First contest entry

Our first success story comes from Cheri Samuels, BSN, MSEd, RN, CPHQ. She writes:

SCIP Core Measure:

• Discontinue ABX within 24 hours of surgical end time.
• A collaborative effort from our medical staff and Pharmacy added the post-op ABX to the policy and placed a “Hard Stop” on the ABX.
• This brought the measure into the 90th percentile.

Thanks for sharing your success story, Cheri. A reminder–all you need to do is tell us about how you’ve used data, collected for core measures requirements or other accreditation or regulatory compliance, to make improvements to your processes, policies, or culture. Send all entries to mphillion@hcpro.com and I’ll post them to the blog!

Contest: core measures!

It’s time for another AHAP giveaway. This time, we’re giving the winner a free copy of the Practical Guide to Core Measures Impovement by Gayle Bielanski, RN, BS, CPHQ, CSHA.

To enter, all you need to do is share a success story about using data to make quality improvements. Everyone is collecting data to meet core measures reporting requirements,  but how to use that data to make meaningful changes to the organizations processes, policies, and even culture can be a challenge.

Do you have a success story you’d like to share? Send a short description to mphillion@hcpro.com and I’ll post your story to the blog right here. In two weeks (October 23rd) we’ll draw a winner from all entries and give away a free copy of the Practical Guide.

prepub standards details

For folks looking for a bit more information on the prepublication standards released last week, the following sums up the changes (and reasons behind the timing):

The Joint Commission traditionally unveils the standards for the coming year a month or more in advance. These will remain posted until December 1, 2009, at which point both the electronic (e-dition) and print version of the 2010 manual will be distributed to hospitals.

In conjunction with the release of the prepublication standards, The Joint Commission has also released a report, free of charge, detailing CMS-related changes to its standards and survey processes. The report—distributed as part of a free edition of Perspectives—looks back through March 2009 at various changes made as part of The Joint Commission’s application to CMS for renewed deeming authority this year.

What have we seen in terms of changes this year?

The Accreditation Survey Findings Report has been modified as of July 1, 2009. It now includes requirements surveyed as below fully compliant for both Joint Commission standards and CMS requirements.

We have also seen changes to CMS Certification Numbers. Though this change effects only a small group of hospitals, it is a pivotal change for those organizations—and The Joint Commission will contact directly every hospital impacted by this change, which will go into effect on July 15, 2010.

The Joint Commission’s Medicare recommendation letter has been altered. It now informs CMS if a new or existing Medicare provider has participated in a deemed status survey. Also, it states whether The Joint Commission, as a result of that survey is making a recommendation about that provider’s Medicare status.

Finally, the hospital standards have been updated to improve “equivalency” with CMS hospital requirements. Elements of Performance were both added and revised to improve this balance.

Of note for the credentialing world: along with the prepublication standards, The Joint Commission has released details on credentialing and privileging with regards to proxy and telemedicine. Changes are expected to be implemented July 15, 2010. Please note that The Joint Commission is still in talks with CMS about telemedicine credentialing, and until a formal agreement can be reached, hospitals will be surveyed according to existing CMS requirements.

All of these documents can be found online at The Joint Commission’s Web site.

The Joint Commission promised us additional details on the 2010 NPSG changes in the October Perspectives, and they weren’t kidding—a hefty 32 page version of Perspectives with a complete overview of the new changes is available online here.

Also discusses changes to IC.02.02.01, an article on changes to the culture of customer service, details on “CMS update” changes related to deemed status application, changes to the accreditation survey finding report (details covered at Executive Briefings), and more.

Also, the pre-pub standards were posted to the Joint Commission site last night. Pre-pub standards can be found here.

From the looks of things, the October Perspectives extravaganza is intended as the official summary/clarification of the pre-pub standards. A lot of interesting stuff in this edition!

Executive Briefings: NPSG info

Just wanted to share the following list–it’s the latest breakdown on which National Patient Safety Goals are being incorporated into the standards, which are deleted in 2010, and which remain the same:

Changes to the NPSGs

Retained as goals:

• NPSG.01.01.01, two identifiers
• NPSG.01.03.01, transfusion ID
• NPSG.02.03.01, critical results
• NPSG.03.04.01, medication labeling
• NPSG.03.05.01, anticoagulant therapy
• NPSG.07.01.01, hand hygiene
• NPSG.07.03.01, multi-drug resistant organisms
• NPSG.07.04.01, central line infections
• NPSG.07.05.01, surgical site infections
• NPSG.15.01.01, suicide prevention
• Universal Protocol

Integrated completely into the standards:

• NPSG.02.02.01, approved abbreviations
• NPSG.03.03.01, look-alike/sound-alike drugs
• NPSG.09.02.01, patient falls
• NPSG.16.01.01, early response to emergent conditions

Some requirements deleted, others incorporated into the standards:

• NPSG.02.02.01, read-back requirements
• NPSG.02.05.01, handoff communication
• NPSG.13.01.01, patient involvement in care

Executive Briefings

Just wanted to share some highlights from the New York Executive Briefings session–possibly the most interesting Executive Briefings I’ve had the opportunity to attend. Lots of intriguing changes on their way from The Joint Commission soon.

* Refocusing surveyors. Ann Scott Blouin, PhD, RN, executive vice president of accreditation and certification operations, told the audience that The Joint Commission has refocused its 500 hospital surveyors to balance their roles as both evaluators and educators/coaches/mentors. According to Blouin, this was received as an invigorating change by “95%” of the surveyors.

* Adaptation. The Joint Commission is using Lean, Six Sigma, and “change acceleration” to change its own culture.  According to Blouin, there is a new focus on customer service and simplification of processes. The Joint Commission has also changed its tactics on criticality–now only direct impact Requirements for Improvement affect accreditation decisions.

They have also made a concerted effort to reduce costs. And, as was discussed earlier this year, there are no more automatic thresholds–there is “no magic tipping point,” said Blouin.

*The Joint Commission has promised to improve the time frame in which hospitals receive their post-survey reports. A recent study within the organization found that hospitals were on average receiving their reports 16.4 days after survey, with massive fluctuations in those time frames–despite a requirement that hospitals receive this report within ten days of their survey (not a ten day average). A new process has been developed reducing the time to develop the report from 38 hours to 4.4 hours and the average time frame to receive the report down to 5.4 days.

* Periodic Performance Review–The Joint Commission is examining changes and enhancements to the PPR based on feedback from the field that the dates of submission are not working.

Okay, more to follow in a bit about the Executive Briefings coverage of the National Patient Safety Goals!

Joint Commission launches Center for Transforming Healthcare

The Joint Commission announced a new effort to address the nation’s biggest issues in terms of quality care and patient safety yesterday when it launched the Center for Transforming Healthcare. At the crux of the Center’s approach to improving patient safety is using Lean and Six Sigma to improve processes and address some of the challenges facing caregivers and patients. It hopes to offer specific guidance on how to solve issues like preventing healthcare-acquired infection, ensuring medication safety, coordinating safe patient handoffs, and focusing on surgical safety.

This not-for-profit has coordinated with some of the nation’s leading health systems to work on some of the above mentioned issues. You can find the full list by clicking here.

I did find it useful to know that starting midway through 2010, hospitals that are Joint Commission-accredited will be able to utilize an application on the site that will work with each facility individually to develop custom solutions.

You can find more information about the Center here.

Executive Briefings

Just wanted to remind everyone that AHAP will be blogging and Tweeting from Executive Briefings in New York on Friday. Stay tuned for updates here, and also check us out on Twitter at AHAPdirector. Word out of the Chicago Briefings have been interesting–we’ll have a full report for you right here.

And as I’ve mentioned here and elsewhere–if you’re going to the New York Executive Briefings, let me know! I’d love the chance to say hello to AHAP members face to face while in town.

AHAP at Executive Briefings?

We’re always curious how well-attended Executive Briefings is by our members. Did you attend yesterday’s Rosemont, IL Briefings, or plan on attending in NYC, Dallas, or LA?

If you were in Rosemont yesterday–was there any news that jumped out at you? We’ve been receiving reports that it was a particularly informative session this year. If you’d like to share your thoughts, you can post below or feel free to email me at mphillion@hcpro.com.

If you’ll be in attendance at the New York Briefings, let me know at the email address above–I’ll be there as well and would love the opportunity to meet with some of our members local to the area!

Joint Commission releases Sentinel Event Alert

The latest Sentinel Event Alert was released by The Joint Commission this morning urging healthcare leaders to become more involved in the prevention of medical errors at their facilities, as well as to take more responsibility when errors do occur. The alert, titled “Leadership committed to safety,” reflects many of the changes made to the leadership chapter in The Joint Commission’s 2009 Comprehensive Accreditation Manual for Hospitals (which contains the standards hospitals need to comply with to attain accreditation by The Joint Commission.)

The alert asks leaders to recognize that if there is a failure of some sort in the organization, no matter the result, they are ultimately responsible, and acknowledging that will go a long way toward fixing those errors. Additionally, building a culture of safety is part of preventing medical errors and is something that can only truly happen when leaders buy-in and show that that doing so is not just something they are preaching–it is something they live every single day.

The alert gives some recommendations to leaders. One of these is creating a transparent environment that encourages reporting of near miss events and allows staff members to talk freely about the facility’s trouble spots without being penalized. Similar to this, one recommendation is to support staff members who are involved in a medical error by recognizing that errors are most often the result of system failures, rather than assigning blame to one or two people involved. Allowing involved staff members to participate in the route cause analysis and investigation will help prevent future errors. However, the alert also recommends that leaders recognize the need to create a functioning disciplinary policy for those staff members who exhibit specific, defined behaviors.

You can read the full list of recommendations, as well as the Sentinel Event Alert here.