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See Joint Commission accreditation changes of 2016

There have been several changes to the accreditation process this year, with more to come in 2017. The Joint Commission has released notes on all changes that went into effect on August 1, such as the elimination of Plans for Improvement. The changes can be viewed in the 2016 Survey Activity Guide.

HFAP releases prepublication standards manual

HFAP this week released its prepublication manual for acute care hospitals. The manual has been changed to include requirements of the 2012 Life Safety Code® (LSC), which was recently adopted by CMS.  The CMS adoption of the 2012 LSC went into effect in July, and the new requirements will go into effect for HFAP facilities on November 1, 2016.

The changes to the accreditation requirements are in Chapters 9, 11, and 13 of the manual and can be read here.

Electronic Clinical Quality Measures survey results published

The Joint Commission, American Hospital Association, and the Federation of American Hospitals sent out a survey to 886 hospitals this March asking for feedback on the Electronic Clinical Quality Measures (eCQM). The eCQMs, which deal with data from electronic health records and health information technology system, are due for release on February 28, 2017. This July, the organizations heard back from 319 hospitals and released the survey results:

•    86% of hospitals say they plan on submitting eCQMs to CMS by the February 2017 deadline.
•    While 76% of hospitals say they have the skill level and knowledge to implement eCQMs, only 64% can afford health IT support. Many said they’ll have to change electronic health record vendors to stay compliant.
•    More than 85% have never successfully submitted eCQM patient level data to CMS.
•    58% haven’t or don’t know if they can generate a Quality Reporting Document Architecture [QRDA] 1 document.
•    79% haven’t or don’t know if they’ve ever successfully generated a QRDA1 doc.
•    Surveyed hospitals asked The Joint Commission for more forums, webinars, and a comprehensive library of eCQM resources to help with the transition.

The Joint Commission’s Pioneers in Quality program is using these results to determine the best way to help facilities comply with the eCQMs. The Joint Commission plans to follow up with a second survey on the eCQMs this fall. Click here to see the full survey results.

Hospital star ratings now online despite Congressional and hospital group efforts

Yesterday, CMS publicly released its hospital star ratings system on its Hospital Compare website. The rankings are meant to provide patients with more transparency on hospital quality.CMS Logo

The release comes one day after Congress announced a bill that, if passed, would have delayed the release for a full year. The bill would have also have required third-party verification of CMS’ data and methodology, which has been a major point of contention for opponents.

Get more details on the CMS decision at HealthLeaders Media.

Congress proposes delaying CMS star ratings for a year

Congress introduced a new bill yesterday that would force CMS to delay the release of its hospital star rating system by a year. The bill, the Hospital Quality Rating Transparency Act of 2016, would also require that a third party analyze CMS’ methodology and data and provide a 60-day comment period for interested parties.

The star ratings are determined by 62 quality measurements and are meant to be a simple, comprehensive look at hospital quality to help consumers make their medical choices. The ratings have come under fire by several hospital organizations who say that the ratings don’t show true quality and that the methodology CMS uses is flawed. One of these groups, the American Hospital Association, applauded Congress’s efforts to delay the ratings.

“Hospitals and members of Congress are in agreement: CMS can do better,” they wrote. “The majority of Congress—60 members of the Senate and more than 225 members of the House—asked CMS to delay and improve upon the star ratings. Our own analysis of preliminary data continues to raise questions and concerns about the methodology, which may unfairly penalize teaching hospitals and those serving the poor.

“We continue to urge CMS to work with hospitals and health systems to provide patients with a rating system that accurately reflects the quality of care provided at their facilities, and will work with Reps. [James] Renacci [R-OH] and [Kathleen] Rice [D-NY] to move this legislation forward.”

CMS: 2% of hospitals earn a “five star” rating

rating-153609_1280 The agency says it will be posting those ratings on its Hospital Compare site “shortly.” Out of 4,599 hospitals previewed:
• 2.2% will receive 5 stars
• 20.3% will receive 4 stars
• 38.5% will receive 3 stars
• 15.7% will receive 2 stars
• 2.9% will receive 1 star
The remaining 20.4% didn’t meet the minimum measure/group reporting thresholds set forth in the Star Ratings Methodology Report and are unrated.
The star ratings are meant to be a simple, comprehensive look at hospital quality to help consumers make their medical choices. The ratings have come under fire by several hospital organizations who say that the ratings don’t show true quality and that the methodology it uses is flawed.

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]