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Joint Commission Updates on HAI-related National Patient Safety Goal on HAIs

The Joint Commission has revised several of its requirements for National Patient Safety Goal (NPSG) 7, which focuses on the issue of healthcare-associated infections (HAI). The revisions go into effect on January 1, 2018, and apply to hospitals, critical access hospitals (CAH), and nursing care centers (NCC).

NPSG 07.03.01: Multidrug-resistant organisms (MDRO)

•    NCCs are now expected to follow the MDRO NPSG.07.03.01. Nursing homes experience a high rate of MDROs such as methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). This was particularly concerning because nursing home patients were bringing MDROs to hospitals and vice versa.
•    The Joint Commission is adding a new infection, carbapenem-resistant enterobacteriaceae (CRE) to NPSG.07.03.01. This change applies to hospitals, CAH, and NCCs.

NPSG 07.04.01: Central line-associated bloodstream infections (CLABSI)

•    The EPs for the NPSG 07.04.01 have been reordered.
•    EP 11 was revised to specify the use of chlorhexidine for antiseptic skin preparation.
•    For both NPSG 07.03.01 and NPSG 07.04.01, facilities are now allowed to determine how frequently they need to re-educate staff and licensed independent practitioners on MDROs and CLABSIs.

CMS issues Legionella reduction memo

On June 2, CMS issued a new memo to surveyors on the importance of reducing cases of Legionella infections. Accredited facilities should double check their waterborne pathogens compliance, as surveyors will likely pay more attention to it in upcoming surveys.

Legionellosis is comprised of a sometimes fatal form of pneumonia called LD as well as Pontiac fever. The bacterium grows in the parts of hospital water systems that are continually wet and is spread through inhalation of aerosolized droplets of contaminated water. Legionellosis poses a particular risk to patients older than 50, who smoke or have chronic lung or immunosuppression conditions. Approximately 9% of reported legionellosis cases are fatal.

Badly maintained water systems have been linked to the 286% increase in legionellosis between 2000-2014. There were 5,000 cases of it reported to the Centers for Disease Control and Prevention (CDC) in 2014 alone. About 19% of outbreaks were associated with long-term care facilities and 15% with hospitals. Just a few items that can spread the contamination include:

•    Decorative fountains
•    Shower heads and hoses
•    Electronic and manual faucets
•    Hot and cold water storage tanks
•    Water heaters and filters
•    Pipes, valves, and fittings
•    Eyewash stations
•    Ice machines
•    Cooling towers
•    Medical devices (e.g., CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units)

“Healthcare facilities are expected to comply with CMS requirements to protect the health and safety of its patients,” the agency writes in its memo. “Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance with the CMS Conditions of Participation. Accrediting organizations will be surveying healthcare facilities deemed to participate in Medicare for compliance with the requirements listed in this memorandum, as well, and will cite noncompliance accordingly.”

The memo tells surveyors to review policies, procedures, and reports documenting water management implementation results to ensure facilities:

1.    Conduct a facility risk assessment to identify where Legionella and other waterborne pathogens could grow and spread in the facility water system.

2.    Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit. The program should include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.

3.    Specify testing protocols and acceptable ranges for control measures. Document the results of testing and corrective actions taken when control limits are not maintained.

The contents of this memo go into effect immediately.

Help us out with a survey!

Dear Accreditation Professional,

Your feedback is essential to us at HCPro. Please take just a few minutes to share your thoughts with us regarding your salary and job duties. We will compile the survey results in a special report to provide insight into the state of the profession. Simply click on the link below to begin the survey.

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All your answers are confidential and anonymous. Please fill out the survey before the deadline on July 15, 2017.

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Associate Product Manager, Accreditation and Safety
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TBT: Building a better self-reporting structure

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

Does your organization have a formalized process for debriefing after an adverse event? And if so, is it working? For many organizations, reporting of adverse events can be problematic, with challenges ranging from time management and inefficient processes to the age-old challenge of shame?reporting near misses and adverse events can be a challenge in an industry where everyone pursues the field to help, not hurt.

“Everyone wants to leave work happy and feel like they did a good job,” says Anngail Smith, VP of operations and risk management for CRG Medical, Inc., in Houston. “Someone once said that healthcare is the intersection of care and being able to hurt people. A client told me that healthcare is a courageous activity.”

Because healthcare rides along that fine line between safe care and risk of harm, the industry needs to build an environment where people are willing to report errors and near misses so that the industry as a whole can work on the problem without being afraid.

“I think the fear of hurting someone is always there,” says Douglas Dotan, president and CEO of CRG Medical. “The question is, are you willing to incorporate that into learning how to make your processes better?”

The pressures to report are staggering for providers, Dotan says. Personal liability, risks to reputation, job security, and even peer pressure can all come into play with the issue of reporting. But the industry needs physicians to speak up and identify hazards to patient safety, share their knowledge about near misses, and propose actions to improve the delivery of care. This requires a culture change to create an environment in which providers feel safe to talk about these things without putting themselves at risk.

“If there is something that really stresses caregivers out, we need to find a way to fix it, and we need to share that fix,” says Dotan. “That won’t happen if they’re afraid.”

This is not a new issue, Dotan points out. Donald Berwick’s Institute of Healthcare Improvement talked about these factors 15 years ago, Dotan notes, and yet most events which occur today have occurred in the past, and the latest reports state that the industry has well over 400,000 preventable deaths in healthcare every year.

“That’s about 1,000 deaths that occur every day from preventable medical errors,” says Dotan.

And the contributing factors leading up to these preventable errors occur all the time. The same situation may occur 200 or 300 times before a sentinel event occurs, leading to hundreds of thousands of dollars spent in litigation and reparations because it wasn’t prevented the first 300 times, Dotan says.

This comes down to continual process improvement, he says.

“What we’ve been working on is identifying those hazards and unsafe conditions and putting an easier way for people to communicate in place,” says Dotan. “You need to have a way of documenting and giving feedback. If I continuously give you information I think is important to act on and leadership doesn’t act on it, I will stop communicating that information. So when future problems arise, they will not be reported.”

An open communication system will help overcome the fear of reporting, Smith says.

“Are you good at your job? If you did it badly would you want to tell someone? We spend more time doing our jobs than anything else. For an inexperienced person, if they make a mistake, they might report it. ‘I am new at this; I will make mistakes,’ ” says Smith. “But if the experienced person makes a mistake, they’d think they would be embarrassed to talk about it.”

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Joint Commission issues another warning about improperly cleaned medical devices

For the second time in three years, The Joint Commission has released a Quick Safety issue on the topic of improperly sterilized or high-level disinfection (HLD) equipment and devices. The accreditor writes that despite bringing the problem to light in 2014, there’s an increase in cases of medical devices not being cleaned properly.

“Immediate threat to life (ITL) declarations related to improperly sterilized or high-level disinfected (HLD) equipment have increased significantly from 2013-2016,” wrote Lisa Waldowski, DNP, PNP, CIC, Joint Commission infection control specialist, in a blog post. “In 2016, 74% of all ITL declarations from The Joint Commission were related to improperly sterilized or HLD equipment. As reports of sterilization and HLD-related issues continue to be received by our Office of Quality and Patient Safety, our surveyors also are seeing it firsthand in hospitals, ambulatory care sites and other healthcare settings across the country.”

According to Quick Safety Issue 33, noncompliance with standard IC.02.02.01 (which deals with sterilization) has been on the rise since 2009 in Joint Commission-accredited hospitals, critical access hospitals, ambulatory centers, and office-based surgery facilities.

There are several risks tied to improper reprocessing such as infection and outbreaks, loss of accreditation, litigation, negative publicity, and lost revenue. A prime example of this occurred during the 2015-2016 outbreaks, when it was discovered that the design of the duodenoscopes could prevent them from being properly sterilized.

There are several factors that are causing this rise in noncompliance, according to The Joint Commission. These include:

•    The incorrect assumption that the risk of infection to patients is low or nonexistent
•    Staff either don’t know how to properly sterilize or HLD equipment or they knowingly chose not to follow proper procedures
•    Lack of leadership oversight and the belief that sterilization or HLD is a low priority
•    A culture that discourages the reporting of safety risks
•    No dedicated staff person to oversee the proper sterilization or HLD of equipment
•    Facility design or space issues prevent proper sterilization or HLD of equipment
•    Lack of monitoring or documentation of sterilization or HLD of equipment

“Healthcare organizations need to prioritize improving sterilization and HLD efforts year-round and well before a survey occurs to best protect patients,” says Waldowski. “Together, we can work to change news headlines from reporting on sterilization or HLD-related outbreaks to touting reductions in outbreaks through quality improvement efforts.”

CMS publishes new emergency preparedness Interpretive Guidelines

On June 2, CMS published its final rule for emergency preparedness guidelines and survey procedures. These rules affect all 17 providers and suppliers and the rules will be enforced starting November 15, 2017.

While the survey process will remain the same, the new rule creates compliance tags for emergency preparedness requirements. These tags will be similar to how K-tags are used to cite noncompliance with the Life Safety Code® (LSC).

The emergency preparedness tags will be called “E Tags” and are accessible to both health and safety surveyors and LSC surveyors. State survey agencies will have the discretion to decide which surveyor group will conduct the emergency preparedness surveys.

First set of SAFER Matrix data is online

The Joint Commission released the first set of data collected from its new Survey Analysis for Evaluating Risk™ (SAFER™) scoring methodology this May. The SAFER matrix was first rolled out to psychiatric hospitals as part of their accreditation surveys. It has been since implemented for all Joint Commission-accredited programs.

The accreditor made a chart of the most frequently cited compliance challenges for deemed psychiatric hospitals between Aug. 1, 2016 to Feb. 17, 2017.

The Joint Commission writes that it plans to keep analyzing aggregate SAFER data going forward to:

  • Continuously improve consistency
  • Identify potential EPs for revision
  • Assist in identifying areas of high risk noted within each program

Study: Single step reduces readmissions by 25%

A new study published in the Journal of the American Geriatrics Society has found that integrating informal, unpaid caregivers into the discharge process can cut readmission rates by a quarter. The study found that by using these caregivers when discharging elderly patients, they were able to reduce readmissions 25% over 90 days.  The study reviewed 4,361 patient cases and 10,715 scientific publications to come up with its results. The study found that:

•    66% of the caregivers were female
•    61% were a spouse or partner
•    35% were adult children

The study also found that informal caregivers significantly reduced time-to-readmission, rehospitalization lengths, and costs of post-discharge care.

“Due to medical advances, shorter hospital stays, and the expansion of home care technology, caregivers are taking on considerable care responsibilities for patients,” said lead author Juleen Rodakowski, OTD, MS, OTR/L, assistant professor in the Department of Occupational Therapy in the University of Pittsburgh’s School of Health and Rehabilitation Sciences, in a statement.

“This includes increasingly complex treatment, such as wound care, managing medications, and operating specialized medical equipment. With proper training and support, caregivers are more likely to be able to fulfill these responsibilities and keep their loved ones from having to return to the hospital.”

“While integrating informal caregivers into the patient discharge process may require additional efforts to identify and educate a patient’s family member, it is likely to pay dividends through improved patient outcomes and helping providers avoid economic penalties for patient readmissions,” said senior author A. Everette James, JD, MBA, director of the University of Pittsburgh’s Health Policy Institute, in a statement.

Caregiver statistics aggregated from the AARP, the Family Caregiver Alliance (FCA), the Institute of Medicine (IOM), and the National Alliance for Caregiving (NAC) reveal that:

•    More than 34 million unpaid caregivers provide care to someone age 18 and older who is ill or has a disability (AARP, 2008)
•    Unpaid caregivers provide an estimated 90% of the long-term care (IOM, 2008)
•    The majority (83%) are family caregivers—unpaid persons such as family members, friends, and neighbors of all ages who are providing care for a relative (FCA, 2005)
•    The typical caregiver is a 46-year-old woman with some college experience and provides more than 20 hours of care each week to her mother (NAC, 2004)

See the full article at HealthLeaders Media and read previous Accreditation Insiderarticles for more on readmissions:

Throwback Thursday: Hospital near-death ­experience: An organization’s fight for survival after CMS decertification

Editor’s Note: The following is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation! 

After reading this article, you will be able to:

  • Describe where an organization’s goals can be counterintuitive to quality
  • Discuss leadership’s role in decertification
  • Identify ways nursing staff are key to recertification
  • Discuss physician involvement in rescuing the facility after CMS decertification

 Closed Sign

The threat of loss of accreditation is one that keeps survey coordinators and hospital leaders awake at night, but for most hospitals, it’s more of a bogeyman than an actual threat-there are many stages an organization must go through and fail before their accrediting bodies slam the hammer down. However, a recent case of decertification and recertification by Medicare stands as a cautionary tale for hospitals across the country to never lose sight of the goals of quality and safety.

Compass Clinical Consulting, an independent consulting group, recently had the experience of helping one hospital recover from the rare event of decertification from CMS. (For the privacy of the organization, the hospital’s name has been omitted from this article.)

“How we got here is pretty straightforward,” says Kate Fenner, RN, PhD, managing director of Compass Clinical. “It was an organization with a very strong leader, and they were focused on entrepreneurship and building the base of the organization.”

The organization had been fairly aggressive in acquisition and reservice, and its board of trustees was on board with this concept. An unintentional downside to this approach, however, was the neglect of day-to-day clinical operations, says Fenner.

“They got very involved with growth-it became their mantra,” she says. “But making certain that their core business was well served did not hit high on the radar. Board meetings were dominated by financial discussions, acquisition discussions, real estate, and building, with little to no discussion about clinical quality or issues going on at the hospital.”

This lack of attention to clinical operations did not go unnoticed. Physicians became concerned-so much so that one physician submitted a complaint to CMS, bringing the state survey office in. The physician’s fears turned out to be legitimate, and the organization received an immediate jeopardy finding.

Too little too late

CMS wanted an action plan on how the deficiencies it found would be addressed. Amazingly, the board did not even know about the immediate jeopardy finding, says Fenner. Instead, the CEO-that same leader who had led the charge toward acquisition and growth-delegated addressing the CMS finding to the chief nursing officer (CNO), who was an interim CNO at the time.

“She did her best,” says Fenner. But despite the CNO’s efforts, CMS came back in and found the facility still out of compliance.

“The second immediate jeopardy had a tight timeline on it,” says Fenner. “Their CEO chose to say, ‘You can’t do that to us.’ Well, they can! CMS is like the IRS-they have a lot of power. And this was a legitimate clinical concern.”

Despite this, the state government gave the facility another opportunity to save itself-the surveyors even chose to stay in the area over a weekend, coming back on Sunday night, to give the organization one more chance to clean up and comply.

It failed.

“At this point they received notice of decertification,” says Fenner, whose organization was brought in to help. “I wish they’d called us a week or two earlier.”

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Joint Commission deletes standards during third phase of EP review

On April 25, The Joint Commission announced it had completed the third phase of its Element of Performance (EP) review project. Phase three looked at standards from seven Joint Commission programs, deleting those deemed duplicative or have become standard operating procedure.

It should be noted that what was deleted varies based on each program. For example, an EP deleted for the hospital program might still exist for home care. Chapters affected include Environment of Care and Infection Prevention and Control.

Below are links to the various prepublication standards, which are effective July 1, 2017.