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Medical errors and HACs on the decline

A new report from the Agency for Healthcare Research and Quality’s (AHRQ) found that medical error rates have dropped 28% in the past decade. To determine medical error trends, the Chartbook on Patient Safety compared the number of medical malpractice payment reports between 2004 and 2014, finding a yearly decline in medical error rates save a minor spike in 2013.AHRQ logo

Hospital-acquired condition (HAC) rates are also in decline, albeit more gradually. The AHRQ found that 121 per 1,000 discharges contracted an HAC in 2014 as compared to the 145 per 1,000 in 2010. Pressure ulcers rates saw the biggest decrease, dropping from 1.3 million events annually to 1 million. There was also an improvement in approximately 60% of quality measures, 80% of person-centered care measures, and 60% of measures for effective treatment, patient safety, and healthy living.

Read the Chartbook on Patient Safety for more data, graphs, and information on national healthcare quality.

HFAP publishes top-cited deficiencies of 2012-2015

The Healthcare Facilities Accreditation Program (HFAP) recently released information on top-cited deficiencies for acute care hospitals  , clinical laboratories, critical access hospitals, and ambulatory surgical centers.

Covering data from 2012-2015, the documents identify each deficiency by its HFAP standards number and its corresponding Code of Federal Regulations number. The documents also include graphs showing the percentage of Conditions of Participation cited by year. For acute care hospitals, the most-cited deficiencies were standards 15.01.09 (exercise of patient rights) with 54%, 10.01.01 (content of the record) with 40%, and 30.00.09 (standards of practice) with 37%.


Joint Commission revamps Quality Check

Originally launched in 1996, The Joint Commission’s Quality Check website gives customers a way to search for accredited and certified organizations. The site can be used to find how many facilities there are in a given area by typing in a state, city, or zip code. Or if one is trying to find out what certifications a specific facility has, they can type its name or Joint Commission ID number.

This month, The Joint Commission announced that it was updating the Quality Check site as part of an ongoing effort to provide “meaningful information about accredited organizations’ performance to the public.” The updated page is easier to navigate and allows customers:

  • To search by services and Doing Business As (DBA) names.
  • Interact with The Joint Commission via its Facebook, Twitter, LinkedIn and Vimeo accounts.
  • View overviews of accreditation and certification components using Shareable Quality Reports®
  • Download accreditation and certification data

Visit the updated Quality Check website here.

Joint Commission to elaborate on texting policy in June

The Joint Commission plans to release additional information on its new texting policy next month. The accreditor says that the new guidance will cover how frequently medical orders can be texted, the requirements for read back/text back confirmation, and the difference between text orders that are digitally or manually entered into the electronic health record.

Click here to read the full Accreditation Insider article on the new texting policies. 

Joint Commission announces Pioneers in Quality panel members

The Joint Commission this week selected 13 technical experts to work on its Pioneers in Quality Advisory Panel. The panel was created to help accredited hospitals transition towards the use of electronic clinical quality measures (eCQM). Along with providing support and education to facilities, the panel will also update The Joint Commission on challenges facilities are facing as well as the best methods of using eCQMs to measure and improve the quality of care.

“The combined expertise of this outstanding group will better inform our efforts and benefit hospitals who need real world solutions,” said David Baker, MD, MPH, FACP, executive vice president of The Joint Commission, in a press release. “We are steadfastly focused on developing viable solutions to the measurement-related issues that hospitals are facing.”

The advisory panel members are:

  • David W. Baker, MD, MPH, FACP, executive vice president, Healthcare Quality Evaluation, The Joint Commission
  • Jennifer Besch, director, Population Health, Cerner Corporation
  • Zahid Butt, MD, FACG, CEO, Medisolv, Inc.
  • Jayne Hart Chambers, MBA, senior vice president Quality, Federation of American Hospitals
  • Paul Conlon, PharmD, JD, senior vice president, Chief Quality and Patient Safety, Trinity Health
  • Nancy Foster, vice president for Quality and Patient-Safety Policy, American Hospital Association
  • Thomas French, MStat, system director of Clinical Analytics, Division of Clinical Effectiveness and Quality, Providence Health & Services
  • Steve Horner, RN, BSN, MBA, vice president, Clinical Analytics, HCA, Inc.
  • Deborah Krauss, MS, BSN, RN, nurse consultant, Division of Electronic and Clinician Quality, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services
  • Kevin Larsen, MD, FACP, medical director, Meaningful Use, Office of the National Coordinator for Health Information Technology; CMS Lean Implementation, Office of the Administrator/Center for Medicare & Medicaid Innovation, U.S. Department of Health and Human Services
  • Lynn Lenker, BSN, MS, RN-BC, ONC, NE-BC, system chief nursing information officer, SSM Healthcare; Nurse Champion-Project Beacon
  • Helen Lindsay Macfie, Pharm D, FABC, chief transformation officer, Certified Lean Leader, MemorialCare Health System
  • John S. Pirolo, MD, senior vice president and chief medical information officer, Ascension
  • Cindy Tourison, MSHI, acting director, Division of Quality Measurement, Quality Measurement and Value-Based Incentives Group, Centers for Medicare & Medicaid Services

For more information on the Pioneers in Quality ™ Program, click here.

Newest Joint Commission Speak Up campaign targets identity verification

The Joint Commission launched its “Speak Up™: Right ID, Right Care” campaign on May 6, focusing on the importance of dual identifiers in healthcare. The accreditor’s press release contains an animated video, podcast, and infographic that are free for download and reuse.

The campaign is aimed at teaching patients why healthcare providers ask them for two forms of identification every time they come in; such as name, birthday, or phone number. The accreditor says that patients can become confused or worried if they don’t know why they are continuously asked to identify themselves. The campaign hopes to teach patients that the verification process is to prevent patient mix-ups and potentially giving the wrong treatment to the wrong patient.

Click here to visit the “Speak Up™: Right ID, Right Care” page.

HCPro Accreditation Professional Survey

Dear accreditation professional,

Your feedback is essential to us at HCPro. Please take just a few minutes to share your thoughts with us regarding ongoing and new challenges faced by you and your accreditation colleagues. In gratitude for your participation, you also have a chance to win $50 off any product in the HCPro Marketplace. Simply click on the link below to begin the survey. If the click-through does not work, please cut and paste the URL below into the address bar of your browser.

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Your responses are confidential, help us create better content, and give you the chance to win $50 off any HCPro product.

Here’s the link to the survey:

All your answers are confidential and anonymous. If you have questions related to this survey, please contact me at the email below. The deadline to fill out the survey is May 30, 2016.

Thank you!


Jay Kumar
Associate Product Manager

Advanced heart failure certification requirements updated

The Joint Commission this week released its prepublication standards for advanced certification for heart failure. The updated standards go into effect on January 7, 2017, and are based on the 2013 “American College of Cardiology/American Heart Association Guideline for the Management of Heart Failure.”

Click here to see the advanced certification for heart failure prepublication standards. 

Featured Webcast: How to Establish an Antimicrobial Stewardship Program

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How to Establish an Antimicrobial Stewardship Program Webcast

Antimicrobial overuse is a major problem for hospitals. Overuse of antibiotics can lead to the development of multidrug-resistant organisms, unintended antibiotic toxicity, and Clostridium difficile infections. CMS and The Joint Commission have increased their emphasis on antimicrobial stewardship programs as a way to control this growing issue.

On Wednesday, May 18, from 1-2:30 p.m. Eastern, join expert speaker Jennifer Pisano, MD as she explains why antimicrobial stewardship programs (ASP) are important and how to establish a one for your facility. Utilizing her experience and successful track record, she will show attendees how her center has achieved a 95% acceptance rate by providers for stewardship recommendations.

At the conclusion of this program, participants will be able to:

  • Discuss the importance of antimicrobial stewardship and its relation to overall patient care (inside/outside the acute care setting)
  • Understand how to get an ASP started
  • Discuss ways to measure outcomes of an ASP
  • Outline the aspects of ASPs that are of interest to regulatory bodies

To sign up or learn more, visit the HCPro Marketplace.

Sponsored by:
Patient Safety & Quality Healthcare


Joint Commission rolls out changes to Denial of Accreditation decisions

The Joint Commission has set up a program for healthcare organizations that receive Preliminary Denial of Accreditation (PDA) decision PDA02. The decision is rendered when a facility has serious and widespread noncompliance issues. The accreditor says the new policies are to help organizations with a PDA02 improve themselves and get back up to standard.

The changes include:

  • Organizations must submit an acceptable Evidence of Standards Compliance (ESC) within 30 days and address the Requirements for Improvement (RFI) identified as the drivers of the PDA decision.
  • Upon approval of the ESC, the accreditor will conduct an on-site ESC survey.
  • If Condition-level findings are identified, a Medicare Deficiency Survey must be conducted within 45 days. The organization will have the option of combining this survey with the on-site ESC survey.
  • If the organization has a successful on-site ESC survey, the accreditation decision will change from PDA to Accreditation with Follow-up Survey (AFS).
  • Areas of risk and available Joint Commission resources will be reviewed in a conference call with leadership from The Joint Commission and the organization.
  • The organization’s leadership must participate in the Intracycle Monitoring (ICM) process, which occurs at 12 and 24 months.
  • The organization’s next triennial survey will occur in the earlier segment of the 18-to-33–month window.
  • If the organization’s next triennial survey results in a repeat PDA decision, the organization will receive a recommendation for Denial of Accreditation (DA) with the opportunity of an expedited appeal.