Announcing a New Partnership!

I am pleased to announce that MBD Consulting, LLC has a new partnership with MSL Healthcare Partners.  MSL Healthcare Partners will be partnering with MBD Consulting to provide Life Safety and Environment of Care expertise to our already highly experienced group.  Our Principal, Maureen D’Agostino said, “their website states a clear vision that fits well with MBD Consulting. One belief, one philosophy”

From their web site, At MSL Healthcare Partners, we have an obsession with safety. We will never conceal, compromise or apologize for our dedication to making the healthcare environment safer, with an ultimate goal of completely eliminating preventable errors. Yes, we’re saying it, and we’ll say it again: We believe that all members of the healthcare community can work together to one day eliminate preventable errors in our healthcare environments. To achieve such a goal, the status quo will not suffice. The lowest common denominator, the bare minimum, the excuses, the don’t-raise-your-head-up philosophy will never do.

Welcome to the MBD Consulting family.

 

Joint Commission Advises Hospitals to Help Staff After Traumatic Events

 

By Maria Castellucci Modern Healthcare | January 31, 2018
The Joint Commission issued an advisory report this week urging its accredited healthcare organizations to provide support services to staff after traumatic patient events.

Healthcare providers can experience psychological trauma when their patients experience adverse health events like an unexpected death or medical error. The emotional toll such events can have on providers has been coined “second victims” and although healthcare organizations have begun to address the issue, programs and tools haven’t been widely adopted, according to the Joint Commission.

“We are trying to improve the awareness and importance of this issue,” said Dr. Ana McKee, executive vice president and chief medical director of the Joint Commission.

In its advisory, which was sent out to the roughly 21,000 healthcare organizations it accredits, the Joint Commission offers various tactics for healthcare leaders to support staff after traumatic events. The commission recommends organizations create a culture that encourages communication about defects and errors, engage all team members to share lessons learned when an adverse event occurs and provide guidance to staff about how they can properly support each other during trauma.

“(Doing) nothing is not the right answer … an organization has to find some approach to raise awareness about the second victim,” McKee said.

The commission also offers ways for healthcare organizations to implement “second victim” programs. These programs provide peer-to-peer support services to staff and have been adopted at some hospitals and health systems across the country like Johns Hopkins University and Health System.

Rise, which was launched in 2011 at Johns Hopkins, is a 24/7 call center staffed by roughly 30 clinicians at the organization who have volunteered to be part of the program. The participants are trained in psychological first aid, a technique used to help victims debrief soon after a traumatic patient event.

“It’s intended to be a safe (space for staff) — we don’t report it to managers,” said Dr. Albert Wu, a professor of health policy and management at Johns Hopkins who helped launched the program.

The program has encouraged staff at Johns Hopkins to be more open about their emotions, Wu said. Whole clinical teams will go together for support after a particularly traumatic event. “It is changing the culture,” he said.

The Joint Commission took best practices from “second victim” programs like Johns Hopkins in its recommendations. Healthcare organizations are encouraged if they want to form such a program to obtain buy-in from leadership, emphasize the importance of patient safety and develop an educational campaign.

At Nationwide Children’s Hospital, resources to establish the YOU Matter Second Victim Program were initially scarce.

Jenna Merandi, director of the “second victim” program, said she partnered with the marketing department to raise awareness. Informational messages were displayed on digital quality boards and Merandi and her team spoke at meetings across various departments.

“The first several years we didn’t have funds, we started from the ground up,” she said. “(After) we showed the value of the program and how it was changing the culture, we did receive funding and support.”

YOU Matter Second Victim Program, which first launched in 2013, has now trained more than 700 Nationwide staff members to be peer supporters.

The Columbus, Ohio-based children’s hospital has surveyed its staff on feelings of burnout and stress since the program has been in place, and the results are promising.

“We have been able to show the effectiveness of the program … it’s improving negative psychological impact on front line staff,” she said

CMS Bans Texting of Patient Orders!

By Debra A. Geroux
248.258.2603
geroux@butzel.com

January 3, 2018

In a Letter to State Surveyors, the Centers for Medicare & Medicaid Services (“CMS”) has clarified its position on texting patient information, and more notably Orders, among members of a patient’s care team. In a nutshell: Don’t Do It!
In its December 28, 2017 Memo regarding Texting of Patient Information among Healthcare Providers, CMS recognizes the benefits and long standing practice of texting patient information among members of a patient’s healthcare team, but explains that it is only permissible if performed through a secure, encrypted platform in accordance with HIPAA privacy and security regulations. CMS expects that providers and organizations that utilize secure, encrypted texting systems will implement procedures for regularly assessing the security of the system.
However, CMS also indicates that, as it concerns Orders from a provider to a member of the care team, texting is never permissible, encrypted or otherwise, as the Conditions of Participation and Conditions for Coverage mandate that Orders be dated, timed, authenticated and promptly placed in the medical record. See 42 CFR 482.24(b).[1] According to CMS, the best (and preferred) practice for entering orders is through Computerized Provider Order Entry (CPOE), which ensure immediate and authenticated entry into the electronic health record.
While the texting prohibition has not yet been addressed in the Interpretative Guidelines,[2] Interpretive Guideline A-0454 concerning section 482.24(c)(2) provides slight guidance on the “promptly” directive, noting that it is to be “performed readily or immediately” so that all members of the patient’s care team have access to it. The use of texting for Orders does not meet either the requirements for authentication or prompt placement, at a minimum.
Healthcare providers and entities must take steps to educate staff about the problems associated with texting generally, and texting Orders specifically. While CMS recognizes texting is commonplace, it does not mean it can be condoned. If not already in place, hospitals and entities that are subject to certification surveys should take steps to eradicate these standard practices through policy changes and education.

 

 

Thanks to AHRQ: Toolkit To Promote Safe Surgery In Hospitals

The Toolkit To Promote Safe Surgery helps perioperative and surgical units in hospitals identify opportunities to improve care and safety practices and implement evidence-based interventions to prevent surgical site infections. The toolkit has evidence-based, practical resources that reflect the real-world experiences of the frontline clinicians and subject matter experts who participated in the AHRQ Safety Program for Surgery, a national implementation project in which approximately 200 hospitals participated and successfully reduced surgical site infections. It builds on AHRQ’s Comprehensive Unit-based Safety Program (CUSP) and the core CUSP toolkit by providing specific tools focused on the surgical setting to help hospitals reduce surgical site infections and other complications.
The toolkit has two complementary guides that should be used together and are a good starting point: Applying CUSP To Promote Safe Surgery, and Surgical Complication Prevention. These two guides address respectively adaptive and technical work, which are both critical elements for improvement to occur. Technical work changes procedural aspects of care that can be explicitly defined, such as surgical skin preparation procedures. Adaptive work is designed to change the attitudes, values, beliefs, and behaviors of the people who deliver care and improve safety culture within an organization, thereby enabling consistent use of evidence-based practices. Both guides should be used simultaneously. Supplemental tools accompany the guides.
The toolkit also includes 15 instructional modules to help clinical teams address specific areas of competency. The modules are spread across the three phases that clinical teams will undergo as part of their quality improvement efforts: onboarding, implementation, and sustainability.
Toolkit Materials
The toolkit includes two guides, supplemental tools for each guide, and 15 instructional modules within three phases to support change at the unit level.
Guides
Applying CUSP To Promote Safe Surgery
Supplemental tools
Surgical Complication Prevention
Supplemental tools
Instructional modules
Onboarding
Implementation
Sustainability

Go to:  https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/surgery/index.html

Geisinger Holy Spirit Hospital Cited After Patient Dies Under Restraint

December 27, 2017

The patient became combative and was held down by two security guards while a physician and a nurse applied the restraints.
A hospital in central Pennsylvania has been cited by the Pennsylvania Department of Health after a patient died while being placed in restraints.
An investigation into Geisinger Holy Spirit Hospital’s handling of a restrained patient indicated staff failed to “protect the patient’s safety during restraint application” on September 26, reports Penn Live.
According to the health department’s investigative report, the patient became agitated and belligerent and attempted to exit the hospital, pushing through staff members.
Two security guards then held the patient down on a bed while a physician and a nurse applied restraints. The unidentified patient’s body went limp, their face turned blue and they began foaming at the mouth, according to the report.
The hospital staff declared a code blue, used to label a patient in cardiac arrest. The patient later died from what the hospital called a “diffuse anoxic brain injury,” which is typically caused by severe head trauma, according to The Sentinel.
The department says some of the restraints that were used did not have a required order from a doctor.
Another violation included failure to report the death to the Pennsylvania Patient Safety Authority within a week of the incident. The hospital also did not notify the patient’s family of the event, says the report.
The hospital submitted a plan of correction but the first version was rejected by the state.
The second plan was approved and includes educating staff about the use of restraints and the establishment of a “code grey team” to be trained in handling a combative patient who does not have a weapon. The report did not give elaborate details on the hospital’s plan to institute the team.

While we would prefer not to restrain patients, at times such measures are indicated for the safety of all involved. We are saddened whenever a patient passes away, and are confident that the care our team provided was consistent with Geisinger Holy Spirit’s mission of delivering professional and compassionate care to all,” says Lori Moran, director of corporate communications at Geisinger Holy Spirit.
Holy Spirit has a locked mental health unit and specializes in mental health crisis situations.

About the Author

Amy Rock, Web Editor
Amy Rock is the Campus Safety Web Editor.

The CMS Clarifies What It Means To Be A Hospital

“Hospitals must have at least two inpatients at the time of the survey in order for surveyors to conduct the survey. However, just because a facility has two inpatients at the time of a survey does not necessarily mean that the facility is primarily engaged in inpatient care and satisfies all of the statutory requirements to be considered a hospital for Medicare purposes. Having two patients at the time of a survey is merely a starting point in the overall survey and certification process.”

One of the industry’s fastest-emerging trends—micro-hospitals—could take a hit thanks to new CMS guidance that has hospital accreditors tweaking their policies regarding what counts as a hospital.

Micro-hospitals are small-scale, inpatient facilities with eight to 15 short-stay beds. They perform many of the same acute-care and emergency services done at larger hospitals, but are cheaper to operate. Micro-hospitals have cropped up in 19 states, mostly in underserved urban locations or areas that are farther away from large hospitals.

Prior to the CMS’ declaration in the fall, there was no guidance with respect to what it took to be considered “primarily engaged” or to count as an inpatient provider.

If smaller hospitals are not deemed to be primarily engaged in inpatient care, they may be prohibited from providing medical services or be paid at a lower rate for free-standing facilities.

Concerns are that the guidance was released without a public comment period, is effective immediately, and has a 12-month look-back period for compliance when there was not any clear guidance on expectations. That could affect the validity of surveys already performed.

Excerpts from Modern Healthcare Virgil Dickson | December 16, 2017

 

TJC Final Emergency Management Standards Effective November 15, 2017

Standard EM.01.01.01
Element(s) of Performance for EM.01.01.01
The hospital engages in planning activities prior to developing its written Emergency Operations Plan.  Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization’s services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events. The findings of this analysis are documented. (See also EM.03.01.01, EP 1; IC.01.06.01, EP 4)  Note 1: Hospitals have flexibility in creating either a single HVA that accurately reflects all sites of the hospital, or multiple HVAs. Some remote sites may be significantly different from the main site (for example, in terms of hazards, location, and population served); in such situations a separate HVA is appropriate. Note 2: If the hospital identifies a surge in infectious patients as a potential emergency, this issue is addressed in the “Infection Prevention and Control” (IC) chapter.

The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies within the organization and the community that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events. The findings of this analysis are documented. (See also EM.03.01.01, EP 1; IC.01.06.01, EP 4)  Note 1: Hospitals have flexibility in creating either a single HVA that accurately reflects all sites of the hospital, or multiple HVAs. Some remote sites may be significantly different from the main site (for example, in terms of hazards, location, and population served); in such situations a separate HVA is appropriate. Note 2: If the hospital identifies a surge in infectious patients as a potential emergency, this issue is addressed in the “Infection Prevention and Control” (IC) chapter.

Standard EM.02.01.01
Element(s) of Performance for EM.02.01.01
The hospital has an Emergency Operations Plan.  Note: The hospital’s Emergency Operations Plan (EOP) is designed to coordinate its communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities during an emergency (refer to Standards EM.02.02.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, EM.02.02.09, and EM.02.02.11). Although emergencies have many causes, the effects on these areas of the organization and the required response effort may be similar. This “all hazards” approach supports a general response capability that is sufficiently nimble to address a range of emergencies of different duration, scale, and cause. For this reason, the plan’s response procedures address the prioritized emergencies but are also adaptable to other emergencies that the organization may experience.
For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan includes a continuity of operations strategy that covers the following: – A succession plan that lists who replaces key leaders during an emergency if a leader is not available to carry out his or her duties – A delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors during an emergency and criteria or triggers that initiate this delegation Note: A continuity of operations strategy is an essential component of emergency management planning. The goal of emergency management planning is to provide care to individuals who are incapacitated by emergencies in the community or in the organization. A continuity of operations strategy focuses on the organization, with the goal of protecting the organization’s physical plant, information technology systems, business and financial operations, and other infrastructure from direct disruption or damage so that it can continue to function throughout or shortly after an emergency. When the organization itself becomes, or is at risk of becoming, a victim of an emergency (power failure, fire, flood, bomb threat, and so forth), it is the continuity of operations strategy that provides the resilience to respond and recover.

For hospitals that use Joint Commission accreditation for deemed status purposes: If a hospital has one or more transplant centers (see Glossary), the following must occur: – A representative from each transplant center must be included in the development and maintenance of the hospital’s emergency preparedness program – The hospital must develop and maintain mutually agreed upon protocols that address the duties and responsibilities of the hospital, each transplant center, and the organ procurement organization (OPO) for the donation service area where the hospital is situated, unless the hospital has been granted a waiver to work with another OPO, during an emergency
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a procedure for requesting an 1135 waiver for care and treatment at an alternative care site.  Note: During disasters, organizations may need to request 1135 waivers to address care and treatment at an alternate care site identified by emergency management officials. The 1135 waivers are granted by the federal government during declared public health emergencies; these waivers authorize modification of certain federal regulatory requirements (for example, Medicare, Medicaid, Children’s Health Insurance Program, Health Insurance Portability and Accountability Act) for a defined time period during response and recovery.

The Emergency Operations Plan describes a means to shelter patients, staff, and volunteers on site who remain in the facility.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has one or more emergency management policies based on the emergency plan, risk assessment, and communication plan. Procedures guiding implementation are defined in the emergency management plan, continuity of operations plan, and other preparedness and response protocols. Policy and procedure documents are reviewed and updated on an annual basis; the format of these documents is at the discretion of the hospital.

Standard EM.02.02.01
Element(s) of Performance for EM.02.02.01
As part of its Emergency Operations Plan, the hospital prepares for how it will communicate during emergencies.
For hospitals that use Joint Commission accreditation for deemed status purposes: As part of its communication plan, the hospital maintains the names and contact information of the following: – Staff – Physicians – Other hospitals and CAHs – Volunteers – Entities providing services under arrangement – Relevant federal, state, tribal, regional, and local emergency preparedness staff – Other sources of assistance

For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan describes the following: – Process for communicating information about the general condition and location of patients under the organization’s care to public and private entities assisting with disaster relief – Process, in the event of an evacuation, to release patient information to family, patient representative, or others responsible for the care of the patient Note: These processes are consistent with privacy and disclosure requirements specified under 45 CFR 164.510(b)(1)(ii) and 45 CFR 164.510(b)(4).

For hospitals that use Joint Commission accreditation for deemed status purposes:  The organization maintains documentation of completed and attempted contact with the local, state, tribal, regional, and federal emergency preparedness officials in its service area. This contact is made for the purpose of communication, and where possible collaboration, on coordinated response planning for a disaster or emergency situation. Note: Examples of these contacts may be written or email correspondence; in-person meetings or conference calls; regular participation in health care coalitions, working groups, boards, and committees; or educational events sponsored by a third party (such as a local or state health department).

Standard EM.02.02.03
Element(s) of Performance for EM.02.02.03
As part of its Emergency Operations Plan, the hospital prepares for how it will manage resources and assets during emergencies.
The Emergency Operations Plan describes the following: How the hospital will obtain and replenish nonmedical supplies that will be required throughout the response and recovery phases of an emergency.

The Emergency Operations Plan describes the following: How the hospital will obtain and replenish nonmedical supplies (including food, bedding, and other provisions consistent with the hospital’s plan for sheltering on site) that will be required throughout the response and recovery phases of an emergency.

Standard EM.02.02.07
Element(s) of Performance for EM.02.02.07
As part of its Emergency Operations Plan, the hospital prepares for how it will manage staff during an emergency.
The Emergency Operations Plan describes the following: The roles and responsibilities of staff for communications, resources and assets, safety and security, utilities, and patient management during an emergency.

The Emergency Operations Plan describes the following: The roles and responsibilities of staff for communications, resources and assets, safety and security, utilities, and patient management and evacuation during an emergency.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a system to track the location of on-duty staff during an emergency.

For hospitals that use Joint Commission accreditation for deemed status purposes: Initial and ongoing training relevant to their emergency response roles is provided to staff, volunteers, and individuals providing on-site services under arrangement. This training is documented and then reviewed and updated annually and when these roles change. Staff demonstrate knowledge of emergency procedures through participation in drills and exercises, as well as post-training tests, participation in instructor-led feedback (for example, questions and answers), or other methods determined and documented by the organization.
For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan describes the use of volunteers in an emergency, including emergency staffing strategies, such as the role and process for integration of state or federally designated health care professionals to address surge needs during an emergency.

Standard EM.02.02.09
Element(s) of Performance for EM.02.02.09
As part of its Emergency Operations Plan, the hospital prepares for how it will manage utilities during an emergency.
As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Electricity.

As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Electricity and lighting.

As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Utility systems that the hospital defines as essential (for example, vertical and horizontal transport, heating and cooling systems, and steam for sterilization).

As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Utility systems that the hospital defines as essential (for example, vertical and horizontal transport, heating and cooling systems, and steam for sterilization). Note: The essential utility systems include mechanisms for maintaining temperatures at a level that protect patient health and safety and the safe and sanitary storage of provisions.

For hospitals that use Joint Commission accreditation for deemed status purposes: The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, TIA 12-6); Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, TIA 12-4); and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

Standard EM.02.02.11
Element(s) of Performance for EM.02.02.11
As part of its Emergency Operations Plan, the hospital prepares for how it will manage patients during emergencies.
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a system to track the location of patients sheltered on site during an emergency. This system includes documentation of the name and location of the receiving facility or alternate site in the event a patient is relocated during the emergency. Note: The name and location of receiving facilities or alternate sites may be defined in the emergency management plan, formal transfer agreements, or other accessible documents.

Standard EM.04.01.01
Element(s) of Performance for EM.04.01.01
For hospitals that use Joint Commission accreditation for deemed status purposes: If the hospital is part of a health care system that has an integrated emergency preparedness program, and it chooses to participate in the integrated emergency preparedness program, the hospital participates in planning, preparedness, and response activities with the system.
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital demonstrates its participation in the development of its system’s integrated emergency preparedness program through the following: – Designation of a staff member(s) who will collaborate with the system in developing the program – Documentation that the hospital has reviewed the community-based risk assessment developed by the system’s integrated all-hazards emergency management program – Documentation that the hospital’s individual risk assessment is incorporated into the system’s integrated program – Documentation that the hospital’s patient population, services offered, and any unique circumstances of the hospital are reflected in the system’s integrated program – Documentation of an integrated communication plan, including information on key contacts in the system’s integrated program – Documentation that the hospital participates in the annual review of the system’s integrated program

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has implemented communication procedures for emergency planning and response activities in coordination with the system’s integrated emergency preparedness program.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s integrated emergency management policies, procedures, or plans address the following: – Identification of the hospital’s emergency preparedness, response, and recovery activities that can be coordinated with the system’s integrated program (for example, acquiring or storing clinical supplies, assigning staff to the local health care coalition to create joint training protocols, and so forth) – The hospital’s communication and/or collaboration with local, tribal, regional, state, or federal emergency preparedness officials through the system’s integrated program – Coordination of continuity of operations planning with the system’s integrated program – Plans and procedures for integrated training and exercise activities with the system’s integrated program.