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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.

ACS releases new standards for overlapping and concurrent surgeries

The American College of Surgeons (ACS) released a much anticipated update to its “Statements on Principles” addressing both concurrent and overlapping surgeries.
More than six months after a Spotlight Report from the Boston Globe into the concurrent surgeries at Massachusetts General Hospital, the ACS updates stipulate “a primary attending surgeon’s involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate.”

ACS also outlined two scenarios in which overlapping operations may occur. In both situations, the organization says patients must be informed of the overlapping surgery.
“The performance of overlapping procedures should not negatively impact the seamless and timely flow of either procedure,” the guidelines state.
Critics told the Boston Globe the changes did little to change unsafe surgical practices associated with double-booking surgeries.

Read the updated guidelines here and for the Boston Globe article, click here.

 

Joint Commission updates CT technologist prepublication standards

The Joint Commission announced that it was updating two standards involving advanced-level computed tomography (CT) certification. The accreditor had originally announced changes to the CT certification back in February and received several comments from customers concerned over the new minimum qualifications for CT technologists. In response to the feedback, The Joint Commission decided to delete one note and suspend one Element of Performance from the standards.

The prepublication standards for hospitals, critical access hospitals, and ambulatory care centers are now on The Joint Commission website. The standards go into effect on September 1, 2016.

 

CMS releases list of proposed rules, makes antibiotic stewardship mandatory

Last week, CMS published a list of proposed rule changes for hospitals and laboratories.  One of the more notable proposals would make antibiotic stewardship programs [ASP] mandatory. ASPs are viewed by many as a way to prevent antibiotic misuse and the spread of drug-resistant disease.

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“We propose to change the introductory paragraph [in Infection Control Condition of Participation §482.42] to require that a hospital’s infection prevention and control and antibiotic stewardship programs be active and hospitalwide for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship,” according to the proposed rule.

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.

The document also changed included changes to patient rights, restraint usage, physician assistants, medical records, diet orders, periodic evaluations, and several more. To see the full list of changes, click here.

Healthcare professionals can comment on the proposed rules until 5 p.m. on August 15, 2016. Comments can be sent by traditional mail to CMS or done online.

 

Joint Commission announces delay on texting ban repeal

This spring, The Joint Commission reversed its ban on texting medical orders, citing critical improvements in the technology’s security. The accreditor has now announced it will delay the repeal until it can create additional guidance on appropriate texting policies, according to an article in the July issue of Joint Commission Perspectives. The Joint Commission and CMS will be collaborating on a set of FAQs and hope to publish their additional guidance by September.

Joint Commission approves new antimicrobial stewardship standard

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 hospitals, critical access hospitals, and nursing care centers.

The new standard can be viewed in the July issue of Joint Commission Perspectives.

HFAP releases updated 2015 Acute Care Manual

On June 10, the Healthcare Facilities Accreditation Program (HFAP) released the second version of its 2015 Acute Hospital Care Final Standards. The updated manual supersedes the prepublication standards that the accreditor had published on January 25. All of the prepublication standards released this January were approved as written except for Standard 25.00.05 Management, which clarifies the expectations and job description of the pharmacy director. The changed text now reads: “The Pharmacy Director must meet the qualifications established by the Medical Staff.  It is NOT required that the Pharmacy Director undergo the Medical Staff Credentialing and Privileging process.”

The updated manual will go into effect on September 1, 2016 and includes 11 revised pharmacy related standards:

  1. Standard 25.00.00 Condition of Participation: Pharmaceutical Services
  2. Standard 25.00.01 Pharmacy Services
  3. Standard 25.00.04 Pharmacy Management & Administration
  4. Standard 25.00.05 Management
  5. Standard 25.01.01 Medication Control & Distribution
  6. Standard 25.01.02 Supervision of Pharmacy Activities
  7. Standard 25.01.03 Security of Medications
  8. Standard 25.01.07 Inventory Management System:
  9. Standard 25.01.09 Automatic Stop Medication Orders
  10. Standard 25.01.12 Informational Resources
  11. Standard 16.01.01 Preparation and Administration Drugs

HFAP has also published a new crosswalk, Acute Care Manual 2015 v2 New Standards to Old Standards. Those with questions about the 2015 version 2 Acute Care Hospital manual should email info@hfap.org.

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CMS proposal would make antibiotic stewardship programs mandatory

Healthcare professionals have 60 days to comment on a proposed CMS rule to make antibiotic stewardship programs (ASP) mandatory for all hospitals and critical access hospitals.

“We propose to change the introductory paragraph [in Infection Control Condition of Participation §482.42] to require that a hospital’s infection prevention and control and antibiotic stewardship programs be active and hospital-wide for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship,” according to the proposed rule.

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.

Joint Commission releases Enterprise Content Library Index

The Joint Commission recently released its Enterprise Content Library (ECL) Index, a 177-page PDF of Joint Commission content organized by topic.

Topics include:
• Care Coordination & Transitions
• Diagnostic Imaging
• Emergency Management
• Facilities – EC & Life Safety
• Governance & Leadership
• Health IT & EHRs
• Human Resources
• Infection Control
• Laboratories

The ECL Index will be updated every quarter and the majority of its content is free. However, some items are only available to Joint Commission customers. Information can also be accessed for a fee. Click here to visit the Index.

California Department of Public Health gives deeming authority to Joint Commission for lab surveys

On June 3, the California Department of Health’s Laboratory Field Services granted deeming authority to The Joint Commission to survey clinical labs within the state. The accreditor proved that its standards matched the unique requirements of California clinical lab laws, according to a press release.

“We are pleased to receive this important deeming authority from LFS and are prepared to take on the responsibilities of inspection and oversight for clinical laboratories to ensure ongoing compliance with California law,” said Joint Commission executive director Stacy Olea, MT(ASCP), FACHE, in the release. “As a quality improvement organization, the deemed status will allow us to bring our dedication to patient safety and quality care to the forefront of clinical laboratories across California.”