updates apply to hospitals with swing beds.

The following standards have been updated:

  • Standard MS.01.01.01
  • Standard PC.02.02.01
  • Standard PC.04.01.03
  • Standard PC.04.01.07
  • Standard RC.02.04.01
  • Standard RI.01.01.01
  • Standard RI.01.06.03
  • Standard RI.01.07.07
  • Standard MS.01.01.01

The updates go into effect July 1, 2015.

Plans to increase hospital infection reporting

The Centers for Medicare & Medicaid Services (CMS) plans to expand reporting of certain hospital-acquired infections (HAIs) beyond ICUs in an effort to reduce confusion among providers, HealthLeaders Media reported on Friday.

A two-pronged federal effort launching this year seeks to more accurately collect HAI rates.

The new, more specific definitions of infections seek to reduce confusion among providers, health officials say. The aims are first to assure clinicians report beyond the ICU to general med-surg patients, and second, to prevent hospitals’ from subjectively interpreting what qualifies as a reportable infection.

In the first effort, CMS plans to expand reporting of central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) to all medical and surgical beds throughout a hospital, with reports starting Jan. 1, 2015.

In the second effort, the CDC has refined the definitions of what constitutes a CLABSI and a CAUTI in several ways to ensure clinicians consistently report the same thing, eliminating interpretive variation.

Read the full article at

Editor’s choice: j-Mail 2016 Edition: Tools for Ongoing Joint Commission Survey Prep

Hot off the virtual presses! j-Mail 2016 Edition: Tools for Ongoing Joint Commission Survey Prep is a ready-made tools library that allows you to download, customize if needed, and start using the tools and training today.

This new edition is a quick and easy way to train your staff, featuring ready-made emails and compliance questions with varying levels of difficulty that can emailed, posted on bulletin boards, or included in newsletters.

j-Mail is a “no-prep needed” electronic tool that addresses all levels of training and allows for customization. This latest editions puts forth the same tried and true question-and-answer format as found in earlier editions.

For more information or to order a copy, click here.

Most frequently identified root causes of sentinel events

The usual suspects topped the list of root causes for sentinel events – human factors, leadership, and communication, according to a report released by The Joint Commission on Friday, April 24, 2015. The report covered root causes for sentinel events from 2012 through 2014.

Health information technology-related (new to the report), operative care, and continuum of care rounded out the top 10 list for 2014.

Read the full report at The Joint Commission.

Editor’s Choice: Emergency Planning: Conducting an Effective Preparedness Exercise

Tuesday, April 28, 2015

1-2:30 pm Eastern

Join us for a 90-minute webcast on how to plan and conduct an emergency drill with clear measurable objectives, and how to use the lessons learned from that drill to educate your staff.

CMS and The Joint Commission require your hospital to have plans in preparation for any emergency, but they also have two lifelike exercises per year that test your ability to respond under pressure.

Take the stress out of preparation with tips and advice provided by our healthcare emergency management experts.

The webcast is presented by expert speakers Tracy Buchman Sonday, DHA, CHPA, CHSP, and Christopher Sonne, CHE.

Click here for more information.

Joint Commission releases sentinel event statistics

Unintended retention of foreign objects, patient falls, and suicide were the top three sentinel events reported to The Joint Commission in 2014. The accreditor last week released the report, which examines sentinel events from 2004 through 2014.

Of the 764 events reported in 2014, foreign objects (91), falls (91), suicide (82), delay in treatment (73), and “other unanticipated event” (73) were far and away the most common. Overall since 2004, there have been 8,645 incidents reported; that list is topped by wrong patient/wrong site/wrong procedure with 1,102 (the category was sixth on the 2014 list with 67).

Read The Joint Commission’s sentinel events summary.

OSHA updates healthcare workplace violence prevention guidelines

In 2013 there were more than 23,000 significant injuries in the workplace due to assaults, according to a recent report by OSHA. More than 70% of these assaults were in healthcare and social service settings. Further, OSHA says that healthcare and social service workers are almost four times as likely to be injured as a result of violence than private sector employees.

The above statistics prompted OSHA to release an update to its Guidelines for Preventing Workplace Violence for Healthcare and Social Workers, also known as OSHA Rule 3148. The update recommends that all healthcare facilities develop an effective workplace violence prevention program. According to our sources, The Joint Commission is following these changes very closely.

The updated guidelines are specific in the types of workplace controls employers should consider, especially in terms of facility security and keeping track of both on-site and off-site employees. Some examples:

  • The use of silent alarms and panic buttons in hospitals and medical clinics
  • Providing safe rooms and arranging furniture to make sure there are clear exit routes for employees and patients
  • Installing permanent or hand-held metal detectors to detect weapons, and providing staff training on the use of these devices
  • Ensuring nurse stations have a clear view of all treatment areas, including the use of curved mirrors and installing glass panels in doors for better viewing, as well as closed circuit cameras to help monitor areas
  • Using GPS, cell phones, and other location technology to help keep track of staff working with patients in off-site locations
  • Protecting front-end triage staff using facility design elements such as deep counters, secure bathrooms for staff separate from patient treatment areas, and using bulletproof glass and lockable doors with keyless entry systems.

Recommendations also include employing administrative controls designed to track patients and visitors who have a history of violence, to better educate workers on the dangers and signs of impending violence, and to ensure better reporting procedures. Some examples:

  • Providing clear signage in the facility that violence will not be tolerated
  • Instituting procedures that require off-site staff to log in and log out, as well as checking in with office managers periodically
  • Keeping a behavioral history of patients, including identifying triggers and patterns
  • If necessary, establishing staggered work times and exit routes for workers who may be subjects of stalkers
  • Keeping a “restricted visitor” list for suspected violent people, such as gang members, and making sure all staff are made aware of the list

OSHA also recommends employers provide updated training for employees, including:

  • Risk factors that cause or contribute to violent incidents
  • Early recognition of escalating behavior or recognition of warning signs
  • Ways to recognize, prevent or defuse volatile situation or aggressive behavior, manage anger and appropriately use medications.
  • Self-defense procedures where appropriate
  • How to apply restraints properly and safely when necessary
  • Ways to protect oneself and coworkers, including use of the “buddy system”

For further information on the updated rule, visit

NEWS ALERT! New IPPS rule proposed

CMS released the IPPS proposed rule for fiscal year 2016, which includes changes to MS-DRGs and the expansion of its value-based payment quality measures as it has in the past.

Included in the proposed rule, CMS is asking for public comments regarding the implementation of bundled payments for inpatient care. As of now, CMS has not discussed how it will implement payments.

CMS is proposing removing two measures from the hospital value-based purchasing (HVBP) program:

  • IMM-2, Influenza Immunization
  • AMI-7a, Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival

If the measures are removed, PC-01 (Elective Delivery) to the Patient Safety domain will move to the Patient Safety domain and remove the Clinical Care—Process subdomain for FY 2018 and beyond. This change will have an increased weight in the HVBP scoring methodology in FY 2018 (from 20% to 25%).

CMS is proposing the addition of two measures to the HVPB program:

  • 3-Item Care Transition Measure for FY 2018
  • Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Chronic Obstructive Pulmonary Disease Hospitalization beginning in FY 2021

CMS is asking for input from the hospital community. Comments are due by June 16, 2015. They may be submitted electronically or in hard copy.


2015 Accreditation Professional salary survey

Are you an accreditation specialist or handle survey preparation for your organization? If so, we invite you to take the 2015 Accreditation Professionals salary survey.

All responses are anonymous and we’ll provide the survey results in an upcoming issues of Briefings on the Joint Commission.

Click on this link to take the survey.