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Joint Commission to check for FDA powdered glove compliance

The Joint Commission surveyors will now check to see if hospitals are compliant with the Food and Drug Administration’s (FDA) ban on powdered medical gloves. The ban went into effect in January, with the administration citing the powder’s potential to cause severe airway and wound inflammation, granulomas, and post-surgical adhesions in the tissue between internal organs. Powdered latex gloves also carry the risk of allergic reaction in patients. The Joint Commission will now issue citations on the powdered glove ban under LD 04.01.01, element of performance 2.

“This ban is about protecting patients and healthcare professionals from a danger they might not even be aware of,” said Jeffrey Shuren, MD, director of FDA’s Center for Devices and Radiological Health, in a press release. “We take bans very seriously and only take this action when we feel it’s necessary to protect the public health.”

To learn more about the FDA’s decision, read our previous coverage on the ban.

Workplace violence prevention resources added to Sentinel Event Alert 45

The Joint Commission has updated Sentinel Event Alert, Issue 45: Preventing Violence in the Health Care Setting with new resources:

In related news, The American Society for Healthcare Risk Management (ASHRM) has released multiple toolkits on how to assess workplace violence risks in healthcare settings. The toolkits also provide guidance and checklists on what to do if violence breaks out and how to protect staff. The toolkits cover five main areas:

  • Staff-to-staff violence/harassment
  • Physician- or third-party professional-to-staff violence/harassment
  • Patient-to-staff violence
  • Visitor/family-to-staff violence
  • Stranger/nonemployee-to-staff violence

Read Briefings on Accreditation and Quality for more on workplace violence protection.

Joint Commission clarifies “observer” standards

The Joint Commission announced an update of its “observer” definition in its accreditation and certification manuals. The new definition is meant to clarify the roles of surveyors and reviewer management staff during on-site surveys and reviews.

The new definition can be found under Accreditation Participation Requirement APR.07.01.01 and Certification Participation Requirement (CPR) 10, and goes into effect on July 1, 2017.

According to the new definition, observers will only participate in the survey/review process if they notice a potential finding or observation that they think the surveyor, reviewer, or organization needs to know about. Field directors are not included in this new definition and are still allowed to take part in the survey process.

Joint Commission makes more revisions to EC, LS standards

The Joint Commission has announced additional revisions to its Environment of Care (EC) and Life Safety (LS) chapters. The revisions are meant to bring the accreditor in closer alignment with the National Fire Protection Association’s 2012 Life Safety Code® (LSC). The LSC was adopted by CMS and The Joint Commission last year. The revisions go into effect July 1, 2017 and apply to hospitals, critical access hospitals, ambulatory healthcare centers, home care, and nursing care centers.

NFPA to vote on healthcare codes this summer

At the National Fire Protection Association’s (NFPA) annual conference in June, members will be asked to vote on changes to NFPA 99 and NFPA 101. While CMS and various accreditors recently adopted and implemented the 2012 edition of the NFPA’s Life Safety Code®, the NPFA is currently working on changes to the 2018 edition. The American Society for Healthcare Engineering (ASHE) called to members who are part of the NFPA to take part in the voting process.

“ASHE has been working hard to align all of the various codes and standards to have less overlap, fewer gaps and fewer code conflicts,” wrote Chad Beebe, ASHE’s deputy executive director. “This work doesn’t happen over one code development cycle, however. Aligning the codes is a long process that occurs over several editions. Each code cycle is a chance for negotiations with code development committees to draw the boundary lines between codes to ensure that the codes don’t overlap, which is where most of the conflicts occur. To maintain these boundaries, continuous involvement in the development of the codes and standards is necessary.”

Last Chance: “How Parkland Health & Hospital System Successfully Implemented a Suicide Risk Screening Program Webinar”

Date: Tuesday, February 7

1:00-2:30 p.m. ESTHCPro Webcast Icon

Presented by:
Kimberly Roaten, PhD, CRC
Celeste Johnson, DNP, APRN, PMH CNS

Level of Program: Intermediate

Suicides were the third most common sentinel event of 2015. Universal screening is the best strategy to identify patients in general healthcare settings whose suicide risk would otherwise go undetected. This webinar will take a case study approach to bring to light proven methods to reduce patient suicide.

Join Parkland Health and Hospital System expert speakers Kimberly Roaten, PhD, CRC, and Celeste Johnson, DNP, APRN, PMH CNS, as they explain how Parkland became the first in the nation to establish a universal suicide screening program in all its departments. Parkland was recognized in Sentinel Event Alert 56 for making significant progress in suicide prevention. Roaten and Johnson will discuss processes for implementation, strategies to obtain support, universal screening data, and lessons learned from implementation.

At the conclusion of this program, participants will be able to:

  • Discuss the process for implementation of a hospitalwide suicide screening protocol
  • Describe strategies for obtaining nursing and physician stakeholder support for universal suicide screening
  • Describe the prevalence data collected from the first two years of a universal screening program
  • Apply lessons learned from the implementation of the program in a large hospital system

Sign up today! 

 

FAQs on Joint Commission antimicrobial stewardship standard

In the wake of a CMS ruling that will make antibiotic stewardship programs (ASP) mandatory, The Joint Commission recently announced that it will roll out a similar standard. Effective January 1, 2017, the new Medication Management standard 09.01.01 requires facilities to create an effective ASP. The standard applies to:

Syringe

To help facilities with the new requirements, The Joint Commission has compiled a set of FAQs on antimicrobial stewardship, which can be viewed here.

CMS extends eCQM reporting deadline

In a new blog post, CMS announced that it was extending its electronic clinical quality measure (eCQM) submissions to March 13, 2017 at 11:59 p.m. PST. This gives facilities and extra 13 days to get their submissions in on time.

The data being submitted is from the 2016 reporting period, which will impact facilities’ 2018 fiscal year (FY) payments. The deadline applies to hospitals and critical access hospitals enrolled in either the Hospital Inpatient Quality Reporting (IQR) program or the Medicare Electronic Health Record (EHR) Incentive program. CMS Logo

“CMS also intends to initiate the rulemaking process regarding modifications to the eCQM requirements established in the FY 2017 Inpatient Prospective Payment System (IPPS) final rule in response to concerns raised by stakeholders,” Kate Goodrich, MD, CMS chief medical officer, wrote. “In order to help reduce reporting burdens while supporting the long term goals of these programs, we intend to include proposals regarding the 2017 eCQM reporting requirements for the Hospital IQR and EHR Incentive Programs for eligible hospitals and critical access hospitals in the FY 2018 IPPS proposed rule that we anticipate to be published in the late spring of 2017.”

CMS says it will address stakeholder concerns with the FY 2018 IPPS proposed rule. In particular, they will look at
•    Challenges associated with hospitals transitioning to new EHR systems or products
•    Upgrading to EHR technology certified to the 2015 Edition
•    Modifying workflows
•    Addressing data element mapping
•    Time allotted for hospitals to implement eCQM specifications updates in 2017

The agency is also proposing to adjust the number of eCQMs required to be reported for 2017 as well as to shorten the eCQM reporting period.
“We believe that these efforts reflect the commitment of CMS to create a health information technology infrastructure that elevates patient-centered care, improves health outcomes, and supports the healthcare providers who care for patients,” she wrote. “We continuously strive to work in partnership with hospitals and the provider community to improve quality of care and health outcomes of patients, reduce cost, and increase access to care.”

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SAFER Matrix goes into effect, new tool available

Accredited organizations now receive a new SAFER Matrix Tool and a user guide, following their first survey with the new matrix. The SAFER Matrix was announced last July as a replacement for the old “Category A and C” method of evaluating safety issues. As of January 1, all accredited organizations now receive the SAFER matrix after their surveys.

The new tool can be used to filters out specific portions of the SAFER report, such as Requirements for Improvement, which then can be saved and sent to people within the facility. The guide shows users how to:

  • Use filters
  • Select specific survey or review events to view
  • Switch between different accreditation programs
  • Switch between accreditation and certification

The tool and guide can be found on Joint Commission Connect in the “Post-Survey” section of the “Survey Process” tab.

Feedback sought on Joint Commission Pain Assessment and Management program

The Joint Commission seeks feedback on the proposed requirements for Pain Assessment and Management for Hospitals. Comments will be accepted until February 20, 2017.
The accreditor hopes that by aligning its requirements with existing best practices, it will be able to better promote patient safety and quality of care.

The proposed requirements are available here to read.

After reading, interested parties can submit their feedback via:
•    Online survey
•    Online form
•    Traditional mail, sent to the address below:

The Joint Commission
Standards and Survey Methods
Hospital Pain Assessment and Management Field Review
One Renaissance Blvd.
Oakbrook Terrace, IL 60181