The ECRI Institute has published its 2017 list of top patient safety hazards and concerns. The Institute publishes the list to highlight and educate healthcare workers on various dangers affecting patients. The list includes guidance on how to effectively respond to these concerns, along with implementing priorities and corrective action plans. This year the list includes:
1. Information Management in electronic health records (EHR)
2. Unrecognized patient deterioration (UPD)
3. Implementation and use of clinical decision support
4. Test result reporting and follow-up
5. Antimicrobial stewardship
6. Patient identification
7. Opioid administration and monitoring in acute care
8. Behavioral health issues in non-behavioral-health settings
9. Management of new oral anticoagulants
10. Inadequate organization systems or processes to improve safety and quality
“The 10 patient safety concerns listed in our report are very real,” Catherine Pusey, RN, ECRI associate director told HealthLeaders. “They are causing harm (often serious harm) to real people.”
The proper use and timely access to EHRs for patient information management was the main concern this year, Lorraine B. Possanza, program director for ECRI’s Partnership for Health IT Patient Safety said in a press release. She says the vast storehouses of patient data now available to physicians have created new challenges.
“The object is still for people to have the information that they need to make the best clinical decision,” she wrote. “Health information needs to be clear, accurate, up-to-date, readily available, and easily accessible.”
The second concern, UPD, has recently been the subject of increased training, education, better clinical protocols, and public awareness campaigns. However, despite faster recognition and response, UPD is still a major concern.
“People have seen how well the campaigns have worked for stroke and STEMI and how much they’ve improved outcomes,” Patricia N. Neumann, RN, ECRI senior patient safety analyst and consultant told HealthLeaders. “What if those same principles could be applied to other conditions that require fast recognition and management? We could have a big impact on improving outcomes.”
Read more at HealthLeaders Media
The Joint Commission has eliminated its post-survey category of “Contingent Accreditation.” Now organizations can only receive one of four decisions: Accredited, Accredited with Follow-up Survey, Preliminary Denial of Accreditation, or Denial of Accreditation.
Accreditation— Given to a facility that’s compliant with all applicable standards or has successfully addressed all Requirements for Improvement (RFI). Once the Evidence of Standards Compliance (ESC) is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.
Accreditation with follow-up survey— Given to a facility that isn’t in compliance with specific standards that require a follow-up survey within 30 days to six months. Also requires that problem areas listed in an ESC submission are corrected. Once the ESC is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.
Preliminary denial of accreditation— Given to a facility when there’s evidence of one or more of the following:
• An immediate threat to health or safety to patients or the public
• Falsified documents or misrepresented information was given to surveyors
• The facility is missing a required license or certification
• The facility is significantly out of compliance with Joint Commission standards
Additional rules for receiving a “Preliminary Denial of Accreditation” ranking have been listed in the “important updates” section of Joint Commission Connect and are as follows:
• Failing to fix all Requirements for Improvement (RFI) after two opportunities to submit ESCs have passed
• Failing a second Medicare Deficiency Survey for not meeting a Condition of Participation or a Condition Level Deficiency
• Evidence reveals patients have been put in jeopardy due to potential fraud or abuse committed by the organization
A Preliminary Denial of Accreditation (PDA 02) decision is made; organizations are now expected to submit a Plan of Correction (POC) within 10 business days of the final report’s posting. After which, there’ll be a survey within two months to validate the implementation of the POC. This will be done in lieu of submitting ESC within 60 days.
For PDAs, facilities can appeal The Joint Commission to review this decision.
Denial of accreditation - A facility is completely denied accreditation. This happens when a facility:
• Doesn’t to pay its survey or annual fees
• Refuses to let The Joint Commission conduct a survey
• Fails to address the conditions of their Accreditation with Follow-up Survey status
• Fails to submit an ESC
At this point, there are no more appeals or reviews that a facility can use to stay accredited.
Finally, The Joint Commission’s governance structure has changed. Now, decisions on accreditation matters will be made by an executive team rather than an Accreditation Committee. The executive team is now in charge of making accreditation decisions, considering survey reports, follow-up activities, staff recommendations, and any unusual problems raised by the organization seeking accreditation.
Check out Briefings on Accreditation and Quality to learn more about the importance of avoiding denial of accreditation.
Last Chance: “How Parkland Health & Hospital System Successfully Implemented a Suicide Risk Screening Program Webinar”
Date: Tuesday, February 7
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
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 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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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.
Earlier this month, the American Society of Health-System Pharmacists (ASHP) released a new set of nationally recognized drug diversion prevention guidelines. The purpose of the guidance is to help healthcare facilities create effective strategies to prevent the theft and misuse of medications and controlled substances.
“Diversion of controlled substances by healthcare workers remains a serious problem that increases the potential for serious patient safety issues, causes harm to the diverter and elevates the liability risk to healthcare organizations,” said David Chen, BSPharm, MBA, senior director of the ASHP Section of Pharmacy Practice Managers, in a press release. “These guidelines give pharmacists tools to not only improve controlled substances management, but also to play a prominent role in systemwide diversion prevention efforts at their practice sites.”
The 2015 National Drug Threat Assessment found that controlled prescription drugs are abused more often than cocaine, methamphetamine, heroin, Ecstasy, and PCP combined. And there have been cases of healthcare workers potentially infecting patients by using needles filled with diverted drugs and putting them back into circulation.
The guidelines can be applied to a number of healthcare settings and is based off best practices and recommendations from the Drug Enforcement Agency, state hospital associations, and scientific literature. You can read the guidelines in full here , along with the ASHP announcement.
Earlier this year, The Joint Commission updated its National Patient Safety Goal (NPSG) on catheter-associated urinary tract infections (CAUTI) for hospitals and critical access hospitals. It also created a new CAUTI NPSG for nursing care centers.
“An estimated 1 to 3 million healthcare-associated infections strike nursing home residents annually, and many of these are infections related to urinary catheters,” wrote David Baker, MD, MPH, FACP, Joint Commission executive vice president, in a blog post. “CAUTIs can lead to serious complications and hospitalizations. And, the rate of these infections is even higher for hospital patients. This is why The Joint Commission felt it was important to implement its new National Patient Safety Goal for nursing care centers and an updated goal for hospitals and critical access hospitals to reflect the latest scientific evidence.”
Among the new changes are requirements to:
• Educate staff on how to correctly use and insert indwelling catheters.
• Educate patients and family on CAUTI risks and prevention
• Use evidence-based guidelines to write catheter use policies.
• Follow written procedures based on established evidence-based guidelines for inserting and maintaining an indwelling urinary catheter.
• Maintain an up-to-date record of catheter use; who has one inserted, when was it implanted, etc.
All the changes go into effect on January 1, 2017 and are meant to improve staff training, educate patients, and update policies with evidence-based practices. In addition, the Department of Health and Human Services announced that it wants to see a 50% reduction in CAUTI by 2020.
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Date: Tuesday, January, 24, 2017 1:00–2:30 p.m. EST
Summary: After much anticipation, CMS has approved its own emergency preparedness rules separate from The Joint Commission and other accreditation agencies. Hospitals and healthcare organizations now have until November 15, 2017 to enact the changes and maintain compliance.
Join expert speakers Marge McFarlane, PhD, MT(ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, and Thomas Huser, MS, CHSP, CHEP, as they guide you through the changes. They will help you identify resources for implementation, provide helpful tips, outline the special focus on fire drills for critical access hospitals, and list the optional and required CMS emergency management standard categories.
- The list of required and optional categories of the CMS emergency management regulations
- The tips, resources, and potential challenges to implementing an emergency prep plan
- How to conduct fire drills for critical access hospitals
Registration: To order the webcast on demand, call HCPro customer service at 800-650-6787 or visit hcmarketplace.com
The Joint Commission just published its 2017 Survey Activity Guide, with information on how to prepare for your next survey. It also contains details on policy changes in 2017, such as the new antimicrobial stewardship program standard for hospitals, critical access hospitals, and nursing homes.
Efforts to improve patient safety are paying off, according to a new Health and Human Services (HHS) department report. Between 2010 and 2015, increased patient safety efforts have:
• prevented 3.1 million hospital-acquired conditions (HAC), a 21% decline
• saved 125,000 lives
• saved $28 billion in healthcare costs
In the announcement, HHS Secretary Sylvia Burwell cited the Affordable Care Act as a major cause of the improvement in patient safety.
“The Affordable Care Act gave us tools to build a better healthcare system that protects patients, improves quality, and makes the most of our healthcare dollars and those tools are generating results,” said HHS Secretary Sylvia M. Burwell. “Today’s report shows us hundreds of thousands of Americans have been spared from deadly hospital-acquired conditions, resulting in thousands of lives saved and billions of dollars saved.”
There are other federal patient safety efforts mentioned in the report as aiding in patient safety improvement. Among those cited were the Partnership for Patients initiative, a public-private partnership launched in 2011 though CMS Innovation to target a specific HACs. CMS also worked with hospital networks and aligned payment incentives to improve focus on making care safer.
“These achievements demonstrate the commitment across many public and [more]