Author Archive for Ruth Elzer
Ruth Elzer, RN, MS Accreditation and Compliance Services Ruth Elzer is an expert at keeping hospitals compliant. Trained as a nurse, and later as a hospital surveyor, Ruth understands healthcare quality on both the clinical and administrative levels. She has the unique ability to see every facet of a compliance issue, drawing from a deep knowledge of many regulatory bodies. As the Practice Leader for Accreditation and Compliance Services at Compass Group, Ruth gives clients practical solutions that work across the board. Contact: Ruth Elzer 513-241-0142, relzer@compassgroupinc.com
Verbal Orders in Outpatient Settings
As more care is provided in outpatient settings, where on-site physician presence may be sporadic, the need to obtain verbal or telephone orders is on the rise.
New CMS Anesthesia Regulations: Pre- and Post-anesthesia Evaluation
This article discusses pre- and post-anesthesia evaluations and is the fourth installment in a series outlining compliance challenges associated with the new CMS Anesthesia Services CoPs.
New CMS Anesthesia Regulations: Anesthesia Administration and Privileging Practitioners
This second post in a four-part series discusses who can administer anesthesia and how they should be privileged in order to comply with new CMS Anesthesia Services CoPs.
New CMS Anesthesia Regulations: Defining Anesthesia Services
CMS has issued changes to its Anesthesia Services CoPs. This first post in a four-part series clearly defines both anesthesia and sedation to help hospitals assess vulnerabilities in these areas.
Security for Syringes and Sharps: The Regulatory Expectations
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.
Knock, Knock, State’s Here: Reporting Restraint Deaths
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.
Joint Commission Medical Staff Changes: A Few Surprises
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.
Choosing the Right Tool for Hospital Risk Assessment: Failure Mode and Effects Analysis
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.
Investigating Errors: Investing in Prevention
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.
In 2010, Hospitals Must Take Patient Complaints Seriously
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.
Rising Health Care Costs? In California, Sponges Can Cost $50,000 Guide Wires $100,000
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.
Joint Commission Surveys: Unannounced – and in 2010 – Unplanned
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.
23 Days to Fix Everything: Responding to Immediate Jeopardy Findings Before It’s Too Late
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.
Involving the Board in Quality and Patient Safety
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.
Haunted by Hospital-Acquired Conditions?
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.
Just When You Thought It Was Safe to Go Tracing
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 Rising Costs of Poor Quality
The fines being levied in California and other states represent only one of the potential costs of poor survey results.
Good News, Bad News for System Surveys
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.
Deadly Policies, Part III: Communicating the Essential Messages
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.
Deadly Policies, Part II: Writing Effective Policies
Writing policy calls for more than knowledge of the policy content – it requires an understanding of how to communicate the information most effectively.
Deadly Policies, Part I: The Gap Between Policy and Practice
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.
To Flush Or Not To Flush: Drug Patch Disposal
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.
Your Turn To Be A Surveyor . . .
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.
Labels: Friend or Foe?
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.
CMS Welcomes Comments on Joint Commission Deemed Status Application
By Ruth Elzer, RN, MS The Joint Commission (TJC) continues to work with the Centers for Medicare and Medicaid Services (CMS) to complete an acceptable deeming application for its hospital program. The Medicare Improvements for Patients and Providers Act for 2008 (MIPPA) revoked the Joint Commission’s statutory deeming status for its hospital program, mandating a [...]
Physicians Beware: CMS Ups the Financial Ante on Wrong-site Surgery
By Ruth Elzer, RN, MS: What the public may be surprised to know is that as recently as the first half of 2008 (prior to implementation of the “Never List”), twenty percent of Joint Commission surveyed hospitals were cited for failing to have a proper “time out’, part of the Universal Protocol, the process designed to prevent wrong-site surgery.
EARN CASH for Joint Commission Compliance?
Earn cash for Joint Commission Compliance?
Well, not in the way that you think.
EARN CASH is a mnemonic device that outlines expectations for patient education in applicable patients. The expectations for the specific elements of patient education have gradually increased over the years and have now been combined under a single standard, PC.02.03.01.
What’s Cookin’ in the Hot Lab? Radioactive Eggs!
Recent consultation with several hospitals concluded with the discovery of radioactive food products being prepared and consumed in the nuclear medicine department. Further investigation and polling of others concluded that this could be happening in your organization.