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HFAP will hold off on assessing certain Life Safety Code standards

Earlier this year, CMS announced that it was finally adopting the 2012 Life Safety Code [LSC], which went into effect on July 5. However, until CMS had approved modification to HFAP’s manuals the accreditor isn’t allowed to enforce the new LSC requirements. CMS has announced that the new requirements will go into effect on November 1, 2016.

This means for the next four months, HFAP facilities will not be assessed on the following requirements:

  • Fire watches must be continuous, ‘constantly circulating’ through the impaired area.
  • Maximum 4 inch projection into corridors.
  • All side-hinged swinging fire doors must be tested annually.
  • Once every 5 years, an internal inspection of sprinkler pipe is required.
  • Fire hose valves must be inspected quarterly and tested annually/3 years, depending on size.
  • 1-hour fire rated barriers are required between non-sprinklered construction areas and occupied egress areas.

Blood management guidelines save $2 million and reduce blood use 30%

At Vanderbilt University Medical Center [VUMC] in Tennessee, a multidisciplinary team has been working on an evidence-based guidelines for limiting blood use and waste. Presenting their results at this year’s American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Conference, they announced that their program had saved the hospital $2 million and reduce blood use by 30%.

The VUMC researchers said in a press release that the first step was to get hospitals to assess how many units of blood are needed during a transfusion. Many facilities automatically order two units of blood for a transfusion, which isn’t always necessary.

Using an enhanced Computerized Provider Order Entry (CPOE), researchers were able to order a single unit of blood based on the merits of each case, with more blood ordered when necessary. That step alone cut VUMC’s red blood cell transfusions down from 675 units per 1,000 discharges in 2011 down to 432 units per 1,000 discharges in 2015.

Read more about blood management techniques at HealthLeaders Media. 

Joint Commission’s 2017 antibiotic stewardship standards

In the wake of a CMS ruling that will make antibiotic stewardship programs (ASP) mandatory, The Joint Commission recently announced that it will roll out a similar standard. Effective January 1, 2017, the new Medication Management standard requires facilities to create an effective ASP. The standard applies to:

The Joint Commission released the standard a month after attending the White House Forum on Antibiotic Stewardship, which focused on implementing changes over the next five years to slow the emergence of antibiotic-resistant bacteria, detect resistant strains, promote stewardship of existing antibiotics, and prevent the spread of resistant infections. Representatives from 150 retailers, food organizations, healthcare organizations, and animal health organizations were in attendance.

Only 40% of U.S. hospitals have an antibiotic stewardship program and an estimated 30% to 50% of prescribed antibiotics are unnecessary or inappropriate.  In the U.S., drug-resistant diseases cause 23,000 deaths and 2 million illnesses each year. That number is expected to increase exponentially in the upcoming decades. 

See more articles like this by subscribing to The Accreditation Insider. 

Study: 45% of ICU physicians suffering from severe burnout

Earlier this month, the Critical Care Societies Collaborative published a report simultaneously in the American Journal of Respiratory and Critical Care Medicine, Chest, the American Journal of Critical Care, Critical Care Medicine on the issue of burnout syndrome (BOS) in the ICU. The report defines BOS as when is when excessive and prolonged stress causes a state of emotional, mental, and physical exhaustion. Researchers found that 45% of critical care physicians and 25%-33% critical care nurses working in the U.S. are currently suffering from severe burnout.

“With more than 10,000 critical care physicians and 500,000 critical care nurses practicing in the United States, the effects of burnout syndrome in the ICU cannot be ignored,” says senior author Curt Sessler, MD. “We believe that protecting the mental and physical health of healthcare professionals who are at risk for burnout syndrome is vitally important for not only the professionals but for all stakeholders, including our patients.”

There are three main symptoms of BOS: exhaustion, depersonalization, and reduced personal accomplishment. There’s also a host of nonspecific symptoms such as the inability to feel happiness or contentment, and experiencing feelings of frustration, anger, fear, or anxiety.

To treat and prevent BOS, the study authors recommend: [more]

Joint Commission eliminates life safety Plans for Improvement

As of August 1, The Joint Commission will no longer accept hospital Plans for Improvement for life safety deficiencies identified by surveyors, the accreditor announced today. Hospitals will now have 60 days to fix any and all life safety deficiencies, unless they receive a waiver from a CMS regional office for additional time. The change was announced at the American Society of Healthcare Engineering (ASHE) annual conference by George Mills, director of engineering for The Joint Commission, according to an ASHE advisory alert. The change comes at the request of CMS, which had asked The Joint Commission to revise its Statements of Conditions process. Visit here for more information on the changes.

Joint Commission to test its stroke care performance measures in August

Stroke is the fourth leading cause of death in America, resulting in 133,103 deaths in 2014. In response, The Joint Commission is working a new performance measure set for its Advanced Certification Program for Acute Stroke Ready (ASR) Hospitals. The accreditor is working with both the American Heart Association and American Stroke Association on the development of the measure sets.

So far, the accreditor has developed two new performance measures for ASR hospitals and has updated several other stroke measures. Volunteer facilities will test the measures from August to November 2016, with results to be reviewed and finalized in 2017.

Click here to see the list of draft performance measures. 

Joint Commission releases checklist for new diagnostic imaging standards

Recently, The Joint Commission published an imaging compliance checklist to help healthcare organizations prepare for new standards that go into effect on September 1. The checklist can be used for self-assessment and survey preparation.

In February, the accreditor released prepublication standards for all facilities with diagnostic imaging services. The requirements address the minimum qualifications needed for personnel to conduct diagnostic computed tomography exams:

Click here to download the “The Imaging Compliance Checklist.” 

CMS begins oncology bundles

On July 1, nearly 200 group practices began a five-year demonstration program of CMS’s. The model’s goal is to improve the quality and decrease the costs of cancer care nationwide. Cancer is the second leading cause of death in America, with 22.5% of all deaths in 2014 resulting from some form of it. Meanwhile, the costs of cancer care are expected to rise to $158 billion in 2020, an increase of 27% over 2010.

“The Oncology Care Model encourages greater collaboration and information sharing so that cancer patients get the care they need,” said U.S. Department of Health and Human Services Secretary Sylvia M. Burwell, in an announcement. “This patient-centered care model furthers the goal of the Vice President’s Cancer Moonshot to improve coordination, care, and outcomes while spending dollars more wisely.”CMS Logo

Participating physicians will receive performance-based payments for caring for Medicare cancer patients under a bundled payment model. They’ll also receive a monthly care management payment for each beneficiary. Participating in the Oncology Care Model is 17 health insurance companies, more than 3,200 oncologists, and approximately 155,000 Medicare beneficiaries. The group practices involved will all follow nationally recognized clinical guidelines for chemotherapy, with improved services including: [more]

U.S. House passes mental health bill

On June 6, the House of Representatives passed the “Helping Families in Mental Health Crisis Act” by a 442-2 vote. The bill would allow CMS to reimburse providers for treating Medicaid patients’ mental health and physical health on the same day, increase the number of psychiatric hospital beds, and cut CMS spending by $5 million over 10 years. The bill was created and led by Rep. Tim Murphy, a licensed child psychologist, in response to the Sandy Hook shootings.

“This historic vote closes a tragic chapter in our nation’s treatment of serious mental illness and welcomes a new dawn of help and hope,” he said in a press release. “We are ending the era of stigma. Mental illness is no longer a joke, considered a moral defect and a reason to throw people in jail.”

The Senate is expected to vote on the bill by the end of the year.


Joint Commission updates hospital quality measures Specifications Manual

The Joint Commission recently published its updated Specifications Manual for National Hospital Inpatient Quality Measures.

CMS and The Joint Commission worked on the manual together to create a single set of documentation and create an identity amongst common hospital performance measures. The document includes measure sets for tobacco use, substance abuse, stroke, and venous thromboembolism and its release notes are applicable from July 1 through December 31.