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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!

Update: NIAHO certification program


I just wanted to share a snippet from a recent article in Briefings on The Joint Commission about a pair of hospitals which have switched to DNV, Inc.’s accreditation program. The following explains a bit about the NIAHO survey process. Hope this is of interest.

Six surveyors showed up at Citizens Medical Center (Victoria, TX) for what would end up being a three-day survey. They were presented with a list of documents to present for review, along with a tentative three-day schedule. As part of prior preparation, the documentation was quickly pulled and presented.

The survey consisted of document reviews and discussions, review of open patient records, interviews with staff, life safety tours, and more.

“All in all, the survey was very thorough, comprehensive, collaborative, and educational,” says Caren Adamson, assistant administrator at Citizens Medical Center. “We were held accountable to the prescriptive requirements of the CoPs and were assessed with our compliance with the ISO standards and our underlying framework for ongoing compliance.”

Purdy has found that the survey process for her facility has been a less stressful process for staff.

“They make it clear they’re looking at the process, not the individual,” says Judith Purdy, RN, risk/quality director at Hays (KS) Medical Center. “The staff appreciate that.

It’s not so much a new survey process,” says Purdy. “They survey the CoPs. The hospital is very familiar with those and comfortable being surveyed by those standards.”

Staff is trained in the CoPs and very aware of those standards, she explains.

“We’ve been talking to the employees for over a year that this is the agency we’re looking towards shifting to. They’ve been hearing this information for months,” says Purdy. “There is a sense of anticipation waiting for this to really happen.”

Purdy also noted there will likely be a learning curve on both sides of the survey process at first.

“To some degree they’re still training the surveyors, but as a rule there will be a generalist, a clinical person and a life safety person,” says Purdy. This list does not necessarily include a physician, and the generalist can fulfill a clinical or nonclinical role or both and will be trained in the standards to do so.

DNV has stated that they will attempt to send the same surveyors each year, with the thought that the survey process will benefit from a surveyor that has a level of knowledge about the facility and how it functions and operates.

TJC, DNV, and HFAP all to speak at conference

We’ve now confirmed speakers from The Joint Commission, DNV Healthcare, and HFAP for the May 2009 conference. Should be a great conference!

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.