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Joint Commission deletes standards during third phase of EP review

On April 25, The Joint Commission announced it had completed the third phase of its Element of Performance (EP) review project. Phase three looked at standards from seven Joint Commission programs, deleting those deemed duplicative or have become standard operating procedure.

It should be noted that what was deleted varies based on each program. For example, an EP deleted for the hospital program might still exist for home care. Chapters affected include Environment of Care and Infection Prevention and Control.

Below are links to the various prepublication standards, which are effective July 1, 2017.

Throwback Thursday: Assisting the impaired clinician

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

How to overcome barriers to recognition

By the time the general public hears about an impaired clinician, whether it’s a nurse, technician, or physician, it is often too late to head an incident involving that clinician off at the pass-whether that incident is a medical error, diversion of medication, or something even worse, like the technician recently accused of inadvertently exposing thousands of patients to hepatitis C.

But the healthcare industry is well aware that ­impaired clinicians exist, and it has methods for addressing, confronting, and helping these medical professionals. Where are the industry’s gaps to success in ­preventing this far too common occurrence? BOAQ recently sat down with Jill Pollock, RN, LMFT, administrator of Loma Linda University Behavioral Medicine Center and ­frequent lecturer on chemical dependency recognition and intervention, to discuss this topic.

It takes a case as shocking as the hepatitis C outbreak in New Hampshire to bring a topic like this to light, she says.

“I think it’s difficult for people in healthcare to wrap their heads around it,” says Pollock. “What do you think one of our biggest barriers is to recognition of addiction and confronting it? If I can get people to talk just a little bit, we start hearing how there is a fear that confronting someone’s addiction could ruin someone’s life.”

For many healthcare professionals, the thinking is backward, she says–they’re focused on saving a coworker’s career. But we have a professional responsibility to our patients, our loved ones, and the public in general.

“What happens if someone drives impaired and kills someone in a car crash? Would you worry about their professional life?” says Pollock. “Or if your facility has an outbreak of hepatitis C?”

After talking with audiences about the possible outcomes of not confronting versus trying to help the impaired professional, she has found that the best tactic is to bring in personal, relatable example scenarios. “If someone is diverting drugs, then that patient, that ­mother or father, son or daughter, husband or wife, is not getting their pain medications,” she says. “Or, ­alternately, is being cared for by an impaired nurse. I try to bring it home to something we can all relate to.”

Who would you want taking care of your loved one? Pollock asks. Would you be comfortable with a caregiver who is impaired or thinking about where to find his or her next fix?



Transparency and Termination Notices; CMS proposes changes for Accreditation Orgs.

Early this April, CMS sent out a memo with big proposals for accreditation. If passed, the proposed rule would require accrediting organizations (AO) to make their survey reports publicly available and publish termination notices somewhere other than in local newspapers.

Currently, AOs like The Joint Commission and DNV aren’t required to make their survey reports or plans of corrections available to the public. Under the proposed rule, AOs would have to post these on their websites. CMS Logo

The agency does acknowledge that this information is already available on CMS regional office and state agency websites. However, the new rule is intended to make this information easier for patients to find.

“Access to survey reports and PoCs will enable health care consumers, in addition to Medicare beneficiaries, to make a more informed decision regarding where to receive health care thus encouraging health care providers to improve the quality of care and services they provide,” the memo states.

That interest in transparency leads into the second half of the proposed rule on termination notices. Previously, when an ambulatory surgical center, federally qualified health center, rural health clinic, or organ procurement organization receives a Medicare termination notice, it has to be published in a local newspaper. Acknowledging approximately 23% of the general public continues to read print newspapers, CMS has come up with a list of additional posting options.

If you want to read and comment on the proposed rule, you can find a copy of the memo and commenting instructions here. CMS will accept comments until June 13, 2017.

Proposed seven-day limit to opioid bill enters Congress

A new Senate bill would limit the amount of opioids a patient can initially receive for acute pain. If passed, physicians could only prescribe seven days’ worth of opioids when first treating a patient’s condition.

The bill was put forward by Senators John McCain (R-Ariz.) and Kirsten Gillibrand (D-N.Y.) as a way to prevent opioid addiction. The limit is backed up by medical literature and is there are nine states with similar opioid laws in place.

“Our legislation builds on the important steps taken by Arizona Governor Doug Ducey last fall to tackle a root cause of this epidemic by limiting the supply of an initial opioid prescription for acute pain to seven days. We have a long way to go to end the scourge of drugs across our communities, but this legislation is an important step forward in preventing people from getting hooked on these deadly drugs,” said McCain in a press release.

“Too many lives have been destroyed, too many families have been torn apart, and too many communities all over New York are suffering because of this tragic epidemic. I am proud to join with Senator McCain in this urgent fight against the overprescription of opioids, and I look forward to seeing it pass through the Senate as quickly as possible,” said Gillibrand in a press release.

New CMS requirements for fire door inspection

The American Society for Healthcare Engineering (ASHE) recently published answers involving CMS’ new fire safety regulations. The new Conditions of Participation require fire doors be routinely inspected by “qualified persons.”

ASHE clarified to members that there isn’t any class or certification to qualify for door inspection. Anyone who’s familiar with the code requirements for fire doors will meet the “qualified” standard.

For more details, see the ASHE brief on the topic.

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Joint Commission urges providers to prevent medication compounding-related errors

In a recent blog post, The Joint Commission called on providers to work toward the elimination of medication compounding-related infections (MCRI). When not mixed in sterile conditions, compounded medicines can cause several types of infections, including bacterial bloodstream infections and cases of fungal meningitis.

MCRIs were in the news recently, after a three-month trial wrapped up last month in which the president of a Boston compounding pharmacy was convicted of racketeering and mail fraud stemming from a 2012 fungal meningitis outbreak that infected 778 and killed 76.

“The health care community, including The Joint Commission, recognize that as the need for compounded medications continues to grow it is more important than ever to ensure safe policies and procedures are being appropriately and effectively implemented to prevent patient harm,” wrote Robert Campbell, PharmD.

In the post, Campbell reminds providers that guidelines for compounding medications (sterile and non-sterile) are derived from the United States Pharmacopeial Convention’s (USP) General Chapters <797>, <795>, and <800>. USP Chapter <800> goes into effect in 2018 and covers guidelines for compounding hazardous materials.  All three chapters have requirements on the environment, personnel, and products used during compounding.

Campbell writes that many facilities still struggle with compounding compliance. In response, The Joint Commission unveiled a new Medication Compounding Certification (MCC) program in January. All compounding pharmacies are eligible to enroll in the program including organizations not accredited by The Joint Commission. The accreditor says that the goal of the MCC program is to:

•    Ensure pharmacies are compliant with USP and Joint Commission standards
•    Reduce the risk and harm stemming from drug compounding
•    Uncover and fix problems in existing compounding policies and procedures
•    Train personnel on the correct use of PPE and aseptic techniques
•    Ensure the physical environment meets guidelines for cleaning and documentation
•    Ensure the proper labeling, dating, and sterility of compounded products

TBT: North Carolina hospital uses Lean methodology to reduce patient falls

Editor’s Note: The following is a free Patient Safety Monitor Journal article from yesteryear! If you like it, check out more of our work covering quality and patient safety!

One year ago the patient fall rate at New Hanover Regional Medical Center (NHRMC) in Wilmington, North Carolina was deemed “acceptable” compared to national standards. Statistically, the hospital wasn’t any worse off than hospitals of a similar size, but patient safety experts and administrators within the institution still felt there were missed opportunities to reduce their rates and improve patient care.

“We were doing a good job,” says Mary Ellen Bonczek, chief nurse executive at NHRMC. “It’s not like we had a problem compared to national organizations our size, but we clearly felt like we could do a better job and we began to change our mind-set towards prevention and elimination.”

The facility had already seen some positive gains in reducing infections simply by focusing on prevention and elimination strategies, and administrators within the facility felt they would see the same progress if they applied those principles toward reducing patient falls.

One year later, patient falls have decreased 22% to 2.5 falls per 1,000 patient stays, which translated to an estimated $500,000 in savings, according to an op-ed by NHRMC President and CEO Jack Barto published on

“This is but one example of how healthcare providers, by standardizing best processes and consistently following them, can change the delivery of care, one improvement at a time,” Barto wrote. “Over time, these improvements will add up to better patient experience, better quality of care and significant savings.”

The patient fall reductions that the facility saw were a result of a few simple, no-cost interventions developed by a patient services fall team, which implemented a patient risk assessment, standardized best practices, hourly rounding, and visual cues to focus on eliminating preventable falls.

“We challenged ourselves to look at things differently and begin to change our mind-set around patients at risk for falls,” Bonczek says.

Reevaluated patient falls

Although NHRMC already had a fall prevention team, last summer it applied Lean methodology to improve its process of discovering preventable patient falls. The multidisciplinary team?consisting of physicians, nurses, therapists, pharmacists, transportation employees, and environmental services employees?utilized value-stream mapping to uncover process improvement and design modifications.



ECRI Introduces HIT-based Patient Identification Tools

The toolkit aims to prevent patient misidentification through the use of health information technology.

Patient misidentification is a big and likely underreported problem for hospitals and health systems, as well as for patients.

The consequences can be significant. ECRI Institute research shows that 9% of patient misidentification events lead to temporary or permanent harm or death.

That’s why the ECRI Institute and a stakeholder collaborative it convened, the Partnership for Health IT Patient Safety, has launched a new patient identification resource to help prevent patient misidentification through the use of health information technology.

ECRI is a Pennsylvania-based nonprofit that works to improve the safety, quality, and cost-effectiveness of patient care.

The toolkit divides its recommendations into two sections:

  1. Attributes addresses “the information-gathering aspects of patient identification, including the fields and the formats that are available to accommodate acquisition of required information.”
  2. Technology addresses “new technologies to improve identification and ways to leverage existing technologies for safe patient identification.”

Continue reading at HealthLeaders Media. 

Throwback Thursday: Medicine from afar

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

How one critical access hospital turned to telemedicine to better serve its community

After reading this article, you will be able to:

  • Describe the needs a telemedicine program meets at a ­rural or remote facility
  • Identify surmountable barriers to implementation for a telemedicine program using robotic instrumentation
  • Identify the types of programs or services a telemedicine link can help a remote facility provide
  • Describe the financial benefits, both to the organization and to patients, that come with having a strong telemedicine program in place
  • Discuss credentialing challenges that an organization ­implementing a telemedicine program might face

Tucked away on the far side of mountain passes in northeast Oregon, the 25-bed critical access Grande Ronde Hospital in La Grande provides much-­needed care for a populace that can be cut off from larger facilities by a single snowstorm. The hospital provides all that it can for the local population, but, as with every critical access facility, there are inherent limits to the services that can be provided on-site. Certain specialties and medical services simply do not have the demand to draw full-time physicians or other professionals to the area.Middle-aged man measures his blood pressure in front of virtual doctor. In the meantime, telemedicine physician is carefully looking at his brain x ray picture in the monitor.

Grande Ronde has, however, found a high-tech solution to this issue-one that ensures its patient population can receive services locally rather than traveling hundreds of miles, as might have been necessary in the past.

“We were asked by Saint Alphonsus Hospital in Boise to take part in a grant program,” explains Doug Romer, the hospital’s executive director of patient care services. “Their outreach director got in touch with us and said, ‘I have these robots through a grant. Would you like to try providing telemedicine services?’ “

At the time, Grande Ronde did not have a telemedicine program and was interested in taking part in the process. And so its robot, a nearly human-height, mobile machine with a monitor where the “face” would be, ­arrived at the facility.

The program is what is known as a hub-and-spoke model-the tertiary hospital, in this case Saint ­Alphonsus, is the hub, and the rural facilities are the spokes. This model has evolved for Grande Ronde and is now known as a remote presence healthcare network. The network connects Grande Ronde with four states and five cities for specialty healthcare. For example, patients in the Grande Ronde ICU receive telemedicine services from St. Louis.

“The physicians log in, can see our electronic medical records, review images, review labs, review vital signs, and they will come in and visit patients face-to-face [via the robot’s camera and monitor],” explains Romer. “They are able to assist and direct the care of patients throughout the day and through the night when our nurses have questions. They will call ICU doctors in St. Louis and they will make decisions or change therapies as needed.”