HCPro.com - Accreditation - DO NOT USE Top Stories

The Joint Commission appoints new laboratory executive director

Mon, 16 Nov 2009 16:54:00 GMT

The Joint Commission has named Jennifer F. Rhamy, MBA, MA, MT(ASCP), SBB, HP to the role of executive director of the Laboratory Accreditation Program, according to a press release on its official Website.

Rhamy is a veteran healthcare professional who has experience in hospital and blood center settings, with her most recent work being involved as a blood center consultant and serving as vice president of laboratory sevices for the Indiana Blood Center in Indianapolis for eight years. Rhamy is also a certified Lean Six Sigma and has a masters of arts in Language and Communication from Regis University (CO).

The Laboratory Accreditation Program was launched in 1979 and to date accredits nearly 2,000 organizations that offer laboratory services.

To read more on the story, click here.

Joint Commission changes preliminary denial of accreditation rules

Mon, 16 Nov 2009 16:51:00 GMT

The Joint Commission has announced two changes to its Preliminary Denial of Accreditation (PDA) decision— the elimination of one rule and revision of another.

Rule PDA06, which addresses the need to have a license, certificate, or permit, has been altered.

Previously, if an organization was found to lack certain specific licenses, certificates, or permits at the time of survey, the organization would receive a PDA decision. This lack of license or permit often was the result of the organization being unaware such a permit was needed, and would result in immediately obtaining the permit (or, if the permit application is already in process, demonstrating during the survey that steps to apply for the permit have been taken).

Under this change, however, the organization lacking the license must now show an acceptable Evidence of Standard Compliance demonstrating that the organization has received the necessary license, certificate, or permit—until that time the organization receives an accreditation decision pending receipt of this documentation and receive a Requirement for Improvement (RFI).

In order to assure The Joint Commission that appropriate processes or policies are in place for obtaining this license or permit (and thus it will be renewed in the future in a timely manner), the RFI will remain in the survey report.

Additionally, the accreditation organization has completely eliminated rule PDA07, which was invoked after a healthcare organization received a Preliminary Denial decision on two consecutive full surveys.

To read more on the story, click here.

Greeley Reflections

Mon, 16 Nov 2009 16:40:00 GMT

Gray matters: Red alert

Part 1 of 5

I will freely admit that things are a little calmer this year on the survey front, at least in terms of survey jeopardy (Preliminary Denial/Conditional Accreditation), but even though the 2010 survey year appears not to represent an increased risk in Environment of Care, there are still two areas (located in the Life Safety chapter) that can run you afoul of those most very adverse accreditation decisions:

the management of Life Safety Code® (LSC) deficiencies through the Statement of Conditions/Plan For Improvement (SOC/PFI) process
the management of Interim Life Safety Measures, which are actions that one would take to ensure that an appropriate level of life safety is maintained during various activities like construction and renovation projects

And when you have LSC deficiencies of significant risk/impact or are going to take a while to correct. The most “prominent” application of the latter circumstance is when an organization chooses to manage an LSC issue through the aforementioned SOC/PFI process (see how these two wrap themselves neatly around each other?).

Each of these areas minimally contains the potential for a finding of Conditional Accreditation, and if the deficiency is considered egregious enough, maybe Preliminary Denial. Scary stuff? You bet! But you can do something to avoid such a fate. So huddle up and we’ll talk you through some basic questions to ask.

Study finds MRSA strain resistant to treatment

Mon, 09 Nov 2009 18:27:00 GMT

One strain of Methicillin-resistant Staphylococcus aureus (MRSA), USA600, has been found to be partially immune to an antibiotic that is used to treat the condition, according to HealthDay.com. MRSA causes infections in the skin and bloodstream, and can infect surgical wounds and pneumonia.

Half of the patients who developed this strain died within a month, which is five times faster than other people infected with MRSA are. These statistics were presented at the Infectious Diseases Society of American, held October 29 through November 1, in Philadelphia, PA.

Researchers believe that the USA600 strain is unique and that the age of the patient could play a part in whether antibiotics can treat the infections or not. Patients who developed the USA600 strain averaged around 64 years of age, as compared to 52 years of age.

To read more on the story, click here.

Rhode Island hospital fined after fifth wrong-site surgery in two years

Mon, 09 Nov 2009 18:24:00 GMT

The Rhode Island Department of Health will fine Rhode Island Hospital, Providence, RI, $150,000 after a surgeon operated on a patient's wrong finger last month, according to ABC News. Since 2007, five wrong-site surgeries have occurred, three of which were brain surgeries performed on the wrong location.

To prevent future wrong-site surgeries, RIH must install video cameras in all of its operating rooms and a clinical professional, not on the surgical team, trained in surgical safety measures, will observe all surgeries.

"This is now deemed inexcusable. It's a 'never to happen' occurrence in a hospital," Sidney Wolfe, MD, president of the consumer advocacy group Public Citizen said in an official statement.

To read more on the story, click here.

Greeley Reflections

Mon, 09 Nov 2009 17:06:00 GMT

Taking a quick look at the NPSG updates

Part 4 of 4

NPSG.03.04.01 now requires that solution labels include both quantity and volume. Volume need not be on the label if it is apparent from the container. Quantity always needs to be on the label. That does not make sense.

We hear that the Joint Commission intends to relax its 90% threshold for hand hygiene compliance (NPSG.07.02.01), but we’ve yet to see this in writing. In the mean time, the new for continued improvement (EP3) can be a problem.

Unfortunately, medication reconciliation remains in limbo until sometime next year. On one hand, the 2009 version of the language applies and hospitals are expected to comply. On the other hand, it is not being scored during survey until the new version comes out (intended for the second quarter of 2010).

Like we said, it’s mostly good news. From where we sit, the Joint Commission is moving in a very positive direction… but there is much more ground to cover.

Stay tuned!

Wall Street Journal reports on most effective ways to reduce HAIs

Mon, 02 Nov 2009 18:14:00 GMT

Nearly two million patients a year will be hospitalized by an infection, resulting in nearly 100,000 deaths, according to The Wall Street Journal (WSJ). These infections are not inevitable, so with the help of doctors, nurses, administrators, the nonprofit Committee to Reduce Infection Deaths, and the Association for Professionals in Infection Control and Epidemiology, WSJ came up with two lists of new technologies and old techniques hospitals may want to implement to stop infections.

The first list focuses on ways hospitals can use these new technologies to help double-check the cleanliness of a room, data mining, and the use of anti bacterial soap. One technology WSJ suggests is using fluorescent markers to spray all over patient rooms. A black light then reveals areas that were not cleaned thoroughly.

The second list highlights basic techniques to which hospitals should still pay attention. Hand hygiene remains number one on the list—hospitals that have placed dispensers of alcohol-based sanitizer around their facilities have seen dramatic increases in compliance, reports the WSJ. Hospitals are also creating "can't miss kits" that are filled with all the equipment needed for proper hygiene compliance for common procedures.

Bar codes on patient arm bands to improve safety and prevent medical errors

Mon, 02 Nov 2009 18:11:00 GMT

Polk County hospitals in Florida are using bar-code technology at the bedside to help improve patient safety, according to The Ledger. Every year, medication errors harm at least 1.5 million people, the Institute of Medicine of the National Academies reported in 2006.

Now, nurses employed by the Polk County hospitals will routinely scan a bar code on each patient's armband as well as read the patient's name. The scan will also help automate the checks and balances nurses normally go through before administering medication. This process helps the patients see the initiatives hospitals are taking to improve their own safety.

Winter Haven Hospital is the latest to join the Polk County system in using bar codes on patient armbands. Other hospitals using bar codes include Bartow Regional Medical Center, Heart of Florida Regional Medical Center, and Lakeland Regional Medical Center. Also planning to implement the bar codes soon is Lake Wales Medical Center.

To read more on the story, click here.

Greeley Reflections

Mon, 02 Nov 2009 18:06:00 GMT

Taking a quick look at the NPSG updates

Part 3 of 4

The Universal Protocol now applies to ALL invasive procedures rather than those that put the patient at more than minimal risk. On its face, this appears to cover many procedures not currently subject to the time out. However, we also understand that the Joint Commission intends to ease back on the scope of the Universal Protocol.

The Universal Protocol now requires that items in the procedure room be “matched to the patient.” We believe that traditional room setup practices will meet this requirement, but the language is a little confusing.

For some reason the requirement for active communication during the time out was removed from UP.01.03.01. We don’t believe this was intentional.

It is now clear that a second time out is only required when the person doing the procedure changes (UP.01.03.01). However, we’re still a little confused about the requirement for a time out before anesthesia. For example, must we document the time out twice if it is done in two phases: once before induction/intubation and again immediately before the procedure?

Medicare patients suffer from a medical error every 1.7 minutes

Mon, 26 Oct 2009 17:52:00 GMT

A recent evaluation of almost 5,000 hospitals across the nation found that 913,000 "patient safety events" occurred between 2005 and 2007, according to NaturalNews.com. The evaluation, conducted by HealthGrades, reviewed a Medicare database and the hospitals' performance on 12 different measures of patient safety. The patient safety events were errors that led to medical problems.

The most common errors were bed sores, postoperative respiratory failure or serious infection, and death from serious but treatable complications among surgical inpatients. Results shows that 2.3% of Medicare patients suffered from errors at these hospitals, which means, on average, such patients suffer from an error every 1.7 minutes.

Another statistic derived from the evaluation was that patients staying at an award-winning hospital were 43% less likely to be at risk of a medical error.

"The good news is that there are hospitals out there doing an amazing job when it comes to patient safety," lead researcher and orthopedic surgeon Rick May said in an official statement. "Patients need to know that they have a substantially lower risk of experiencing a medical error and therefore a lower risk of death or complication when they are admitted to one of these exceptional top-performing hospitals."

To read more on the story, click here.

WHO warns hospitals about expected surge

Mon, 26 Oct 2009 17:48:00 GMT

After a three-day meeting at the headquarters of the Pan American Health Organization in Washington D.C., where more than 100 experts gathered to review the H1N1 flu, the World Health Organization (WHO) has warned hospitals to ready themselves for the next wave of sick patients, according to The Washington Post. The WHO warns that young adults, especially woman, infected with H1N1 virus are falling seriously ill at an unexpectedly rapid pace.

So far, 41 states are reporting cases of swine flu and widespread flu activity, with Virginia and Maryland recently joining the list. In addition, the number of deaths in children with the H1N1 virus has climbed to 86. Since the outbreak of the H1N1 virus, at least 2,914 Americans have died from flu-related illnesses.

The Centers for Disease Control and Prevention recently reported that the swine flu vaccine production is proceeding at a slower pace than expected. Originally expected to produce 40 million doses, they will fall short by about 10 – 12 million.

To read more on the story, click here.

Greeley Reflections

Mon, 26 Oct 2009 17:44:00 GMT

Taking a quick look at the NPSG updates

Part 2 of 4

Seven goals were moved to the standards. (The requirement will remain, but will receive less emphasis during the survey.)

NPSG.02.01.01 Verbal/telephone order, critical test result read back
NPSG.02.02.01 Do Not Use entries
NPSG.02.05.01 Handoff communication
NPSG.03.03.01 Look-alike/sound-alike medications list
NPSG.09.02.01 Falls
NPSG.13.01.01 Patient involvement in care
NPSG.16.01.01 Rapid response
NPSG.02.03.01 (cited on 38% of 2009 survey reports) has been relaxed.

The requirement to monitor critical tests is gone, and the remaining language is intended to allow more flexibility in the way that timeliness of critical result reporting is monitored.

A few questions remain. We hope most questions will be clarified in forthcoming FAQs, but we are disappointed that FAQs remain necessary.

The National Quality Forum releases 2009 Updates; HFAP adopts safe practices

Mon, 19 Oct 2009 14:39:00 GMT

Since The National Quality Forum (NQF) released the 2009 Update of its Safe Practices for Better Healthcare, Healthcare Facilities Accreditation Program (HFAP) has adopted the 34 safe practices, which will now be implemented by all HFAP-accredited hospitals, according to an official statement by the organization.

NQF has added seven new practices that will be incorporated in the new standards throughout the manual. Two of these will be retired because other measurement strategies covering the same events. These new practices include disclosure, support of caregivers, pharmacist leadership structures and systems, glycemic control, and fall prevention.

"There is no doubt that the implementation of these 34 practices will improve patient safety," said Mike Zarski, CEO of HFAP, in an official statement. "We studied them in great detail, and they are a vital part of our survey process."

Cedars-Sinai Medical Center exposes patients to dangerous radiation levels

Mon, 19 Oct 2009 14:30:00 GMT

More than 200 patients who received brain scans after February 2008 were exposed to radiation dosages after the CT scanner was reprogrammed, according to the Los Angeles Times. Cedars was beginning to use a new protocol for a specialized type of scan used to diagnose strokes. In order to do this, the machine had to be reset to override the original scanner instructions.

An error in the default setting applied to the machine caused any patient receiving a CT scan to get a dose of radiation eight times what it should have been. For 18 months, this error went unnoticed until a patient complained he had begun losing his hair after a scan. After checking patient records, the hospital found that 206 patients had been affected, with 40% of them experiencing hair loss, and even some reddening of the skin.

This discovery caused the Food and Drug Administration to issue an alert to all hospitals across the country, warning them to check their CT protocols.

Greeley Reflections

Mon, 19 Oct 2009 14:07:00 GMT

Taking a quick look at the NPSG updates

Part 1 of 4

The release of the 2010 National Patient Safety Goals (NPSG) rolled back some of the difficult and unclear expectations introduced last year about this time: requirements such as documenting hand hygiene education to all patients, even outpatients, are now gone…effective immediately.

We’re still waiting for the other shoe (or shoes) to drop. We’re expecting revised FAQs (hopefully soon) and we would love to see the actual language of the goals that were moved to standards September 9.

Many of the troublesome requirements introduced last year are gone. Designation of an individual to participate in the identification process on behalf of the patient has been removed (NPSG.01.01.01).

Documentation of patient education about hand hygiene, respiratory hygiene, and other issues at the time of admission is no longer required (NPSG.13.01.01). (However, common sense requirements about patient/family education remain in various locations throughout the standards.)

The immediate “pre-transfer” checklist process has been removed from the Universal Protocol (UP.01.01.01). It has been replaced by language that allows the continued use of separate pre-procedure forms by the preoperative nurse and the circulator as the patient progresses toward the procedure.

Broward General Medical Center warns patients of potential HIV infection

Mon, 12 Oct 2009 16:27:00 GMT

A Fort Lauderdale nurse has resigned after being accused of reusing equipment to conduct cardiac stress tests on patients at the Broward General Medical Center, according to CNNhealth.com. Qui Lan, the nurse in question, admitted to using disposable IV equipment on multiple patients, which is a violation of safety standards.

Since Lan's resignation, the hospital has reviewed all of her patient files, dating back to January 2004. Leading up to the present time, authorities determined she conducted the cardiac stress test on 1,851 patients. These patients are now being urged to get tested for the Hepatitis B and C virus, along with HIV.

Although the risk for infection is low, Broward has set up a 24-hour patient hotline and asks concerned patients to visit their Web site or call the hotline number.

Unannounced Joint Commission survey leaked to hospital via e-mail

Mon, 12 Oct 2009 16:22:00 GMT

New York's Bellevue Hospital was alerted by Eric Manheimer, MD, the head of patient safety, via e-mail to expect an almost immediate visit from The Joint Commission, according to the New York Daily News. The recent increase in unannounced surveys at several hospitals in the Health and Hospitals Corporation (HHC) circuit, in response to Daily News' series on cover-ups of medical mistakes, prompted the email to be sent out.

The email, sent out to 20 staff members, instructed staff to discharge those patients who did not need hospitalization over the weekend and that all supervisors check on the documentation of all inpatients to verify completeness, as well as that the documentation included all National Patient Safety Goal information.

"Putting people on notice of the possibility of a survey allows them to make plans in advance and adjust their schedules so they don't have to abandon important commitments that are already in place," said Manheimer in an official written statement to the Daily News.

The Joint Commission has yet to visit Bellevue Hospital, but has visited other HHC hospitals including Kings County Hospital in Brooklyn and Metropolitan Hospital in Harlem.

To read more on the story, click here.

Greeley Reflections

Mon, 12 Oct 2009 16:10:00 GMT

Prudence or wisdom? Can your policies pass muster?

Part 4 of 4

If you were one of the excited lucky ones setting up the first hospital in the United States, you would have been writing the rules from scratch. That groundwork has long been established but there are guidelines that can serve as valuable resources.

The 2009 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official Handbook contains a chapter entitled ?Required Written Documentation.? This chapter provides a list of all of the Joint Commission EPs requiring written documentation for hospitals. Not all of the items listed require policies--many are references to logs, licenses, annual reports, etc.--but this is an excellent starting place for the prioritization process.

However your organization manages the process of developing, reviewing, and revising policies, invest the time to evaluate it to ensure it can pass muster. Your process should give you the confidence that your patients are being consistently provided quality and safe care.

The Joint Commission awards first Disease-Specific Care Advanced Certification Program in Heart Failure

Mon, 05 Oct 2009 18:32:00 GMT

Advocate Christ Medical Center in Oak Lawn, Illinois has become the first organization in the country to be certified according to the new Advanced Certification Program in Heart Failure, according to an official statement released on the Joint Commission's Web site.

Developed by the Joint Commission, in collaboration with the American Heart Association, the certificate will recognize those hospitals making efforts to foster better quality of care and outcomes for heart failure patients.

In order to qualify for the certification program, organizations must meet the following criteria:

Meet the standards and performance measurement requirements under the Joint Commission's Disease-Specific Care Certification program.
Achieve and sustain for 90 days or more at least 85 percent compliance with the five achievement measure of Get With The GuidelinesSM - Heart Failure, the American Heart Association's hospital-based quality improvement program designed to close the treatment gap in cardiovascular disease.
Collect data on Joint Commission's core measures for heart failure and use this data in ongoing performance improvement activities.