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CMS announces Physician Quality Reporting Programs Strategic Vision

When CMS shared the findings of the 2015 Physician Quality Reporting System (PQRS) payment system, they also released the publication of the Physician Quality Reporting Programs Strategic Vision, or “Strategic Vision”.

The Strategic Vision is part of a long-term quality measurement plan for healthcare providers and public reporting programs and how those can be enhanced to support better decision-making from physicians, consumers, and everyone involved in healthcare.

For more information about the plan, click here.

CMS updates eCQMs for 2016 reporting

Last Friday, CMS posted the annual update for the 2014 electronic clinic quality measure (eCQMs) for eligible hospitals and professionals. Providers should use these measures to report 2016 quality data for CMS reporting programs, including the Physician Quality Reporting System (PQRS), Inpatient Quality Reporting Program (IQR), and the EHR Incentive Programs.

CMS updated 29 measures for eligible hospitals and 64 measures for eligible professionals.

Read the updated measures here.

Don’t forget to take the salary survey!

Thanks to everyone that has already taken the salary survey.  If you’ve been meaning to take the survey, now’s your chance as we’ll be closing the survey in a few days.

Stay tuned to the blog and Briefings on The Joint Commission for the results.

You can take the survey here.

The Joint Commission updates FAQ section

In case you missed it, The Joint Commission added a new frequently asked question (FAQ) and updated 19 existing FAQs last week. The new question tackles the issue of physician texting medical records.

You can read the updates here.

Most frequently identified root causes of sentinel events

The usual suspects topped the list of root causes for sentinel events – human factors, leadership, and communication, according to a report released by The Joint Commission on Friday, April 24, 2015. The report covered root causes for sentinel events from 2012 through 2014.

Health information technology-related (new to the report), operative care, and continuum of care rounded out the top 10 list for 2014.

Read the full report at The Joint Commission.

Editor’s Choice: Emergency Planning: Conducting an Effective Preparedness Exercise

Tuesday, April 28, 2015

1-2:30 pm Eastern

Join us for a 90-minute webcast on how to plan and conduct an emergency drill with clear measurable objectives, and how to use the lessons learned from that drill to educate your staff.

CMS and The Joint Commission require your hospital to have plans in preparation for any emergency, but they also have two lifelike exercises per year that test your ability to respond under pressure.

Take the stress out of preparation with tips and advice provided by our healthcare emergency management experts.

The webcast is presented by expert speakers Tracy Buchman Sonday, DHA, CHPA, CHSP, and Christopher Sonne, CHE.

Click here for more information.

Joint Commission releases sentinel event statistics

Unintended retention of foreign objects, patient falls, and suicide were the top three sentinel events reported to The Joint Commission in 2014. The accreditor last week released the report, which examines sentinel events from 2004 through 2014.

Of the 764 events reported in 2014, foreign objects (91), falls (91), suicide (82), delay in treatment (73), and “other unanticipated event” (73) were far and away the most common. Overall since 2004, there have been 8,645 incidents reported; that list is topped by wrong patient/wrong site/wrong procedure with 1,102 (the category was sixth on the 2014 list with 67).

Read The Joint Commission’s sentinel events summary.

OSHA updates healthcare workplace violence prevention guidelines

In 2013 there were more than 23,000 significant injuries in the workplace due to assaults, according to a recent report by OSHA. More than 70% of these assaults were in healthcare and social service settings. Further, OSHA says that healthcare and social service workers are almost four times as likely to be injured as a result of violence than private sector employees.

The above statistics prompted OSHA to release an update to its Guidelines for Preventing Workplace Violence for Healthcare and Social Workers, also known as OSHA Rule 3148. The update recommends that all healthcare facilities develop an effective workplace violence prevention program. According to our sources, The Joint Commission is following these changes very closely.

The updated guidelines are specific in the types of workplace controls employers should consider, especially in terms of facility security and keeping track of both on-site and off-site employees. Some examples:

  • The use of silent alarms and panic buttons in hospitals and medical clinics
  • Providing safe rooms and arranging furniture to make sure there are clear exit routes for employees and patients
  • Installing permanent or hand-held metal detectors to detect weapons, and providing staff training on the use of these devices
  • Ensuring nurse stations have a clear view of all treatment areas, including the use of curved mirrors and installing glass panels in doors for better viewing, as well as closed circuit cameras to help monitor areas
  • Using GPS, cell phones, and other location technology to help keep track of staff working with patients in off-site locations
  • Protecting front-end triage staff using facility design elements such as deep counters, secure bathrooms for staff separate from patient treatment areas, and using bulletproof glass and lockable doors with keyless entry systems.

Recommendations also include employing administrative controls designed to track patients and visitors who have a history of violence, to better educate workers on the dangers and signs of impending violence, and to ensure better reporting procedures. Some examples:

  • Providing clear signage in the facility that violence will not be tolerated
  • Instituting procedures that require off-site staff to log in and log out, as well as checking in with office managers periodically
  • Keeping a behavioral history of patients, including identifying triggers and patterns
  • If necessary, establishing staggered work times and exit routes for workers who may be subjects of stalkers
  • Keeping a “restricted visitor” list for suspected violent people, such as gang members, and making sure all staff are made aware of the list

OSHA also recommends employers provide updated training for employees, including:

  • Risk factors that cause or contribute to violent incidents
  • Early recognition of escalating behavior or recognition of warning signs
  • Ways to recognize, prevent or defuse volatile situation or aggressive behavior, manage anger and appropriately use medications.
  • Self-defense procedures where appropriate
  • How to apply restraints properly and safely when necessary
  • Ways to protect oneself and coworkers, including use of the “buddy system”

For further information on the updated rule, visit

NEWS ALERT! New IPPS rule proposed

CMS released the IPPS proposed rule for fiscal year 2016, which includes changes to MS-DRGs and the expansion of its value-based payment quality measures as it has in the past.

Included in the proposed rule, CMS is asking for public comments regarding the implementation of bundled payments for inpatient care. As of now, CMS has not discussed how it will implement payments.

CMS is proposing removing two measures from the hospital value-based purchasing (HVBP) program:

  • IMM-2, Influenza Immunization
  • AMI-7a, Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival

If the measures are removed, PC-01 (Elective Delivery) to the Patient Safety domain will move to the Patient Safety domain and remove the Clinical Care—Process subdomain for FY 2018 and beyond. This change will have an increased weight in the HVBP scoring methodology in FY 2018 (from 20% to 25%).

CMS is proposing the addition of two measures to the HVPB program:

  • 3-Item Care Transition Measure for FY 2018
  • Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Chronic Obstructive Pulmonary Disease Hospitalization beginning in FY 2021

CMS is asking for input from the hospital community. Comments are due by June 16, 2015. They may be submitted electronically or in hard copy.


2015 Accreditation Professional salary survey

Are you an accreditation specialist or handle survey preparation for your organization? If so, we invite you to take the 2015 Accreditation Professionals salary survey.

All responses are anonymous and we’ll provide the survey results in an upcoming issues of Briefings on the Joint Commission.

Click on this link to take the survey.