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Start Small to Create a Safety Culture

By: January 22nd, 2020 Email This Post Print This Post

By Jenny Slayton, Institute for Healthcare Improvement

We often hear about health care organizations that focus on creating a culture of safety. At Vanderbilt University Medical Center, it reminds us of how often in our journey we’ve paused and asked ourselves, “Will we ever get there?” The correct answer is that the job will never really be done because it’s an ongoing process. But we have a plan and we are on our way.

We started small. Just a few tests of change led us to establish a systemwide strategic plan for safety and quality. But it didn’t happen overnight.

Personnel in any size health care organization face massive amounts of work. This can paralyze us from trying anything new. We think we don’t have time, but just about everyone has time to start their pursuit of a safety culture.

How Vanderbilt Started Small

Start by doing something focused enough to represent a proof of concept. Run some PDSA cycles to fail fast and learn before presenting a plan to leadership. We chose something that allowed us to work out some of the kinks in our system.

We had been working on quality and safety initiatives for years, but our turning point occurred when we decided to improve our handwashing. “Choosing handwashing may seem trivial,” says Gerald Hickson, MD, Vanderbilt University Medical Center Senior Vice President for Quality, Safety and Risk Prevention. “But in years of working on this challenge, we still had difficulty performing this basic task in a highly reliable way.” Consequently, what sounded like a simple project became a stepping stone towards creating Vanderbilt’s organization-wide plan to address change.

At Vanderbilt, we didn’t ask, “Who in the world could be opposed to washing their hands?” Instead, we asked, “Are we willing to mutually support each other in our pursuit of high reliability?” This was important because the second approach is about values and our willingness to work together on our journey. It’s not about singling out individuals for blame.

In a safety culture, if one medical professional observes another who is not using the foam dispenser, they should avoid being judgmental. Instead, they should be willing to speak up about our collective commitment to our patients and each other. That is the type of culture we are pursuing.

4 Keys to Building a Safety Culture

At Vanderbilt, we’ve applied what we learned from our handwashing work to a range of other safety improvement opportunities. Says Hickson, “We first learned to wash our hands. We then decided that reliably implementing a certain practice bundle would reduce surgical site infections. Vanderbilt team members understood that [we were going to use] the same approach to roll out our new safety plan.” Here are some important lessons we’ve learned:

  • Commit to safety — We must be dedicated to preventing injury to our patients and each other. “You ensure that each new quality and safety initiative is aligned with your strategic goals,” says Hickson.
  • Demonstrate Respect — Modeling respect begins with senior leaders. You don’t have a culture of safety if people, especially leaders, don’t treat each other with respect and don’t respect safe medical practices like washing our hands, scrubbing the hub [to prevent central line infections], or using antibiotics thoughtfully. “Medical professionals have to trust that, if they speak up, what they say is going to be heard,” says Hickson.
  • Focus on quality — At Vanderbilt, this means measuring ourselves against the best health care systems in the world. We wouldn’t be satisfied with being average.
  • Focus on value — Remember that the goal should be to pursue high-quality outcomes from the patient and community perspectives. Our hand hygiene and surgical site infections prevention work, for example, have brought value to Vanderbilt, our patients, and our entire community.  

Personalizing Safety

At Vanderbilt, we have also tried to shift our culture from just thinking about rates and incidences to seeing our patients as individuals. “We harmed Sue. She was a 29-year-old mother of two.” Using our patients’ names puts our numbers into context and motivates us to design better systems to improve care. This approach reminds us why we got into health care in the first place.

Creating a safety culture also means promoting professional accountability while respecting fellow health care team members. For example, imagine someone who has repeatedly declined to follow the handwashing protocol. We sit down and have a conversation with them instead of pointing fingers. We acknowledge that team members work hard, and we all struggle from time to time. We work together to identify what’s gone well, sort out what the data tells us, and find best practices to move forward.

You also need to equip key team members to create a culture of safety and respect. For Vanderbilt, IHI’s Certified Professionals in Patient Safety (CPPS) credential has become instrumental to our organization’s mission. We have 26 individuals who are certified so far. Certification connects our team members to others outside Vanderbilt who regularly think about the pursuit of safety. Our team members also see certification as a professional development credential because they enter our leadership pipeline upon completion.  

We can’t always predict the challenge of the day, but we can prepare team members with the right training and support them throughout our safety journey. You don’t go out one day and run a marathon. You start by running for 30 minutes, and then building strength and stamina from there. The journey can begin by doing just one new thing.

Jenny Slayton, RN, MSN, is Executive Director of Quality Improvement for Vanderbilt University Medical Center.

Suicide prevention NPSG now applies to Critical Access Hospitals

By: January 21st, 2020 Email This Post Print This Post

By Brian Ward

Critical access hospitals (CAHs) accredited by The Joint Commission (TJC) will be expected to implement National Patient Safety Goal (NPSG) Standard NPSG.15.01.01 starting July 1, 2020. This standard is aimed at preventing suicides among patient populations and has been posted on the prepublications standards pages.
In the December edition of The Joint Commission’s Perspectives announcing the requirement, the accreditor noted concerns about the very high rate of suicides in rural communities that critical access hospitals serve. Suicide rates in rural counties are 25% higher than in urban areas.  

NPSG.15.01.01 has applied to hospitals and behavioral healthcare programs since 2007 and there were several significant standard changes that took effect in 2019. The Joint Commission released a clarification about those changes in May 2019.

Those who want to learn more about the suicide prevention NPSG are asked to contact Stacey Paul, RN, MSN, APN, PMHNP-BC, project director, clinical, Department of Standards and Survey Methods.

Medical Malpractice Rate Dropped Over 10-Year Period

By: January 20th, 2020 Email This Post Print This Post

By Jay Kumar

The last decade has seen a decline in the number of medical malpractice claims in the United States, which can be attributed to tort reform and improved quality of care, according to experts on a panel at the American Society for Health Care Risk Management’s (ASHRM) annual conference in Baltimore.

Looking at the findings of a 2018 benchmarking report from CRICO Strategies, there were 124,000 malpractice claims made from 2007 to 2016, said Gretchen Ruoff, MPH, CPHRM, CPPS, senior program director for patient safety at CRICO Strategies. A division of The Risk Management Foundation of the Harvard Medical Institutions Incorporated, CRICO Strategies published its report Medical Malpractice in America earlier this year and made it available for free download.

“We really feel this is a true representation of medical malpractice in America,” said Ruoff, noting that the medical professional liability case rate decreased 27% over the 10-year span. “There’s been an overall drop in risks across the country.”

Tort reform helped drive down the number of cases, said Paul Greve, JD, RPLU, DFASHRM, senior director, healthcare risk solutions, Markel Assurance.

When looking at the number of defendants per 100 physicians, the steepest decline was in OB-GYN claims with a 44% drop over 10 years, Ruoff said. The drop is possibly attributable to focused safety efforts in labor & delivery over the last 15 years, but more research is needed, she added.

A second report released by The Doctors Company examined rates of physician claims from 2006 to 2018. Ruoff said expenses and indemnity payments rose as expected. Case management expenses increased over time, outpacing inflation, Ruoff said.

From a claims perspective, the time to resolution has decreased, but experts have become increasingly expensive and costs have gone up for physician support and trial preparation, she said.

The proportion of cases naming multiple defendants is growing, with the study finding the following:

  • Cases with two-plus defendants increased, adding expense costs to every case (31% in 2007 to 37% in 2018)
  • 260 additional defendants per year since 2007
  • Average expenses per defendant is $25,000
  • $6.5 million in additional expenses per year since 2007

Average expenses are rising the fastest for zero-indemnity cases, going up by 4.7% per year. Contributing factors may include provider protection-focused philosophies of resourcing vigorous defense for cases without merit, and an unwillingness to pay on cases without malpractice.

Average indemnity payments increased 3% annually. In line with expectations, increase outpaced CPI by 1.3% per year (but slower than medical inflation)

Ruoff said cases closed with indemnity payments under $1 million are going down, while payments over $1 million are up 6%.

Growth is fastest in the $3 million to $11 million layer, growing from 17% to 22% over the last decade. Growth is driven by the volume of these cases, not increase in the average severity per layer, she added.


The CRICO report findings identified several general trends that impacted medical professional liability over the 2007-2016 period, including hospitals purchasing physician practices/employment model, Greve said. Hospital merger and acquisition activity increased notably, and the rapid rise of  hospital/healthcare costs has led to a disdain of healthcare organizations, he noted.

“Our hospitals and hospital systems are being viewed, especially by juries, as sitting on a big pot of money,” said Greve. “This corporatization has caused a deterioration of goodwill toward hospitals,” which explains why we’re seeing some of these mega-verdicts.

On the physician side, “we are seeing groups grow larger and larger,” said Darrell Ranum, JD, CPHRM, vice president, patient safety and risk management for The Doctors Company. There’s a concern about the influence of investor money on these groups, he added.

This is where high reliability helps, Ruoff said. Organizations are being encouraged to “change internal culture to have an impact on these big external things.”

The report also found that deeply coded cases provide actionable insights, said Ruoff. High-severity injuries are 41% more likely to lead to an indemnity payment. In addition, medical expenses for patients under 40 with grave injuries drive costs up.

The vast majority of cases stem from three categories: Surgical, medical, and diagnosis. Surgical cases are most prevalent, diagnosis is most costly, and medical treatment is becoming more common.

Forty-four percent of surgical cases involve ambulatory care patients, Ruoff said. Orthopedic procedures are most prevalent, with perforations/lacerations as the top injury category.

Ranum said The Doctors Company report had very similar findings to the CRICO report.

Ambulatory or day surgery cases comprised 54% of the cases, with hospital operating room cases at 46%.

“When we repeat studies a few years down the line, we’re seeing fewer cases, but repeat issues,” said Ranum.

Looking at diagnosis-related cases, the majority (30%) were led by missed/delayed cancer diagnoses, including breast, lung, colorectal, uterine and ovarian, and skin cancers, noted Ruoff.

Of a total of 55,377 closed claims in the CRICO claims database, 21% were diagnostic-error claims, said Greve. The median patient age was 49 and 51.7% of patients were female.

“It’s a pervasive and persistent problem,” he added.

The “big three” disease categories of claims were cancers (37.,8%), vascular events (22.8%), and infections (13.5%). They accounted for 61.7% of all diagnostic error claims. A majority of errors (71%) occurred in the ambulatory care setting.

Ruoff said cases with clinical judgment factors are most prevalent and they increase the odds of high-severity injury and high payment. Clinical judgment is the key component of missteps during assessment, testing, and follow up, she noted.

“The diagnosis of complications that occurred in surgery that were not recognized during surgery is a huge component,” said Ranum.

Using the data

Organizations must use this data to effect change, Ruoff said. “There’s safety in numbers,” she added. “Use numbers like this to collaborate and form patient safety strategies.”

Patient feedback is valuable, Ruoff said. Complaints can be indicators of faulty systems, provider-related behavior, and issues of provider well-being.

Greve recommended creating a list of resources: Insurance company materials, CRICO Strategies website (for algorithms, case studies, practice assessment and education resources), and specialty society websites.

Review information available to you, he said. While you don’t need to do quantitative analysis, you can  look for evidence that should prompt further investigation. Then seek comparative perspective (via your patient safety organization and national medical professional liability claims data) for context and collaboration, Greve noted.

“Your data doesn’t have to be perfect,” he said.

CMS offers training on new electronic form for restraint-related deaths

By: January 17th, 2020 Email This Post Print This Post

By A.J. Plunkett (

As of January 1, CMS eliminated the paper version of the form to report patient deaths associated with restraint or seclusion. Form CMS-10455 must be filed through an electronic version.

CMS announced the new electronic form and provided instructions on how to use it, including a video, in an Quality, Safety & Oversight Group memo, on December 2, 2019. Memo #QSO-20-04-Hospital-CAH DPU, “Electronic Form CMS-10455, Report of a Hospital Death Associated with Restraint or Seclusion,” can be found online here:

In a newsletter to clients, Patton Healthcare Consulting noted that the requirements on which deaths to report remain the same. Only the method of reporting has changed.

“The QSO memo also details the specific fields of information which must be submitted, but this becomes somewhat easy in that you are filling in the blanks on the form,” says Patton Healthcare. “CMS also describes what the regional office will do with the information submitted including evaluating it for a potential survey and sharing of information with the accrediting bodies. Since this new process is effective immediately you will want to review the QSO memo and slide deck and make sure that the individual responsible at your hospital for reporting such deaths has the information.”

The memo also includes a link to the video for surveyors on how the deaths are to be reported. That can be viewed at:

IHI Pushes Safety as a Primary Business Strategy

By: January 15th, 2020 Email This Post Print This Post

By John Commins, HealthLeaders Media

Hospital leaders must adopt safety and quality as primary business strategies, rather than regarding them as tertiary metrics that rank below finances and other stressors on the C suite’s list of top priorities.

That’s according to Derek Feeley, president and CEO of the Institute for Healthcare Improvement.

Speaking to reporters here this month at IHI’s 31st National Forum, Feeley says there are moral and financial imperatives for making safety a priority.

“The thing that should be uppermost in every healthcare leaders’ minds is safety,” he says. “If we create high-quality, safe healthcare systems, they are much more likely to be thriving and financially viable than healthcare systems that are unsafe and delivering a quality of care that patients need or want.”

Given the stressors of hospital operations, Feeley says it’s not surprising that hospital leaders get sidetracked.

“It’s the way the system works. The current environment is one of growing consolidation and (people) are trying to figure out how to make sense of these often-conflicting payment models,” he says. “Some of it’s also what the board of governance and senior executives value, and part of that is the financial vitality of the institution.”

“I keep trying to bring them back to there’s another way to think about this. Is it at least possible to conceive that we can make quick progress on safety as our business strategy?” he says.

In August, the World Health Organization issued a report that one-in-10 hospital patients in “high-income countries” suffer harm, and that half of those adverse events are preventable.

IHI President Emeritus and Senior Fellow Donald M. Berwick, MD, was asked by reporters to assess what progress the healthcare sector has made over the past 20 years since the Institute of Medicine’s landmark 1999 To Err is Human report.

“I’d say it’s a B+ on the project-level improvements,” Berwick replied, citing notable reductions in infections, pressure ulcers, ventilator pneumonia and surgical complications.

“Place-by-place you can see pretty serious improvements once people decide to work on it,” he says.

The problem, he says, is that safety improvements are missing on a system level and can vary greatly among healthcare providers, and within geographic areas.

“We’re at the really the point now where it’s time to get serious,” Berwick says. “We now know we really don’t need to have pressure ulcers. We really don’t need to have surgical site infections. We know how to virtually eliminate them.”

“The bad news is we’re seeing surveys, and when you ask healthcare executives and senior teams to rank what’s on their mind, whereas safety was pretty high up there, number one or two a few years ago, it’s now five or six, and we’re finding places backing away,” he says.

Rick Pollack, president and CEO of the American Hospital Association, disagreed “categorically” with the IHI leaders, adding that the “focus on quality in the DNA of our own organizations.”

He noted that, between 2014 and 2018, hospitals in the AHA’s Hospital Improvement Innovation Network program saved $1.2 billion in health care costs, prevented 141,000 patient safety events and saved 14,000 lives.

“To coin a phrase, quality is job one. If you’re not providing the highest quality possible, then you’re not serving your mission,” Pollack told HealthLeaders. “The reality is that what you often see is people will rather shut down the service completely in order to provide the highest quality and services that they do provide.

That commitment to quality and safety metrics plays out in executive compensation.

“We see more performance-based compensation linked to quality Improvement than we ever have the past,” he said.

Feeley said quality and safety are being address, but not quickly enough.

“It’s not that we haven’t made progress, but 20 years on, this ought to be the norm,” he says. “We should have already moved on from patient safety being something we do and our project being a way (to do it), but it’s not yet embedded. It still requires constant attention and maybe it always will.”

“That’s why I’m feel so passionately about this, as I see the risk of that diversion of attention and energy. It’s right that we remind people that what started 20 years ago in earnest has made some progress but there’s still so much to do,” he says.

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

Q&A: What You Need to Know About CMS’ Antimicrobial Stewardship Rule

By: January 15th, 2020 Email This Post Print This Post

By John Palmer, PSQH

Editor’s note: The following is a Q&A with two experts at Chicago-based Lumere, a healthcare think tank focused on helping health systems eliminate medical errors and cut unnecessary costs. Gina Thomas, BSN, RN, is chief nursing officer, and Samantha Bastow, PharmD, is pharmacy solution advisor.

On September 26, 2019, the Centers for Medicare and Medicaid Services (CMS) released revised Conditions of Participation for hospitals and critical access hospitals that require the development and implementation of antimicrobial stewardship programs (ASP) to help reduce inappropriate antibiotic use and antimicrobial resistance. The rule, first proposed by CMS in 2016, also finalized requirements for nursing facilities to have a stewardship program.

The Joint Commission also requires acute care hospitals, critical access hospitals, nursing homes, and ambulatory care centers to have an antibiotic stewardship program to maintain their accreditation.

PSQH spoke with two experts to get their thoughts on the new regulations and what measures healthcare facilities should be putting in place.

Q: What are the top five things all hospitals need to know about the new CMS ruling?

Samantha Bastow: It is encouraging that more regulatory agencies like CMS and The Joint Commission, among others, are establishing standards to promote safer antibiotic prescribing practices for our patients and communities. In fact, shortly after the CMS ruling was announced, the Society for Healthcare Epidemiology of America (SHEA) praised the CMS decision, stating “the update by CMS moves U.S. hospitals closer to the goal of making patients safer by reducing inappropriate antibiotic use by 20% in inpatient settings by 2020.”

Given this, hospitals need to consider the following:

  1. Start working on these updated requirements now. Each organization has six months from the decision date to implement their ASP.
  2. Explicit instructions in meeting CMS requirements aren’t provided in this ruling, but hospitals are encouraged to seek guidance from established organizations like the CDC, Infectious Diseases Society of America (IDSA), and SHEA.
  3. Hospitals should also collaborate with other institutions who have well-established ASPs. Check out some examples online.
  4. An interdisciplinary team of quality, patient safety, infectious disease physicians, pharmacists, and information systems analysts should collaborate to develop, implement, and expand ASPs.
  5. Keep in mind resource constraints often pose one of the biggest challenges with implementing ASPs. Hospitals should identify where they can tap into existing resources and where new or repurposed resources are needed.

Q: What does the optimal ASP look like in terms of required staffing and the specific outcomes to measure? What are the things to consider when either creating or revamping your ASP?

Gina Thomas: One of the biggest challenges to consider is that there is a major education gap among patients that antibiotics can cure all manner of ills. Therefore, providers need to be equipped with patient education materials so they can explain what the potential consequences are of overuse.

Providers also must be equipped to help patients manage their discomfort with alternative methods.

Bastow: While CMS does not specifically outline what the ASP must consist of, organizations such as the CSC, IDSA, and SHEA provide guidance on the following areas:

  • Formulary management. Set formulary restrictions for select antibiotics and establish a clear approval process for restricted antimicrobials.
  • Consistently review organizationwide antimicrobial prescribing patterns (especially those which are restricted) and use this information to provide targeted education to providers.
  • Outcomes measures. Determine which outcomes will measure the impact of ASP efforts and the resources required to pull and analyze this data. Examples of outcomes may include the rate of hospital-acquired infections, the rate of antibiotic-associated adverse drug events, the rate of resistance for specific pathogens, annual expenditures for antibiotic medications, etc.

Other recognized best practices include standing up formal education processes, developing clinical guidelines and/or pathways, establishing de-escalation practices, and antibiotic cycling. Fortunately, there is a plethora of resources for hospitals to use to develop or improve an ASP.

Q: How do you manage the most common barriers to developing a top-notch ASP? What are the problems surrounding antibiotics in hospitals, and why can’t they seem to get it right?

Thomas: Antibiotic stewardship, isn’t a new concept and hospitals have been focused on this for years. The most successful ASPs would include alignment with outpatient providers and walk-in clinics. However, this has historically been a challenge because of the fragmentation between healthcare systems and outpatient providers. Another challenge is building greater awareness of antibiotic stewardship among the public. For years, the public has been conditioned to ask for antibiotics as a first-line treatment. This is where widespread education programming comes into play. However, patient education has typically been deprioritized due to lack of resources and budget. An important point to remember is that these costs will be offset by a decrease in both inappropriate utilization of antibiotics and denied reimbursement claims.

Bastow: Sometimes resource constraints limit how robust an ASP is at a given institution. Because it often requires additional staff, information systems support, and quality measures processes, this may be difficult for a hospital to prioritize if it is not viewed as an “essential” function for providing patient care. Using the business case and proposal examples provided by other hospitals is a great way to illustrate long-term payoff.

Q: How are factors such as increasing rates of antimicrobial resistance and government programs supporting the development of new agents that are making strong ASPs more important than ever?

Thomas: While pharmacists have been tackling appropriate utilization of antibiotics for some time, we see continued antibiotic over-prescription. This has given way to a rise in superbugs which make strong ASPs more necessary than ever. In fact, the CDC estimates at least 2 million people get an antibiotic-resistant infection and at least 23,000 people die in the U.S. each year. These superbugs wreak havoc on individuals’ health (especially those who are immunocompromised) as well as impact the out-of-pocket costs for individuals and increase the potential for decreased hospital reimbursement for inappropriate utilization.

Bastow: The CDC also reports that one in three patients who die in a hospital are diagnosed with sepsis, further emphasizing the importance of having effective antimicrobial medications for life-threatening diseases such as this. The reality is that resistant bacteria are being identified faster than new antibiotics are being developed to treat them. However, support is growing from regulatory agencies such as CMS and The Joint Commission as well as national organizations like IDSA, SHEA, and the CDC. There is now better guidance for developing rigorous ASPs as well as enforcement of these “best practices.” With more support from legislative action, we hope to see more development of new antimicrobial agents to target multidrug-resistant organisms.

Q: Some new antibiotics demonstrate superior outcomes despite very high cost. Can you elaborate on some of the latest analysis?

Bastow: In the past five years, there have been four new beta-lactamase inhibitor combination products approved: Zerbaxa® (ceftolozane and tazobactam) in 2014, Avycaz® (ceftazidime and avibactam) in 2015, Vabomere® (meropenem and vaborbactam) in 2017, and Recarbrio® (imipenem, cilastatin, and relebactam) in 2019.

There are also at least four more antibiotics in this class in Phase III trials. Hospitals will need to evaluate the evidence to gauge whether these new agents result in superior outcomes when compared to older antibiotics like Zosyn®. Once the evidence is better understood, hospital pharmacy leaders can decide if these products should be added to the formulary and how to best steward the use of these broad-spectrum antibiotics. If there is no clear benefit to patients beyond what is currently available, then hospitals should consider reserving new agents in the event resistant organisms are uncovered.

It’s important to note that some of these newer agents are more than 1,000 times the cost of oral therapy within this drug class and up to 15 times the cost of older IV options in the class. Hospitals need to consider whether it makes sense to restrict the use of the newer agents to patients who are infected with pathogens demonstrating resistance to all other options. Not only does this type of restriction help from a cost perspective, but limited exposure prevents resistance.

There is currently a high volume of persistent drug shortages among antimicrobials. According to an American Society of Health-System Pharmacists report, antimicrobials are in the top five categories of medications affected. Therefore, drug shortages remain an impediment to successful antimicrobial stewardship.

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at

CMS updates its surveyor’s manual for first time in more than a year

By: January 13th, 2020 Email This Post Print This Post

Just in time for the holidays, CMS is offering the gift of a newly revised State Operations Manual (SOM), one of the first significant overhauls in more than a year, especially for hospitals. Expect updated standards from accrediting organizations (AOs) to follow.

The updated interpretive guidelines for CMS surveyors includes most—but not all—of the new or revised Conditions of Participation (CoP) for discharge planning and burden reduction outlined in two final rules published in September.

There are revisions for the SOM appendices to the interpretive CoP guidelines are for hospitals, psychiatric hospitals, home health agencies,  portable x-ray units, rural health clinics and federally qualified health centers (RHC/FQHC), end stage renal disease facilities (ERSD), comprehensive outpatient rehabilitation facilities, ambulatory surgical centers, hospice care,  religious nonmedical healthcare institutions, critical access hospitals (CAH), organ transplant programs and emergency preparedness.

The updates were published December 20, in a 608-page memo from CMS Quality, Safety & Oversight Group to CMS’ state regional offices and state survey agencies, as well as AOs. The memo can be found here:

While the two final rules were for the most part effective on November 29, 2019, the memo does note that changes regarding antibiotic stewardship programs for hospitals and CAHs, are not effective until March 30, 2020, and regulations quality assessment and performance improvement programs (QAPI) are not effective until March 30, 2021.

The revised interpretive guidelines for antibiotic stewardship and QAPI are expected in the spring, says CMS.

The final rules were “Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction” (CMS 3346-F) and “Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies” (CMS 3317-F).

Other changes in this SOM release, as outlined in the Dec. 20 memo, include:

“• CAH- Revisions to Appendix W also include renumbering the C-Tags; inserting regulations §485.601, §485.603, §485.604, and §485.606; and inserting the CAH Distinct

Part Unit and Emergency Medical Treatment and Labor Act (EMTALA) C-Tags for reference. The changes also include updates to the Life Safety Code (LSC).

• Hospital/CAH/RHC/FQHC- Detailed requirements of United States Pharmacopeia (USP) have been removed from Appendices A, G, and W accordingly, as CMS requires compliance with applicable Federal and State law and adherence to accepted general standards of practice or guidelines for pharmaceutical services and medication administration issued by nationally recognized professional organizations.

• Psych Hospitals- The Special Conditions of Participation (CoPs) for the regulations §482.60 through §482.62(g)(2) psychiatric hospitals have been moved from the SOM Appendix AA to the SOM Appendix A. Appendix AA is being deleted as surveyors will now refer to Appendix A.

• Transplant Programs – Requirements at §482.82 that state that transplant centers must meet all data submission, clinical experience, and outcome requirements for Medicare reapproval have been removed. In addition, the special procedures for re-approval at §488.61 (f) through (h) is revised to remove the requirements with respect to the reapproval process for transplant centers. The change corresponds to the remove of the provisions at §482.82.

• ESRD Facilities: Appendix H updates the regulatory text based on requirements set forth in the 2008 Conditions for Coverage for ESRD Facilities and also includes revisions based on recent Federal regulation changes set forth in “Fire Safety Requirements for Certain Dialysis Facilities (CMS–3334–P).

• RHC/FQHC – Revisions to Appendix G include updates to regulatory text and interpretative guidance for both §491.9(b)(4) and §491.11(a) changing the requirement for an annual review to a biennial review.”

CMS officials say they are also developing online training for its surveyors on the revisions.

Sections of the main SOM have been revised over the last months and years, as have the individual appendices for each organization type that must adhere to the CoPs. The appendix for hospitals, for instance, was last updated online in October 2018. However, the appendix for ambulatory surgical centers has not been updated online since 2014.

Other sections have been added, such as Appendix Z on emergency preparedness, while the appendix for swing beds was deleted and folded into requirements for hospitals and CAHs.

The opening sections of the manual can be found online here:

The appendices can be found here:

Crisis communication: 10 tips for hospitals to prepare for a disaste

By: October 21st, 2019 Email This Post Print This Post

By Jody Moore, PSQH

Hurricanes, floods, fires, and other natural and manmade incidents can strike anytime, anywhere. Faced with such disasters, hospitals must not only respond to the emergency but also maintain continuity of patient care under the most trying circumstances imaginable.

What can your hospital do to be better prepared when the next crisis hits? How can you minimize the physical, psychological, and emotional stresses that can overwhelm staff and patients? What strategies, resources, and practices can you deploy when a natural disaster cripples the technological systems needed for essential functions?

Several hospital leaders with firsthand experience in crisis management shared insights on how to address communication issues—a core element of emergency preparedness—in a discussion I moderated at the annual Voalte User Experience conference (VUE18). The panelists included:

  • Scott McCarty, unified communications manager at Tampa General Hospital, who is a member of its Emergency Preparedness/Disaster Planning committee and helped the hospital prepare for Hurricane Irma in 2017
  • Roberta Romeo Shannon, project manager of strategic projects and clinical systems at UConn Health in suburban Hartford, which recently opened a new hospital tower that gave staff the experience of evacuating inpatients similar to what would happen during an emergency
  • Keith Turner, manager of clinical enterprise systems at Texas Children’s Hospital in Houston, who was on-site in 2017 when the Category 4 storm Hurricane Harvey made multiple landfalls and caused massive flooding and $125 billion in damage statewide

The following are 10 practical tips from this discussion that can help hospitals be better prepared to communicate during a crisis:

1. Understand and comply with CMS regulations on crisis communication preparation

Hospitals, along with multiple other provider types, must comply with CMS’ Emergency Preparedness rule to participate in the Medicare or Medicaid program. Developing and executing a communication plan is one of the rule’s four core elements, and the plan should include:

  • Compliance with federal and state laws
  • A comprehensive method to contact staff, including patients’ physicians and other necessary persons
  • Well-coordinated communication within the facility, across healthcare providers, and with state and local public health departments and emergency management agencies

2. Establish one available and secure endpoint to simplify emergency communication

When developing an emergency plan, it’s important to consider all the hospital’s systems and endpoints that people use and how those systems are integrated. Also keep in mind that nurses and staff could be working anywhere in the hospital and may not have access to their desk phones.

According to McCarty, “We’re getting away from pagers by using an SMTP setup that gives us a bridge to funnel communications to our Voalte smartphone platform endpoint. This means that one operator can then quickly send an emergency code without logging in to multiple systems.”

3. Prepare to be home alone

Flooding, power outages, and impassable roads can cut off connections to the outside world. When Hurricane Irma was bearing down in 2017 on the island where Tampa General is located, the hospital faced the possibility of being physically isolated from the rest of the city.

Since it couldn’t rely on the internet, Tampa built redundancies into its core on-premise Wi-Fi network, including data recovery servers. It has backup generators on the island and diesel fuel for four days, with more available if needed. Core switches are located on higher floors in case of flooding. These redundancies ensure that Tampa can continue running its Voalte communication platform if it is ever cut off from the mainland.

4. Use mobile technologies to track and connect patients

Federal regulations require that hospitals’ emergency preparedness programs include systems to track the location of on-duty staff and sheltered patients in the hospital’s care during an emergency. Hospitals must be able to quickly reunite families with their loved ones, which can be especially challenging on sprawling campuses with millions of square feet of space.

One solution is to use apps that enable physicians, nurses, and staff to take pictures using a smartphone linked to a secure communication platform. These pictures can be stored temporarily on hospital servers and prevented from being uploaded or sent to anyone without access to the platform.

5. Be flexible and redundant, and don’t forget low-tech and old-tech alternatives

The urgency and frequency of alarms, messages, and other patient communications don’t abate just because a network shuts down. Hospitals need backup communication solutions to ensure the continuity of patient services.

“If there’s a system outage, we’ll employ different communications, such as a ticker on our intranet page,” said Turner. “We also keep a directory of phone numbers that can be used for ‘phone tree’ communications and can still pull out walkie talkies if needed.”

At Tampa General, McCarty became interested in ham radio as a result of Irma. The hospital now has a ham radio in its command center with an antenna on its roof as well as three iridium satellite phones—two at the hospital and the other at a large outpatient facility that has a freestanding ED and a helipad.

6. Build muscle memory with training drills

When a crisis happens, chaos and confusion supplant the natural order of everyday routines. To ensure that hospital staff are prepared to function in these high-stress situations, CMS requires facilities to demonstrate completion of two emergency exercises per rolling 12-month interval. Regulations also currently require hospitals to update their training and testing methods at least once a year.

The panelists emphasized that routinely conducting these drills several times a year builds much-needed “muscle memory” that enables the staff to react reflexively in high-stress situations. At Tampa General, each unit has its own downtime plan and downtime boxes that are routinely updated.

Four more tips

  • Ensure IT and communication leaders are included on disaster planning committees
  • Align communication policies with current technologies, clinician and patient needs, and various disaster scenarios, including active shooter events
  • Keep an extra supply of smartphones on hand and strategically place them in certain units for use only in an emergency
  • Don’t put all your eggs in one basket; always have a plan B, C, and D

Final word

Ultimately, crisis communication is all about meeting the needs of staff, patients, and their caregivers. As Shannon pointed out, “Our priority during any emergency is to support and connect the people who are doing the most important work. We may find ourselves swirling around trying to get everything right, but our focus should always be helping all those who are caring for patients.”

Jody Moore is co-founder and principal partner of Crisis Focus, an emergency management consulting company for healthcare providers.

Featured webcast: PPE in Healthcare: How to Improve Culture, Consistency and Compliance

By: October 13th, 2016 Email This Post Print This Post

After the October 2014 outbreak of Ebola in the U.S. led to several life-threatening cases in U.S. hospitals, it became apparent that many healthcare workers don’t follow proper protocol, either because they didn’t realize the risks or weren’t properly trained. Too often healthcare organizations find themselves unprepared for a hazardous situation or patient. It is in these tense moments that proper PPE training is put to use to protect staff and patients while minimizing risk.

Join expert speakers Kevin Bussiere, RN-CIC and Marjorie Quint-Bouzid, MPA, RN, NEA-BC, for a special live program, “PPE in Healthcare: How to Improve Culture, Consistency and Compliance,” on Wednesday, October 26, 2016 from 1–2:30 p.m. ET

During this program, our experts will clarify confusing PPE situations as well as explain when and how to properly implement PPE best practices, and how to implement an effective worker training program. Bussiere and Quint-Bouzid will demonstrate the role of technology, risk assessment, and PPE needs for their staff, as well as how to use peer support to improve compliance.

At the conclusion of this program, participants will be able to:

  • Demonstrate understanding the role of technology, research and development, and regulations on healthcare PPE advancements
  • Identify different types of PPE and when their use is most appropriate for worker safety
  • Use a risk assessment to determine how to identify categories of staff and their PPE needs
  • Demonstrate how to use peer support to improve worker compliance

Don’t miss this opportunity to hear practical advice and ensure your staff is protected through awareness and training on an organization-wide level, in a program suitable for your whole facility. To order the webcast on demand, call HCPro customer service at 800-650-6787 or visit the HCPro Marketplace.

Guest blog: A discussion about fire attention and prevention

By: October 3rd, 2016 Email This Post Print This Post

In this guest column, Dan Scungio, MT(ASCP), SLS, laboratory safety officer for Sentara Healthcare, a multihospital system in the Tidewater region of Virginia and otherwise known as “Dan, the Lab Safety Man,” discusses the important issues that affect your job every day.

October is here, and it’s that time when you should be raising awareness about fire safety in the laboratory. It’s National Fire Safety/Prevention Month, and fires occur in high enough numbers in the United States (even in laboratories) that we need to pay attention and focus on prevention.

The College of American Pathologists uses eight checklist standards to cover lab fire safety, and even though they have made some changes in the past few years, all of the elements are there to help you prepare and protect your staff in the event of a fire. There are many fire sources in the lab setting, and even more fire accelerants, and those alone should help us realize the importance of fire safety knowledge. However, many go through their daily work routines without giving it a second thought. When the fire occurs, they will not be ready, and the results could be devastating.

Fire safety training should occur with all staff. OSHA requires that if fire-fighting equipment is in the facility, staff must have documented training. CAP “strongly recommends” hands-on fire extinguisher training tht includes actual activation of the equipment. I agree, and I also recommend that this is performed at least annually. Operating a fire extinguisher is not a natural process, and some people struggle with it. Extinguishers can be heavy, and pulling the pin can sometimes not be a smoot, easy motion. Staff should practice these tasks and not experience them for the first time in an actual fire event. Most use the acronym PASS (Pull, Aim, Squeeze, and Sweep) to help people remember how to use an extinguisher, but there are other things to consider as well. If the fire is larger than the size of a waste basket, get out and let the professionals handle it. Never use two fire extinguishers at the same time, the force can actually push burning debris back onto someone who is trying to stop the fire. Also, make sure you are always between the fire and an exit- never let yourself be trapped in the room by the fire. These are training nuances that shouldn’t be herd once during a lab employee’s career.

CAP used to enforce the actual evacuation of each employee in a fire drill, but that is no longer required. Now an annual documented assessment of the evacuation route is considered sufficient. Again, a fire situation, especially one where evacuation is necessary, is not when you want staff learning for the first time how to get to a designated evacuation location. There should be primary and secondary routes, and if staff has not walked them, they may not know how to go there safely and efficiently in an emergency. Walk with staff annually so they know where to go- take a few people at a time, you do not need to stop work to make this happen.

OSHA and CAP do require annual fire safety training. That training should include knowledge of other fire-fighting equipment (such as fire blankets if provided), the location of fire alarm pull stations, and staff responsibilities during a fire. It is considered to be acceptable to review all of that safety information via a computer or a test. Again, I state strongly that the annual review needs to be more comprehensive in order to be truly effective. Fire drills are often required via local fire code or hospital and clinic regulatory agencies. Make sure your staff is participating to the fullest extent.

Fires do occur, and it is never where or when you might expect. The element of surprise is enough of an obstacle when facing a situation. With regular training and drills, laboratory staff can overcome that one obstacle and not run into more- not knowing how to use a fire extinguisher or not knowing what to do or where to go. Those obstacles are life-threatening, and they can and should be avoided with regular safety training and drills.

Proper placement and compliance for eyewash stations

By: September 21st, 2016 Email This Post Print This Post

We get lots of reader mail from folks looking for information about eyewash stations, and what OSHA and other accreditation agencies require from healthcare facilities. Healthcare compliance consultant Brad Keyes, CHSP, attempts to explain the complex world of eyewash stations.

When and where are eyewash stations required in a healthcare facility? This is one of the more frequent issues with which healthcare professionals struggle. There is a tendency to place these stations nearly everywhere, but in reality there aren’t as many locations that require eyewash stations as one may think.

Eyewash stations are required wherever there is a possibility that caustic or corrosive chemicals could splash into an individual’s eye. It is important to note that blood and body fluids are not considered to be caustic or corrosive. It is also important to note that the use of personal protective equipment (PPE) such as face shields, glasses or goggles does not exempt a facility from its need for an eyewash station.

Here are some recommendations on evaluating your existing eyewash stations for compliance:

  • In a healthcare setting, eyewash stations are typically found where cleaning chemicals are mixed (such as housekeeping areas), where plant operations take place, and in kitchens, generator rooms, environmental services storage rooms for battery-powered floor scrubbers, in-house laundries, dialysis mixing rooms, and laboratories. Find out whether a risk assessment has been conducted to determine the need for eyewash stations.
  • All required eyewash stations must be the plumbed type, which can operate in one second or less. This means the faucet-mounted type that requires turning the hot water lever and the cold water lever and then pulling a center lever is not permitted.
  • Access to the eyewash station must be within 10 seconds (or 55 feet) of the hazard. The individual seeking an eyewash station may travel through one door to get to an eyewash station, provided the door does not have a lock on it and swings toward the eyewash station.
  • If an eyewash station is observed outside of an area where one is typically needed, ask the staff who work in the area why it is there. See if they have a risk assessment that requires it to be there. Advise them that if there is no valid reason for the eyewash station to be there, it can be removed, which may save them the time and resources spent in maintaining it.
  • Eyewash stations may need to have a mixing valve to maintain a flow of water in the 60 to 100 degrees Fahrenheit range. Ask to see the risk assessment to determine whether a mixing valve is required.
  • Every eyewash station needs to be tested weekly by flowing water to clear any sediment and bacteria. There is no requirement regarding how long the water must flow. Every eyewash station must be inspected annually to determine whether the eyewash station still conforms to the installation parameters. The weekly test and annual inspections must be documented.
  • The presence of eyewash bottles indicates someone in the organization decided it was needed. Investigate and ask why the bottles are located there. Determine whether they need a plumbed eyewash station within 10 seconds’ travel time (or 55 feet) of the perceived hazard. Check the expiration date on the bottles.

Always check with your state and local authorities to determine whether they have any additional requirements.

How to stay on top of OSHA compliance

By: September 8th, 2016 Email This Post Print This Post

OSHA fines these days have a bit more of a bite. In August, the agency increased its maximum penalty from $7,000 per violation to $12,471, plus an extra $12,471 per day each day past the abatement date. And fines for repeated or willful violations have also grown from $70,000 to a whopping $124,709 per violation.

Because of the relative rarity of OSHA inspections compared to other agencies such as CMS or The Joint Commission, some clinics have seen OSHA compliance a lower priority. However, the new costs of noncompliance may give clinics a reason to shore up their workplace safety program, fast. So how can a clinic, particularly one strapped for resources, become OSHA ready?

Rose Comstock, COHSM, risk manager at Southern Trinity Health Services, Scotia, California has worked for 25 years in safety and compliance. The key to OSHA compliance, she says, is making sure leadership supports and cultivates a safety culture. For safety officers, that means making sure the hospital executive understands why these regulations matter.

“Safety initiatives can be met with some resistance, but safety regulations are generally promulgated because someone, or many people, died or were seriously injured as a result of circumstances at a workplace,” she says. “If you read the history behind OSHA anyone would fully appreciate why workplace safety is where it is today.”

Comstock says the first step to achieving full OSHA compliance is conducting a full review of all policies and programs. Clinics need to know that their policies are all up-to-date with current state and federal OSHA regulations.

Chris Mancillas, CIH, is senior vice president of EPIC Insurance Brokers and Consultants in Boston and has been working in the health and safety field for over 20 years. He says that when it comes to OSHA compliance, the biggest issue that most clinics encounter is a lack of resources. Part of this is that clinics can’t always afford to hire someone to deal solely with OSHA requirements. Therefore, the work gets added to someone else’s plate within the facility to deal with. Still, he says there are ways to resolve this.

“Aside from the typical third party safety consultants, there’s also their insurance broker,” he says. “They may have access to certain services through the insurance company. Sometimes you can ask the insurance carrier for some logics control, but sometimes the logics control guy is only going to so the eyes and ears for the underwriter. So I think going to their agent, their broker, can help in getting some services. They may have some internal safety consulting services. That person is not the eyes and ears for the underwriter, but he works for them and can provide a perspective of what an OSHA inspector might look at.”

Along with annually scheduled safety training, Comstock says that employees will need to be trained every time changes are made to clinic policies or after there’s a safety incident. This goes for all employees, even temp or part-time workers.

Questions you should ask when evaluating your training program are:

  • When was the last time you gave your employees a copy of your Injury and Illness Prevent Program (IIPP?)
  • Do they know what’s in your IIPP and which rules apply to them?
  • Do they know how to report an illness or injury?
  • Do they know who the program administrator is?

Clinics should also ensure that facility inspections are both regularly scheduled and properly recorded. When OSHA comes, you need to show that hazards had been identified and mitigated using proper documentation.

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