All Entries in the "By Author" Category
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.
New Study Provides Concrete Guidelines for Preventing Surgical Site Infections . . . Finally
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?”
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.
National Patient Safety Goal 7: Three Easy Tips for Compliance
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.
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.
What is a Hospital Near-Death Experience?
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?”
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.
Hospital Leaders Face Another Accreditation Challenge
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.”
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 reapplication [...]
Infection Prevention Caught in Squeeze on Budgets
By Amanda Brown, RN, BSN, MSM, CIC
The economic impact on hospitals continues to play out across the country. The latest area of focus seems to be the resources provided to manage infection control programs. Even as the H1N1 pandemic looms, half of the IC professionals responding to a recent survey reported reductions in overall [...]
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.
How Do You Figure Out the 2009 Joint Commission Standard Numbering System?
Compass Clinical Group Accreditation and Compliance Practice Leader Ruth Elzer, RN, MS, Services explains the 2009 Joint Commission Standard Numbering System in this video clip.