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New CMS requirements for fire door inspection

The American Society for Healthcare Engineering (ASHE) recently published answers involving CMS’ new fire safety regulations. The new Conditions of Participation require fire doors be routinely inspected by “qualified persons.”

ASHE clarified to members that there isn’t any class or certification to qualify for door inspection. Anyone who’s familiar with the code requirements for fire doors will meet the “qualified” standard.

For more details, see the ASHE brief on the topic.

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Joint Commission urges providers to prevent medication compounding-related errors

In a recent blog post, The Joint Commission called on providers to work toward the elimination of medication compounding-related infections (MCRI). When not mixed in sterile conditions, compounded medicines can cause several types of infections, including bacterial bloodstream infections and cases of fungal meningitis.

MCRIs were in the news recently, after a three-month trial wrapped up last month in which the president of a Boston compounding pharmacy was convicted of racketeering and mail fraud stemming from a 2012 fungal meningitis outbreak that infected 778 and killed 76.

“The health care community, including The Joint Commission, recognize that as the need for compounded medications continues to grow it is more important than ever to ensure safe policies and procedures are being appropriately and effectively implemented to prevent patient harm,” wrote Robert Campbell, PharmD.

In the post, Campbell reminds providers that guidelines for compounding medications (sterile and non-sterile) are derived from the United States Pharmacopeial Convention’s (USP) General Chapters <797>, <795>, and <800>. USP Chapter <800> goes into effect in 2018 and covers guidelines for compounding hazardous materials.  All three chapters have requirements on the environment, personnel, and products used during compounding.

Campbell writes that many facilities still struggle with compounding compliance. In response, The Joint Commission unveiled a new Medication Compounding Certification (MCC) program in January. All compounding pharmacies are eligible to enroll in the program including organizations not accredited by The Joint Commission. The accreditor says that the goal of the MCC program is to:

•    Ensure pharmacies are compliant with USP and Joint Commission standards
•    Reduce the risk and harm stemming from drug compounding
•    Uncover and fix problems in existing compounding policies and procedures
•    Train personnel on the correct use of PPE and aseptic techniques
•    Ensure the physical environment meets guidelines for cleaning and documentation
•    Ensure the proper labeling, dating, and sterility of compounded products

TBT: North Carolina hospital uses Lean methodology to reduce patient falls

Editor’s Note: The following is a free Patient Safety Monitor Journal article from yesteryear! If you like it, check out more of our work covering quality and patient safety!

One year ago the patient fall rate at New Hanover Regional Medical Center (NHRMC) in Wilmington, North Carolina was deemed “acceptable” compared to national standards. Statistically, the hospital wasn’t any worse off than hospitals of a similar size, but patient safety experts and administrators within the institution still felt there were missed opportunities to reduce their rates and improve patient care.

“We were doing a good job,” says Mary Ellen Bonczek, chief nurse executive at NHRMC. “It’s not like we had a problem compared to national organizations our size, but we clearly felt like we could do a better job and we began to change our mind-set towards prevention and elimination.”

The facility had already seen some positive gains in reducing infections simply by focusing on prevention and elimination strategies, and administrators within the facility felt they would see the same progress if they applied those principles toward reducing patient falls.

One year later, patient falls have decreased 22% to 2.5 falls per 1,000 patient stays, which translated to an estimated $500,000 in savings, according to an op-ed by NHRMC President and CEO Jack Barto published on

“This is but one example of how healthcare providers, by standardizing best processes and consistently following them, can change the delivery of care, one improvement at a time,” Barto wrote. “Over time, these improvements will add up to better patient experience, better quality of care and significant savings.”

The patient fall reductions that the facility saw were a result of a few simple, no-cost interventions developed by a patient services fall team, which implemented a patient risk assessment, standardized best practices, hourly rounding, and visual cues to focus on eliminating preventable falls.

“We challenged ourselves to look at things differently and begin to change our mind-set around patients at risk for falls,” Bonczek says.

Reevaluated patient falls

Although NHRMC already had a fall prevention team, last summer it applied Lean methodology to improve its process of discovering preventable patient falls. The multidisciplinary team?consisting of physicians, nurses, therapists, pharmacists, transportation employees, and environmental services employees?utilized value-stream mapping to uncover process improvement and design modifications.



ECRI Introduces HIT-based Patient Identification Tools

The toolkit aims to prevent patient misidentification through the use of health information technology.

Patient misidentification is a big and likely underreported problem for hospitals and health systems, as well as for patients.

The consequences can be significant. ECRI Institute research shows that 9% of patient misidentification events lead to temporary or permanent harm or death.

That’s why the ECRI Institute and a stakeholder collaborative it convened, the Partnership for Health IT Patient Safety, has launched a new patient identification resource to help prevent patient misidentification through the use of health information technology.

ECRI is a Pennsylvania-based nonprofit that works to improve the safety, quality, and cost-effectiveness of patient care.

The toolkit divides its recommendations into two sections:

  1. Attributes addresses “the information-gathering aspects of patient identification, including the fields and the formats that are available to accommodate acquisition of required information.”
  2. Technology addresses “new technologies to improve identification and ways to leverage existing technologies for safe patient identification.”

Continue reading at HealthLeaders Media. 

Throwback Thursday: Medicine from afar

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

How one critical access hospital turned to telemedicine to better serve its community

After reading this article, you will be able to:

  • Describe the needs a telemedicine program meets at a ­rural or remote facility
  • Identify surmountable barriers to implementation for a telemedicine program using robotic instrumentation
  • Identify the types of programs or services a telemedicine link can help a remote facility provide
  • Describe the financial benefits, both to the organization and to patients, that come with having a strong telemedicine program in place
  • Discuss credentialing challenges that an organization ­implementing a telemedicine program might face

Tucked away on the far side of mountain passes in northeast Oregon, the 25-bed critical access Grande Ronde Hospital in La Grande provides much-­needed care for a populace that can be cut off from larger facilities by a single snowstorm. The hospital provides all that it can for the local population, but, as with every critical access facility, there are inherent limits to the services that can be provided on-site. Certain specialties and medical services simply do not have the demand to draw full-time physicians or other professionals to the area.Middle-aged man measures his blood pressure in front of virtual doctor. In the meantime, telemedicine physician is carefully looking at his brain x ray picture in the monitor.

Grande Ronde has, however, found a high-tech solution to this issue-one that ensures its patient population can receive services locally rather than traveling hundreds of miles, as might have been necessary in the past.

“We were asked by Saint Alphonsus Hospital in Boise to take part in a grant program,” explains Doug Romer, the hospital’s executive director of patient care services. “Their outreach director got in touch with us and said, ‘I have these robots through a grant. Would you like to try providing telemedicine services?’ “

At the time, Grande Ronde did not have a telemedicine program and was interested in taking part in the process. And so its robot, a nearly human-height, mobile machine with a monitor where the “face” would be, ­arrived at the facility.

The program is what is known as a hub-and-spoke model-the tertiary hospital, in this case Saint ­Alphonsus, is the hub, and the rural facilities are the spokes. This model has evolved for Grande Ronde and is now known as a remote presence healthcare network. The network connects Grande Ronde with four states and five cities for specialty healthcare. For example, patients in the Grande Ronde ICU receive telemedicine services from St. Louis.

“The physicians log in, can see our electronic medical records, review images, review labs, review vital signs, and they will come in and visit patients face-to-face [via the robot’s camera and monitor],” explains Romer. “They are able to assist and direct the care of patients throughout the day and through the night when our nurses have questions. They will call ICU doctors in St. Louis and they will make decisions or change therapies as needed.”



CMS releases new information on emergency preparedness requirement

CMS has issued new information on the training and testing requirements for its Emergency Preparedness final rule. The rule went into effect last year, and all applicable facilities must be in full compliance with the rules by November 15, 2017. CMS Logo

“In order to meet these requirements, we strongly encourage providers and suppliers to seek out and to participate in a full-scale, community-based exercise with their local and/or state emergency agencies and health care coalitions and to have completed a tabletop exercise by the implementation date,” the agency wrote. “We realize that some providers and suppliers are waiting for the release of the interpretive guidance to begin planning these exercises, but that is not necessary nor is it advised. Providers and suppliers that are found to have not completed these exercises, or any other requirements of the Final Rule upon their survey, will be cited for non-compliance.”

The rule requires healthcare facilities to meet the following four standards:

1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.

2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.

3. Communication plan: Develop and maintain a communication plan that complies with both federal and state law. Patient care must be well coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency systems.

4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.

Facilities unable to complete a full-scale community exercise by the deadline will have to finish an individual facility-based exercise and give proof that they why the full-scale exercise couldn’t be done. For those having trouble meeting the new rule, CMS has provided related resources. These include:

•    checklists
•    links to emergency preparedness agencies
•    planning templates
•    a state-by-state listing of healthcare coalition

@HCProAccred; bringing you the news

Hi everyone,

Yesterday we launched the HCPro Accreditation Twitter account to help you stay ahead of the quality and accreditation game.

Please take a moment to find and follow @HCProAccred on Twitter and receive:

  • Up-to-the minute news
  • Educational materialsHCPRo logo small
  • Details about upcoming events and webinars
  • Free Briefings on Accreditation and Quality  articles 
  • User polls on hot topics
  • And much more!


Thanks and have a great spring!

Brian W.

Joint Commission FAQs on H&P and titration orders

The Joint Commission has released new FAQs regarding the new updates to history and physical (H&P) updates and titration orders. The FAQs apply to hospitals, hospital clinics, and critical access hospitals.

The FAQs cover questions such as:

 When is an H&P update required?

What specific elements are required for titration orders? And what other safety and quality factors should be considered?

What are the requirements for updating an H&P after a procedure requiring anesthesia is performed after admission?

Throwback Thursday: Perfecting infection control on everyday items

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

After reading this article, you will be able to:

  • Identify everyday items that may require additional thought when it comes to infection control procedures
  • Describe who should be involved when developing policies for cleaning everyday items in the patient room
  • Discuss the development process of disinfection policies for certain challenging items
  • Describe leadership’s role in building an effective policy for patient room equipment cleaning routines

Think back to your last visit to a hospital as a patient or family member. Every patient care area has recognizable, ubiquitous items, such as automated blood pressure pumps, compression pumps, and IV pumps. But how do you know if those items were cleaned and/or disinfected? Were they used with the last patient, or have they sat dormant for weeks? Such items are easy to overlook, but in terms of patient safety and infection control, they need to be addressed in every facility.

One organization, St. Joseph’s Healthcare System-which includes St. Joseph’s Regional Medical Center in Paterson and St. Joseph’s Wayne Hospital in Wayne, N.J.-has implemented a method for cleaning these everyday items and identifying them as clean without adding an additional burden to its staff.

“As you know, in healthcare it can be challenging to change processes,” says Anne Marie Pizzi, M.Ed., RN, HACP, TeamSTEPPS trainer, Six Sigma Green Belt, and performance improvement coordinator with St. Joseph’s. “This began as a work in progress three or four years ago as we were struggling with preventing infection control issues and trying to find a way to make life easier for staff to clearly identify items that were already clean, or that needed to be cleaned.”

So the organization-a regional tertiary medical center and an acute care community hospital-brought together all the key departments, including infection prevention and control, nursing, central sterilization processing, and environmental services, to work collaboratively to improve the process.

“In the beginning, the problem boiled down to a real estate issue,” says Pizzi. “The hardest thing for us to decide when we talked about the equipment was, whose job is it to clean it?”

In addition, the team looked at what type of equipment was involved, how frequently it needed to be cleaned, and what kind of cleaning was necessary.

“Anything requiring more than low-level disinfection is not left to the staff on the unit,” says Pizzi. “So there were specific pieces of equipment that had to go to central supply or to individual departments where staff are trained to clean and care for that equipment.”

The equipment that environmental services or the staff on the units will typically clean include automated blood pressure pumps, Accu-Chek® meters­, pulse oximeters, and IV pumps.

“You may believe that you have designed a solid process when discussing it in a meeting, but when it is rolled out to the staff, change can be a challenge,” says Pizzi. “So it was really important we talked to the staff to determine the processes they were using and the possible solutions they would suggest.”

 [Continued –>]