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Joint Commission changes standards as part of deeming authority application

The Joint Commission announced yesterday that, as part of its application to the Centers for Medicare & Medicaid Services (CMS), a number of changes will be made to the accreditation process.

Industry experts have noted that many of the changes are requirements hospitals already meet due to existing state or other regulatory requirements. According to The Joint Commission’s announcement, many of the requirements are already being met by accredited facilities.

“A lot of these [requirements] are current law or regulation,” says Elizabeth Di Giacomo-Geffers, RN, MPH CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor.

Di Giacomo-Geffers suggests facilities compile a list of the changes to see which changes the hospital already complies with–a checklist of yes, no, or not applicable.

“If the answer is no, you’re not complying with the requirement, then ask, what do we need to make this happen?” she says.

Many of the changes have resulted in added specificity to existing standards, though others have required the creation of entirely new standards. All changes go into effect immediately. These requirements will not be scored, however, until July 2009. The Joint Commission has a policy that it will, when possible, give its accredited organizations six months notice for new requirements.

The Joint Commission’s official announcement can be found here. The new requirements can be downloaded here.

Stay tuned to the AHAP Blog for further analysis on this issue in the coming days.

AHAP Conference update

Hello, everyone. We’ve just completed this year’s full-color AHAP Conference brochure, and we wanted to share an advance copy with our members. We’re very proud of the conference we’re putting together for you this year and excited to have the chance to meet with everyone again in May.

Make sure to keep an eye out for the print brochure, which will be arriving in the next few weeks. But for now, please take a look at here if you’d like an early preview of what we’re offering at this year’s AHAP Conference.

New Sentinel Event posted

Hello, everyone. The Joint Commission has released its latest Sentinel Event Alert, this time on errors related to the use of technology in the healthcare setting.

The Alert states that there is very little data documenting the frequency with which technology-related errors occur, but notes that computers and automated medication dispensing devices are frequently involved when an error occurs. The Alert also advocates using Joint Commission Information Management standards to improve the use of technology in the healthcare environment.

The Joint Commission suggests 13 steps to prevent healthcare technology errors, including training for new users and refresher courses for those who continue to use technology in the hospital, and clearly defining who is authorized and responsible for the technology. Their complete press release and additional information can be found here.

Agenda for AHAP conference posted

Hello AHAP blog readers,

The Agenda for the 2009 AHAP annual conference has been posted (click here to see the full agenda). I thought you might like to know about a few highlights:

As listed below, we’ll be having an accreditation panel with speakers from the Joint Commission, HFAP, and DNV.

Additionally, both days of the conference will start out with a general session (after the keynote speaker on the first day). Day one’s session will be lead by Ken Rohde, a Senior Consultant for The Greeley Company. He’ll talk about the 2009 Joint Commission leadership standards and how your facility’s leaders can emphasize creating a culture of safety.

The second day’s general session will be lead by Kurt Patton, principal at Patton Healthcare Consulting. He’ll be discussing The Joint Commission’s scoring changes for 2009.

Hope to see you at the conference!

CMS proposes changes to wrong site, wrong patient, wrong surgery rules

Hello, everyone. The Centers for Medicare & Medicaid Services (CMS) issued several proposed decision memos yesterday indicating they will not pay for wrong site/patient/surgery cases. The proposed decision memos can be found on the CMS Web site at the following links:

Surgery on the Wrong Body Part

Surgery on the Wrong Patient

Wrong Surgery Performed on a Patient


Exclusive panel discussion on the options for healthcare accreditation

Our 2009 conference will include a special session featuring executives from The Joint Commission, DNV Healthcare Inc., and the Healthcare Facilities Accreditation Program.

Speakers will include Ann Scott Blouin, PhD, RN, Executive Vice President in the Division of Accreditation and Certification Operations at The Joint Commission, Patrick Horine, Executive Vice President of Accreditation Services at DNV Healthcare Inc., Rebecca Wise, Chief Operating Officer at DNV Healthcare Inc., and George A. Reuther, Chief Operation Officer at the Healthcare Facilities Accreditation Program.

Each organization will have 15 minutes to present, followed by 45 minutes of Q&A. Join us for what will undoubtedly be an interesting discussion on how all three organizations are changing accreditation in healthcare.

Standards FAQs released

Hello,

Just a quick announcement before the holiday–The Joint Commission has released the FAQs for the 2009 hospital standards. They’re available online here. Rumor has it we’ll see National Patient Safety Goals soon after the holiday.

Look for further coverage and analysis of this batch of FAQs in the coming days and weeks.

Happy Thanksgiving!

AHRQ issues final rule for patient safety organizations

Hi AHAP members,

The Agency for Healthcare Research and Quality (AHRQ) issued its final rule for Patient Safety Organizations (PSO) last week. The final rule provides some finality to the Patient Safety and Quality Improvement Act of 2005, which provided for the creation of PSOs. The PSOs are supposed to encourage hospitals to voluntarily submit data and other information to a PSO so that the industry as a whole will benefit. Those facilities who participate in a PSO are afforded some legal protections.

The final rule did not change much from the proposed rule issued in February. However, some additions were made, including the need for a PSO to inform its providers if the PSO inappropriately releases confidential patient safety work product (PSWP), and increased flexibility in how a PSO differentiates itself from its parent organization. Some changes include additions to the list of which organizations cannot become a PSO, and more flexibility of how PSOs can store PSWP.

The final rule will become effective January 19, 2009. Until then, the Interim Guidance issued by the AHRQ will serve as the effective rule. To read more, click here.

Happy Thanksgiving!

Joint Commission releases FAQs for Universal Protocol

Hello AHAP members,

I thought you might be interested in the following snippet of an article I recently wrote for Briefings on Patient Safety, about the Joint Commission’s recently released FAQs, concerning the Universal Protocol.

The Joint Commission released frequently asked questions (FAQ) specifically about the 2009 Universal Protocol in November 2008, clarifying some areas of confusion that were brought about by the release of the 2009 National Patient Safety Goals in June 2008. Traditionally, The Joint Commission does not release FAQs about their standards until the year in which they apply, so this release of FAQs was considerably early.

“The Joint Commission has posted them before January 1 and they need to be applauded for getting them out now,” says Elizabeth Di Giacomo-Geffers, RN, MPH CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA.

Originally much of the field thought that although the Joint Commission had added in more detail to the standard, there were still instances in which it was difficult to judge whether completing all or parts of the Universal Protocol was necessary. The FAQs have specifically listed procedures that do and do not require compliance with the Universal Protocol, which is something that will prove helpful to the field.

“I think the most significant changes were that it really did clear up some ambiguity for what was not included,” says Gloria Rawn, RN, MS, JD, healthcare accreditation consultant from Kennebunkport, ME. The FAQs specifically list electroconvulsive therapy, closed reduction, lithotripsy, radiation oncology, and performance of dialysis (excluding insertion of dialysis catheters) as procedures that do not require the Universal Protocol to be carried out.

Congrats to our most recent CSHAs!

Congratulations to Emily Alvarez, Melinda Smith-Vaughn, Amy Boykin, Barbara Meacomes, and Cassie Seiler–our most recent Certified Specialists in Healthcare Accreditation!

The CSHA certification program is still new, and we’ve already had over 50 people take the exam. Congratulations to all who have passed!