While regulatory standards govern the appropriate use of syringes and sharps, no specific regulations require that syringes be totally absent in any location. The lack of regulations about the location of sharps does not, however, remove the hospital’s responsibility for safeguarding sharps and syringes.
Compass Clinical Consulting’s Practice Leader for Accreditation and Regulatory Compliance, Ruth Elzer, RN, MS, will be speaking at seminars across the country this summer. Check out the following events for the most recent information regarding compliance with the standards of The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS).
In the past, hospitals were only required to report deaths that occurred in behavioral health. However, the most recent requirements – in place since 2008 – expand the types of deaths that must be reported to the Centers for Medicare and Medicaid Services (CMS) regional office.
The Journal of Healthcare Management recently featured a column by Compass Clinical Consulting Practice Leader for Accreditation and Regulatory Compliance, Ruth Elzer, RN, MS. The column, which is included in the March/April edition of the journal, offers insight and practical advice and expert analysis on how to comply with regulations from the Centers for Medicare and Medicaid Services (CMS) in 2010.
Since The Joint Commission’s MS.1.20 Implementation Task Force was convened in December 2007, the group has been working to define which aspects of the management of the Medical Staff need to be written specifically into the bylaws, and which items can be adopted through rules, regulations and related documents. The recently announced changes to the MS.01.01.01 standard include a few modifications that will come as a surprise to some hospitals and require action before the March 31, 2011, effective date.
Fox Business News anchor Dagen McDowell interviews Compass Clinical Consulting CEO Kate Fenner on the impact of the healthcare reform law on the nation’s hospitals.
Kate Fenner, RN, PhD, CEO of Compass Clinical Consulting, will present with Alton Byers, MS, FACHE, at this year’s ACHE Congress on Healthcare Leadership. The presentation, “Medicare Decertification: A Hospital Near-Death Experience,” will focus on one hospital’s real-life crisis when faced with termination by the Centers for Medicare and Medicaid Services (CMS).
Parts I and II of this series outlined two tools for risk assessment and how each can assist in evaluating the impact of potential risks within a hospital. This installment will focus on Failure Mode and Effects Analysis (FMEA). This tool can be used to examine an event and its component parts to discover weaknesses and decrease the likelihood that they will occur.
by Amanda Brown, RN, MSM, CIC Part I of this series outlined the power of simple risk assessment to identify, mitigate, and eliminate hazards in the day-to-day operations of a hospital. Parts II and III will present approaches to risk assessment that are more complex and require more attention from multidisciplinary teams. In this installment, [...]
How can hospitals ensure that patients, employees, and visitors are safe in an environment rife with its own unique risks? The solution begins with risk assessment. This installment of our three-part series on risk assessment will describe the approach and tools that accompany simple risk assessment.
Serious events that result in harm to patients leave a mark on a hospital, and all those involved. But, depending on the approach taken by investigators of the event, these events can teach valuable lessons that will positively impact future patient care.
Both The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) require hospitals to arm patients and families with specific instructions about how to register complaints. These expectations have likely increased the volume of complaints processed over the last year. But, even more importantly, subtle changes in the content of complaints may pose a challenge for hospitals in 2010, particularly if the impact of these complaints is underestimated.
There has long been talk of the link between quality of care and health care costs. While quantifying the benefit of improvements in quality and efficiency will continue to be difficult, hospitals in California are living the consequences of not addressing the most basic elements of safety.
So you heard that the survey process was unchanged for 2010. Not so fast. As it turns out, The Joint Commission’s (TJC) 2010 Survey Guide subtlety outlines a survey process that holds some surprises for the new year. The latest surprise includes a new challenge for hospitals, the requirement to develop an agenda with surveyors minutes before the survey begins.
After reading Pam Belluck’s New York Times article on preventing hospital-acquired surgical site infections, I couldn’t help but cheer. The study published recently in the New England Journal of Medicine that focused on skin preparation brings us closer to answering a decades-old question: “Which product do we use to prep the skin before surgery?”
An increasing number of hospitals are being forced to deal with findings of Immediate Jeopardy and subsequent termination procedures. Responding to termination procedures is inevitably stressful and confusing. To help you navigate the process, here are a couple of basic tips on what to expect and how to respond to prevent Immediate Jeopardy findings from turning into Medicare termination.
In 2009, three new requirements were added to NPSG 7 to aid in the ongoing campaign to prevent healthcare-associated infections. For each of these new requirements, there are three actions that Nurse Managers can take to facilitate compliance and – even better – protect patients.
You’ve studied the new standards, updated policies, and conducted tracers to monitor compliance. What else can you do to strengthen your hospital in preparation for more rigorous regulatory surveys? Communicate with your board! The board should serve as a resource for the hospital and provide oversight, not just for financial performance, but for quality as well.
The idea of a hospital near-death experience might sound a bit strange. What would cause a hospital to “die,” and how could it “come back to life?”
Increasing the awareness of HACs and their impact on patients and the hospital is an important step toward focusing on HAC risk reduction. As Halloween approaches, consider adopting a “Haunted Ward” for in-service education.
The evolution of other standards and increasing pressure from the Centers for Medicare and Medicaid Services (CMS) will force tracer teams to be more knowledgeable and skilled to protect their hospitals from unexpected survey results.
The fines being levied in California and other states represent only one of the potential costs of poor survey results.
The news from the Joint Commission’s Hospital Executive Briefings is always a mixed bag of information. This year is no different. Hospitals surveyed as part of a healthcare system, though, should brace themselves for a big change.
When caregivers understand policies they are more likely to follow them. Finding ways to efficiently highlight the essential messages ensures that clinicians receive the information they need in a way that supports understanding and compliance.
Writing policy calls for more than knowledge of the policy content – it requires an understanding of how to communicate the information most effectively.
Since The Joint Commission moved to the tracer methodology, forcing surveyors out of the board room and to the bedside, the gap between written policies and their implementation has widened.
Hospitals across the country continue to struggle with the issue of how to dispose of medication patches in a manner that is both safe for patients and families and convenient for caregivers. Yet, regulatory agencies have few regulations applicable to hospitals regarding the disposal of medication patches.
The July edition of “The Joint Commission Perspectives” contained an ominous signal for hospital executives facing survey and accreditation decisions in the coming months. Of particular concern is the mention of situations in which the “surveyor has identified leadership changes over the past 12 to 18 months.”
This picture illustrates a rather absurd example of how noncompliance can escape notice during our busy days. It should also serve as a cautionary tale for compliance with Joint Commission and CMS Life Safety Code standards.
Requirements for the appropriate use of labels have been stepped up since the introduction of the National Patient Safety Goals (NPSGs), but hospitals are discovering that the requirements do not end there.
