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Accreditation Insider

AHAP is a community in which survey coordinators and other accreditation specialists share the latest tested tips, tools, and strategies to implement successful accreditation programs and achieve professional growth. In this e-newsletter, you'll read helpful tips and timely news items related to accreditation and survey-readiness improvement. Plus, train your staff and yourself with our weekly quiz questions included with clickable answers.

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Issue 52, December 27, 2016

• Joint Commission Leadership standard now aligns with CMS

  On January 9, 2017, Joint Commission Leadership (LD) standard 01.03.01, element of performance (EP...

Issue 51, December 20, 2016

• Joint Commission targets CAUTIs with updated NPSG

  Earlier this year, The Joint Commission updated its National Patient Safety Goal (NPSG) on...

Issue 50, December 13, 2016

• Report: $28 billion saved through patient safety efforts

  Efforts to improve patient safety are paying off, according to a new Health and Human Services...

• The New CMS Emergency Management Rule: Tips for Successful Implementation

  Date: Tuesday, January, 24, 2017 1:00–2:30 p.m. ES Summary: After much anticipation, CMS...

Issue 49, December 6, 2016

• AHA asks Trump to change CMS regulations

  On December 2, the American Hospital Association (AHA) sent a letter to president-elect Donald...

• Join our last Accreditation Specialist Boot Camp of 2016

  The final HCPro Accreditation Specialist Boot Camp of the year is coming up fast. Sign up now for...

Issue 48, November 29, 2016

• CMS releases potential reporting measures

  CMS last week released a list of 97 reporting measures for hospitals, clinician practices, nursing...

• Study: Link between CMS hospital star ratings and socioeconomic factors

  It’s been almost five months after CMS publicly released its hospital star ratings system...

Issue 47, November 22, 2016

• Report: Mayo Clinic suggests nine ways to prevent physician burnout

  he high rate of burnout and unengaged physicians and nurses is an increasing concern for the...

Issue 46, November 15, 2016

• Study: 50 million patients suffer postop complications worldwide, 1.5 million die

  A new study found that out of the 310 million surgery patients who receive surgery every year, 50...

Issue 45, November 8, 2016

• Care quality and an effective EHR

  Logic says that electronic health records (EHR) should be a huge boon to healthcare quality...

Issue 44, November 1, 2016

• Joint Commission and HFAP start surveying to the 2012 Life Safety Code®

  As of today, CMS, The Joint Commission, and HFAP will be surveying hospitals to the 2012 Life...

• Report: Hospitals are improving quality and patient safety

  A new report from The Joint Commission finds that U.S. hospitals are improving patient safety and...

Issue 43, October 25, 2016

• GAO asks HHS for universally aligned quality measures

  The Government Accountability Office (GAO) sent a report on October 13 to the Department of Health...

Issue 42, October 18, 2016

• CMS launches new physician engagement initative

  On October 13, CMS announced a push to improve physician engagement and their experience within the...

Issue 41, October 11, 2016

• Joint Commission launches healthcare violence resource center

  The Joint Commission this month launched a digital resource center aimed at reducing workplace...

Issue 40, October 4, 2016

• CMS gives $347 million to improve patient safety

  Hospital associations, Quality Improvement Organizations (QIO), and health system organizations now...

• Pediatric quality measures receive $13.4 million from AHRQ and CMS for testing

  Six Pediatric Quality Measures Program (PQMP) grantees have been given $13.4 million to test new...

Issue 39, September 27, 2016

• Joint Commission unveils 2017 requirements for ORYX reporting

  The Joint Commission released its 2017 reporting requirements for ORYX, a performance measurement...

• ECRI: Most wrong-patient errors are preventable

  In a newly published analysis, the ECRI Institute reviewed 7,600 wrong-patient events in 181...

• UN declares drug resistance a global threat to humanity

  During the 71st session of the UN General Assembly in New York City last week...

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

  Join expert speakers Kevin Bussiere, RN-CIC and Marjorie Quint-Bouzid, MPA, RN, NEA-BC, for a...

• Medication Reconciliation: Improve Compliance Across Healthcare Settings

  Presented on: Tuesday, October 18, 2016 1:00–2:30 p.m. Eastern Presented by: Molly...

Issue 38, September 20, 2016

• CMS: Hospital readmission rate drop nationwide

  Between 2010 and 2015, hospital readmission rates have dropped an average of 8% nationally, with...

• Study: Quality isn't affected by physician employment

  A new study published in the Annals of Internal Medicine found that between 2003 and 2012, the...

• Finding the causes of EHR failure

  One study by the Office of the National Coordinator for Health Information Technology (ONC) found...

Issue 37, September 13, 2016

• CMS finalizes new emergency preparedness rule

  CMS announced on September 8 that it had finalized new emergency response requirements for...

• Surgeons rail against reporting every 10 minutes to CMS

  A proposed CMS change to the 2017 Medicare Physician Fee Schedule will require surgeons document...

• HFAP releases 2017 CAH, ASC prepublication manuals

  HFAP this week released its prepublication manual for critical access hospital (CAH), and...

Issue 36, September 6, 2016

• Avoid fire drill citations with new matrix

  was denied full Joint Commission accreditation, in part due to its handling of fire drills. The...

• Study: Readmissions sometimes improve patient health

  John Hopkins researchers looked at three years and 4,500 acute-care facilities worth of readmission...

• 10 ways to prevent drug diversion

  The Mayo Clinic experienced a highly publicized case of drug diversion back in 2008, where a nurse...

• 10 ways to prevent drug diversion

  The Mayo Clinic experienced a highly publicized case of drug diversion back in 2008, where a nurse...

Issue 35, August 30, 2016

• Three new Joint Commission questions for building tours

  During your next Joint Commission survey, be prepared to answer three new questions before even...

• ACOs improve patient care and save $1.29 billion since 2012

  In 2015 alone, all 392 Medicare Shared Savings Program (MSSP) participants and 12 Pioneer ACO Model...

• Four methods to limit redundant and unnecessary prescribing

  The Hospitals & Health Network recently published an article on the issue of polypharmacy...

Issue 34, August 23, 2016

• Joint Commission and CDC team up on ambulatory infection prevention

  The Joint Commission and the Centers for Disease Control and Prevention (CDC) are working on a new...

• AHRQ toolkit teaches how to face up to medical errors

  The Agency for Healthcare Research and Quality (AHRQ) published an online toolkit this May that...

• Joint Commission releases analysis of eCQM data

  In 2015 hospitals were given the option of submitting their eCQM data to meet ORYX requirements...

• Introducing the PSQH Forum!

  We’re proud to release the newest feature of the Patient Safety & Quality Healthcare...

Issue 33, August 16, 2016

• Joint Commission gives rationale behind new eating disorder standards

  It’s been eight months since The Joint Commission’s new eating disorder standards for...

• Administrative burdens driving practices out of Medicaid

  The time and effort spent on reporting quality measure data has been a major drain on healthcare...

• Study: Culture of safety scores have no impact on catheter infections

  Many hospitals have focused on improving their culture of safety through a patient safety culture...

Issue 32, August 9, 2016

• CMS to save millions by increasing hospital readmission fines

  At the beginning of the 2017 fiscal year in October, CMS will add new criteria to the Hospital...

• Overview of upcoming Joint Commission changes

  Over the next couple of months, several Joint Commission programs, standards, and updates will go...

• CMS to launch new demonstration on improving rural healthcare

  Ten critical access hospitals (CAH) have agreed to take part in CMS’ Frontier Community...

Issue 31, August 2, 2016

• What's your score? Hospital star ratings now online

  On July 27, CMS publicly released its hospital star ratings system on its Hospital Compare website...

• Study: 30% of pediatric readmissions are preventable

  Researchers found that when a child is sent to the hospital, there’s a 6.5% chance they'll be...

• Implementing new EHRs has little impact, good or bad, on care quality

  Anyone who’s had to upgrade a computer system can tell you it’s never as easy as...

Issue 30, July 26, 2016

• CMS: Only 2% of hospitals earn a "five star" rating

  Last week, CMS released data on its new hospital star ratings system, previewing the scores of...

• Electronic Clinical Quality Measures survey results published

  The eCQMs, which deal with data from electronic health records and health information technology...

• Blood management guidelines save $2 million and reduce blood use 30%

  At Vanderbilt University Medical Center (VUMC) in Tennessee, a multidisciplinary team has been...

• New CMS program targets heart attacks and strokes

  More than 500 healthcare practices are taking part in a CMS pilot program aimed at preventing heart...

Issue 29, July 19, 2016

• Joint Commission eliminates life safety Plans for Improvement

  As of August 1, The Joint Commission will no longer accept hospital Plans for Improvement for life...

• Hospitals fall short on ICU staffing levels

  A new study by the Leapfrog Group has found that 53% of hospitals meet the group’s standards...

• CMS and FDA back medical device ID numbers for billing

  On July 13, CMS and the Food and Drug Administration [FDA] sent a letter to Congress asking that...

Issue 28, July 12, 2016

• Study: 45% of ICU physicians suffering from severe burnout

  Earlier this month, the Critical Care Societies Collaborative published a report that found that...

• Second gene discovered that makes bacteria resistant to last-resort antibiotic

  Scientists in Europe have discovered a new colistin-resistant gene, mcr-2, in the intestines of...

• Mortality rates in the ER nosedive over past 15 years

  Between 1997 and 2011, the number of deaths in emergency departments (ED) has been cut nearly in...

Issue 27, July 5, 2016

• CMS begins oncology bundles

  On July 1, nearly 200 group practices began a five-year demonstration program of CMS’s...

• Study: Restricting access to lethal means cuts suicide rates

  A recent study published in Lancet Psychiatry compared data from 164 studies related to suicidal...

• Researchers find that checklists and error tracking are better ways to train surgeons

  A new study has found that incorporating error tracking with checklists can give a more accurate...

Issue 26, June 28, 2016

• Joint Commission to make antibiotic stewardship mandatory by 2017

  In the wake of a CMS ruling that will make antibiotic stewardship programs (ASP) mandatory, The...

• ACS releases new standards for overlapping and concurrent surgeries

  The American College of Surgeons (ACS) released a much anticipated update to its "Statements...

• Delay on texting ban repeal

  The Joint Commission has announced it will delay the repeal of the texting ban until it can create...

Issue 25, June 21, 2016

• House approves bill to change CMS readmissions program

  Last week, the U.S. House of Representatives passed the Helping Hospitals Improve Patient Care Act...

• CMS releases list of proposed rules, makes antibiotic stewardship mandatory

  Last week, CMS published a list of proposed rule changes for hospitals and laboratories. One of the...

• Study: 20% of trauma deaths preventable, looking to the military for answers

  A new study by The National Academies of Sciences, Engineering, & Medicine estimates that 20...

Issue 24, June 14, 2016

• Joint Commission to survey on 2012 Life Safety Code® in November

  Joint Commission surveys will include requirements from the National Fire Protection...

• Study: One in five hospitals don't have a plan for never events

  A new study by the Leapfrog Group has found that 20% of facilities don’t have policies to...

• HFAP releases updated 2015 Acute Care Manual

  On June 10, the Healthcare Facilities Accreditation Program (HFAP) released the second version of...

Issue 23, June 7, 2016

• New antibiotic stewardship playbook meshes NQF, CDC, and Joint Commission guidelines

  Released late last month, the National Quality Forum’s (NQF) Antibiotic Stewardship in Acute...

• Study: ICUs less successful at cutting CAUTI rates than non-intensive units

  Despite the efforts of CMS and the Department of Health and Human Services, the rate of...

• Single question test to determine opioid abuse

  At the American Pain Society’s (APS) 35th Annual Scientific Meeting, researchers unveiled a...

Issue 22, May 31, 2016

• U.S. woman contracts infection resistant to last-resort antibiotic

  In April, a Pennsylvania patient was being treated for a urinary tract infection when her...

• CMS announces new Hospital Improvement and Innovation Network program

   Between 2010 and 2014, preventable patient harm has been reduced by 39%, or 2.1 million fewer...

• Fewer than 60% of U.S. hospitals have an antimicrobial stewardship program

  Researchers announced that, as of 2014, only 40% of all hospitals have a comprehensive...

Issue 21, May 24, 2016

• House bill will change CMS readmission penalties to reflect socioeconomic factors

  The Helping Hospitals Improve Patient Care Act was introduced to the House of Representatives last...

• Joint Commission seeks volunteers to test new acute stroke ready measures

  Together with the American Heart Association and the American Stroke Association, The Joint...

• Physicians favor texting medical orders more than nurses

  Medscape News recently held a poll asking what healthcare workers if they approved of the...

• HCPro Customer Survey

  Dear readers, HCPro is conducting a customer survey to better understand your responsibilities...

Issue 20, May 17, 2016

• CDC: Air pressure played role in patient mold infections and death

  While the Centers for Disease Control and Prevention (CDC) is still investigating four deaths...

• Study: 20 of 21 billing metrics unreliable for measuring care quality

  A new meta-study by a John Hopkins research team questions the validity of using the Agency for...

• CMS outlines the methodology behind its five-star hospital ratings

  CMS held a webinar on May 12 explaining the methodology and upcoming changes to its controversial...

Issue 19, May 10, 2016

• CMS adopts 2012 Life Safety Code®

  In a highly-anticipated move expected to significantly affect the regulatory rules that hospitals...

• Study: a One-third of antibiotics are wasted on unnecessary treatments

  Despite efforts to improve antimicrobial stewardship, the Centers for Disease Control and...

• Recall of defective endoscope reprocessesors cancelled without explanation

  The Food and Drug Administration (FDA) announced last week that it was cancelling the recall of...

• Accreditation Professional Survey

  Dear accreditation professional, Your feedback is essential to us at HCPro. Please take just a...

• Featured Webcast: How to Establish an Antimicrobial Stewardship Program

  Antimicrobial overuse is a major problem for hospitals. Overuse of antibiotics can lead to the...

Issue 18, May 3, 2016

• Joint Commission reveals SAFER scoring system for hospital risk

  In the May edition of The Joint Commission Perspectives, The Joint Commission announced its new...

• Joint Commission permits texting of medical orders, with caveats

  In 2011, The Joint Commission ruled that physicians and practitioners were forbidden from using...

• Study: Medical errors unseat respiratory disease as third leading cause of death

  A new study conducted by John Hopkins researchers estimates that the Centers for Disease Control...

Issue 17, April 26, 2016

• Quality check on quality reporting

  Since there aren’t any standards for determining the accuracy and timeliness of quality data...

• Joint Commission releases rebuttal to critics of pain management standards

  The Joint Commission last week published a press release and an eight minute video defending its...

• CMS updates acceptable control materials

  CMS recently clarified policy on acceptable control materials for lab testing. While not changing...

Issue 16, April 19, 2016

• Petitions ask Joint Commission and CMS to change pain management policies

  More than 60 medical experts and nonprofit organizations signed petitions last week, asking The...

• Opponents try to delay five-star CMS rating system

  This month, CMS plans to add a new “five-star” hospital rating system to its Hospital...

• CDC considers changes to CAUTI and bloodstream infection reporting methods

  The Centers for Disease Control and Prevention (CDC) is attempting to develop better methods of...

Issue 15, April 12, 2016

• Physicians' concerns over CMS sepsis bundle

  In February, an international task force ruled that systemic inflammatory response syndrome (SIRS...

• Lab work no longer requires paper records of credentials; CMS allows use of PSV

  CMS recently updated its Clinical Laboratory Amendments (CLIA) for lab work at critical access...

• Predicting and preventing readmissions

  Facilities with excessively high readmissions can have their Medicare payments docked between 1% to...

Issue 14, April 5, 2016

• An inexpensive way to prevent strokes and heart attacks

  To find an inexpensive treatment to this problem, a research team conducted a study of different...

• $8 million in prizes for CMS quality improvement projects

  CMS is calling on healthcare providers to team up with Quality Innovation Network-Quality...

• EHR copy and paste best practices toolkit released

  Copying and pasting information in electronic health records (EHR) is a common practice that can...

Issue 13, March 29, 2016

• Be compliant before 2017: Cutting CAUTI rates in half

  What can healthcare facilities do before then to improve CAUTI compliance before the Joint...

• FDA proposes ban on most powdered surgical gloves

  Last week, the Food and Drug Administration (FDA) proposed banning most powdered gloves in the U.S...

• Antibiotic-impregnated catheters reduce blood infections in children

  A new study published in The Lancet has found that using antibiotic-impregnated central venous...

Issue 12, March 22, 2016

• Hopkins: ’Cascading Accountability’ Boosts Ambulatory Quality, Safety

  Johns Hopkins Medicine coordinates high-quality care across ambulatory care centers, using a model...

• How many will adopt the new CDC opioid guidelines?

  The Centers for Disease Control and Prevention (CDC) finally published its Guideline for...

• Over 1,000 injuries, 35% accuracy, and still for sale: FDA questioned over INRatio blood-testing device

  For the second time in less than six months, the Food and Drug Administration (FDA) is being...

• Time's running out to sign up for the Drug Diversion Webcast!

  Preventing the theft of controlled substances at hospitals continues to be an tremendous issue even...

Issue 11, March 15, 2016

• Study: 98 days, $15.4 billion lost annually to reporting quality metrics

  The average medical practice spends 785 hours a year on quality measure reporting. That’s...

• Alarm management compliance shifts into second gear

  For the last two years, healthcare organizations have been working to comply with the first phase...

• Tiny percentage of physician groups earned CMS value-based care bonus

  It’s the second year for CMS’s value-based payment modifier (VBM) program, a part of...

• The CMS Restraint Training Requirements Handbook

  Ensure compliance with CMS’ restraint guidelines! Use of restraint and seclusion is...

Issue 10, March 8, 2016

• Bribery on Two Continents: Olympus Corp., to Pay $646 Million Settlement

  On March 1, the Department of Justice (DOJ) charged Olympus Corp. with paying millions of dollars...

• New pay-for-performance rate disagrees with physicians 90% of the time

  CMS has begun adopting the preventable quality indicators (PQI) rate into its incentive and...

• Fewer than 32,000 physicians allowed to prescribe opioid addiction medication

  There’s around 1 million American physicians who’re allowed to write opioid...

Issue 9, March 1, 2016

• Patient suicide risk highlighted by Joint Commission alert

  There were 1,089 patient suicides logged into the Joint Commission’s Sentinel Event Database...

• Big plans and big problems for new FDA Chief

  On February 24, the U.S. Senate voted to confirm Robert Califf, MD, as the new Food and Drug...

• New guidelines list 32 steps for treating post-op pain

  A new set of guidelines was released this February, highlighting the successes of evidence-based...

• Join an Accreditation Specialist Boot Camp near you!

   Accreditation and quality professionals are being asked to do more than ever to comply with...

Issue 8, February 23, 2016

• AMA: What physicians are doing during the prescription epidemic

  To find out what physicians think of the prescription problem and how to fix it, the American...

• CMS: Core quality measures to be accepted across healthcare sector

  In a few years’ time, all of Medicare and 70% of all private plans will have switched to the...

• FDA: Duodenoscopes from three major companies now safe to use with updated instructions

  On February 19, the Food and Drug Administration (FDA) announced that reprocessing instructions for...

• The Compliance Guide to The Joint Commission's Patient Safety Systems Chapter

  How prepared are you for the Joint Commission’s new Patient Safety Systems (PSS) chapter? The...

Issue 7, February 16, 2016

• Study: Small tweaks drop unnecessary antibiotics by 11%

  A few emails and simple tweaks to electronic health records were shown to drop unneeded antibiotic...

• Should pain management be considered for federal funding?

  On February 9, 26 senators from 17 states sent a letter asking for a review of the pain management...

• Report: Vaccines the key to reducing superbugs

  A new report by the United Kingdom’s Review on Antimicrobial Resistance (RAR), says...

Issue 6, February 9, 2016

• Medical devices enter the realm of partisan politics

  Both Democrats and Republicans have condemned the FDA’s handling of multiple superbug...

• CDC and FDA take new approach toward opioid addiction

  The Centers for Disease Prevention and Control (CDC) and the Food and Drug Administration (FDA...

• Consistency and surgical safety checklists: the key to saving lives

  A new study published in The Journal of the American Medical Association (JAMA) found that 17- to...

Issue 5, February 2, 2016

• Study: Post-discharge home visits save money and lives of heart patients

  A new study by the Society of Thoracic Surgeons discovered that having a physician assistant (PA...

• For patients with memory loss, family involvement key to care

  A new study published in The American Journal of Accountable Care has found that when a patient...

• Study: Poor communication leads to malpractice, death

  Poor communication in healthcare has tangible, measurable effects. A new study released by CRICO...

• Building a High-Reliability Organization: A Toolkit for Success

    A practical guide to becoming a high-reliability organization (HRO), Building a...

Issue 4, January 26, 2016

• Nurses not following bloodborne pathogen precautions 83% of the time

  Despite the risk that bloodborne diseases represent, a new study published in The American Journal...

• Post-acute care tradeoff: shorter stays for higher readmission

   A new national study published in The Journal of Medical Care found the number of postacute...

• Drug makers join forces at Davos to fight superbugs

  During this year’s World Economic Forum in Switzerland, drug companies from 16 different...

• JAMA: Nurses key to surviving surgery

  A study released in The Journal of the American Medical Association has found that surgery...

• The Joint Commission Mock Tracer Made Simple: 17th Edition

  The newest version of HCPro’s premier survey prep guide, this updated edition lets you...

Issue 3, January 19, 2016

• Even more infections linked to dirty duodenoscopes than previously feared

  A new Senate committee report has tripled the number of confirmed Olympus scope infections to 142...

• Fujifilm Medical Systems only duodenoscope manufacture to have its revised reprocessing instructions validated by the FDA

  Fujifilm Medical Systems issued revised reprocessing instructions late last month for Model...

• Statins pre-surgery can reduce post-surgical complications in heart patients

  An article in the February edition of the Annals of Thoracic Surgery has found that statins can be...

• Risk Reduction Strategies

  What is the best way to prepare for patients each and every day? A basic risk assessment is a...

Issue 2, January 12, 2016

• New guidelines released for geriatric perioperative care

  In 2013, 44.7 million Americans were over the age of 65 with current trends predicting that number...

• Study: Infections are leading cause of elderly patient ER visits

  A new study published in The Journal of the American Geriatrics Society found that infectious...

• Study: Discharge notes are often written grades above patient reading levels

  A study published in The American Journal of Surgery found that low literacy rates can drive up the...

Issue 1, January 5, 2016

• Fighting drug-resistant disease in 2016

  One of healthcare’s biggest concerns has been the misuse of antibiotics and resulting rise in...

• How do you determine if someone is brain-dead? Study shows hospitals disagree

  Determining if a patient’s brain functions have irreversibly shut down is a crucial...

• FDA to crack down on medical device safety

  The Food and Drug Administration (FDA) will be taking a stronger stance on the reporting possible...

Issue 3, February 15, 2016

• Featured Webcast- "CMS Surveys: Preparing With Confidence"

  Please join us on Wednesday, February 24 for our featured webcast: "CMS Surveys: Preparing...