Congratulations to Emily Alvarez, Melinda Smith-Vaughn, Amy Boykin, Barbara Meacomes, and Cassie Seiler--our most recent Certified Specialists in Healthcare Accreditation!
The CSHA certification program is still new, and we've already had over 50 people take the exam. Congratulations to all who have passed!
Brian Driscoll
AHAP Director
Hello,
I just wanted to share a snippet from a recent article in Briefings on The Joint Commission about a pair of hospitals which have switched to DNV, Inc.’s accreditation program. The following explains a bit about the NIAHO survey process. Hope this is of interest.
Matt Phillion
Senior Managing Editor, BOJ
Six surveyors showed up at Citizens Medical Center (Victoria, TX) for what would end up being a three-day survey. They were presented with a list of documents to present for review, along with a tentative three-day schedule. As part of prior preparation, the documentation was quickly pulled and presented.
The survey consisted of document reviews and discussions, review of open patient records, interviews with staff, life safety tours, and more.
“All in all, the survey was very thorough, comprehensive, collaborative, and educational,” says Caren Adamson, assistant administrator at Citizens Medical Center. “We were held accountable to the prescriptive requirements of the CoPs and were assessed with our compliance with the ISO standards and our underlying framework for ongoing compliance.”
Purdy has found that the survey process for her facility has been a less stressful process for staff.
“They make it clear they’re looking at the process, not the individual,” says Judith Purdy, RN, risk/quality director at Hays (KS) Medical Center. “The staff appreciate that.
It’s not so much a new survey process,” says Purdy. “They survey the CoPs. The hospital is very familiar with those and comfortable being surveyed by those standards.”
Staff is trained in the CoPs and very aware of those standards, she explains.
“We’ve been talking to the employees for over a year that this is the agency we’re looking towards shifting to. They’ve been hearing this information for months,” says Purdy. “There is a sense of anticipation waiting for this to really happen.”
Purdy also noted there will likely be a learning curve on both sides of the survey process at first.
“To some degree they’re still training the surveyors, but as a rule there will be a generalist, a clinical person and a life safety person,” says Purdy. This list does not necessarily include a physician, and the generalist can fulfill a clinical or nonclinical role or both and will be trained in the standards to do so.
DNV has stated that they will attempt to send the same surveyors each year, with the thought that the survey process will benefit from a surveyor that has a level of knowledge about the facility and how it functions and operates.
We've now confirmed speakers from The Joint Commission, DNV Healthcare, and HFAP for the May 2009 conference. Should be a great conference!
Brian Driscoll
I just wanted to let everyone know The Joint Commission has released an FAQ on National Patient Safety Goal NPSG.01.01.01. The FAQ looks at whether there are any exceptions for active involvement of the patient or responsible caregiver.
The FAQ specifically looks at sleeping patients and the nurse’s role in identifying non-communicative or confused patients when another healthcare worker uses two patient identifiers. The Joint Commission states that the purpose behind this is to increase patient safety through such things as medication, diagnostic, and treatment errors. The organization must decide how to assess sleeping/non-communicative/confused patients. The organization must also determine when active involvement is necessary on the part of the responsible nurse or other caregiver.
These decisions must, obviously, be communicated to the staff and be brought about specifically for reasons of patient safety.
The NPSG.01.01.01 FAQ can be found online here.
In the upcoming issue of Briefings on The Joint Commission, I was able to talk with accreditation professionals at two hospitals who have applied for and been surveyed by DNV and intend to leave The Joint Commission as soon as their DNV application is approved. The conversations left me curious--how many of our members here at AHAP are looking at DNV's accreditation process as a possible alternative?
My question to the field is--are you going through any sort of process, formal or informal, to take a look at DNV as an alternative? Has anyone decided to make the switch? What factored into the decision (for or against changing accrediting organizations)?
In case you missed them, we've posted our October 16 and October 28 calls on critical test results. Listen to them now by clicking here
Joining us on the calls was Gayla J. Jackson, RN, BSN. Gayla is a member of the AHAP advisory board and nurse manager at Mount Auburn Hospital in Cambridge, MA. She has 26 years of experience in acute care and was one of the 17 advisory committee participants chosen to work on a three-year federal grant from the Agency for Healthcare Research and Quality (AHRQ). The AHRQ provided funding to The Massachusetts Coalition for the Prevention of Medical Errors along with the Massachusetts Hospital Association for the purpose of identifying, choosing, and implementing two patient safety initiatives, one of which was communicating critical test results.
I hope you all found these calls useful. And look for Gayla at the 3rd annual AHAP conference in May. She will be joining us in Las Vegas for the second year in a row.
Brian Driscoll
AHAP Director
Just wanted to follow up on Matt's posting and offer some details on our 2009 conference. We've already confirmed the following speakers and topics:
Hello, everyone. I just wanted to let you know that we'll be announcing speakers and topics very soon for the upcoming AHAP Conference May 14-15 in Las Vegas. Make sure to keep an eye on this blog for additional information in the comings days and weeks.
As always, you can find the basics about AHAP's annual conference here.
Hello, everyone. Just wanted to let you know about some breaking news out of today's Federal Register:
The Centers for Medicare & Medicaid Services (CMS) announced in the October 24, 2008 Federal Register that The Joint Commission’s critical access hospital accreditation program will undergo a 180-day probationary period while gaps between the standards and CMS Conditions of Participation (CoP) are fixed.
According to the Federal Register, “review of The Joint Commission revised accreditation standards for hospitals revealed that significant gaps remain between The Joint Commission standards and the Medicare hospital CoPs.”
In addition, “if we determine that an AO [accreditation organization] has failed to adopt requirements comparable to CMS requirements, we may grant a conditional approval of the AO’s deeming authority for a period of up to 180 days to adopt comparable requirements.”
You can read the complete announcement in the Federal Register here.
We'll be watching this as things develop both here in the blog as well as in Briefings on The Joint Commission. What's your impression on this situation? Do you feel like CMS is cracking down deliberately on The Joint Commission? Or is this just a step towards getting everyone on the same page?
