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Positive results in Joint Commission’s annual report

Hospitals are making progress in healthcare quality, according to The Joint Commission’s recently published annual report, “America’s Hospitals: Improving Quality and Safety.”  The report covers results from more than 3,300 accredited hospitals on measures covering:

  • Children’s asthma
  • Inpatient psychiatric services
  • Venous thromboembolism care
  • Stroke care
  • Perinatal care
  • Immunization
  • Tobacco use treatment
  • Substance use care

The report said that because of hospitals’ consistent and excellent quality performance over the past few years, the accreditor has been able to retire 20 accountability measures. Hospitals have been so diligent in using these measures that The Joint Commission no longer sees the need to survey for them. Meanwhile, 39 hospitals were declared Pioneers in Quality for their work in the evolution and utilization of electronic clinical quality measures.

“The results featured in The Joint Commission’s 2016 annual report are important because they show that accredited hospitals have continued to improve the quality of the care they provide, and the data that hospitals collect help them identify opportunities for further improvement,” said Mark R. Chassin, MD, FACP, MPP, MPH, Joint Commission president and CEO, in a press release. “The results also show it’s important to note that where a patient receives care makes a difference. Some hospitals perform better than others in treating particular conditions.”

HHS: New HAI targets for 2020

This October, the Department for Health and Human Services (HHS) announced ambitious, new targets for reducing healthcare-associated infections (HAI) in acute care hospitals, long-term care facilities, and ambulatory surgical centers. The changes have been outlined in the National Action Plan to Prevent HAI: Road Map to Elimination. The HHS used HAI data from 2015 as a baseline, with the new target date set for 2020.

The previous targets for HAI reduction expired in 2013, with only the goal of reducing central line-associated bloodstream infections (CLABSI) by 50% achieved. All others saw partial success, save catheter-associated urinary tract infections (CAUTI) and Clostridium difficile (C. diff) hospitalizations. Between 2009 and 2014, there was no change in CAUTI reduction. Meanwhile, C. diff hospitalizations actually increased by 18%.

Now, the HHS’s new goals require:

  • 50% CLABSI reduction
  • 50% CAUTI reduction
  • 25% invasive Methicillin-resistant Staphylococcus aureus (MRSA) reduction
  • 50% facility-onset MRSA reduction
  • 50% diff Infection (CDI) reduction
  • 30% surgical site infection (SSI) reduction
  • 30% reduction of diff hospitalizations


Facilities should have already started working on reducing CAUTIs, since The Joint Commission’s newest National Patient Safety Goal (NPSG) on CAUTIs will go into effect on January 1, 2017. 

Today the Joint Commission and HFAP start surveying to the 2012 Life Safety Code®

As of today, CMS, The Joint Commission, and HFAP will be surveying hospitals to the 2012 Life Safety Code® (LSC). The LSC was adopted by CMS in June, with some of the big changes required under the final rule including:

  • Facilities located in buildings taller than 75 feet are required to install automatic sprinkler systems within 12 years after the rule’s effective date.
  • Facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than 10 hours.
  • Greater flexibility for long-term care (LTC) facilities in what they can place in corridors. LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms.
  • Fireplaces will be permitted in smoke compartments without a one-hour fire wall rating, which makes a facility more home-like for residents.
  • For ambulatory surgical centers, alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.
  • Fire watches must be continuous, “constantly circulating” through impaired
  • All side-hinged swinging fire doors must be tested annually.
  • Once every five years, an internal inspection of sprinkler pipe is required.
  • Fire hose valves must be inspected quarterly and tested annually/every three years, depending on size.
  • 1-hour fire-rated barriers are required between non-sprinklered construction areas and occupied egress areas.

Visit the Federal Register to see the full list of changes

Click here to learn more about the updated standards and policies The Joint Commission and HFAP have made.


CMS launches new physician engagement initative

On October 13, CMS announced a push to improve physician engagement and their experience within the Medicare system. To achieve this goal, the agency is trying to reduce the reduce administrative burdens that physicians have to handle with the new Medicare Access and CHIP Reauthorization Act (MACRA).

“Physicians and their care teams are the most vital resource a patient has. As we implement the Quality Payment Program under MACRA, we cannot do it without making a sustained, long-term commitment to take a holistic view on the demands on the physician and clinician workforce,” said Andy Slavitt, CMS Acting Administrator, in a press release. “The new initiative will launch a nationwide effort to work with the clinician community to improve Medicare regulations, policies, and interaction points to address issues and to help get physicians back to the most important thing they do—taking care of patients.”

CMS has begun an 18-month pilot program to reduce medical reviews for certain physicians. The pilot will relieve some of the scrutiny that certain types of advanced Alternative Payment Models (APM) providers receive for medical review programs. Advanced APMs were considered for this pilot they share financial risk with the Medicare program, giving them a powerful motivation to deliver the most efficient care possible. Once the pilot is over, CMS will analyze the results to see if they can be replicated in additional advanced APMs, specialties, and provider types.

“Like all successful changes, we will begin with the basic steps and build over time,” said Ashby Wolfe, MD, MPP, MPH, Region IX chief medical officer. “Most importantly, we are excited to build on the listening and engagement process we began this year by creating more opportunities for physicians to interact with CMS, especially through our regional offices.”

GAO asks HHS for universally aligned quality measures

The Government Accountability Office (GAO) sent a report on October 13 to the Department of Health and Human Services (HHS) urging for better alignment of healthcare quality measures. The conclusion of the 42-page document is that payers haven’t agreed on what quality measures to track, which puts a burden on healthcare organizations.

“For example, a physician may participate in Medicare and a private health plan that each use different measures for assessing the care of diabetic patients,” the GAO wrote. “In another example, a physician may report similar measures to multiple payers that assess blood sugar levels among diabetic patients, but each measure may use a different threshold to determine which patients have their blood sugar levels under control.”

The GAO says there are three main drivers of these misalignments:

  • Dispersed decision-making:Each public and private payer decides which quality measures they want to use and which specifications apply. This is done without regard to the measures that other payers are using.
  • Variation in data collection and reporting systems:The electronic health record (EHR) systems, paper records, or clinical data registries that physicians use all differ in how they collect and report quality data. Without standard measures, there’s little incentive for EHR vendors to create systems to facilitate data collection and reporting.
  • Few meaningful measures:Of the hundreds of quality measures currently used, only a few are seen as leading to meaningful quality improvements.

“What we have right now is a labyrinth of confusing metrics, specifications and reporting rules that serve no one,” said Kathleen Ciccone, RN, introducing a Healthcare Association of New York State report calling for streamlined measures.

The GAO report recommends that HHS, CMS, and the Office of the National Coordinator for Health Information Technology develop a comprehensive plan, including timelines, for more meaningful quality measures and electronic quality measures. The GAO particularly wants to see the creation of standardized data elements to report on core electronic quality measures.

Joint Commission updates Enterprise Content Library Index

The Joint Commission Enterprise Content Library Index was updated this month with thousands of resources on hospital accreditation. The index includes articles, books, webpages, videos, webinars, podcasts, lessons, and FAQs on a myriad of topics. While much of the content is free, some of it is only available to paying Joint Commission customers.

Joint Commission revises advanced certification requirements for inpatient diabetes care

On July 1, 2017, The Joint Commission’s prepublication requirements for the advanced certification for inpatient diabetes care (IDC) will go into effect. The update is part of the accreditor’s ongoing effort to keep its certification programs current. The IDC program has been updated using information from the 2016 American Diabetes Association’s Standards of Medical Care in Diabetes.

Some of the changes include:

  • Educating healthcare staff and physicians on diabetes program policies, procedures, and patient management
  • Identifying target glucose range for critically ill patients
  • Following protocols regarding insulin therapy for persistent hyperglycemia and the treatment of patients with poor oral intake
  • Scheduling follow-up appointments for patients who have had hyperglycemia during their hospitalization
  • Including education in a newly diagnosed diabetes patient’s plan-of-care (see DSSE.3, EP 5a)
  • Documenting insulin pumps for patients who use them in the hospital

CMS: Hospitals must work with PSOs to keep their insurance plans

Hospitals will face new requirements for getting Health Insurance Marketplace (HIM) plans starting on January 1, 2017. The final rule, which was issued by CMS this year, says that hospitals with 50 beds or more can only receive HIM insurance if they:

  • Work with a Patient Safety Organization (PSO).
  • Are a member of a Quality Improvement Organization.
  • Are a member of a Hospital Engagement Network.
  • Are accredited by The Joint Commission. 
  • Implement an evidence-based initiative to improve healthcare quality through the collection, management, and analysis of patient safety events. The initiatives must meet reasonable exception criteria.

The Agency for Healthcare Research and Quality has a list of all the PSOs that apply for the rule. For more information on the new rule and it’s reasonable exception criteria, you can view CMS’ presentation and accompanying Q&A.

Joint Commission launches healthcare violence resource center

The Joint Commission this month launched a digital resource center aimed at reducing workplace violence in healthcare settings. The Workplace Violence Prevention Resources site was created in response to a number of healthcare organizations and providers telling the accreditor about the high levels of verbal, written, and physical abuse leveled against patients and healthcare workers.

“Workers in healthcare are five times more likely to be victims of nonfatal assaults or violent acts than the average worker in all other occupations, according to the Bureau of Labor Statistics,” says Ann Scott Blouin, RN, PhD, FACHE, executive vice president of customer relations at The Joint Commission, in a press release. “As a result, it is critical that we share key resources with those in the healthcare community to help them prepare for and address, as well as hopefully prevent, this type of unfortunate situation from taking place.”

The resource center gathers materials from federal and state agencies, professional associations, healthcare organizations, and The Joint Commission. The library is an easy-to-use source for workplace violence prevention and preparedness; with policies, procedures, guidelines, research, case studies, white papers, and toolkits available for use. Topics include:

•    Violent and criminal event preparedness and prevention
•    Active shooter situations
•    Workplace safety measures
•    Behavioral threat management
•    Emergency operations planning
•    Rudeness and bullying

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Joint Commission seeks input on infection prevention NPSG

Between October 4 and November 15, hospitals and critical access hospitals (CAH) are being asked to give input on newly proposed requirements for the healthcare-associated infections (HAI) National Patient Safety Goal (NPSG). The proposed requirements now cover central line-associated bloodstream infections (CLABSI) and surgical site infections (SSI). The Joint Commission is asking that hospitals and CAHs read the proposed requirements then provide feedback via online survey, online form, or traditional mail.