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Enforcing Joint Commission standards the hard way

Now, we here at AHAP don’t condone using brute force for getting staff to comply with Joint Commission standards, National Patient Safety Goals, and the like, but I thought you might get a kick out of this Youtube video doing just that.

It’s a little over the top on comedic/slapstick violence, and a tad dated, but definitely laugh-worthy for anyone working in survey coordination and standards compliance.


Simple solutions for patient safety

The HealthLeaders Media Industry Survey 2009, released earlier this week, shows that many healthcare leaders think that while technology is an important part of patient care, driving home the fundamentals of patient safety is actually more important. For example the notion that handwashing is far more effective at preventing HAIs than implementing some sort of technology that monitors infection rates. In fact, only 12% of who answered the survey said that their electronic medical records played a large part in improving quality and patient safety.

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Restraints questions answered

Restraints use never stops generating questions from the field. During their upcoming audioconference, AHAP Chair Jodi Eisenberg, MHA, CPMSM, CPHQ, CSHA, and Susan W. Hendrickson, MHRD/OD, RN, CPHQ, FACHE, will be fielding questions from the audience on the latest restraints challenges as well as those ongoing areas of confusion which still demand clarification.

For example:

Q: Does everyone who provides care to patients required to have the same amount of training?

Jodi:Not everyone needs the same training. The role the staff plays in the care of the patient in restraints determines the content, the depth and the frequency of training. The best way to meet this standard is to develop an educational plan which highlights the levels of education necessary for staff in the care of the patient in restraints.

Q: Are lap belts to prevent patients from falling out of bed or a chair considered a restraint if they could unfasten it because it fastens in front (like a seat belt)?

Susan: No, devices that the patient can easily remove themselves are not considered a restraint.

If you’d like to join us on March 11 for this program–yours truly will be acting as moderator–more information can be found here.

If he can do it… so can you!

I wanted to take a minute to let you know that Matt Phillion, my fellow blogger and colleague has passed the Certified Specialist in Healthcare Accreditation exam! He is now an official CSHA and surely will continue to keep us up-to-date on all accreditation-related news. Congrats Matt!

If anyone is interested in finding out more about the exam, visit the Certified Specialist in Healthcare Accreditation Web site.

Have a great afternoon! 

Med rec: feedback from the field

The latest news from The Joint Commission about medication reconciliation has everyone talking. I thought you might be interested in hearing the reactions to yesterday’s announcement. The following will appear in Monday’s Accreditation Connection e-newsletter, but I thought you might enjoy an early look just in time for the weekend:

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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!