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Joint Commission posts prepublication standards online

The Joint Commission just posted prepublication standards for disease-specific care critical access hospitals, nursing care centers, laboratories and point-of-care testing. The standards have not been officially published in print or added to the Joint Commission’s collection of e-manuals.

Joint Commission puts antimicrobial stewardship standard up for field review

The Joint Commission seeks comments from healthcare facilities about a proposed standard that would require organizations to establish antimicrobial stewardship programs. The purpose of the new standard is to decrease the use of antimicrobials whenever possible to prevent the creation of drug-resistant strains of disease.

The deadline to provide feedback via comments or completing a survey is December 30.

Read the proposed standard and submit your comments here.

December webcast to highlight survey hot spots for 2016

What are the CMS and Joint Commission hot spots for 2016? Join Bud Pate, REHS, and Lisa Eddy, RN, CPHQ, on Wednesday, December 16 at 1 p.m. ET as they examine current survey focuses and point out where CMS and The Joint Commission will concentrate their efforts during your next survey.

In just 90 minutes, find out how to prepare for your next accreditation survey and comply with the most troublesome CMS and Joint Commission requirements. Pate and Eddy will provide strategies for preparing your staff for survey and give you valuable tips about what surveyors will expect when they arrive at your facility.

For more information and to register for the webcast, call HCPro customer service at 800-650-6787 or visit the HCPro Marketplace.

Joint Commission releases list of top performing hospitals

The Joint Commission just released its annual report on improving quality and safety in 3,300 American hospitals. The report recognizes 1,043 hospitals as the best facilities in the “Top Performer on Key Quality Measures” program. Within that group, 23 hospitals collected and reported data on seven or more core measure sets in 2014 and were named top performers in all of those areas.

The Joint Commission shows its results as “composites,” or the sum of all the accountability measures and steps taken to meet certain measure sets. This is the first year the accreditor had data on its new tobacco treatment and substance use measure sets, reporting tobacco measure compliance at 75.8% and substance use at 58.2%. The report found that the most improved area was perinatal care, which jumped from a composite score of 74.1% in 2013 to 96.3% in 2014.

However, only 80.3% of accredited hospitals that received a total composite score greater than 95% this year. This marks a 0.8% decrease from the prior year, which the report claims is due to hospitals adjusting to the new tobacco treatment and substance use measure sets.

Read the full report here.

Opinions are like…

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, recently wrote an excellent article about the changing accreditation regulations and I wanted to share it with you.

Over time, I’ve developed certain thoughts relative to the management of the survey process, one of which relates to the ever-changing (maybe evolution, maybe mutation) regulatory survey process and I think it boils down to a couple of basic expectation (at least on my part):

  • You always run the risk of having a surveyor disagree with any (and every) decision you’ve ever made relative to the operational management of risk, particularly as a function of standards-based compliance.
  • Your (or indeed any) Authority Having Jurisdiction always reserves the right to disagree with anything they, or anyone else, has ever told you was “okay” to put into place (and this includes plan review for new or renovated spaces)

Recent survey experiences are littered with the remains of practices and conditions that were never cited in the past, but in the latest go-round have become representative of a substandard approach to managing whatever risk might be in question. For example, just consider how the survey of the surgical environment has changed (and changed very rapidly, if you ask me) from what was typically a fairly non-impactful experience (there were any number of instances in which the Life Safety surveyor didn’t even dress out to go into the OR proper) to the area generating the top three most frequently cited standards during The Joint Commission surveys in 2014. That, my friends, is a whole lot of schwing in the survey process.

Continue reading the article at Mac’s Safety Space.

Editor’s Choice: Live accreditation training with Jean Clark

When: June 1-3, 2015

Where: Boston area

Are you in the New England Area? Jean Clark, RHIA, CSHA, is leading a two-and-a-half day boot camp in June and if you haven’t attended one of our boot camps yet, you won’t want to miss this experience.

The boot camp provides survey coordinators and accreditation professionals with best practices for survey prep, training, and overall management, focusing on CMS and Joint Commission requirements.

At the end of the boot camp, you’ll have learned:

  • Where to find resources to assist your survey prep and accreditation knowledge
  • How to interpret accreditation standards and regulations and measure your organization’s compliance
  • How to identify organizational weaknesses so you can fix them before accreditors arrive and therefore improve your survey results

I will be attending this boot camp and I’m looking forward to Jean’s practical and insightful teaching as well as meeting some of you!

Please feel free to send me an email if you would like to connect during the boot camp.

Sign up for the boot camp here.

New name, new direction

Welcome to Accreditation & Quality Advisor, HCPro’s relaunched healthcare accreditation-centric blog! This site previously hosted the AHAP Blog (the archives are still available to read), which ran through November 2013. Going forward, we’ll be providing you three or more posts every week about issues of interest to accreditation professionals such as CMS and The Joint Commission requirements, patient safety and quality initiatives, infection control, and much more. We’ll also highlight HCPro products and free offerings for accreditation professionals. We hope you’ll find the blog useful, return often, and comment on the posts to make your opinions heard.