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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.

Transparency and Termination Notices; CMS proposes changes for Accreditation Orgs.

Early this April, CMS sent out a memo with big proposals for accreditation. If passed, the proposed rule would require accrediting organizations (AO) to make their survey reports publicly available and publish termination notices somewhere other than in local newspapers.

Currently, AOs like The Joint Commission and DNV aren’t required to make their survey reports or plans of corrections available to the public. Under the proposed rule, AOs would have to post these on their websites. CMS Logo

The agency does acknowledge that this information is already available on CMS regional office and state agency websites. However, the new rule is intended to make this information easier for patients to find.

“Access to survey reports and PoCs will enable health care consumers, in addition to Medicare beneficiaries, to make a more informed decision regarding where to receive health care thus encouraging health care providers to improve the quality of care and services they provide,” the memo states.

That interest in transparency leads into the second half of the proposed rule on termination notices. Previously, when an ambulatory surgical center, federally qualified health center, rural health clinic, or organ procurement organization receives a Medicare termination notice, it has to be published in a local newspaper. Acknowledging approximately 23% of the general public continues to read print newspapers, CMS has come up with a list of additional posting options.

If you want to read and comment on the proposed rule, you can find a copy of the memo and commenting instructions here. CMS will accept comments until June 13, 2017.

Throwback Thursday: Medicine from afar

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! 

How one critical access hospital turned to telemedicine to better serve its community

After reading this article, you will be able to:

  • Describe the needs a telemedicine program meets at a ­rural or remote facility
  • Identify surmountable barriers to implementation for a telemedicine program using robotic instrumentation
  • Identify the types of programs or services a telemedicine link can help a remote facility provide
  • Describe the financial benefits, both to the organization and to patients, that come with having a strong telemedicine program in place
  • Discuss credentialing challenges that an organization ­implementing a telemedicine program might face

Tucked away on the far side of mountain passes in northeast Oregon, the 25-bed critical access Grande Ronde Hospital in La Grande provides much-­needed care for a populace that can be cut off from larger facilities by a single snowstorm. The hospital provides all that it can for the local population, but, as with every critical access facility, there are inherent limits to the services that can be provided on-site. Certain specialties and medical services simply do not have the demand to draw full-time physicians or other professionals to the area.Middle-aged man measures his blood pressure in front of virtual doctor. In the meantime, telemedicine physician is carefully looking at his brain x ray picture in the monitor.

Grande Ronde has, however, found a high-tech solution to this issue-one that ensures its patient population can receive services locally rather than traveling hundreds of miles, as might have been necessary in the past.

“We were asked by Saint Alphonsus Hospital in Boise to take part in a grant program,” explains Doug Romer, the hospital’s executive director of patient care services. “Their outreach director got in touch with us and said, ‘I have these robots through a grant. Would you like to try providing telemedicine services?’ “

At the time, Grande Ronde did not have a telemedicine program and was interested in taking part in the process. And so its robot, a nearly human-height, mobile machine with a monitor where the “face” would be, ­arrived at the facility.

The program is what is known as a hub-and-spoke model-the tertiary hospital, in this case Saint ­Alphonsus, is the hub, and the rural facilities are the spokes. This model has evolved for Grande Ronde and is now known as a remote presence healthcare network. The network connects Grande Ronde with four states and five cities for specialty healthcare. For example, patients in the Grande Ronde ICU receive telemedicine services from St. Louis.

“The physicians log in, can see our electronic medical records, review images, review labs, review vital signs, and they will come in and visit patients face-to-face [via the robot’s camera and monitor],” explains Romer. “They are able to assist and direct the care of patients throughout the day and through the night when our nurses have questions. They will call ICU doctors in St. Louis and they will make decisions or change therapies as needed.”



CMS releases new information on emergency preparedness requirement

CMS has issued new information on the training and testing requirements for its Emergency Preparedness final rule. The rule went into effect last year, and all applicable facilities must be in full compliance with the rules by November 15, 2017. CMS Logo

“In order to meet these requirements, we strongly encourage providers and suppliers to seek out and to participate in a full-scale, community-based exercise with their local and/or state emergency agencies and health care coalitions and to have completed a tabletop exercise by the implementation date,” the agency wrote. “We realize that some providers and suppliers are waiting for the release of the interpretive guidance to begin planning these exercises, but that is not necessary nor is it advised. Providers and suppliers that are found to have not completed these exercises, or any other requirements of the Final Rule upon their survey, will be cited for non-compliance.”

The rule requires healthcare facilities to meet the following four standards:

1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.

2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.

3. Communication plan: Develop and maintain a communication plan that complies with both federal and state law. Patient care must be well coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency systems.

4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.

Facilities unable to complete a full-scale community exercise by the deadline will have to finish an individual facility-based exercise and give proof that they why the full-scale exercise couldn’t be done. For those having trouble meeting the new rule, CMS has provided related resources. These include:

•    checklists
•    links to emergency preparedness agencies
•    planning templates
•    a state-by-state listing of healthcare coalition

@HCProAccred; bringing you the news

Hi everyone,

Yesterday we launched the HCPro Accreditation Twitter account to help you stay ahead of the quality and accreditation game.

Please take a moment to find and follow @HCProAccred on Twitter and receive:

  • Up-to-the minute news
  • Educational materialsHCPRo logo small
  • Details about upcoming events and webinars
  • Free Briefings on Accreditation and Quality  articles 
  • User polls on hot topics
  • And much more!


Thanks and have a great spring!

Brian W.

Joint Commission FAQs on H&P and titration orders

The Joint Commission has released new FAQs regarding the new updates to history and physical (H&P) updates and titration orders. The FAQs apply to hospitals, hospital clinics, and critical access hospitals.

The FAQs cover questions such as:

 When is an H&P update required?

What specific elements are required for titration orders? And what other safety and quality factors should be considered?

What are the requirements for updating an H&P after a procedure requiring anesthesia is performed after admission?

Throwback Thursday: Perfecting infection control on everyday items

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:

  • Identify everyday items that may require additional thought when it comes to infection control procedures
  • Describe who should be involved when developing policies for cleaning everyday items in the patient room
  • Discuss the development process of disinfection policies for certain challenging items
  • Describe leadership’s role in building an effective policy for patient room equipment cleaning routines

Think back to your last visit to a hospital as a patient or family member. Every patient care area has recognizable, ubiquitous items, such as automated blood pressure pumps, compression pumps, and IV pumps. But how do you know if those items were cleaned and/or disinfected? Were they used with the last patient, or have they sat dormant for weeks? Such items are easy to overlook, but in terms of patient safety and infection control, they need to be addressed in every facility.

One organization, St. Joseph’s Healthcare System-which includes St. Joseph’s Regional Medical Center in Paterson and St. Joseph’s Wayne Hospital in Wayne, N.J.-has implemented a method for cleaning these everyday items and identifying them as clean without adding an additional burden to its staff.

“As you know, in healthcare it can be challenging to change processes,” says Anne Marie Pizzi, M.Ed., RN, HACP, TeamSTEPPS trainer, Six Sigma Green Belt, and performance improvement coordinator with St. Joseph’s. “This began as a work in progress three or four years ago as we were struggling with preventing infection control issues and trying to find a way to make life easier for staff to clearly identify items that were already clean, or that needed to be cleaned.”

So the organization-a regional tertiary medical center and an acute care community hospital-brought together all the key departments, including infection prevention and control, nursing, central sterilization processing, and environmental services, to work collaboratively to improve the process.

“In the beginning, the problem boiled down to a real estate issue,” says Pizzi. “The hardest thing for us to decide when we talked about the equipment was, whose job is it to clean it?”

In addition, the team looked at what type of equipment was involved, how frequently it needed to be cleaned, and what kind of cleaning was necessary.

“Anything requiring more than low-level disinfection is not left to the staff on the unit,” says Pizzi. “So there were specific pieces of equipment that had to go to central supply or to individual departments where staff are trained to clean and care for that equipment.”

The equipment that environmental services or the staff on the units will typically clean include automated blood pressure pumps, Accu-Chek® meters­, pulse oximeters, and IV pumps.

“You may believe that you have designed a solid process when discussing it in a meeting, but when it is rolled out to the staff, change can be a challenge,” says Pizzi. “So it was really important we talked to the staff to determine the processes they were using and the possible solutions they would suggest.”

 [Continued –>]


NQF recommends reduction of quality metrics

Cut Red RibbonThis March the federal government received an unusual suggestion from the National Quality Forum’s (NQF) Measure Applications Partnership (MAP). In MAP’s 2017 guidance to the Department of Health and Human Services (HHS),the organization recommended eliminating around 51 out of 240 of all federal quality metrics used to determine payment in seven federal healthcare programs. This is meant to make the requirements for providers more efficient and streamlined.

MAP’s job is to review the quality measures put out by NQF each year. however, it’s CMS’s job to decide which of those measures to use.

“We want to make sure we can take away measures that are adding burden but not value,” said Helen Burstin, MD, MPH, FACP, NQF’s chief scientific officer, in a call with reporters. “This is really just the start.”

Many in the healthcare field state that the 634 quality measures applicable to federal healthcare programs is putting an undue burden on providers. However, as the industry is switching between payments based on quality rather than volume, the need for quality metrics is apparent. MAP aims to work towards both ends by culling measures that are redundant or pointless.

The measures that MAP recommends eliminating come from several programs, such as the Prospective Payment System—Exempt Cancer Hospital Quality Reporting Program, the Ambulatory Surgery Center Quality Reporting Program, the Inpatient Psychiatric Facility Quality Reporting Program, and the Home Health Quality Reporting Program. It also recommends eliminating:

•    Four out of 18 measures used in the End-Stage Renal Disease Quality Incentive Program
•    13 out of 29 used in the Outpatient Quality Reporting Program
•    Six out of 62 used in the Inpatient Quality Reporting Program

AMA: Surprise surveys improve mortality rates

A new study published in the Journal of the American Medical Association found that patients are less likely to die if they are treated on the same day as a surprise Joint Commission survey. During a survey week, patients had a 1.5% better chance of survival within 30 days of admissions, as compared those treated three weeks before or after the survey. At teaching hospitals, the presence of surveyors caused a 5.9% decrease in fatalities.

Researchers suspect that when they know they’re being watched, physicians work extra hard to provide quality care and follow standards.

“This study highlights that there is potential for us to learn what is going on during those weeks that is associated with better patient outcomes,” Vineet Arora, a researcher at University of Chicago Medicine who wasn’t involved in the study, told Reuters. “The question is whether it is due to a concerted effort on the part of the hospitals to follow safe practices or whether there is something else going on.”

The study was conducted by Harvard Medical School and Harvard T.H. Chan School of Public Health researchers. They analyzed Medicare admissions data from 1,984 surveyed hospitals, with more than 1,462,000 patients admitted in the three weeks before and after a survey and 245,000 during.

Joint Commission seeks comments on proposed suicide prevention requirements

The Joint Commission is seeking comments on its proposed requirements on National Patient Safety Goal (NPSG) 15.01.01 for suicide prevention in healthcare facilities. Specifically, it’s seeking feedback the revisions for hospitalcritical access hospital, and behavioral health accreditation programs. The comment period ends on May 1.