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Increased oversight means more pressure on AOs

Expect CMS to continue to put pressure on The Joint Commission (TJC) and other accrediting organizations (AO) to find more of the serious fire safety and infection control issues the federal agency says they are still missing during surveys.

Also, you may find CMS surveyors showing up soon with your AO team. But they won’t be there to watch you. They’re going to be watching the watchers, as a part of a pilot program that could potentially end the 60-day validation survey process.

In a new report to Congress, CMS says the disparity rate between serious problems identified by the AOs and those found by CMS surveyors within 60 days of survey was 46% in fiscal year 2016, up from 38% and 39%, respectively, in the two preceding fiscal years.

Most of those disparities were in infection control and physical environment, which includes fire safety violations.

Fiscal year 2016 began on October 1, 2015, and ended September 30, 2016, about a month before CMS began enforcing compliance with the 2012 editions of the NFPA 101 Life Safety Code® (LSC)  and NFPA 99 Health Care Facilities Code on November 1, 2016.

Both fire codes were adopted by CMS in June 2016 after more than a decade of requiring hospitals to adhere to the 2000 version of the LSC. Although long warned that the change was coming, many hospitals scrambled to play catch-up to the new requirements, as did AOs that had to update standards.

CMS is required by regulation to evaluate how its approved AOs do their jobs and must report to Congress every year. After last year’s report was highly critical of AO performance, TJC and other AOs stepped up their efforts to find problems and are likely to do so again, say consultants.

In addition, the Senate Energy and Commerce committee earlier this year announced it was seeking answers from each of the hospital AOs about patient safety.

CMS evaluates AOs based on their ability to meet certain quality measures, including providing information back to CMS on problems found at hospitals in a timely fashion, and by conducting what it calls validation surveys in which CMS inspectors conduct a second survey within 60 days of an AO survey.

In those validation surveys, CMS state survey agency inspectors look for any problems in which a hospital fails to meet federal Conditions of Participation, which allows the facilities to bill Medicare. CMS assumes those condition-level problems were present during the AOs survey, and that is marked against the AO as a missed deficiency.

Consultants and others have noted that the practice of doing validation surveys as long as 60 days after an AO visit is unfair because the condition-level problem identified later might not have existed when AO teams were on site.

On October 4, CMS announced several changes it says will make hospital patient safety and accountability more transparent for the public, including posting deficiency reports online for hospitals where it identifies condition-level problems.

Executive Briefings: Joint Commission Surveyor Focus Remains on EC, LSC, Ligature Risks

Highlight the zip codes where employees live so you can have a handy reference of where staff is available in emergencies, keep policies consistent and updated with the most relevant references, and focus suicide prevention efforts on making your physical environment ligature-resistant.

Those were some of the top takeaways for environment of care and other healthcare and quality professionals attending The Joint Commission’s (TJC) annual Hospital Executive Briefings held September 14 in New York City. The state of healthcare “is not good,” said Ana Pujols McKee, MD, TJC’s chief medical officer, rattling off uncomfortable facts such as the U.S.’s rising maternal mortality rate and that medical errors are the third leading cause of death. She urged attendees to accept nothing less than achieving zero harm in their hospitals and facilities.

Attendee Brian Pitt, safety director of SUNY Downstate Medical Center said his biggest takeaway from the briefings was that there are a lot of opportunities to make changes and improve. That was particularly true for the areas of environment of care and infection control, which never seem to get full administrative support, he noted. Among other things, the briefing taught him the need for consistency in what organizations — such as the CDC or the Association for the Advancement of Medical Instrumentation — you reference in your hospital policies.

“These policies can be used against us if you don’t keep it consistent and follow a consistent national standard,” said Pitt.

Here are some brief highlights from the day’s topics:

1. Suicide Prevention and Ligature Risk

Emily Wells, CSW, MSW, TJC’s project director, surveyor management and development, said that the accreditor has realized that no environment can be “ligature free,” so it’s changed the terminology to “ligature resistant.” That said, you still need to do risk assessments and have protocols to keep patient safe including removing as many ligature risks from a patient room as reasonably possible.  Facilities should pay extra attention to standard EC.02.06.01 EP 1 which was the most cited standard related to Immediate Threat. The standard requires hospitals to maintain a safe environment and EP 1 RFI include self harm risks like door hinges, beds, and drop ceilings.

Kathryn Petrovic, MSN, RN-BC, TJC field director of surveyor management and development, stressed was the need to test ligature resistant products to ensure they’re properly installed. Buying special anti-pinch point doorknobs doesn’t matter if they’re put in the wrong way, seize up and create a ligature risk, she says.  Surveyors test to see if your products work, not that you have them. And improperly installed equipment can result in a patient hurting themselves on something you thought was safe.

2. Emergency Management

Jim Kendig, MS, CHSP, CHCM, CHEM, LHRM, field director of surveyor management and development, recommends facilities run zip code tests to determine where most of their employees live. Most staff won’t come to work in during an emergency if their homes and family are in the affected area. Doing a zip code test can tell you ahead of time if you’ll need to call in help from other facilities.

Kendig also said security staff should work with local law enforcement on what to do in the event a hospital becomes a crime scene. There have been cases where a crime was committed in a hospital and police prevented hospital staff from re-entering the facility or move between rooms. That’s a possibility that needs to be dealt with before it happens, he said.

3. Physical Environment 

Kenneth A. Monroe, PE, CHC, PMP, TJC director of engineering, started off the physical environment and environment of care section with a look at Legionella. There have been multiple cases of the bacteria in hospitals, he said, and facilities need to be vigilant to protect their patients.

He also noted that 98% of all surveyed hospitals had at least one finding in the EC chapter, with ligature risks as the leading driver of Immediate Threat findings. However, the most common EP finding in the red category was EC.02.02.01 EP 5 — hazardous material handling and storage.

Ninety-seven percent-of hospitals had a finding in the Life Safety chapter, with LS.02.01.35 (sprinklers) being the most cited. Facilities don’t clean their sprinklers, test them, or put things that block the spray. Easy ways to get a finding. That said, only about 12% of LS findings were in the moderate or high risk range, with LS.01.02.01 EP 1 (No ILSM policy) being the most common high risk finding.

Revisions deeming EPs

Starting January 1, five revisions to The Joint Commission’s Elements of Performance (EP) will go into effect. The revisions deal with the deeming in hospitals and critical access hospitals. The changes are a result of CMS’ review of The Joint Commission’s EP Review Project for the Leadership (LD) chapter.

Some of the changes include specifying that if hospitals provide emergency services that they comply with 42 CFR 482.55 and  that operating rooms have available a communications system that can summon staff outside the OR.

The affected EPs are:

• EC.02.03.01 EP 9

• LD.01.03.01 EP 13 (hospitals only)

• LD.04.03.01 EP 2

• LS.01.01.01 EP 1

• PC.02.02.03 EP 7 (critical access hospitals only)

• PC.03.01.01 EPs 5 and 8

You can read the prepublication changes to hospital and critical access hospitals here.

Be ready for surveyor focus on dialysis

Surveyors from CMS and The Joint Commission are taking an interest in dialysis compliance. Which means you should, too. Each year, 468,000 patients receive dialysis as treatment for end-stage renal disease (ESRD). A single procedure takes about several hours, during which a patient’s blood is filtered and cleaned inside their body (peritoneal dialysis) or outside of it (hemodialysis). There are many possible points of failure in a dialysis treatment, and infections are a major risk. That’s why surveyors are being extra stringent about compliance, say Jennifer Cowel, RN, MHSA, president of Patton Healthcare Consulting in Naperville, Illinois, and Kathleen Good, MSN, RN, an associate of the company. Both are Joint Commission alumni.

The Joint Commission isn’t delicate when telling people what surveyors are looking for, nor when citing them. Three focus areas have come up repeatedly at Joint Commission presentations: sterile compounding, pain standards, and dialysis. And there’s been a corresponding uptick in scoring for all of these areas in 2018.

“When The Joint Commission indicated that dialysis is going to be a focus area, the field should be prepared for more detailed surveys than we have seen in the past,” Cowel says. “Take this as a heads-up notice. We have seen an uptick in dialysis scoring; in fact, we have seen scoring in dialysis in more than half of the survey reports we have seen in recent months.”

There are plenty of examples that hospitals can focus on, Good notes.

“Note that hospitals that are providing inpatient hemodialysis or contracting for the service need to pay attention to the room where dialysis is being provided, particularly if [it’s] not in the patient’s room,” Good says. “I have seen rusty air conditioning units, soil around the unit, blood spots on the floor, tiles missing behind the dialysis machine, wet towels on the floor, [and] sinks designated solely for hand hygiene being used for emptying bottles of concentrate that were used for patient dialysis.”

Cowel and Good have seen numerous findings in dialysis in recent months, including the calibration of the pH/conductivity meter not being tested per the manufacturer instructions for use (IFU). Other common findings they’ve seen include:

  • Not having an eyewash station when bleaching of a portable dialysis machine is done in a patient room.
  • Not conducting a special check of a patient’s catheter that was locked with high-concentration anticoagulant, in clear violation of the hospital’s policy on high-risk medications.
  • Improper management of medicines administered during or before dialysis treatment. For example, a dialysis nurse transporting multidose vials of heparin, despite the fact they should be considered single-dose vials.
  • Not documenting vascular site assessment (e.g., redness, warmth, tenderness, swelling) before and after dialysis, per hospital policy.
  • Not recording that consent was received from a new dialysis patient or that a conversation about risks and benefits occurred.
  • Not verifying that the amount of fluids or medications administered to a patient match the medical order. For example, if a nurse administers 100cc normal saline (NS) instead of 200cc NS per the protocol order set for hypotension during dialysis.

More on dialysis compliance will be in the upcoming edition of Briefings on Accreditation and Quality

Safety Standards Pose Problems for TJC-Accredited Hospitals

Safety-related requirements continue to plague hospitals, according to The Joint Commission’s latest list of most-cited standards data through the first six months of 2018.

Released in the September issue of Perspectives, the data was aggregated from 676 applicable Joint Commission hospital surveys from January 1 through June 30.

The top-cited standard is LS.02.01.35, related to providing and maintaining fire extinguishing systems, with 88% (86% in 2017). The rest of the list is as follows:

  • EC.02.05.01 – The hospital manages risks associated with its utility systems (80%; 73% in 2017)
  • IC.02.02.01 – The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (74%; 72% in 2017)
  • EC.02.06.01 – The hospital establishes and maintains a safe, functional environment (73%; 70% in 2017)
  • LS.02.01.30 – The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72%; 72% in 2017)
  • LS.02.01.10 – Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (69%; 66% in 2017)
  • LS.02.01.20 – The hospital maintains the integrity of the means of egress (66%; 62% in 2017)
  • EC.02.05.05 – The hospital inspects, tests, and maintains utility systems (64%; 62% in 2017)
  • IC.02.01.01 – The hospital implements its infection prevention and control plan (61%; not on list in 2017)
  • EC.02.02.01 – The hospital manages risks related to hazardous materials and waste (61%; 63% in 2017)

See the September Perspectives for lists of the most-cited standards for critical access hospitals, home health, nursing care centers, and other Joint Commission certification programs.

IHI Launches Maternal Care Improvement Project

The Institute for Healthcare Improvement (IHI) has begun a three-year project that aims to improve maternal outcomes for women and babies in the U.S. Supported by a grant from Merck for Mothers, the project’s goals are to spread the use of evidence-based care practices to reduce complications such as hemorrhaging, hypertension, and blood clots. It also plans to implement strategies to reduce disparities in maternal outcomes, and partner with women, their caregivers, healthcare providers, and community initiatives to better learn and address factors to improve health outcomes for mothers and newborns.

“IHI has proven experience in helping healthcare providers adopt and scale up best practices that save lives across whole systems, regions, and countries,” said Trissa Torres, MD, MSPH, FACPM, chief operations and North American programs officer at IHI, in a release. “We believe that by forging partnerships with others working on these problems and combining existing expertise with IHI’s improvement methodology, we can significantly improve care delivery outcomes for new and expectant mothers.”

Annually, an estimated 750 women die in the U.S. as a result of complications of childbirth, with more than 50,000 suffering serious complications, according to the IHI. African-American women have maternal mortality rates estimated to be three to four times higher than those of white women.

Merck for Mothers is a 10-year, $500 million initiative to help improve maternal mortality rates. The program began in 2011 and has expanded to more than 30 countries.

HFAP ligature risk updates

To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care Manual with new prepublication requirements on removing ligature (hanging) risks in rooms meant for suicidal patients. Several standards have been affected:

04.01.01 – Staff Training – Identification of Patients at Risk for Harm

11.01.01 – Periodic Monitoring for Safety Issues

11.01.02 – Building Safety

11.01.08 – Review of Safety Policies and Procedures

11.02.01 – Building Security

13.00.01 – Life Safety Code Compliance

13.01.06 – Exit Discharge

13.05.09 – Utility Systems

15.01.17 – Privacy and Safety: Safe Setting

15.01.19 – Privacy and Safety: Identify Patients at Risk

15.01.20 – Privacy and Safety: Environmental Risk Assessment

27.03.01 – Privacy and Safety: Identify Patients at Risk

27.03.02 – Privacy and Safety: Environmental Risk Assessment

To see the changes to the standards, visit the HFAP website. And for more analysis of the changes read Briefings on Accreditation and Quality. 

Editor’s note: HFAP announced these standards won’t be revised again due to the July CMS memo on ligature risks. 

Catheters Pose More Risks Than Just CAUTIs

Catheter-associated urinary tract infections are a well-known issue related to urinary catheters. However, a new study in JAMA Internal Medicine finds the devices can cause more issues that previously thought. In fact, UTIs are five times less common than non-infectious problems caused by indwelling urinary catheters.

In-depth interviews and chart reviews from more than 2,000 patients found more than half of catheterized hospital patients experienced a complication of some kind.

The issues ranged from pain, bloody urine and activity restrictions while the catheter was in, to problems with urination and sexual function after it was removed.

“Our findings underscore the importance of avoiding an indwelling urinary catheter unless it is absolutely necessary, and removing it as soon as possible,” says the study’s lead author Sanjay Saint, MD, MPH, chief of medicine at the VA Ann Arbor Healthcare System, George Dock professor of internal medicine at the University of Michigan and director of the U-M/VA Patient Safety Enhancement Program.

A wide array of issues

For the study, Saint and his colleagues from U-M, VAAAHS, and two Texas hospitals analyzed data from 2,076 patients who had recently had a catheter placed for short-term use. Most catheters were placed because the patients were having surgery. Researchers followed-up with patients two weeks after catheter placement and again one month after their catheter placement to ask about their catheter-related experience.

Nearly three quarters of the patients were male, and the catheter was removed within three days of the insertion for 76% of patients. Among the study’s findings:

  • Just over 10% of patients reported infections
  • 55% of patients reported at least one complication of a non-infectious kind
  • 31% of patients whose catheters had been removed at the time of the first interview said it hurt or caused bleeding coming out.
  • More than half of those interviewed while the catheter was still in place said it was causing them pain or discomfort.
  • One in four patients reported the catheter had caused bladder spasms or a sense of urgency about urinating.
  • 10% said the catheter led to blood in their urine.
  • Nearly 40% of patients interviewed while a catheter was still in place, said it restricted their daily activities
  • About 20% who had their catheters removed said they experienced urine leakage, or difficulty starting or stopping urination.

“While there has been appropriate attention paid to the infectious harms of indwelling urethral catheters over the past several decades, recently we have better appreciated the extent of non-infectious harms that are caused by these devices,” says Saint.

Story first appeared in PSQH.

Study: CMS Penalties for Hospital-Acquired Conditions Have Little Impact

A study published in Infection Control & Hospital Epidemiology found that hospitals may have dodged financial penalties by billing hospital-acquired conditions (HAC) as present at the time of the patient’s admission. The findings showed that a CMS policy to penalize hospitals for preventable complications had minimal impact on the reduction of hospital-associated infections.

The targeted billing codes were rarely used by hospitals, and the study found that when hospitals billed for HACs during a patient’s stay, it infrequently affected the diagnosis-related group assignment, impacting hospital reimbursement.

“With this policy, CMS was hoping to see more attention paid to improving quality care, but it appears that the original HAC policy mostly led to changes in coding practices,” said study lead author Michael S. Calderwood, MD, MPH, regional hospital epidemiologist at Dartmouth-Hitchcock Medical Center, in a release. “It’s worth further investigation to determine whether Medicare reimbursement codes are being incorrectly used, or if there is now a greater effort to document conditions at the time of the patient’s admission.”

Ten years ago, CMS’ Hospital Inpatient Prospective Payment System stopped reimbursing hospitals for HACs not present on admission (POA), with the hopes of encouraging hospitals to improve their infection prevention practices.

The researchers analyzed more than 65 million Medicare fee-for-service hospitalizations from 2007 to 2011 in acute care facilities, specifically examining documentation for central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) and whether the codes for those HACs were submitted as POA (which aren’t counted as preventable complications).

The study found that CLABSI and CAUTI affected 0.23% and 0.06% of hospitalizations, respectively, and in the three years immediately after the 2008 CMS policy took effect, 82% of CLABSI codes and 91% of CAUTI codes were marked as POA. This was a significant increase compared with before the HAC policy was implemented.

Diagnosis coding for CAUTI and CLABSI that was not POA from 2007 to 2011 dropped dramatically. In 2007, hospitals discharged 6,172 patients with a CAUTI diagnosis code, 99.8% of whom were marked not POA; comparatively, in 2011 when 6,448 patients were coded as having a CAUTI, just 10.7% of them had the no POA designation.

First published in PSQH

CMS Reverses Plan to Cut Reporting of HAIs

The Centers for Medicare & Medicaid Services (CMS) has decided not to carry out a proposal to remove public reporting of hospital-acquired infections (HAI), medical errors, and injuries. Instead, CMS will publish the information on the Hospital Compare site and in a database.

After the plan was announced in June, there were complaints from patient safety advocates. A new rule, published last week, restores reporting of data through the Inpatient Quality Reporting Program, including infection rates of Clostridium difficile, Methicillin-resistant Staphylococcus aureus, and post-surgery sepsis.

The Trump administration had initially agreed to remove the reporting measures at the request of the American Hospital Association, which argued that they unfairly penalize hospitals for safety problems.