Briefings on Accreditation and Quality, August 2017

Briefings on Accreditation and Quality, August 1, 2017

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Editor's Note: Click the PDF button above for a full edition of the August 2017 edition of Briefings on Accreditation and Quality

High- and low-risk devices are all the same to surveyors; New maintenance standards could prove costly for hospitals

Many were shocked by The Joint Commission’s newest standards and elements of performance (EP) on medical device maintenance. The accreditor will no longer distinguish between “high-risk” and “non-high-risk” equipment when surveying maintenance and inspection compliance. Instead, facilities are expected to achieve 100% inspection compliance for both types of devices.

But hold off before panicking over how you’re supposed to track down and inspect 100% of the medical devices in your facility. The new standards have exceptions written into them for items that are in use or have gone missing.

CMS tells surveyors to double check for Legionella contamination

On June 2, CMS issued a new memo to surveyors on the importance of reducing cases of Legionella infections. Not long after, the Centers for Disease Control and Prevention (CDC) sent out a Vital Signs report underlining the bacterium’s risk to patients. Accredited facilities should double-check their waterborne pathogens compliance, as surveyors will likely pay more attention to it in upcoming surveys. The contents of this memo go into effect immediately.

Experts weigh in on CMS transparency proposal: Balancing public's right to know with quality

This April, CMS published its hospital inpatient prospective payment system (IPPS) proposed rule for fiscal year 2018. One section in particular would require accrediting organizations (AO) to make survey reports or plans of corrections (PoC) publicly available online within 90 days of the information becoming available to the healthcare organization. However, there are concerns that this move creates an uneven playing field in hospital quality and oversight. It’s also argued that the public might have trouble deciphering the contents of accreditation reports, leading to more confusion. 

Q&A: What you need to know about compounding medicine

The Joint Commission unveiled a new Medication Compounding Certification (MCC) program in January with the goal of reducing the harm stemming from drug compounding and ensuring compliance with U.S. Pharmacopeial Convention (USP) and Joint Commission standards. All compounding pharmacies are eligible to enroll in the program, including organizations not accredited by The Joint Commission. Meanwhile, USP Chapter <800> goes into effect on July 1, 2018 and contains major changes aimed at protecting healthcare workers from exposure to hazardous drugs and materials. The following is an edited Q&A with Kurt Patton, MS, RPh, a former director of accreditation services for The Joint Commission and founder of Patton Healthcare Consulting in Naperville, Illinois. He spoke with BOAQ on the details surrounding medication compounding.

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