Author Archive for Bud Pate
Mr. Pate serves as Vice President for Content and Development at The Greeley Company. He is a nationally recognized expert in patient flow and in hospital and health system regulation and accreditation with over 25 years experience in high profile problem solving.
Hold Off on Credentialing Changes!!
There are two versions of the 2009 CMS changes made by the Joint Commission: the version that was emailed on January 6 and the version currently posted at the Joint Commission web site. (It took us a very long time to find the posted version: it’s NOT under standards, it’s under “What’s New.” Go figure!)
The bottom line is that the changes to MS.13.01.01 that were in the January 6 email are not on the web. Is the change to MS.13.01.01 in? Is it out? Is it under discussion? We’ve asked the Joint Commission but they have not yet responded.
In the meantime: do not make any changes to the way you credential or privilege Nighthawk and other remote diagnostic-only practitioners! Wait for clarity from Oakbrook Terrace.
A Handful of New FAQs
Over the last month or so the Joint Commission posted a handful of new or revised frequently-asked questions or FAQs to help clarify expectations of the standards. You can find these under the “Standards” then “Standards FAQs” tab at the Joint Commission website (http://www.jointcommission.org). The following is a synopsis of the changes. (We encourage you to read the official FAQs for yourselves.) Overall, we found these limited revisions to be quite helpful and on target. [more]
165 New Requirements … So What?
We’ve completed an analysis of the January 2009 additions to the accreditation manual. There are 165 brand new (or revised) elements of performance. A significant percentage of these requirements (60 or 36%) may have an impact on current practice at your hospital. We’ll be blogging about each new requirement we believe has the potential for significant impact. In the meantime, we’ve attached an analysis of these new EPs for your review.
Will the Joint Commission Score the New Requirements Now?
On January 6, 2009 the Joint Commission released 165 brand new elements of performance intended to bring existing Joint Commission standards in line with the Medicare Conditions of Participation. In the February, 2009 issue of Perspectives, the Joint Commission said that the new requirements were “schedule for July 1, 2009 implementation but are subject to change pending further Joint Commission discussions with CMS.”
We wonder what these discussions have yielded, because some of these new requirements were already being cited on surveys taking place in January, 2009!
Reconsider Dating Open Multidose Vials
Over my 30 year carreer I’ve reviewed medication storage locations in about 500 hospitals. Guess what I’ve learned? It doesn’t work (except that it gives surveyors a “for sure” citation). I can remember only one hospital that succeeded in putting an outdating process in place for open multi-dose vials — it took tons of leverage from leadership and only lasted until the surveyor came back to clear them. So, what are the options? [more]
CMS Pushes for More Joint Commission Changes
The Joint Commission must for the first time meet CMS expectations to maintain its Medicare “deeming authority.” This has triggered significant changes, since the current Joint Commission standards and survey processes do not match CMS standards and survey processes. The first wave of change was the 300 or so new elements of performance that became effective on January 1, 2009. These changes were done “on the fly” (without the typical pause for comments from the field) and bring the Joint Commission standards in better (but not perfect) alignment with the Medicare Conditions of Participation. [more]
Is Staffing Effectiveness on its Way Out?
Apparently the Joint Commission is close to abandoning the requirement for staffing effectiveness measures. Ann Scott Blouin, the Joint Commission’s new Executive Vice President Division of Accreditation and Certification Operations, indicated that removing these standards is one of her high priorities. We have two questions:
1. What has taken JC so long? The staffing effectiveness requirement has been around for more than a decade. It has proven itself to be valueless over and over again. We’ve heard it was on the way out five years ago. We hope that this time it’s for real.
2. What about other standards without value, such as “prohibited entries” and “critical values.”
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)