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Sound the alarm…no, wait, silence the alarm…no, wait–what?!?

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, recently wrote an article about alarms and I wanted to share it with you as I know it is an area many are concerned about.

Now that we have almost reached the summer solstice, I guess it’s time to start thinking/talking about 2016 and what it might bring from an accreditation perspective—it will be here almost before we know it (time flies when you’re having fun—and we’re having too much fun, are we not?)

One of the developments that I am watching with a bit of interest (if only because it is not at all clear how this is going to be administered in the field) is the next step in the clinical alarm National Patient Safety Goal (for those of you keeping score, that NPSG.06.01.01 if you need to find it in your accreditation manual—and I’m sure you’re sleeping with that under your pillow…). Presumably at this point, you have covered the elements that are in full surveyability—establishment of alarm system safety as an organizational priority (pretty simple, that one) and identification of the most important alarm signals based on:

  • input from medical staff and clinical departments (Have you got documentation for that?)
  • risk to patients if the alarm signal is not attended or if it malfunctions
  • whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
  • potential for patient harm based on internal incident history
  • published best practices and guidelines (Can you say AAMI and ECRI? Sure you can!)

Everyone out there in radioland should have this much of the package in place. Now, it’s time to do something with that process.

Continue reading this post at Mac’s Safety Space.

Joint Commission issues changes to breast milk measures

The Joint Commission is issuing changes that affect perinatal care (PC) measures PC-05a and PC-05. Both measures relate to breastfeeding.

The Joint Commission is retiring the measure PC-05a, which covers breastfeeding exclusively per the mother’s initial plan. Obtaining accurate information on the mother’s wish to not nurse exclusively has been difficult to capture. Retiring this measure will allow hospitals to improving rates for PC-05, breastfeeding exclusively.

PC-05 has been revised to now include maternal medical conditions, similar to PC-02 related to caesarean birth with no excluded conditions. PC-05 will still be an accountability measure, but, The Joint Commission understands that compliance for this measure will fall below 100% as some mothers do not want to or are unable to breastfeed exclusively.

These changes go into effect October 1.

Read the Joint Commission article here for more information.

 

Joint Commission details how to comply with fire safety requirements

The Joint Commission last week, posted tips for complying with elements of performance (EP) 11-13 of EC.02.03.05, which require hospitals to properly maintain fire extinguishing equipment. The standards ranked sixth on the accreditor’s list of top-cited standards in 2014 with 48% of hospitals cited.

The Joint Commission article includes step-by-step instruction on how to comply with the three Eps. EP 11 requires testing of fire pumps in automatic sprinklers every 12 months, EP 12 calls for water-flow tests to be conducted every five years for standpipe systems, and EP 13 days that organizations must inspect any fire-extinguishing systems every six months.

Read the Joint Commission post for more information.

National Time Out Day

Today, June 10th, is National Time Out Day. Started in 2004 by the Association of periOperative Registered Nurses (AORN), as an exercise to encourage surgical nurses to take a “time out” before surgical procedures and ensure safe practices were in place, such as identifying the correct patient, procedure, and surgical site before the surgical procedure began.

The emphasis this year is to encourage nurses and the rest of the healthcare time to analyze how their time outs affect patients at all times.

Visit the AORN website for more information.

Does your team take a “time out” before beginning a procedure either invasive or non-invasive? Do you find yourself taking a “time out” throughout your day to ensure you’re following correct safety procedures?

Drop me a note at mclarke@hcpro.com and I’ll share your responses with our readers.

Editor’s Choice: The Joint Commission’s New Patient Safety Chapter: How to Comply and Promote a Culture of Safety

Wednesday, June 10, 2015

1:00pm-2:30pm EST

Presented by Sena Blickenstaff, BSN, MBA

Prepare for the new Patient Safety Systems chapter and redesigned Sentinel Events chapters with the practical advice and guidance presented in this 90-minute webcast. Accreditation and patient safety professionals will learn how The Joint Commission’s renewed focus on patient safety and quality will affect their organizations. The chapters went into effect on January 1, 2015 and surveyors will expect hospital leadership and staff to be able to explain how their facility is committed to patient safety and quality improvement.

Register for the webcast here.

Joint Commission joins White House to reduce antibiotic overuse

The Joint Commission announced Monday that it was joining the White House effort to reduce antibiotic overuse.

More than 150 healthcare organizations, food companies, and animal health organizations met at the White House Forum on Antibiotic Stewardship on Monday and pledged to incorporate changes over the next five years to slow the growth of antibiotic-resistant bacteria, preserve the effectiveness of antibiotics, and prevent the spread of resistant infections.

The CDC estimates at least two million illnesses and 23,000 deaths in the United States each year are caused by antibiotic-resistant bacteria and 20 to 50% of all antibiotics prescribed in acute care hospitals are either unnecessary or inappropriate.

For its part, The Joint Commission will begin reviewing current standards and work with accredited organizations to determine where new standards may be needed. The Joint Commission plans to simultaneously develop new standards as quickly as possible and provide new tools to help providers use antibiotics appropriately.

The Joint Commission currently has 16 standards and one National Patient Safety Goal related to antimicrobial stewardship.

Read the full release here.

C.diff infections linked to medical clinics

A February 25 report from the CDC suggests that the prevalence of Clostridium difficile, or C. diff, a bacterial infection of the gastrointestinal system primarily found in hospitals, is much higher than once thought, affecting up to half a million people annually.

Perhaps even more disturbing is the study’s revelation that up to 150,000 people who had not previously been in the hospital came down with C. diff in 2011. Of those, about 80% had visited a doctor’s or dentist’s office in the 12 weeks before their diagnosis. CDC officials say the revelation is so concerning that they’re starting a series of “case control studies” to try to assess nationally whether people are getting C. diff in medical offices.

If you’re a safety professional or someone in charge of infection control at a medical clinic, by now you’re asking yourself what you can do to help reduce the risk of an outbreak of C. diff. Our safety experts have shared a list of things you can do to prepare.

Read the full article on the OSHA Healthcare Advisor site.

Briefings on The Joint Commission feedback survey

I know, I know, we just had a survey, but we really like surveys here. They give us an opportunity to find out what’s happening in the accreditation field and then share it with the rest of you.

They also give us a chance to ask you, our readers, what you like or dislike (gasp) about some of our products. In this case, we would like your thoughts on the Briefings on The Joint Commission newsletter.

The survey is quick and should only take about five minutes of your time.

Click on the link to take the survey.

Opinions are like…

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, recently wrote an excellent article about the changing accreditation regulations and I wanted to share it with you.

Over time, I’ve developed certain thoughts relative to the management of the survey process, one of which relates to the ever-changing (maybe evolution, maybe mutation) regulatory survey process and I think it boils down to a couple of basic expectation (at least on my part):

  • You always run the risk of having a surveyor disagree with any (and every) decision you’ve ever made relative to the operational management of risk, particularly as a function of standards-based compliance.
  • Your (or indeed any) Authority Having Jurisdiction always reserves the right to disagree with anything they, or anyone else, has ever told you was “okay” to put into place (and this includes plan review for new or renovated spaces)

Recent survey experiences are littered with the remains of practices and conditions that were never cited in the past, but in the latest go-round have become representative of a substandard approach to managing whatever risk might be in question. For example, just consider how the survey of the surgical environment has changed (and changed very rapidly, if you ask me) from what was typically a fairly non-impactful experience (there were any number of instances in which the Life Safety surveyor didn’t even dress out to go into the OR proper) to the area generating the top three most frequently cited standards during The Joint Commission surveys in 2014. That, my friends, is a whole lot of schwing in the survey process.

Continue reading the article at Mac’s Safety Space.

Editor’s Choice: Live accreditation training with Jean Clark

When: June 1-3, 2015

Where: Boston area

Are you in the New England Area? Jean Clark, RHIA, CSHA, is leading a two-and-a-half day boot camp in June and if you haven’t attended one of our boot camps yet, you won’t want to miss this experience.

The boot camp provides survey coordinators and accreditation professionals with best practices for survey prep, training, and overall management, focusing on CMS and Joint Commission requirements.

At the end of the boot camp, you’ll have learned:

  • Where to find resources to assist your survey prep and accreditation knowledge
  • How to interpret accreditation standards and regulations and measure your organization’s compliance
  • How to identify organizational weaknesses so you can fix them before accreditors arrive and therefore improve your survey results

I will be attending this boot camp and I’m looking forward to Jean’s practical and insightful teaching as well as meeting some of you!

Please feel free to send me an email if you would like to connect during the boot camp.

Sign up for the boot camp here.