RSSRecent Articles

Will medication reconciliation go the way of the dodo?

An interesting announcement went out to hospital associations and others last night from The Joint Commission discussing the future of medication reconciliation as a National Patient Safety Goal.

As of January 1 (hm, looks like we’re doing a little bit of time traveling again in hospital accreditation land) survey findings for NPSG 8 (the accurate and complete reconciliation of meds)  while still being evaluated during the on-site survey, will not be factored into the facility’s accreditation decision. They’ll not generate Requirements for Improvement either, or appear on the accreditation report. So more FYIs than RFIs.

During the on-site survey the facility will be evalutated on its med rec processes. Surveyors will talk about ways to improve med rec and also gather information on how hospitals are progressing in meeting NPSG 8.

The Joint Commission says it will evaluate med rec throughout the year to find means to improve it for implementation in 2010. All of this seems to acknowledge the ongoing struggle hospitals have had in developing working, effective medication reconciliation processes in the four years since it became an NPSG.

What are your thoughts on this? Do you think this is a smart move on the part of The Joint Commission?

Be sure to check back later for further updates. I’ll be following up later on today with additional information.


Some people just don’t test well.

AHAP members, yours truly, senior managing editor of Briefings on The Joint Commission, is about to undertake a very frightening task: I’m taking the CSHA exam.

I like to think of myself as knowledgeable about Joint Commission standards and accreditation in general but having never been a survey coordinator I’m a little nervous. Also, my fellow AHAP bloggers will no doubt give me some serious grief if I don’t pass on the first try. Or second.

Fortunately, I can take comfort in knowing that if I fail, I should persevere. Because someone out there has failed her driver’s license exam 771 times, and she hasn’t given up. So I won’t either. Apparently the woman, who resides in South Korea, has spent approximately $3,000 (or more accurately, 4 million won) since April, 2005 attempting to pass her written exam.

Wish me luck!

Who will replace Tom Daschle?

The secretary of health and human services undoubtedly affects healthcare accreditation, it is under his or her guidance that the government makes the laws that ultimately govern how our hospitals run. Tom Daschle, President Obama’s original nomination for the position, withdrew his candidacy yesterday after it was found that he had failed to pay some of his taxes in the past. So, now the question becomes, who should replace Daschle? An article in the New York Times today suggests a few names, some of whom I am familiar with, others of whom I am not. These include three current state governors and one former governor of Oregon:

  • Gov. Kathleen Sebelius of Kansas
  • Gov. Edward G. Rendell of Pennsylvania
  • Gov. Jennifer M. Granholm of Michigan
  • former Gov. John Kitzhaber of Oregon

I saw Kitzhaber speak at the Institute for Healthcare Improvement‘s 20th Annual National Forum for Quality Improvement in Healthcare back in December. He presented a keynote speech about healthcare in the 21st century. He had many good ideas, but his biggest point was that to change our current system to one that sees producing health as the goal, and not to finance the healthcare system will require a fundamental shift in thinking and doing. You can see his whole speech by visiting his  Web site, The 100th Meridian.

The other names in this list I am less familiar with, although I know that Rendell is known for pushing transparency in his state which implemented one of the nation’s first event reporting systems. He has in recent years taken up the cause of expanding health insurance to those who are uninsured in Pennsylvania.

What have you heard about the other names on this list? What are your thoughts on Daschle withdrawing his nomination?


No relation to our esteemed chairperson, but…

The National Quality Forum and The Joint Commission just announced that the nomination/application forms for the 2009 John M. Eisenberg Patient Safety and Quality Awards are now up on their respective Web sites.

The awards honor facilities and leaders who have, though innovative means, made an enduring improvement to patient safety and quality through research or systems changes. Nominations are due by April 20, 2009.

And no, John M. Eisenberg, MD, who was one of the founding members of the National Quality Forum, is not related to AHAP’s own Jodi Eisenberg. Apparently it’s simply a name that is often tied to quality in healthcare.

Are any of you familiar with past winners of the award? Is anyone planning to nominate someone or work with an organization planning to apply?

When physician identification can be a problem too

A New York Times article today got me thinking about how we mostly discuss the perils of patient misidentification, but what if the patient does not know who his or her physician or nurse is during a hospital stay? The article points to a study published this week in the Archives of Internal Medicine that shows that 75% of the time, patients can’t identify their physicians.

Although the article says this may not be a bad thing (ignorance is bliss) and that patients should be more concerned with the processes used in the hospital to ensure they are receiving the appropriate safe care, what do you think? If you found out that the majority of the patients in your facility were unaware of who was responsible for their care, would you try to better educate them? There are many requirements now by The Joint Commission and others that patients be educated about their care; should who provides that care during their stay be a part of that education?

If you’d like to read the article, you can click here.

Have a great weekend!

CMS and surgical errors

We first received reports that CMS would stop paying for wrong procedure, wrong body part, and wrong patient surgical errors back in the fall. Now, CMS has finalized the policies related to these no-pay events. Here’s the latest on this from the upcoming issue of Accreditation Connection. Thought you might like an advance look.

The Centers for Medicare & Medicaid Services (CMS) has finalized changes, originally proposed in fall 2008, ending payment for three types of medical errors.

The new policy would prevent payment for surgical errors involving the wrong procedure (surgical or invasive), wrong body part, or wrong patient. The non-payment policy is effective immediately, according to the CMS announcement.

All three of these medical errors have been identified by the National Quality Forum as “Serious Reportable Events.”

The new CMS policies can be found online in the following locations:

Wrong procedure

Wrong part

Wrong patient



Suggestions for changing healthcare for the better

An editorial in today’s USA Today caught my eye after reading Paul Levy’s blog Running a Hospital. Levy, as many of you may know, is the CEO of Beth Israel Deconess Medical Center in Boston, MA, who blogs regularly. The editorial talks about how an attitude of nonchalance is making for less safe hospitals and worse patient care systems. The authors outline a few actions that they feel could reverse this trend.

These include better inspections by accrediting bodies (aka more in depth surveys more often by The Joint Commission, DNV, and HFAP), more rigorous reporting of near misses and adverse events, increased attention paid to the overuse of medications (to prevent the spread of MDROs), and stricter adherance to no-payment threats by the CMS.

I think the federal government is taking a step in the right direction with the creation of Patient Safety Organizations to offer more legal protections to facilities and encourage more reporting of near misses and adverse events, but that is just one example.

Do you think these suggestions are on-par? Do you have any you might add?

Check out Patient Safety Monitor Blog

If you’re reading this blog, you probably use many blogs to stay up-to-date with industry news. To that end, I’d like to let you know about a sister blog that HCPro has recently launched, called the Patient Safety Monitor blog.

This blog will provide news and updates of patient safety regulations and information on a daily basis. Topics include patient safety-related regulations from individual U.S. states, the Centers for Medicare & Medicaid Services, The Joint Commission, and other news and information from organizations such as The Leapfrog Group and the Institute for Healthcare Improvement. The blog also provides a another forum for you, the readers, to share your opinion and expertise by posting comments.

I truly think this will be another great resource for the AHAP community and hope you’ll visit the site!

Price drops for hotel rooms at AHAP conference

Hey blog readers,

Just wanted to give you a heads up that for those of you interested in going (or already signed up for) the 3rd Annual AHAP Conference taking place May14-15 at Caesar’s Palace in Las Vegas, the price of staying at Caesar’s has dropped from $239 to $199 per night. This is available if you mention you are attending the AHAP conference when booking your room, and the rate is only good if you sign up by March 13, 2009. If you need any more information about the conference, please click here, or visit the AHAP homepage.

Thanks, hope to see you there!

Pennsylvania study targets HAIs

I just came across this really intriguing study while putting together the upcoming issue of Accreditation Connection and I thought, with healthcare-acquired infections such a hot button issue of late, it might be of interest to AHAP members. Here’s a clip from the article:

Infections acquired during a hospital visit frequently result in a significant increase in the overall cost of care, reports the Philadelphia Inquirer.

A recent report by the Pennsylvania Health Care Cost Containment Council has found that the average bill for a patient who acquires an infection during their hospital visit was roughly five and a half times the amount billed to those who did not acquire an infection. The report also found that nearly 28,000 patients contracted a healthcare-associated infection (HAI) during a hospital visit in 2007.

While HAI numbers were down from 2006 by almost eight percent, patients with HAIs were six times more likely to die, according to the report.

The full report is available online here. The full Inquirer article is available here.

By the way, Accreditation Connection is a free weekly email newsletter. If you don’t already receive it and would like to sign up, feel free to email me at mphillion@hcpro.com and I can make sure you’re on the list.