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Top cited standard summary
It’s not breaking news, but this brief summary of the top-cited standards in the first half of 2009 will appear on Healthleaders Media on Monday and I wanted to give AHAP members a sneak preview. A more extensive article will also appear in next month’s Briefings on The Joint Commission.
Here’s the summary:
The Joint Commission has officially announced the most-cited standards for the first half of 2009 and Life Safety standards top the list. Back in 2007, Life Safety Code consisted of only a single standard (EC.5.20) but was subsequently split into seven standards, leading citations for this area to jump from 29% to 45% in 2008. Three of the top ten most-cited standards (and the two most-cited) fell under the Life Safety chapter.
Those standards are:
- LS.02.01.20 (45%)—maintaining means of egress. This standard was the most cited in the first half of 2009.
- LS.02.01.10 (43%)—building and fire protection features minimize the effects of fire, smoke, and heat. This was the second-most cited standard.
- LS.02.01.30 (36%)—provision and maintenance of building features to protect individuals from the hazards of fire and smoke. This was sixth among the top ten standards.
Record of Care standards were found twice in the top ten most-cited. Verbal orders (RC.02.03.7) was cited 40% of the time, the third-most cited standard, and requirements to maintain complete and accurate medical records (RC.01.01.01), always a trouble area for hospitals, was cited 33% of the time, making it the eighth most-cited standard.
Maintenance of fire safety equipment and fire safety building features (EC.02.03.07) retained a top spot among cited standards at 38%.
The National Patient Safety Goals (NPSG) were cut down significantly for 2010. Requirements for commonly cited NPSGs for critical tests and critical values have been loosened and will not likely appear on future lists of top cited standards, at least for the time being. In the first half of 2009 however, critical tests/critical values (NPSG 02.03.10) were cited 38% of the time. Another top-cited NPSG in years past, do not use entries, has been moved to the standards and out of the Goals.
Universal Protocol is another evolving requirement within the NPSGs and has received extensive review by The Joint Commission in 2009. It is the most cited sentinel event in The Joint Commission’s database, the accrediting body said at Executive Briefings in September. UP.01.03.01, requiring a time out performed immediately prior to starting procedures, was the seventh most-cited standard in the first half of 2009, cited 34% of the time.
Lastly, two Medication Management standards rounded out the top ten—MM.03.01.01 (33%), medication storage, and MM.04.01.01 (32%), clear and accurate medication orders.
The Joint Commission appoints new laboratory executive director
The Joint Commission has announced Jennifer F. Rhamy, MBA, MA, MT(ASCP), SBB, HP, as its new executive director of the Laboratory Accreditation Program by the Joint Commission, according to an official November 9 statement.
Rhamy is a veteran healthcare professional who has experience in hospital and blood center settings. Most recently, she was involved as a blood center consultant and served as vice president of laboratory services for the Indiana blood center in Indianapolis for eight years.
Rhamy is also a certified Lean Six Sigma and has a masters of arts in Language and Communication from Regis University (CO). She is a registered medical technologist and a specialist in blood banking, and a hemapheresis practitioner through the American Society of Clinical Pathology.
“Jennifer’s vast experience in the field gives her a clear understanding of the challenges clinical laboratories face in delivering reliable, quality services,” said Mark Pelletier, RN, MS, executive director of Accreditation and Certification Services at the Joint Commission in a prepared statement.
The Laboratory Accreditation Program was launched in 1979 and to date accredits nearly 2,000 organizations that offer laboratory services.
For more information, visit The Joint Commission’s Web site here.
New benchmarking report released
I just wanted to let you know we’ve released the latest AHAP benchmarking report. This report asked members about their experiences with Lean Six Sigma and ISO standards as well as relevant training. It can be accessed through the AHAP site right here–take a look! As always we’re looking for future topics for these member-only benchmarking reports, so please feel free to contact me any time with suggestions.
Our next report will be our annual salary survey, so keep an eye out–this is always a popular, and interesting, report.
Joint Commission announces update to PDA
The Joint Commission has announced two changes to its Preliminary Denial of Accreditation (PDA) decision, the elimination of one rule and revision of another.
Rule PDA06, which addresses the need to have a license, certificate, or permit, has been altered.
Previously, if an organization was found to lack certain specific licenses, certificates, or permits at the time of survey, the organization would receive a PDA decision. This lack of license or permit often was the result of the organization being unaware such a permit was needed, and would result in immediately obtaining said permit (or, if the permit application is already in process, demonstrating during survey that steps to apply for the permit have been taken).
Under this new change, however, the organization lacking the license must now show an acceptable Evidence of Standard Compliance demonstrating that the organization has received the necessary license, certificate, or permit—until that time the organization receives an accreditation decision pending receipt of this documentation and receive a Requirement for Improvement (RFI).
In order to assure The Joint Commission that appropriate processes or policies are in place for obtaining this license or permit (and thus it will be renewed in the future in a timely manner), the RFI will remain in the survey report.
Additionally, the accreditation organization has eliminated completely rule PDA07, which was invoked after a healthcare organization received a Preliminary Denial decision on two consecutive full surveys.
Performance measurement update
In other Joint Commission news, the organization will introduce a new set of Perinatal Care core measures on April 1, 2010. This new set will be in addition to existing measure sets hospitals can use to fulfill ORYX reporting requirements.
The new Perinatal Care set replaces “Pregnancy and Related Conditions,” which will be retired March 1, 2010. The measure set will include the following:
o Elective deliveries
o Cesarean sections
o Antenatal steroids
o Healthcare associated bloodstream infections in newborns
o Exclusive breast milk feeding
As before, the choice of measure sets is up to the hospital, depending upon appropriate services provided as well as patient population data.
Working Group Call recording
I just wanted to announce that Thursday’s Working Group Call on “Using Lean in the healthcare setting” was a great success. The group had a lively discussion with some fantastic commentary by featured speakers Sarah Cottington, BS, RHIT, CPHQ, Performance Improvement / RAC Coordinator with Pella Regional Health Center, and AHAP member Ronda Reimer, RN Special Projects Coordinator, also of Pella Regional. For anyone who missed the call, the recording has been uploaded to the AHAP site and is free to listen to for all members–just click here and you’ll be brought to the recording, as well as all of our previous AHAP Working Group Calls.
We’re already looking for topics for the next Working Group Call, so if you have any topic suggestions (or would like to be a featured presenter) please contact me any time at mphillion@hcpro.com.
Announcing Patient Safety Monitor!
HCPro is launching its newest product today: Patient Safety Monitor, an online resource for your patient safety needs. The product features the monthly newsletter Briefings on Patient Safety, a tools library, access to our popular “Patient Safety Talk” listserv, and weekly news alert. The main features is the Crosswalk, which organizes many patient safety-related regulations by what is required by The Joint Commission, CMS, and all 50 states.
This blog is actually a part of the larger Patient Safety Monitor product, and you’ll now notice a link back to the home page in the “links” section in the righthand column of the blog. If you’re already a subscriber of Briefings on Patient Safety, you now have access to Patient Safety Monitor as part of your subscription.
If you’re interested in finding out more about Patient Safety Monitor, be sure to check out the demo. You can also sign up for a free 7-day trial.
We don’t often publicize lots of our HCPro products using this blog simply because we know that most readers aren’t coming here for that. But we do think that readers of this blog might be interested in what this product has to offer. We hope you check it out!
Survey coordinator week?
An AHAP member submitted a question this week that caught my attention and I wanted to throw it out to the membership on the whole for discussion. She asked if there was currently a survey coordinator week (similar to other awareness weeks for various healthcare professions–many of which take place in October/November).
What are your thoughts on a possible “survey coordinator week?” If AHAP were to sponsor one, what sort of events/highlights would you be interested in seeing? Would you participate? Would your peers?
Feel free to add your comments/suggestions here on the AHAP Blog, or email me at mphillion@hcpro.com–I’d love to hear your ideas on whether a national survey coordinator week is something AHAP should start the ball rolling on.
Working group call sign-ups announced
AHAP members–keep an eye out in your inbox this week. We’ve sent out the official invitation to our latest AHAP working group call! Our next topic: using Lean in the hospital setting.
Join your peers on one of the following days to discuss possible best practices for this challenging topic:
* Tuesday, November 3rd, 2009, 12-1 p.m. ET
* Thursday, November 5th, 2009, 2-3 p.m. ET
You’ve expressed an interest in having an expert on the call, so joining the call will be Sarah Cottington, BS, RHIT, CPHQ, PI/RAC coordinator, and Ronda Reimer, Joint Commission coordinator, at Pella Regional Health Center in Pella, IA. They were instrumental in implementing Lean at PRHC and will help lead discussion during this call.
Working groups are FREE to AHAP members but space is limited. An official sign-up questionnaire will be arriving in your inbox shortly–it will take just a few seconds to fill out and you’re on your way!
Hope you can attend this upcoming working group call. Lean in the hospital setting is a hot topic and we hope to have some great discussion. As always, feel free to email me at mphillion@hcpro.com with any questions.
Guest presenters for our upcoming working group calls
Just wanted to remind everyone of our upcoming working group calls on using Lean in the hospital setting. The calls will take place on November 3 from 12-1 pm EST, and November 5 from 2-3 pm EST. Our guest presenters, talking about their own experience instituting Lean at their facility, are:
Sarah Cottington, BS, RHIT, CPHQ, with Pella Regional Health Center as the Performance Improvement/RAC Coordinator. Sarah has been a Lean healthcare facilitator since 2006.
Sarah has a background in Health Information, but went into healthcare quality after obtaining a Bachelor of Science degree in Management of Healthcare Services from Spring Arbor University, and is currently working on an MHA degree through Walden University. Sarah is passionate about making things better for patients and team members, and is a student of lean healthcare.
Joining Sarah is Ronda Reimer, RN, Special Projects Coordinator, Pella Regional Health Center (2001-present).
Ronda coordinates and supports organizational regulatory compliance/continuous readiness, and promotes nursing excellence as the Magnet® Coordinator and provides leadership for special projects for the organization.
She is also currently enrolled University of Missouri-Kansas City RN-BSN program with plans for continuing on with the BSN to PhD program beginning in 2010.
Save the date–working group calls!
It’s time for our next round of working group calls, and, as always, we invite all AHAP members to attend and participate–the calls are free to members.
This time around we’ll discuss incorporating the Lean process into the healthcare setting. Is your hospital using Lean? Researching it? Just curious? Call in to learn more, swap success stories, and more!
We’ll have two calls: Tuesday, November 3 from 12-1 pm EST, and Thursday, November 5, from 2-3 pm EST. Keep an eye on your inbox–an official invite is on its way, which will provide information on how to sign up for these calls.
