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Joint Commission targets CAUTIs with updated NPSG

Earlier this year, The Joint Commission updated its National Patient Safety Goal (NPSG) on catheter-associated urinary tract infections (CAUTI) for hospitals and critical access hospitals. It also created a new CAUTI NPSG for nursing care centers.

“An estimated 1 to 3 million healthcare-associated infections strike nursing home residents annually, and many of these are infections related to urinary catheters,” wrote David Baker, MD, MPH, FACP, Joint Commission executive vice president, in a blog post. “CAUTIs can lead to serious complications and hospitalizations. And, the rate of these infections is even higher for hospital patients. This is why The Joint Commission felt it was important to implement its new National Patient Safety Goal for nursing care centers and an updated goal for hospitals and critical access hospitals to reflect the latest scientific evidence.”

Among the new changes are requirements to:

•    Educate staff on how to correctly use and insert indwelling catheters.
•    Educate patients and family on CAUTI risks and prevention
•    Use evidence-based guidelines to write catheter use policies.
•    Follow written procedures based on established evidence-based guidelines for inserting and maintaining an indwelling urinary catheter.
•    Maintain an up-to-date record of catheter use; who has one inserted, when was it implanted, etc.

All the changes go into effect on January 1, 2017 and are meant to improve staff training, educate patients, and update policies with evidence-based practices. In addition, the Department of Health and Human Services announced that it wants to see a 50% reduction in CAUTI by 2020.

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The New CMS Emergency Management Rule: Tips for Successful Implementation

Date: Tuesday, January, 24, 2017 1:00–2:30 p.m. EST

Summary: After much anticipation, CMS has approved its own emergency preparedness rules separate from The Joint Commission and other accreditation agencies. Hospitals and healthcare organizations now have until November 15, 2017 to enact the changes and maintain compliance.HCPro Webcast Icon

Join expert speakers Marge McFarlane, PhD, MT(ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, and Thomas Huser, MS, CHSP, CHEP, as they guide you through the changes. They will help you identify resources for implementation, provide helpful tips, outline the special focus on fire drills for critical access hospitals, and list the optional and required CMS emergency management standard categories.

This webcast will teach you:

  • The list of required and optional categories of the CMS emergency management regulations
  • The tips, resources, and potential challenges to implementing an emergency prep plan
  • How to conduct fire drills for critical access hospitals

Registration: To order the webcast on demand, call HCPro customer service at 800-650-6787 or visit hcmarketplace.com

Joint Commission publishes 2017 Survey Activity Guide

The Joint Commission just published its 2017 Survey Activity Guide, with information on how to prepare for your next survey. It also contains details on policy changes in 2017, such as the new antimicrobial stewardship program standard for hospitals, critical access hospitals, and nursing homes.

Report: $28 billion saved through patient safety efforts

Efforts to improve patient safety are paying off, according to a new Health and Human Services (HHS) department report. Between 2010 and 2015, increased patient safety efforts have:
•    prevented 3.1 million hospital-acquired conditions (HAC), a 21% decline
•    saved 125,000 lives
•    saved $28 billion in healthcare costs

In the announcement, HHS Secretary Sylvia Burwell cited the Affordable Care Act as a major cause of the improvement in patient safety.Money

“The Affordable Care Act gave us tools to build a better healthcare system that protects patients, improves quality, and makes the most of our healthcare dollars and those tools are generating results,” said HHS Secretary Sylvia M. Burwell. “Today’s report shows us hundreds of thousands of Americans have been spared from deadly hospital-acquired conditions, resulting in thousands of lives saved and billions of dollars saved.”

There are other federal patient safety efforts mentioned in the report as aiding in patient safety improvement. Among those cited were the Partnership for Patients initiative, a public-private partnership launched in 2011 though CMS Innovation to target a specific HACs. CMS also worked with hospital networks and aligned payment incentives to improve focus on making care safer.

“These achievements demonstrate the commitment across many public and [more]

AHA asks Trump to change CMS regulations

On December 2, the American Hospital Association (AHA) sent a letter to president-elect Donald Trump asking him to reform CMS regulatory requirements. This is the second letter the group sent the president-elect in the space of three days.

The AHA has 43,000 individual members and nearly 5,000 member hospitals in its ranks. AHA CEO and President Rick Pollack wrote that the balance between flexibility in patient care and regulatory burden was at a tipping point. He continues to say that reducing administrative complexity would save billions annually and allow providers to spend more time on patients, not paperwork.The White House

“[CMS] and other agencies of the Department of Health and Human Services (HHS) released 43 hospital-related proposed and final rules in the first 10 months of the year alone, comprising almost 21,000 pages of text,” he wrote. “In addition to the sheer volume, the scope of changes required by the new regulations is beginning to outstrip the field’s ability to absorb them. Moreover, this does not include the increasing use of sub-regulatory guidance (FAQs, blogs, etc.) to implement new administrative policies.”

CMS LogoThe letter includes a list of 33 changes the AHA wants to be made, including

•    Suspend hospital star ratings
•    Suspend electronic clinical quality measure (eCQM) reporting requirements
•    Delete faulty hospital quality measures
•    Have readmission measures reflect socioeconomic factors
•    Cancel stage 3 of “meaningful use” program.
•    Stop federal agencies (HHS, CMS) from forcing private sector accreditors (Joint Commission, DNV, HFAP) to conform with government accreditation standards
•    Refocus the Office of the National Coordinator (ONC) on certifying electronic health records

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New Comprehensive Cardiac Center certification offered in 2017 

On January 1, 2017, hospitals will be able to submit applications for the Joint Commission’s new advanced Comprehensive Cardiac Center (CCC) certification. The certification will allow hospitals with cardiac care facilities to be evaluated and recognized for their CCC services. This program will help organizations:

  • Comply with consensus-based standards
  • Effectively integrate evidence-based clinical practice guidelines
  • Create and organized approach to performance improvement and measurement
  • Achieve and maintain the requirements for Advanced Disease-Specific Care certification

The certification program is completely voluntary and only offered to hospitals accredited by The Joint Commission. Qualified hospitals will also have to have a scope of care, treatment, and services that covers the management of:

  • Ischemic heart disease
  • Cardiac valve disease
  • Arrhythmias
  • Advanced heart failure
  • Cardiac arrest
  • Cardiac rehabilitation
  • Cardiovascular risk factor identification and cardiac disease prevention

For more info on the CCC certification program, you can go to the Comprehensive Cardiac Center Certification website or view the prepublication requirements at the Joint Commission website. You can also register for a free webinar on January 17, 2017.

Join our last Accreditation Specialist Boot Camp of 2016

The final HCPro Accreditation Specialist Boot Camp of the year is coming up fast. Sign up now for your last chance to learn from instructor Jean S. Clark, RHIA, CSHA, who has more than 30 years of real-world experience and expertise in regulatory and accreditation compliance. The final boot camp will be December 12-14 in Orlando, Fla.

We call it a boot camp because it’s focused, in-depth training and when you finish the class, you’ll be an accreditation expert and ready to handle whatever your organization needs, such as:

  •   Identifying organizational weaknesses to improve survey results
  •   Knowing which regulations are applicable to your organization
  •   Interpreting accreditation standards and regulations
  •   Maintaining organizational readiness and identify vulnerabilities
  •   Implementing continuous survey readiness plans
  •   Coordinating site visits
  •   Identifying future trends likely to affect organizational compliance
  •   Responding to survey results, findings, and Requirements for Improvement

The Accreditation Specialist Boot Camps provide in-depth explanations of CMS and Joint Commission requirements, and briefly cover HFAP and DNV standards if students are accredited by those bodies. Instructors focus on teaching participants how to integrate continuous survey readiness into daily operations. Plus, you will leave with an entire catalogue of tools, templates, and resources that you can use at your organization.

Unique features of this Boot Camp include:

•    Custom-designed course materials: All course materials were custom developed for the Boot Camp’s intensive learning format
•    Take-home tools: Head home armed with customizable tools that will save you time
•    Hands-on teaching methods: Each course module includes exercises that are reviewed and discussed in class
•    Small class size: The number of participants is limited to retain a low student-teacher ratio
 
Sign up today!

Study: Link between CMS hospital star ratings and socioeconomic factors

It’s been almost five months after CMS publicly released its hospital star ratings system amidst widespread controversy and opposition. Now, a new study by WalletHub has provided evidence that hospitals’ ratings are highly linked to their location and socioeconomic factors.

CMS LogoEver since CMS announced the star system, many had argued that it was biased against facilities that treat impoverished, sicker patients. To study this, WalletHub looks at the ratings of 657 hospitals in 150 cities across the U.S. comparing ratings to each city’s “stress level,” a composite of stressor caused by work, money, family, and health and safety. Star Rating

Hospitals in Detroit and Newark, N.J. (the first and ninth most stressed cities) earned an average of 1.5 and one stars respectively. However, hospitals in the California cities of Fremont and Irvine (the least and second-least stressed cities) earned an average of three and five stars, respectively. Meanwhile, CMS reports that safety net hospitals earn slightly lower ratings on average compared to non-safety net hospitals (2.88 to 3.09 stars).

“When we look at hospital quality ratings and rankings, what we are seeing has less to do with what the hospitals themselves are doing and more to do with the communities they are located in and the patients they serve,” said David Nerenz, co-author of the study and the director of the Center for Health Policy and Health Services Research at the Henry Ford Health System in Detroit, to Modern Healthcare. [more]

CMS releases potential reporting measures

CMS last week released a list of 97 reporting measures for hospitals, clinician practices, nursing homes, dialysis facilities, and other settings. The measures are being considered for use in Medicare’s quality and value-based purchasing programs.

This year, 39% of the measures focus on patient outcomes, while the remainder focus on patient safety, cost, and appropriate use of diagnostics and services. There was also an increase in measures submitted by specialty societies. CMS annually publishes a list of potential Medicare quality measures to hear back from patients, clinicians, payers, and purchasers on the which measures they think are the best. CMS is teaming up with the National Quality Forum (NQF) for the sixth year in a row on this effort. The feedback the NQF collects will be sent to the multi-stakeholder Measure Applications Partnership (MAP) for consideration.

“We invite you to review the Measures under Consideration List in detail and to participate in the public process during the MAP review,” wrote Kate Goodrich, MD, MHS, CMS director of the Center for Clinical Standards & Quality, in a blog post. “We believe it is critically important to hear all voices in the selection of quality and efficiency measures that are used for accountability and transparency purposes and look forward to another successful pre-rulemaking season. We are committed to working with patients, clinicians, and others on how to best measure the quality and value of care while reducing burden on providers and driving improved outcomes for patients at lower costs.”

The proposed measures are available on CMS and NQF websites, and comments on can be made until 6 p.m. on December 2 at the NQF website.

Mental disorders and substance abuse are the top U.S. health condition

In its newest Health Index, Blue Cross Blue Shield (BCBS) found that mental disorders are the chief cause of shortened longevity and health in America. The top five conditions cause about 30% of commercially insured Americans’ overall reduction in optimal health, and are as follows:

1. Depression, anxiety, and other mood disorders
2. Hypertension
3. Diabetes
4. High cholesterol
5. Substance use disorders

The BCBS Health Index compares 200 different conditions using millions of BCBS claims, along with healthcare costs and global burden of the disease to find out which ones have the largest impact on American’s quality of life and health.

American Psychiatric Association (APA) President Maria A. Oquendo, MD, PhD, told Medscape that the report, “highlights the impact of mental health and substance use disorders on people’s health and quality of life and reinforces the importance of making access to quality mental healthcare for all a national priority.”