HCPro.com - Accreditation Connection

CLABSI to be included on Hospital Compare

Fri, 03 Feb 2012 16:16:00 GMT

CMS has updated its Hospital Compare website in order to include central line-associated bloodstream infection (CLABSI) data provided by hospitals.

Hospitals must report CLABSI rates for adult, pediatric and neonatal intensive care unit patients to receive a full payment update in fiscal year 2013 under the inpatient prospective payment system. Hospitals with ICUs and are participating in the program began reporting this data to the Centers for Disease Control and Prevention’s National Healthcare Safety Network in January.

For more information, visit the Hospital Compare website.

Joint Commission launches stroke education and awareness program

Fri, 03 Feb 2012 16:13:00 GMT

The Joint Commission has unveiled its latest entry in its Speak Up ™ program. Released on February 1, 2012, this latest educational campaign will focus on “What you should know about stroke.”

Developed in conjunction with the American Academy of Neurology, American Association of Neuroscience Nurses, American Heart Association/American Stroke Association, National Stroke Association and NIH/National Institute of Neurological Disorders and Stroke, the campaign was announced at the International Stroke Conference at the beginning of February. It is intended to help patients understand stroke prevention and the importance of seeking care right away in the event of a stroke.

For more information, visit The Joint Commission’s campaign website.

An important reminder about your Accreditation Connection subscription

Fri, 03 Feb 2012 16:07:00 GMT

Attention, Accreditation Connection subscribers: in just a few weeks, two of our most popular electronic accreditation publications, Accreditation Connection and the AHAP Staff Challenge, are joining forces to give readers a single, improved resource for Joint Commission, CMS, and other regulatory news.

The final issue of Accreditation Connection will arive on February 13th, 2012. Beginning on Feburary 145th, however, subscribers will instead automatically receive this new publication, AHAP Accreditation Connection. If you already subscribe to both Accreditation Connection and AHAP Staff Challenge, there is no need for further steps—you will simply be enrolled in the new, combined newsletter beginning in February. Here’s what readers can expect from the new, combined electronic newsletter:

AHAP Staff Challenge: Weekly survey-prep quiz questions to test your knowledge and train your staff
Two news briefs: Accreditation related news to keep you up-to-date on the latest hot topic issues and regulatory changes
The best of the AHAP blog: The AHAP Blog brings you dialogue from AHAP advisors and other accreditation experts. We’ll feature the most popular blog post that week so you can stay on the forefront of what your peers are talking about.
What’s new with AHAP!: An update on the happenings of our member-based networking community where accreditation professionals share the latest tested tips, tools, and strategies to implement successful accreditation programs and achieve professional growth.

If you are interested in another topic, there are other options for you. You can sign up for any of our other free e-newsletters that cover a variety of topics from infection control to quality and patient safety. Click here to sign up for one of our other e-zines.

Meanwhile, please add our revised address, ahap_connection@list.hcpro.com, to your e-mail address book to ensure that our renamed e-newsletter makes it to your inbox. While the name will change, AHAP Accreditation Connection will continue to bring you free, weekly updates on important accreditation topics.

Joint Commission releases communication guidelines for stroke, heart failure programs

Fri, 27 Jan 2012 16:08:00 GMT

The Joint Commission has released communication guidelines for the organization’s Certified Primary STroke Centers and Advanced Certification in Heart Failure programs.

These guidelines are intended to help organizations in these programs accurately and credibly portray their certifications.

The guidelines can be downloaded here.

Hospitals face growing financial challenges, ratings agencies say

Fri, 27 Jan 2012 15:59:00 GMT

Not-for-profit hospitals in the US face increasing financial pressures, two top credit rating agencies reported n January. Moody’s Investors Service reports that the outlook for hospitals looks negative for 2012, and Standard & Poor’s Rating Service says that “an increasingly difficult operating environment” will adversely impact hospital credit quality and ratings.

Among the challenges identified by Standard & Poor’s are tighter revenues, weaker payer mixes, lingering impact from the recession and health reform.

The Moody’s report can be found here; Standard & Poor’s can be found here (password required).

Point of Care Coordinator of the Year seeks nominees

Fri, 27 Jan 2012 15:52:00 GMT

The American Association of Clinical Chemistry Clinical Point of Care Testing (CPOCT) Division is accepting nominations for their 2012 Point of Care Coordinator of the Year Award.

Nominations are due March 15. For more information on how to nominate a colleague, visit here.

An important announcement for Accreditation Connection subscribers

Fri, 20 Jan 2012 15:54:00 GMT

We would like to announce that two of our most popular electronic accreditation publications, Accreditation Connection and the AHAP Staff Challenge, are joining forces to give readers a single, improved resource for Joint Commission, CMS, and other regulatory news.

Accreditation Connection’s last issue will publish on February 13th, 2012. Subscribers will instead automatically receive this new publication, AHAP Accreditation Connection, beginning on February 14th. AHAP Accreditation Connection will provide you with all the benefits you’ve come to expect from this publication, plus additional resources and tools to help you do your job. If you already subscribe to both Accreditation Connection and AHAP Staff Challenge, there is no need for further steps—you will simply be enrolled in the new, combined newsletter beginning in February. Here’s what readers can expect from the new, combined electronic newsletter:

AHAP Staff Challenge: Weekly survey-prep quiz questions to test your knowledge and train your staff
Two news briefs: Accreditation related news to keep you up-to-date on the latest hot topic issues and regulatory changes
The best of the AHAP blog: The AHAP Blog brings you dialogue from AHAP advisors and other accreditation experts. We’ll feature the most popular blog post that week so you can stay on the forefront of what your peers are talking about.
What’s new with AHAP!: An update on the happenings of our member-based networking community where accreditation professionals share the latest tested tips, tools, and strategies to implement successful accreditation programs and achieve professional growth.

Joint Commission releases revisions to lab deeming authority application

Fri, 20 Jan 2012 14:37:00 GMT

The Joint Commission has released revisions to the elements of performance (EP) of application for deeming authority for clinical laboratories.

The changes followed a review of the application and are intended to help meet Clinicial Laboratory Improvement Amendments of 1988 (CLIA) and apply to the LD and QSA standards.

For more information, visit The Joint Commission’s website.

LD.03.01.01 revised

Fri, 20 Jan 2012 14:34:00 GMT

The Joint Commission has unveiled prepublication standards, effective July 1, 2012, to Leadership chapter standard LD.03.01.01. LD.03.01.01 addresses leadership’s role in maintaining a culture of safety and quality.

The revisions effect The Joint Commission’s ambulatory, behavioral, critical access, hospital, home care, laboratory, long term care, and long term care (Medicare/Medicaid certification-based), and office-based surgery programs.

For more information, visit The Joint Commission’s website.

CMS to require certain facilities to report HAIs, other quality indicators

Fri, 20 Jan 2012 14:31:00 GMT

The Centers for Medicare and Medicaid Services (CMS) will, beginning this month, require some organizations to report specific quality indicators, such as healthcare-associated infections (HAI). The requirements come through the Center for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN).

The requirements vary depending on the type of facility. For example, acute care facilities that participate in the inpatient prospective payment system should report several specific items, such as adult catheter-associated urinary tract infections, as well as those from pediatric intensive care units, and surgical site infections connected to colon surgery and abdominal hysterectomy.

For more information on this topic, visit The Joint Commission’s website.

California Department of Public Health releases HAI reports

Fri, 13 Jan 2012 17:51:00 GMT

The California Department of Public Health (CDPH) has released six reports on data from California hospitals on a range of healthcare-associated infections, including central-line associated bloodstream infections (CLABSI), Methicillin-resistant Staphylococcus aureus (MRSA), and surgical site infections (SSI), among others.

“These reports provide the most detailed picture yet of healthcare-associated infections in California’s hospitals,” Ron Chapman, MD, CDPH director, said in a press release from the organization. “The information in these reports is intended to increase awareness and lead to appropriate changes that will decrease the number of these infections.”

The intent of this data collection program is to enable hospitals to find areas in need of improvement, as well as allowing healthcare purchasers a better method of determining value of care, and to provide patients with the tools to make more informed choices.

For more information on this project, visit the CDPH site here.

IL hospitals contribute over $4.6 billion in community benefits

Fri, 13 Jan 2012 17:48:00 GMT

According to a report released by the Illinois Hospital Association, Illinois hospitals contributed over $4.6 billion in community benefits between 2009 and 2010. This was an increase of 26% since 2005.

The report looks at 109 hospitals in the state which are required to to file community benefit reports with the state. The benefits identified in the report include free and discounted care, shortfalls absorbed by hospitals due to underpayments by government agencies, and costs absorbed by hospitals for healthcare services rendered to patients unable to pay for their care.

To read the report, click here.

Joint Commission announce 2012 board appointments

Fri, 13 Jan 2012 17:10:00 GMT

The Joint Commission has announced the names of its incoming Board of Commissioners for 2012. The organization has also decided this year to make its field representatives in three areas–-long term care, behavioral health, and home care–-all full voting members.

“Our new Commissioners all have a deep understanding of the complexities and challenges facing health care today,” Mark R. Chassin, MD, FACP, MPP, MPH, president of The Joint Commission, said in an official press release. “Their longstanding commitment to quality and patient safety will significantly enhance The Joint Commission’s efforts to achieve its mission of improving health care for the public.”

For more details about these appointments and changes, visit The Joint Commission’s website.

Two new accreditation decision rules approved

Fri, 06 Jan 2012 14:59:00 GMT

Effective January 1, 2012, two new accreditation decision rules have been approved by The Joint Commission for the Contingent Accreditation decision category. Both require the organization in question to resolve its Contingency Status within one year.

The first of these new rules applies to an organization has completed its first Joint Commission survey for deemed status and receives a Requirement for Improvement (RFI) related to a condition level finding. The second is for an organization undergoing its first Joint Commission survey and demonstrates systemic patterns or trends of noncompliance with the accrediting body’s standards.

A third decision rule has been moved to the Contingent Accreditation decision category, when possible fraud or abuse has been identified within an organization. There has been some slight changes to the language of this decision rule.

For full details on these changes, visit The Joint Commission’s website.

From the AHAP Blog: Joint Commission releases latest Survey Activity Guide

Fri, 06 Jan 2012 14:56:00 GMT

The AHAP Blog reports that The Joint Commission has released the 2012 Survey Activity Guide. This annual publication, made available directly through The Joint Commission’s website, is intended to help hospitals prepare for their on-site survey.

The guide also includes a list of activities during an on-site, suggested participants, objectives, and a general overview of the session.

For more information on the 2012 Survey Activity Guide, visit The Joint Commission’s website.

Joint Commission releases Easy-to-Read 2012 NPSGs

Fri, 06 Jan 2012 14:53:00 GMT

The Joint Commission has released the National Patient Safety Goals (NPSGs) for 2012 in an easy-to-read version. Goals for 2012 include identifying patients correctly, improving staff communication, using medications safely, preventing infections, identifying patient safety risks, and preventing mistakes in surgery.

Click on the program links below to view/download the 2012 NPSGs.

Ambulatory health
Behavioral health
Critical access hospitals
Home care
Hospital
Laboratory services
Long term care
Office-based surgery

For more information, visit The Joint Commission Website.

Joint Commission weighs in on worker fatigue

Thu, 15 Dec 2011 16:31:00 GMT

The Joint Commission’s latest Sentinel Event Alert targets an issue that has been oft-discussed in recent years: healthcare worker fatigue and patient safety.

Many studies have shown not only that extended work hours not only lead to worker fatigue, and from there, a loss of productivity–they also increase the opportunity for adverse events. The Joint Commission’s Sentinel Event Alert specifically addresses one cause of worker fatigue, extended work days and the cumulative effect of extended work hours.

The Sentinel Event Alert does acknowledge other potential causes for worker fatigue such as insufficient staffing, but targets this one trouble area for discussion.

For more information, visit The Joint Commission’s website.

Veteran receives $275,000 settlement after two towels are left inside him during surgery

Thu, 15 Dec 2011 16:27:00 GMT

The federal government has agreed to pay a 47 year old veteran $275,000 after two towels were left behind inside him after surgery to remove a cancerous kidney.

The surgery occurred at Louis Stokes VA Medical Center in Cleveland, OH, in May of 2008.

The hospital has since implemented a radio frequency identification chip system that tracks towels, sponges, and other items used during surgery.

To read more about this incident, visit Cleveland.com.

Texting while rounding?

Thu, 15 Dec 2011 16:18:00 GMT

The Patient Safety Monitor Blog has a fantastic post by writer Tami Swartz that might be of interest to accreditation professionals:

But what about frontline care staff? Can they text on the floor? If so, when? Does your hospital have guidelines about this? Many hospitals are worried about the content of texts and other uses of social media, such as Facebook. They worry HIPAA will be violated. But a recent incident exposed on the AHRQ’s “morbidity and mortality rounds on the web” proves that texting while rounding, no matter what the content, can prove distracting and near disastrous, especially when smartphones serve as both a hospital tool for ordering medication and the portal to a resident’s social life.

The case involves a resident and intern who discussed the plan of care for a patient while rounding. An attending told the resident to stop warfarin until an echocardiogram of the heart could be taken. Here’s a key part to this case: The hospital’s CPOE system allows providers to enter orders in the system through smartphones, a convenient option that allows real-time ordering. The resident began submitting the orders on her smartphone. Then she got a text about an upcoming party. The resident chose to respond to the text. The order for the patient was never completed, and the patient continued to receive warfarin for three days. Because of the CPOE system, no one reviewed the medication list, and everyone thought the order for warfarin was stopped. Though not stated in the case, I’m sure at least some of them thought they actually saw the resident put through the order on her phone.

The problem was realized when the patient developed shortness of breath, tachycardia, and hypotension from blood thinning. He needed emergency open heart surgery, and was in the hospital for three weeks before being discharged.

For those who use smartphones, it’s incredibly easy to understand how this happened. Once the decision is made to view a text (or if it pops up automatically), you are interrupted. Your screen is filled with only this text. You reply. Thoughts are now with that conversation, and there is nothing to remind you that another application is open, that you never finished the task.

To view the rest of the post, visit the Patient Safety Monitor Blog here.

Joint Commission proposes revisions to patient flow in the ED

Thu, 08 Dec 2011 16:19:00 GMT

The Joint Commission released on December 7, 2011 a set of proposed revisions to the accrediting body’s requirements in the area of patient flow in the Emergency Department (ED). These revisions, if approved, will impact the hospital accreditation program.

These revisions specifically target standards in the Leadership, and the Provision of Care, Treatment, and Services chapters relating to issues of patient flow, as well as care of patients awaiting admission or transfer. This also includes patients with psychiatric emergencies.

This field review will stay open until January 20, 2012. For more information, visit the field review’s landing page.