Archive for September, 2008

CMS grants DNV deemed status for accreditation of hospitals

Good News!! A new accrediting body joins The Joint Commission and the American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP) in accrediting healthcare organizations for participation in the Medicare and Medicaid programs. Det Norske Veritas Healthcare, Inc., (known as DNV) has been granted, deemed status by CMS, and presents as another approved accreditation alternative. DNV’s accreditation program is called the National Integrated Accreditation for Healthcare Organizations (NIAHO). [more]

Change in wording changes everything in performing the immediate reevaluation for anesthesia

In reviewing the 2009 Provision of Care chapter from TJC I stumbled across another change that (according to information obtained at Executive Briefings “isn’t a change”.) Under PC standard 03.01.03 EP 8 the “hospital” is required to reevaluate the patient immediately before administering sedation or anesthesia. Frankly, I don’t see how a building can assess a patient, but semantics aren’t everything. With this new wording, the anesthesia provider is clearly not required to be the individual conducting the immediate reevaluation. Which means the nurse can take the patient’s vital signs and conduct a brief assessment and document this appropriately as the immediate reassessment. While most organizations have imbedded the anesthesia provider’s immediate reassessment into their procedure forms, if your organization is having difficulty with compliance by your anesthesia providers, you may want to reconsider how the immediate assessment process really works in your facility and make changes as appropriate. Stay tunned, as we continue to drill down into the 2009 standards, there are bound to be more changes coming our way.

Universal Protocol

At the September 19, 2008 Executive Briefings hosted in Los Angeles, California, presented by The Joint Commission, Dr. Angood discussed the increased requirements for the Universal Protocol. Particular attention was paid to the 2009 requirement calling for the UP to be applied to all procedures that involved percutaneous puncture or insertion, opposed to the previous wording which essentially invoked the UP for procedures that placed the patient at risk. Dr. Angood cited with finality, that insertion of a urinary cathether would not call the UP into action (which has been a general understanding since the 2009 goals were published this summer), however, when asked if hospitals would be able to perform a risk assessment and “opt out” of the UP for minor procedures such as lumbar puncture, Dr. Angood stated this concept (anything involving percutaneous puncture/insertion versus “at risk” procedures) would be clarified in upcoming FAQs about the UP. Dr. Angood also stated that simple angiocatheter insertion for IV antibiotics would not call the UP into action, however currently almost every other type of invasive procedure may. There was information provided in handouts at the LA Executive Briefings that the UP would apply to “all invasive and surgical procedures with more than mnimal risk to patients,” which of course differs from the 2009 wording of when the requirements come into play. So, the healthcare public are to keep their collective eyes on the FAQs awaiting more definition from UP revision. Dr. Angood gave his committment to “make every attempt” to release FAQs for the NPSGs with the same frequency FAQs are addressed and released for other program standards. [more]

PPR Changes

As the Joint Commission continues to make the needed changes before 2009, 4th quarter PPR’s will be affected. The PPR tool will not be available on-line from December 1, 2008 to January 1, 2009. This will allow the Joint Commission time to “load” the new standards and EP’s.

As a result of these changes here is the new schedule:

• Organizations with PPR due dates from October 1, 2008 through December 31, 2008 are not required to submit a 2008 PPR.
• Organizations that wish to document Plans of Action for requirements for improvement (Full PPR or post-survey Option 2 PPR) must submit the 2008 PPR by Sunday, November 30, 2008 at 11? p.m. Central Time. [more]

Avoiding an RFI for Missing Crash Cart Checks

Some surveyors have recently discovered EC.6.20 (preventive maintenance) as a way of citing occasional missed crash cart checks. You see, surveyors don’t know what to do when they come across a crash cart logs with a missing entry or two. There is no standard that directly pertains to this issue (in other words, the Joint Commission does not require crash cart checks). The standards require the placement of emergency medications and equipment, but they do not specifically require that this equipment be checked … ever. Yet we all know (including surveyors) that these checks are very important. We’ve learned that having the complete and functional crash carts is essential. So we certainly don’t mind when the surveyors look for this. [more]

Update from Executive Briefings #10: 4Q 2008 PPR Optional

Because of software changes at the Joint Commission to accommodate the 2009 standards, PPR submittals that were due in the 4th quarter of this year will be optional rather than required, according to Pat Adamski at Executive Briefings. This may also extend to other periods, so please stay tuned with your Account Representative.

Update from Executive Briefings #9: More LSC Specialist; More EC Findings

It is difficult to draw conclusions from just one quarter’s data, however the addition of the Life Safety Code Specialist to some survey teams and doubling of their survey days on other surveys has significantly increased the frequency of EC findings. Interesting: double the surveyor time, double the number of findings. Hmmm!? I wonder what this says about thresholds?

Here’s the run down:

• Life Safety Code RFIs (EC.5.20): from 29% in 2007 to 45% in 1Q 2008 (50% increase)
• Testing of LSC Devices (EC.5.40): from 18% in 2007 to 30% in 1Q 2008 (67% increase)
• Emergency Generator Testing (EC.7.40): from 8% in 2007 to 16% in 1Q 2008 (100% increase)
• Medical Gas Systems (EC.7.50): from 6% in 2007 to 14% in 1Q 2008 (130% increase)

Update from Executive Briefings #8: RFI Trends

Pat Adamski reported the following “Problem Standards” from the results from surveys throughout 2007 and the surveys from the first quarter in 2008

EC.5.20: Life Safety Code (LSC). 2007 RFI Rate: 29%; 2008 RFI Rate: 45%. The increasing rate of LSC RFIs is attributed to additions to the number of surveys including a Life Safety Code specialist.

IM.6.50. Verbal Orders Not Authenticated. 2007 RFI Rate: 25%; 2008 RFI Rate: 35%. At present, a single unsigned telephone order is an RFI (Category A). The good news is that this issue will become a Category C element of performance in 2009 … at least a little help. [more]

TJC Releases Top Standards Compliance Issues for 2007

In the September 2008 issue of Perspectives TJC released the top standards compliance issues for all accreditation programs. A quick review of the hosptial program, finds the following standards to be the most problematic for hospitals:

MM.2.20: Medication Storage

NPSG 2C: Critical tests/values measurement, and as appropriate improving reporting timeliness

EC.5.20: Life safety code compliance [more]

Educating Your Medical Staff About Notifying TJC With Safety or Quality of Care Concerns

2008 APR standard 17 requires hospitals to educate staff that they may notify the Joint Commission with any quality of care or patient safety concerns, without fear of punitive or disciplinary action by the hospital. Information disseminated in TJC’s Perspectives, indicated this requirement also pertained to the medical staff; which meant members of the medical staff were also required to receive education on this topic. While many healthcare organizations receive and review Perspectives, not all individuals “read the fine print”, which has resulted in a number of hospitals failing to get this message out to the general medical staff. [more]