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Quality & Patient Safety

Quality & Patient Safety

The quality/patient safety department assists hospitals with meeting The Joint Commission's National Patient Safety Goals, addressing CMS patient safety-related regulations, ensuring patient satisfaction, and improving the overall quality of care.

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  • Joint Commission surveyor focus remains on EC, LS, ligature risks

    Highlight the ZIP codes where employees live so you can have a handy reference of staff availability in emergencies, keep policies consistent and updated with the most relevant references, and focus suicide prevention efforts on making your physical environment ligature-resistant.

    Those were some of the top takeaways for environment of care and other healthcare and quality professionals attending The Joint Commission’s (TJC) annual Hospital Executive Briefings held September 14 in New York City. The state of healthcare “is not good,” said Ana Pujols McKee, MD, TJC’s chief medical officer, rattling off uncomfortable facts such as the U.S.’s rising maternal mortality rate and that medical errors are the third leading cause of death. She urged attendees to accept nothing less than achieving zero harm in their hospitals and facilities.

  • This simple tool predicts readmission risk for heart attack patients

    A new risk model provides a simple and inexpensive way to determine whether acute myocardial infarction (AMI) patients are at high risk for hospital readmission.

    The risk model, which is detailed in a recent study published in the Journal of the American Heart Association, features seven variables that can be scored in as little as five minutes during a patient's first day of hospital admission. With a simple calculation at the bedside or in an electronic health record, physicians can determine whether a heart attack patient is at high risk for readmission and can then order interventions to help the patient avoid a return to the hospital after discharge.

  • CMS to use Joint Commission recommendations on ligature risk as guide

    In a new memo to its state survey agencies, CMS said it would use Joint Commission ligature recommendations—drawn from a task force that was convened by the commission and included several CMS suicide prevention experts—as the federal agency goes forward with clarifying and updating Interpretive Guidelines for its surveyors.

    Regardless of what organization you might use for accreditation, assess your hospital’s suicide prevention compliance against those Joint Commission recommendations with a detailed risk assessment and mitigation plan. If that plan includes renovations or extra staff and training, ensure your C-suite has budgeted money for those items to show surveyors leadership is serious about making changes.

  • PSS-3: Three-question suicide screener for the ER

    In the chaos of the emergency department (ED), it’s easy to miss something you’re not searching for. Up to one in five people who die by suicide visit an ED in the four weeks prior to their death. And those who die by suicide are more likely to come to the ED with a non-psychiatric complaint than a psychiatric one.

    We’ve run an ER checklist of items to be removed from rooms designated for treatment of suicidal patients. But that doesn’t help patients who aren’t screened for suicidality.

    Enter the Patient Safety Screener 3 (PSS-3), a suicide screening tool developed for the fast-paced world of the ED. The tool consists of a short introduction and three questions, with an optional fourth item if the person has previously attempted suicide. It’s meant to be given during triage or primary nursing assessment and has been validated for use on patients 18 and older.

    The three questions are:
    Over the past two weeks, have you felt down, depressed, or hopeless?
    Over the past two weeks, have you had thoughts of killing yourself?
    Have you ever attempted to kill yourself?

    If the person answers “yes” to item three, then you follow up by asking them when the suicide attempt took place.

    A “yes” to question one is a positive screen for depression. A “yes” to question two or if the person’s attempted suicide in the last six months is a positive screen for suicide risk.

  • The pipes are calling: CMS revises Legionella requirements

    You can expect renewed interest in your water management program. This summer, CMS sent out a new memo updating its expectations on Legionella infections. The memo, QSO 17-30-Hospitals/CAHs/NHs, was published July 6. It supersedes the former S&C 17-30-Hospitals/CAHs/NHs, issued in June 2017, and adds more specific expectations for long-term care (LTC) facilities. The update also helps clarify expectations for hospitals and nursing homes.

    The Legionella bacterium is responsible for legionellosis: a respiratory disease that can cause a type of pneumonia called Legionnaires’ disease, which kills about a quarter of the people who contract it. Legionellosis is especially dangerous for patients who are older than 50, who smoke, or who have chronic lung or immunosuppression conditions.

    The bacterium breeds naturally in warm water and can usually be found in the parts of hospital systems that are continually wet. Poorly maintained water systems have been linked to the 286% increase in legionellosis between 2000 and 2014. The CDC says there were 5,000 reported cases of it in 2014 alone, with about 19% of outbreaks in long-term care facilities and 15% in hospitals.

    While there are no new expectations for hospitals or critical access hospitals in the revised CMS memo, it does add a specific statement that “facilities must have water management plans” as well as a new note that testing for waterborne pathogens is left “to the discretion of the provider,” according to the letter to CMS’ Quality, Safety and Oversight (QSO) group, formerly the Survey & Certification (S&C) group.

    “The terms ‘plans’ and ‘policies’ are sometimes confusing to hospitals,” warns Kurt Patton, the former director of accreditation services for The Joint Commission and founder of Patton Healthcare Consulting, now in Naperville, Illinois.

    “The Joint Commission already requires a utilities management plan, and water is a component of that. The unknown will be if CMS surveyors say they don’t want to look at a utilities plan, they want to look at a water management plan,” explains Patton. “At a minimum, I would suggest accredited hospitals have a table of contents and a subject header for ‘Water Management Plan’ inside their overall utilities plan.”

  • Improve patient mobility in five easy steps

    The benefits of mobility among hospitalized patients are well-known: decreased pressure ulcers, deep vein thrombosis (DVT), and functional decline, to name a few.

    “Hospital-acquired pressure ulcers, falls in the hospital, falls that cause injury, DVTs, and pulmonary emboli are also caused by immobility," says Maggie Hansen, RN, BSN, MHSc, senior vice president and chief nurse executive at Memorial Healthcare System in Hollywood, Florida. "They have other factors that contribute to them, but [nursing] is taking ownership for preventing some of those things that should never happen to patients."

    Still, finding the time to ambulate patients during a busy shift is something nurses often struggle to do.

    "We heard feedback [from nurses] like, 'I really wish I had more time to ambulate my patients,' " says Leslie Pollart, RN, MSN, MBA, director of nursing at Memorial Regional Hospital in Hollywood, Florida. "While they knew it was important, competing priorities often impeded their ability to ensure timely patient mobility, and sometimes patients need more than one person to assist them in getting out of bed."

    To address this issue and ensure patients were getting the ambulation they needed to achieve optimal outcomes, the hospital revamped its mobility program, including creation of a designated mobility team.
     

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  • Patient Safety Monitor

    Patient Safety Monitor

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    Patient Safety Monitor
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