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2017 reporting requirements for ORYX

The Joint Commission released it’s 2017 reporting requirements for ORYX. Changes in include deletion of the measure set reporting requirement.

ORYX is a performance measurement and improvement initiative, for which facilities are  required to collect and submit data on six sets of core measures.

Click here to see the full document. 

Avoid fire drill citations with new matrix

Several months ago, Virginia Mason Medical Center (VMMC) in Seattle was denied full Joint Commission accreditation, in part due to its handling of fire drills. The facility received its citation for failing to vary the times and days when drills were conducted.

Now, The Joint Commission has released a new fire drill matrix for facilities to forestall confusion on survey day. The matrix tracks the day, date, time, and shifts when fire drills are conducted to ensure that they were conducted according to Joint Commission and CMS regulations. While they’ll still examine fire drill forms, surveyors will also give a copy of the matrix to hospitals when they arrive; although you can download an Excel copy of it here. 

The accreditor requires facilities to hold fire drills at random times to ensure that staff are ready when an actual emergency happens. Jim Kendig, The Joint Commission’s field director for surveyor management and development, said in a press release that hospitals are often unaware that they are conducting fire drills at similar times and days. The matrix helps them notice any patterns in scheduling that otherwise might escape notice.

“It becomes apparent,” Kendig said. “Hospitals can use this ahead of time, see patterns, and self-correct.”

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Four methods to limit redundant and unnecessary prescribing

The Hospitals & Health Network recently published an article on the issue of polypharmacy, which occurs when a patient is given redundant or unneeded medications. Tamping down on polypharmacy is crucial as many facilities face drug shortages, as well as the fact that inappropriate prescriptions can result in addiction  or drug-resistant disease. The author of the article, Todd Kislak, points out it’s not difficult for inaccuracies to appear on a patient’s medication list.

“When a patient is transferred among facilities, [primary care providers] PCPs tend to lose connection with the patient’s medications regimen,” he writes. “New additions to the medications list may be buried in the details of a discharge notification. There may also be physician specialists adding prescriptions without notifying the PCP. Additionally, in many cases, PCPs lose track of over-the-counter medications and other supplements in the patient’s medicine cabinet.”

Four steps to reduce polypharmacy are:

1.    Build a comprehensive polypharmacy management plan directly into the patient’s transition-of-care program. The discharging physician needs to have direct responsibility for approving and reviewing their patient’s medications list.

2.    Include polypharmacy into the medications therapy management program. Pharmacists should review patients’ current medications list, line-by-line, and give their recommendations to the discharging physician. The optimized medications list should then be communicated to the patient’s PCP and their admitting physician if they’re sent to another facility.

3.    Educate patients as early as possible on their current medications.When possible, review with the patient their current prescriptions, expired prescriptions still in the cabinet, over-the-counter medications and other supplements. This can be done with family members or caregivers in attendance, or done via email or phone.

4.    Hire a medication consultant to conduct polypharmacy management. If you have the funds, hire a physician whose primary duty is reviewing medication records for inconsistencies.

“Facilities that assume a proactive role in polypharmacy management with meaningful physician engagement will enjoy a competitive advantage in managing the health of their local populations,” Kislak writes. “They will profit from improved outcomes for their patients while delivering a benefit to all stakeholders across the care continuum.”

ACOs improve patient care and save $1.29 billion since 2012

CMS reports that between 2012 and 2015, accountable care organizations (ACO) have generated more than $1.29 billion in total Medicare savings. In 2015 alone, all 392 Medicare Shared Savings Program (MSSP) participants and 12 Pioneer ACO Model participants saved a combined $466 million while improving care quality.

“The coordinated, physician-led care provided by Accountable Care Organizations resulted in better care for over 7.7 million Medicare beneficiaries while also reducing costs,” said CMS Acting Administrator Andy Slavitt in the press release. “I congratulate these leaders and look forward to significant growth in the program in the coming year.”

Since 2012, MSSPs’ quality scores have increased 21%, with nine out of 12 MSSPs achieving quality scores over 90%. ACOs showed improvement on 84% of quality measures in both 2014 and 2015. ACOs also improved performance on key preventive measures such as including screening for falls risks, depression, blood pressure, and providing pneumonia vaccinations by 15%.

“Accountable Care Organization initiatives in Medicare continue to grow and achieve positive results in providing better care and health outcomes while spending taxpayer dollars more wisely,” said Dr. Patrick Conway, CMS Principal Deputy Administrator and Chief Medical Officer. “CMS continues to work and partner with providers across the country to improve the way health care is delivered in the United States.”

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Joint Commission releases analysis of eCQM data

The analysis found that missing data was the biggest cause of discrepancies. Some examples of missing data are:

•    Missing data on medication route
•    Use of wrong template ID
•    Diagnosis Active is missing, which puts the case in denominator

The Joint Commission also unveiled its Core Measure Solution Exchange®,which allows hospitals to share how they implemented the eCQMs. Users can post about the implementation issues they’ve had, challenges they’ve faced, and solutions they’ve come up with. They can learn from other facilities about the problems and solutions they came up with as well.

The Exchange is free and is part of your facility’s Joint Commission Connect extranet.

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AHRQ toolkit teaches how to face up to medical errors

Medical errors happen too often, and can cause irreversible and irreparable injury to patients when they do. While there is a myriad of ways to try and prevent errors from happening, every hospital needs to have policies in place for when they occur.

A common approach of responding to medical errors is to hide the details of them from patients, also known as the “deny-and-defend” strategy. Often this is done out of fear that a patient or their family will get angry and sue if they find out a mistake was made during their care. There’s also the possibility that the hospital would have to foot the bill for any follow-up care necessitated by the mistake, or waive a patient’s bills.

That said, studies have found that patients are more inclined to sue if they think their physician has been hiding something from them. Therefore, the Agency for Healthcare Research and Quality (AHRQ) published an online toolkit this May that suggests that physicians do the exact opposite. The toolkit,Communication and Optimal Resolution (CANDOR), emphasizes openness with patients and family when a mistake happens.

Some hospitals are now having physicians and medical students go through role-playing scenarios where they have to explain a mistake to a patient or their family. MedStar Health, a provider in Maryland and Washington, D.C., created a “Go Team” of physicians trained in disclosing medical errors that remains on standby to provide support to staff when they need to tell a patient about a mistake.

“We felt horrible that we couldn’t openly talk to patients and families … our attorneys would tell us we can’t do that because we’re going to give them all the information that will cause us to lose a lawsuit,” David Mayer, vice president of MedStar told Kaiser Health Media.  “There were no winners”

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Three new Joint Commission questions for building tours

During your next Joint Commission survey, be prepared to answer three new questions before even starting your building tour. Jim Kendig, the Joint Commission’s field director for surveyor management and development, told the American Society for Healthcare Engineering (ASHE) that the questions are intended to spur conversations among surveyors and healthcare facility managers about common areas for findings.

The three new questions are:

1. What type of fire-stopping is used in the facility?
2. What is the organization’s policy regarding accessing interstitial spaces and ceiling panel removal?
3. Which materials are used (e.g., glutaraldehyde, ortho-phthalaldehyde, peracetic acid) for high-level disinfection or sterilization?

“They’re pretty straight forward—there’s no hidden agenda here,” Kendig said. “We’re just trying to get some information before we start the building tour.”

Joint Commission and CDC team up on ambulatory infection prevention

The Joint Commission and the Centers for Disease Control and Prevention (CDC) are working on a new initiative to improve infection control in ambulatory care settings. The Adaptation and Dissemination Outpatient Infection PrevenTion (ADOPT) project will promote existing CDC infection prevention (IP) guidance while also making updates and alterations. The collaboration will involve:

•    Evaluating organizations’ infection prevention and control guidelines and materials to find gaps between what’s done in practice and what’s in the CDC materials.
•    Finding new ways and opportunities to raise awareness of IP guidance.
•    Adapting model infection control plans for outpatient-focused professional organizations.
•    Developing new ways of disseminating these materials and models to healthcare organizations to increase their reach, uptake, and adoption in outpatient settings.

There are 12 outpatient-focused professional organizations and 11 ambulatory healthcare systems participating in ADOPT. Other healthcare organizations or state health departments interested in learning more can reach out to Barbara Braun, PhD, at

For examples of CDC ambulatory-focused infection prevention and control guidance, check out the following links:
•    CDC Guide to Infection Prevention for Outpatient Settings:  Minimum Expectations for Safe Care
•    CDC Outpatient Settings Policy Options for Improving Infection Prevention
•    CDC Basic Infection Control and Prevention Plan for Outpatient Oncology Settings
•    The CDC One and Only Campaign
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Share the trials and tribulations of eCQM success

Are you wondering how you’ll ever be prepared for the CMS’ updated Electronic Clinical Quality Measures (eCQM) due for release February 28, 2017? Don’t worry, you don’t have to face it alone.

The Joint Commission recently unveiled its Core Measure Solution Exchange®, which allows hospitals to share how they implemented the eCQMs. Users can post about the implementation issues they’ve had, challenges they’ve faced, and solutions they’ve come up with. They can learn from other facilities about the problems and solutions they came up with as well.

The Exchange is free and is part of your facility’s Joint Commission Connect extranet. There is already an eCQM solution posted by Wooster Community Hospital for viewing.

Introducing the PSQH Forum!

We’re proud to release the newest feature of the Patient Safety & Quality Healthcare website, the PSQH Forum. The forum is for you, the patient safety professional, to voice your opinions, share tools and policies, and receive answers to industry-related questions.

PSQH LogoWe’ve updated the former Patient Safety Talk forum, that long-time readers of Patient Safety Monitor Insider will remember, into a more traditional online forum with different categories in which you can post (and receive email notifications).

We’ve kept the valuable talk threads in a Patient Safety Talk archive on the new site.

Stop by the forum, introduce yourself or just browse through the archives.