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Featured Webcast- “CMS Surveys: Preparing With Confidence”

When: 1:00–2:30 p.m. EST, Wednesday, February 24, 2016

What: CMS has increased the frequency of its hospital surveys, and many healthcare facilities are finding themselves unprepared for the bump in federal scrutiny. This webcast will arm attendees with the preparatory steps and strategies needed to survive a CMS survey.  Attendees will also examine a real-life case study for specific examples of survey citations and how to respond to them. 

Why: This webinar will teach you how to:

  • Utilize a compliance plan to develop an organization-specific, comprehensive approach to accreditation and compliance readiness
  • Identify at least three sources of information to review changes in the Conditions of Participation/survey process
  • Implement a gap analysis of your organization’s compliance readiness

Who: Victoria Fennel, PhD, RN-BC, CPHQ, is the director of accreditation and clinical compliance for Compass Clinical Consulting and has 20 years of healthcare leadership experience. She has spent the majority of her career in nursing leadership roles and brings expertise in evidence-based practice, nursing education, quality management, performance improvement, accreditation, risk management, patient safety, and patient-centered care.

Julie Campbell, MHA, BSN, NE-BC, HACP, is the Baylor Scott & White Health North Texas Division vice president and has than 25 years of nursing leadership experience. Campbell assists in survey preparation, development of corporate policies and procedures, communications on revisions to regulations/standards, and recommendations of regulatory changes to various system councils to maintain continuous readiness. 

For more details on how to join the webcast, please visit our website.  

 

 

Deadline for December webcast fast approaching; Learning about survey hot spots for 2016

There’s still time to join the December webcast on 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.

CMS seeks feedback on new survey for long-term, acute-care hospitals

CMS is asking Medicare patients or their family members to help them develop a new patient-satisfaction survey of long-term, acute-care facilities. The comments will help CMS decide what sorts of information the survey will need to collect. Some of the suggested topics areas include:

• Communication with providers
• Mechanical ventilation
• Therapy services
• Wound care
• Pain management/control or non-pain symptom management
• Rehabilitation services
• Medical and nursing care
• Interdisciplinary team goal setting and care planning
• Family training
• Discharge planning

The survey will also be used in Medicare’s quality reporting program, meaning facilities that fail to deliver data could get a 2% reduction in their payment updates. CMS is accepting comments until 5 p.m. on Jan. 19.

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.

New name for Briefings on The Joint Commission

Briefings on The Joint Commission has a new name: Briefings on Accreditation and Quality!

For the last few years, in addition to covering the latest Joint Commission happenings, we’ve also included a broad focus on CMS compliance and quality improvement. We think our new name better reflects the quality content we strive to bring you each month. You’ll still be able to access prior issues of Briefings on The Joint Commission on our website.

The November issue should be in your inbox. You can view it here and if you haven’t had a chance to subscribe to the newsletter, click here for more information.

We’re excited about this change and hope you will be too. If there are any topics you would like to see covered in upcoming editions of Briefings on Accreditation and Quality, please email me at mclarke@hcpro.com.

 

CMS announces Physician Quality Reporting Programs Strategic Vision

When CMS shared the findings of the 2015 Physician Quality Reporting System (PQRS) payment system, they also released the publication of the Physician Quality Reporting Programs Strategic Vision, or “Strategic Vision”.

The Strategic Vision is part of a long-term quality measurement plan for healthcare providers and public reporting programs and how those can be enhanced to support better decision-making from physicians, consumers, and everyone involved in healthcare.

For more information about the plan, click here.

CMS updates eCQMs for 2016 reporting

Last Friday, CMS posted the annual update for the 2014 electronic clinic quality measure (eCQMs) for eligible hospitals and professionals. Providers should use these measures to report 2016 quality data for CMS reporting programs, including the Physician Quality Reporting System (PQRS), Inpatient Quality Reporting Program (IQR), and the EHR Incentive Programs.

CMS updated 29 measures for eligible hospitals and 64 measures for eligible professionals.

Read the updated measures here.

CMS releases final hospital/CAH CoPs

Last week, the Centers for Medicare and Medicaid Services (CMS) posted the final rule reforming the Hospital/CAH CoPs. This rule is available on display copy only and will publish officially to the Federal Register on May 16th.  The DC office is in the process of completing a thorough review of the final rule and will pull a team together to discuss the provisions, and will provide a comparative analysis of the final provisions to the comments that Joint Commission submitted.

A quick review of the final rule can be found here.

HHS encourages equal visitation and representation rights

The Department of Health and Human Services (HHS) issued a press release this week to give added support to The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COP) rules released in November of last year giving patients the right to choose their own visitors during a hospital stay.

The guidance given by the HHS emphasizes that hospitals should respect patients’ wishes concerning their representatives (whether expressed in writing, orally, or through other evidence unless prohibited by state law) in an effort to make it easier for family members, including a same-sex domestic partner, to make informed care decisions for loved ones who are incapacitated.

The CMS also sent a letter this week to State Survey Agencies (SSAs), highlighting the equal visitation and representation rights requirements and directing SSAs to be aware of the guidance when surveying for hospitals’ compliance with CoPs.

Read the full press release here.

Latest Sentinel Event Alert:Radiation risks of diagnostic imaging

The Joint Commission released its latest Sentinel Event Alert this morning highlighting the need for healthcare facilities and staff to maintain radiation doses as low as possible during diagnostic imaging in order to decrease exposure to repeat doses. The Alert asks healthcare organizations to address contributing factors to eliminate avoidable exposure by weighing the medical necessity of a given level of radiation against the risks.

According to the Alert, the US population’s total radiation exposure has nearly doubled over the past two decades, and  studies have estimated that 29,000 future cancers and 14,500 future deaths could develop due to radiation from the 72 million CT scans performed in the US in 2007.

In response, the Centers for Medicare & Medicaid Services (CMS) will require accreditation of all facilities providing advanced imaging services (CT scans, MRI, PET, nuclear medicine) including non-hospital, freestanding settings beginning January 1, 2012. The state of California is also requiring facilities that furnish CT X-ray services to become accredited by July 1, 2013.

The Joint Commission gives some suggested actions leaders can take to raise awareness among staff and patients of the risk associated with aggregate radiation doses and provide proper testing and dosage through effective processes, safe technology, and a culture of safety.

Click here to download the Sentinel Event Alert and the full list of recommendations.