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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.”

Joint Commission to adopt 2012 Life Safety Code®

The Joint Commission announced this week that it would join CMS in adopting the 2012 edition of the Life Safety Code® (LSC). CMS and Joint Commission surveyors will begin using the 2012 LSC on July 5. In a press release, the accreditor said it would be updating its Life Safety standards chapter in the near future. Details on the update will be published in a future edition of Joint Commission Perspectives.

Click here for our previous coverage on CMS’ adoption of the 2012 LSC. 

Public comment requested on proposed Joint Commission sleep study requirements and lab changes

The Joint Commission seeks comments on a new sleep study requirement as well as revisions to the laboratory standards.

The sleep study requirement would set minimum qualifications for the people interpreting sleep study results. To interpret sleep studies, a physician would require one of the following:

  • Certification in sleep medicine by the American Board of Sleep Medicine or the American Board of Internal Medicine
  • A completed fellowship in sleep medicine
  • Demonstrated competence through the interpretation of a random sample of 10 sleep studies of varied type and complexity that have been reviewed and approved by a physician who is board-certified in sleep medicine

The lab standards are being updated as part of a routine effort to sync Joint Commission standards with current best practices and the Clinical Laboratory Improvement Amendments. The proposed revisions and new standards cover three topics: molecular and genetic testing, clinical chemistry and toxicology, and routine maintenance.

Comments for the sleep study and the laboratory requirements are being accepted until July 6.


New antibiotic stewardship playbook meshes NQF, CDC, and Joint Commission guidelines

Released late last month, the National Quality Forum’s (NQF) Antibiotic Stewardship in Acute Care: A Practical Playbook is broken into five core elements focused on proper antibiotic usage: Leadership commitment, accountability, drug expertise, action, tracking.

Currently, only 40% of U.S. hospitals have an antibiotic stewardship program. The book was created by experts from the NQF, Centers for Disease Control and Prevention (CDC), and the Hospital Corporation of America and is based on the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs. The playbook also aligns with upcoming Joint Commission standards.

Read the full article on the NQF playbook at HealthLeaders Media. 

AAHHS hopes to get deeming status in 2017

The Accreditation Association for Hospitals/Health Systems (AAHHS) hopes to receive deeming status from the CMS by 2017, according to AAHHS spokesperson Laura Bohacz. AAHHS acquired the Health Facilities Accreditation Program (HFAP) last year, with all HFAP-accredited hospitals expected to be fully switched over to AAHHS standards by 2020.
AAHHS had originally hoped to get its deeming status by the end of 2016, though Bohacz says the delay won’t have any other effects on the transition process.

Read the full story on the HFAP acquisition and its impact in the June issue of Briefings on Accreditation and Quality.

New bill would change Medicare readmissions reduction program

A bill is currently being considered by the House of Representatives that would change the structure of Medicare’s Hospital Readmissions Reduction Program (HRRP) to reflect socioeconomic factors. Many in the industry have claimed that facilities are unduly penalized when things like poverty or rurality aren’t considered.

As part of that argument, Steven Lipstein, CEO of BJC HealthCare System, spoke to Kaiser Health News about the costs of HRRP. One of BJC’s facilities, Christian Hospital of St. Louis, is expected to lose $600,000 in Medicare reimbursements because of HRRP, he said. He pointed out that figure doesn’t include the amount lost at BJC’s 13 other facilities. Lipstein said that if Medicare readjusted its reimbursement policy to reflect patients with socioeconomic disadvantages, Christian Hospital would only have to pay $140,000 in penalties.

Medicare penalized almost half of all hospitals for excessive readmissions in 2015 for a total of $420 million.

Quality tool predicts complication risks in post-surgery patients

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) is offering a free, web-based tool that helps predict surgical complication risks. Created in 2013, the NSQIP Surgical Risk Calculator provides customized surgery risk assessments, based on 19 patient-specific preoperative risk factors such as age, BMI, smoking status, and health conditions such as high blood pressure and diabetes. Additionally, the surgeon can adjust the risk score based on his or her subjective assessment of a patient. The tool receives 1,500 hits per day from physicians and patients.

A recent study used 2.7 million individual surgical records from 586 hospitals to analyze how well the tool’s predictions matched actual outcomes.

“Our study demonstrates that the NSQIP Surgical Risk Calculator has excellent calibration,” said study author Mark Cohen, PhD, in a release. “Although no such tool can provide perfect predictions, the Surgical Risk Calculator does what it is intended to do—accurately estimate a patient’s probabilities for important adverse events postoperatively.”

The NSQIP calculator can be used to estimate postoperative risks for 1,500 different types of surgery, providing probabilities on the risk of surgical complications, pneumonia, cardiac arrest, surgical site infection, urinary tract infection, blood clot, kidney failure, or death. The program is expected to be updated to include predictions of several postoperative issues; ileus, a type of bowel obstruction; and leak of an intestinal anastomosis, a surgical connection of two formerly distant parts of the intestine after removal of diseased bowel.


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%.