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Joint Commission releases FAQ on NPSG.01.01.01

I just wanted to let everyone know The Joint Commission has released an FAQ on National Patient Safety Goal NPSG.01.01.01. The FAQ looks at whether there are any exceptions for active involvement of the patient or responsible caregiver.

The FAQ specifically looks at sleeping patients and the nurse’s role in identifying non-communicative or confused patients when another healthcare worker uses two patient identifiers. The Joint Commission states that the purpose behind this is to increase patient safety through such things as medication, diagnostic, and treatment errors. The organization must decide how to assess sleeping/non-communicative/confused patients. The organization must also determine when active involvement is necessary on the part of the responsible nurse or other caregiver.

These decisions must, obviously, be communicated to the staff and be brought about specifically for reasons of patient safety.

The NPSG.01.01.01 FAQ can be found online here.

Who’s making the switch?

In the upcoming issue of Briefings on The Joint Commission, I was able to talk with accreditation professionals at two hospitals who have applied for and been surveyed by DNV and intend to leave The Joint Commission as soon as their DNV application is approved. The conversations left me curious–how many of our members here at AHAP are looking at DNV’s accreditation process as a possible alternative?

My question to the field is–are you going through any sort of process, formal or informal, to take a look at DNV as an alternative? Has anyone decided to make the switch? What factored into the decision (for or against changing accrediting organizations)?

Working group call on critical test results

In case you missed them, we’ve posted our October 16 and October 28 calls on critical test results. Listen to them now by clicking here

Joining us on the calls was Gayla J. Jackson, RN, BSN. Gayla is a member of the AHAP advisory board and nurse manager at Mount Auburn Hospital in Cambridge, MA. She has 26 years of experience in acute care and was one of the 17 advisory committee participants chosen to work on a three-year federal grant from the Agency for Healthcare Research and Quality (AHRQ). The AHRQ provided funding to The Massachusetts Coalition for the Prevention of Medical Errors along with the Massachusetts Hospital Association for the purpose of identifying, choosing, and implementing two patient safety initiatives, one of which was communicating critical test results.

I hope you all found these calls useful. And look for Gayla at the 3rd annual AHAP conference in May. She will be joining us in Las Vegas for the second year in a row.

Speakers for 3rd Annual AHAP conference

Just wanted to follow up on Matt’s posting and offer some details on our 2009 conference. We’ve already confirmed the following speakers and topics:

Tracers: Jodi L. Eisenberg, MHA, CPMSM, CPHQ, CSHA, chair of the AHAP advisory board and program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago, and Jean Clark, RHIA, CSHA, member of the AHAP advisory board and service line director for health information management at Roper St. Francis Healthcare in Charleston, SC
Making the NPSGs come to life: Patricia Pejakovich, RN, BSN, MPA, CPHQ, CSHA, and WendySue Woods, RN, MHSA, CSHA, senior consultants with The Greeley Company, a division of HCPro
Leadership standards: Ken Rohde, senior consultant with The Greeley Company, a division of HCPro
Joint Commission alternatives: Patrick Horine, executive vice president of accreditation at DNV Healthcare, Inc. (we’ve also invited representatives from The Joint Commission and HFAP)
Critical test results 2.0: Gayla Jackson, RN, BSN, member of the AHAP advisory board and a practicing nurse manager at Mount Auburn Hospital in Cambridge, MA
Scoring: Kurt Patton, MS, president of Patton Healthcare Consulting, LLC, and former executive director of accreditation services for The Joint Commission
Survey readiness: Lisa Eddy, RN, CPHQ, CSHA, senior consultant for The Greeley Company, a division of HCPro
Suicide risk assessment: Sharon Chaput RN, CSHA, member of the AHAP advisory board and director of regulatory and quality management at Brattleboro Retreat in Brattleboro, VT
As Matt mentioned, we will be providing more details on the conference, which will take place May 14-15 in Las Vegas. Make sure to keep an eye on this blog in the comings days and weeks.
And, as always, you can sign up for the conference here.
Hope to see you all in Vegas!

Details for 2009 AHAP conference coming soon

Hello, everyone. I just wanted to let you know that we’ll be announcing speakers and topics very soon for the upcoming AHAP Conference May 14-15 in Las Vegas. Make sure to keep an eye on this blog for additional information in the comings days and weeks.

As always, you can find the basics about AHAP’s annual conference here.

News regarding The Joint Commission's critical access hospital accreditation program

Hello, everyone. Just wanted to let you know about some breaking news out of today’s Federal Register:

The Centers for Medicare & Medicaid Services (CMS) announced in the October 24, 2008 Federal Register that The Joint Commission’s critical access hospital accreditation program will undergo a 180-day probationary period while gaps between the standards and CMS Conditions of Participation (CoP) are fixed.

According to the Federal Register, “review of The Joint Commission revised accreditation standards for hospitals revealed that significant gaps remain between The Joint Commission standards and the Medicare hospital CoPs.”

In addition, “if we determine that an AO [accreditation organization] has failed to adopt requirements comparable to CMS requirements, we may grant a conditional approval of the AO’s deeming authority for a period of up to 180 days to adopt comparable requirements.”

You can read the complete announcement in the Federal Register here.

We’ll be watching this as things develop both here in the blog as well as in Briefings on The Joint Commission. What’s your impression on this situation? Do you feel like CMS is cracking down deliberately on The Joint Commission? Or is this just a step towards getting everyone on the same page?

DNV on the Web

Hello,

Thought this might be of interest to our members: healthcare lawyer and consultant David Harlow posted in his blog yesterday about potential benefits and costs to moving to DNV’s NIAHO program for hospital accreditation. Even more interesting, though, is that his post received direct feedback from DNV in the form of a reply by Executive Vice President Darrel Scott.

Scott responded directly to issues about rumored confusion about insurance companies and the NIAHO program, and clarified the timeframe in which a hospital must become ISO-9001 compliant upon entering the NIAHO accreditation program (within two years of their first accreditation effective date).

Looks like DNV is monitoring what folks are saying in the field. Have any of you started exploring the option of changing accrediting organizations in the future? What sort of questions are you hoping to have answered about DNV, NIAHO, and ISO-9001?

3rd Annual Conference in May

I’m thrilled to be serving again as the program chair for the 3rd annual AHAP conference. We’re making great progress now in developing the curriculum for the conference, which will take place May 14-15, 2009, at Caesar’s Palace in Las Vegas. We’re building off all the great feedback from the 2nd annual conference and we will be offering more networking opportunities, interactive sessions, and “real life” information you can use as soon as you get back to your hospitals.

For those who may not know me, I’m Program Manager for Accreditation and Clinical Compliance at Northwestern Memorial Hospital in Chicago. I’ve been involved in healthcare administration and quality for over 20 years, and I’ve been involved with AHAP since HCPro established it more than two years ago. My involvement in this association has provided me with networking opportunities within a community of highly motivated and knowledgeable professionals, and it has become an important avenue to validate the work that we are all doing to drive quality within our organizations through the accreditation process.

I wanted to update you on some of the topics we’ll be covering at the conference. The 2009 conference will include sessions on recent changes to the National Patient Safety Goals, The Joint Commission’s Leadership standards, tracers, critical test results, and more. And we’ve already confirmed a speaker from DNV Healthcare, Inc., the first new organization to receive deeming authority for hospitals in more than 30 years.

I invite you to email me (jeisenbe@nmh.org) or contract Brian Driscoll, AHAP’s director, at briandriscoll@hcpro.com if you have any questions about the AHAP conference, or if you have any suggestions how we can make it better.

I hope to see you all in Las Vegas!

PS: I hope you all saw Brian’s email inviting you to participate in the 2nd annual AHAP Salary Survey. Brian tells me we have almost 100 responses already. Also, stay tuned for the next working group call, which will focus on critical test results and feature AHAP advisor Gayla Jackson.

2008 Survey Coordinator Salary Survey

Just wanted to let everyone know that we launched the second annual salary survey yesterday, and we have already had a lot of interest.

This is a great chance to see where you stand compared to others when it comes to salary, raises, bonuses, and overall responsibilities. Following completion of the survey, we will send out a full electronic report, detailing the results of the survey and comparing them to last year’s results.

This survey is for AHAP members only, so watch your e-mail for instructions on how to participate.

All responses will remain anonymous. Help us get you the information you want. Take advantage of this opportunity to see how you compare to your peers and take this short, 15-question survey.

To help us compile the most accurate data possible, please complete the survey only if your primary responsibilities include managing your organization’s Joint Commission and/or CMS survey preparation and your organization is located in the United States.

Thanks!

CMS approves DNV application to accredit hospitals

Hello, everyone. I just wanted to update you on a developing story:

The Centers for Medicare and Medicaid Services (CMS) announced Friday the approval of DNV Healthcare, Inc. as a deeming authority for U.S. hospitals. DNV is the first new organization to receive deeming authority for hospitals in more than 30 years.

According to the pre-Federal Register announcement, DNV was recognized “as a national accreditation program for hospitals seeking to participate in the Medicare or Medicaid programs” effective September 26, 2008 through September 26, 2012.

“We’re coming into this business not just as another option,” says Yehuda Dror, president of DNV Healthcare. “We want to take a leadership position.”

“I think a lot of people will explore the possibility,” says Bud Pate, REHS, is Vice President for Content and Development for The Greeley Company; a division of HCPro, Inc. “There are some hurdles that people will need to walk through—since DNV is new they’re going to need to work through some residency issues, contract issues, that may exist and may mention The Joint Commission but none of these are insurmountable.”

DNV has crafted a system intended to combine CMS Conditions of Participation (CoP) with ISO 9001 quality management. This program, called the National Integrated Accreditation for Healthcare Organizations or NIAHO(SM), was created to make the accreditation process more streamlined as well as identify means for improving current standards and promoting continual improvement.

“The ISO-9001 certification seems to be a logical progression to the focus on quality assurance and quality improvement that has occurred in healthcare, primarily in hospitals,” says Larry Poniatowski, RN, BSN, CSHA, principal consultant for Accreditation Compliance Services with The University HealthSystem Consortium. “The issue here now will be to see how well it’s embraced by hospitals.”

Twenty seven U.S. hospitals in 22 states have been accredited by DNV Healthcare using the NIAHO(SM) program in addition to other accreditation services.

In mid-2007, DNV Healthcare acquired Cincinnati-based TUV Healthcare Specialists with the belief that the acquisition would help cement DNV’s application to CMS. In 2006, TUV had unsuccessfully applied for deeming authority.

DNV Healthcare is a division of Houston-based DNV USA, a subsidiary of the Norwegian company Det Norske Veritas. DNV focuses on risk management and training in several industries, including healthcare.

We’ll be providing additional coverage here on the blog as well as in Briefings on The Joint Commission in the upcoming issue.

What is your sense of DNV’s chances? Is your facility considering looking into moving away from Joint Commission accreditation? Are you interested in further details on how DNV’s process works?