The role private accreditation has on improving health care quality By Dr. Mark R. Chassin, opinion contributor — 10/03/17 11:20 AM EDT THE HILL

Health care quality is a vital issue for every American because all of us will one day need to rely on it. For that reason, private accreditors of health-care providers are subject to enormous public scrutiny even when everything works as it should. Lately, our industry has come under criticism for a perceived lack of transparency and findings that seem to contradict government regulators. But much of that is rooted in a fundamental misunderstanding of what we do and what the public expects.
I have worked in both the public and private sectors to ensure health care quality, first as Commissioner of the New York State Department of Health and now as the head of the nation’s largest private healthcare accreditation organization.
Among the many things I’ve learned over my career is that being a state health commissioner is very different than being a private accreditor. The former has a duty to protect and improve the health of the public while the latter is a means of improving the way health care is delivered.

As a private accreditor, we create evidence-based quality standards; conduct in depth, on-site surveys of hospitals and other health care providers; evaluate compliance with those standards; work with providers to address opportunities to improve care; and inspire them to excel in providing the safest, highest quality care.
The goal of the private accreditation system is to identify deficiencies in care and have the hospitals correct those deficiencies — it is not to find as many deficiencies as possible to justify removing accreditation from those organizations. Denying accreditation is sometimes necessary if hospitals cannot bring their care up to an acceptable level. However, in the overwhelming majority of cases, hospitals do come into compliance once deficiencies are pointed out.
Regulators, on the other hand, are public institutions with the authority to impose penalties and enforce laws, and their activities are therefore subject to public scrutiny and oversight.
Private accreditors have no such authority and need to balance public transparency with the need for candor between surveyor and healthcare provider. In addition, regulators are typically the first to receive complaints from the public, but often don’t share information about what was found to be noncompliant with private accreditors.
This balance is well understood in high-stakes industries that deal with complex risks every day, such as aviation, rail and marine transportation, and commercial nuclear power. All of these industries combine public reporting of important data with systems of confidential reports that contain sensitive information about safety risks, solutions, and uncertainties around potential process failures.
These oversight systems facilitate the identification of safety hazards – real and potential — in a safe harbor that is free from the fear of reprisal, public humiliation, or litigation. The system works. Confidential evaluations such as these are credited with promoting and sustaining a safety culture that reduces harm substantially over time.
By maintaining an open and candid relationship with a broad range of institutions across the country, private accreditors are able to spot overlooked risks that might appear to be singular events at an individual hospital but are actually part of a nationwide issue. Private accreditors, not public regulators, were the first to identify the presence of concentrated electrolyte solutions such as potassium chloride in patient care areas as the reason for accidental injections of these agents. Today, deaths due to these accidents are unheard of.
It is also important to acknowledge an uncomfortable reality. There are no perfect hospitals anywhere in the world. No known methods or procedures have succeeded in abolishing preventable harm to patients. Neither private accreditors nor government regulators can guarantee that such events will not occur in hospitals that have “passed” their reviews.
Critics of the private accreditation system say there is too much confidentiality between healthcare institutions and accreditors and that hospital survey reports should be made public.
We strongly support the goal of putting valid, useful data on quality of care in the hands of the public. In fact, we were the first to create a program that reports publicly a variety of standardized quality measures that assess hospital performance, a program that continues to this day.
But the responsibility for assessing all sources of data and making a judgment on a healthcare institution’s ability to serve the public rests with a publicly accountable regulator, not a private accreditor.
That’s why we and others have called on the Centers for Medicare and Medicaid Services (CMS) to engage in a dialogue with private accreditation organizations to identify a more effective strategy to better educate the public while ensuring necessary protection for health care quality improvement.
In the end, we all want the same thing: a health care system that consistently delivers the best quality of care and exhibits a culture of excellence that inspires institutions to continually improve their performance.
We are ready to work with CMS and other stakeholders to ensure that we achieve that goal in a way that properly balances public data with confidential quality improvement.
Dr. Mark R. Chassin, M.D., is President and Chief Executive Officer of The Joint Commission, nation’s largest health care standards-setting and accrediting organization.

CMS Review of Accrediting Organizations Disparity Report

The Social Security Act requires a performance evaluation of each CMS-approved accrediting organizations(AO) to verify that the accredited provider demonstrate compliance with the Medicare Conditions of Participation (CoPs). The CMS annual report to Congress (RTC) details the review, validation and oversight of the AOs Medicare accreditation programs as well as those under Clinical Laboratory Improvement Amendments (CLIA).

The CMS evaluation process includes, but is not limited to, the following components:
• On-site observations are conducted to ensure that the accreditation program is fully implemented and operational
– Corporate on-site review
– Survey observation
• Comprehensive review of AO accreditation standards to ensure that the AO standards meet or exceed those of Medicare
• Comprehensive review of the AO’s
– Policies and procedures to ensure comparability with those of CMS
– Adequacy of resources to perform required surveys to ensure comparability with those of CMS
– Survey processes and enforcement to ensure comparability with those of CMS
– Surveyor evaluation and training to ensure comparability with those of CMS
– Electronic data to ensure the AO has the capacity to provide CMS with the necessary facility demographic, survey-related, deficiency, adverse action and accreditation decision data, etc.
– AO financial status to ensure organizational solvency and ability to support operations


Click to access Survey-and-Cert-Letter-17-40.pdf

Vizient 8/2017




CMS drafting guidance on ligature and other self-harm risks

From The Joint Commission 9/6/17

The Centers for Medicare and Medicaid Services (CMS) recently identified the need for increased direction, clarity and guidance regarding the definition of what constitutes a ligature risk, as well as other safety risks involved in the care of patients requiring psychiatric care and treatment. Included in this guidance will be direction on:
How these risks should be surveyed
At what level the deficiency should be cited
The elements required for an appropriate Plan of Correction
What constitutes a suitable mitigation plan to minimize the risks to patients who are cared for in environments with identified deficiencies
CMS stated that the focus of its concern is on psychiatric patients in psychiatric units of hospitals and in psychiatric hospitals. CMS is drafting guidance utilizing the skill and expertise of CMS’ regional offices, state survey agencies, accrediting bodies, providers, mental health clinicians, and other stakeholders. CMS expects this guidance to take approximately six months to complete.
In the meantime, CMS has stated The Joint Commission may use its judgment as to the identification of ligature and safety risk deficiencies, the level of severity for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to remedy the identified deficiencies.
While the guidance is being developed, CMS will review its enforcement actions related to serious ligature risk deficiencies on a case-by-case basis, and will provide updates via Survey & Certification (S&C) policy memos, as necessary.

CMS pulls proposed rule to make private accreditor reports public

By Maria Castellucci | August 3, 2017

Modern Healthcare
The CMS on Wednesday withdrew a proposed rule to require private accreditation organizations publicly release their reports on healthcare facilities, after an overwhelming majority of industry stakeholders came out against the change.

The agency announced the decision as part of its inpatient pay rule. The CMS said it “would be best” if the proposed rule was withdrawn after it considered public comments.

Under the proposal, accreditors like the Joint Commission would have been required to post survey reports and corrective action plans within 90 days after visiting a healthcare organization.

The CMS said the rule needed further “review, consideration and refinement” to ensure it would “inform patients and continue to support high quality care.”

The proposal was an attempt by the CMS to improve transparency in the industry by helping healthcare consumers make more informed decisions about where they receive care and by encouraging providers “to improve the quality of care and services they provide,” the agency said.

The CMS initially introduced the rule in April, and it was immediately panned by private accreditors and even providers including the American Hospital Association.

Private accreditation organizations argued during the comment period that the rule would only confuse consumers, tarnish the candid relationship they have with providers, and be an expensive administrative burden.

In its comment to the CMS, the Joint Commission claimed the rule would cost $3.7 million in the first year to follow, and $2.3 million in expenses for subsequent years because it would have to create new software and hire more staff.

The American Hospital Association also questioned the rule’s effectiveness. Nancy Foster, vice president of quality and patient safety at the AHA, said in a statement that sharing detailed accreditation reports “may not be the most useful or effective strategy for informing the public.”

But patient safety experts applauded the proposal, arguing private accreditors don’t currently do a good job protecting patients from harm at facilities and they should be forced to show how they evaluate providers. Those in favor of the proposal also said that transparency would encourage providers to improve quality outcomes and safety issues because the information would be open to the public.

The CMS only audits about 10% of providers so private accreditors carry the lion’s share of audits of facilities. Congress is currently considering a bill that would add dialysis centers to the list of facilities private accreditors can certify.

TJC enhances pain assessment and management requirements for accredited hospitals

Applicable to hospitals The enhanced pain assessment and management standards include the following new requirements:

• Identify a leader or leadership team that is responsible for pain management and safe opioid prescribing.

• Involve patients in developing their treatment plans and setting realistic expectations and measurable goals.

• Promote safe opioid use by identifying high-risk patients.

• Monitor high-risk patients.

• Facilitate clinician access to prescription drug monitoring program databases.

• Conduct performance improvement activities focusing on pain assessment and management to increase safety and quality for patients. n2018_Prepub.pdf

Recommendations: Review the revised standards and processes within hospital to address pain management and opioid utilization. Update your policy and procedures as applicable to align with requirements.

Effective: January 1, 2018


© 2016 Vizient, Inc. All rights reserved

AT LAST! CMS Says Providers Are Not Required to Put Plans of Correction on Forms Published on July 3, 2017

Elizabeth Hogue
Attorney in Private Practice
At last! On June 16, 2017, the Centers for Medicare and Medicaid Services (CMS) issued New Guidance for the Formatting of Plans of Correction that was effective immediately.

In a Memorandum Summary, CMS stated as follows:

“Format for Plans of Corrections (POCs)/Allegation of Compliance (AOC):
Providers/Suppliers and Clinical Laboratory Improvement Amendments (CLIA) Laboratories will no longer be required to write their PoC (for CLIA, this includes AOCs) on the right side of the CMS Form 2567. Providers/Suppliers or CLIA Laboratories may submit their PoC/AOC as a separate document attachment or may continue to document the PoC on the right side of the CMS Form 2567.
Signature on First Page: The Laboratory Director or Provider/Supplier Representative’s signature is still required on the first page of the CMS Form 2566 for the PoC/AOC. The PoC/AOC can be sent as an attachment to the signed first page of the CMS Form 2567.”
So, this means that providers and suppliers are no longer required to enter their PoCs in the far right hand column of the Statement of Deficiency. Instead, providers and suppliers are allowed to submit their PoC’s in any format so long as they include a signed first page of CMS Form 2567.
CMS also provided several reminders to providers and suppliers regarding PoCs as follows:
“An acceptable plan of correction must contain the following elements:
The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited.
The procedure for implementing the acceptable plan of correction for the specific deficiency cited
The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements
The title of the person responsible for implementing the acceptable plan of correction.”
The content of PoC’s, therefore, remains the same, but there is now flexibility with regard to the format. Form 2567 doesn’t have to be used at all for the content of the PoC!

CMS also reminds providers and suppliers that PoC’s are publically releasable documents so providers and suppliers are required to omit any Privacy Act or Protected Health Information. If such information is included in PoC’s, surveyors will require amended PoC’s that do not include such information.
Flexibility in the format in which PoCs are submitted may seem like a small thing, but under the time pressures and other stresses associated with development and submission of PoCs, it’s “Yuuuge!”

©2017 Elizabeth E. Hogue, Esq. All rights reserved.

The Joint Commission: What’s Your Board’s Competency in Quality and Safety?


May 30, 2017
By Steven Berman
Executive Editor
The Joint Commission Journal on Quality and Patient Safety
Board members play a vital role in ensuring high-quality care and patient safety in health care organizations. However, a new study suggests problematic gaps between what board members think they know and what they do in regards to quality and safety, as well as board members’ capability in quality and safety, as assessed by safety and quality leaders (SQLs) at their own health care organizations.
In “Closing the Gap and Raising the Bar: Assessing Board Competency in Quality and Safety,” from the June 2017 issue of The Joint Commission Journal on Quality and Patient Safety: Patricia A. McGaffigan, RN, MS, CPPS, chief operating officer and senior vice president, Programs, National Patient Safety Foundation, [which has since merged into the Institute for Healthcare Improvement], and co-authors, conducted a 36-question survey with a convenience sample of board members, CEOs and SQLs.
Assessing Board Competency
A large percentage of each group among the 605 respondents—105 board members, 53 CEOs, and 447 SQLs—reported that safety was ranked as number one on their organization’s list of strategic priorities. Analysis of responses concerning their knowledge and understanding of specific concepts, such as leadership, culture, serious events and harm prevention, revealed similar patterns across the three groups. In addition, findings revealed:
CEOs rated their own knowledge and understanding as highest.
Board members reported lower ratings of their own knowledge and understanding.
SQLs were less likely to rate their own board members’ knowledge and understanding as “high.”
The authors conclude that the survey “reveals specific areas of focus for improving governance and leadership practices at board meetings, as well as several areas where knowledge and understanding of safety and quality were variable. Further research and consensus would be beneficial to identify best practices for board education and governance activities to drive quality and safety.”
In an accompanying editorial, “Knowing, and Doing: Closing the Gaps in Board Leadership for Improvement of Quality and Safety,” James L. Reinertsen, MD, president, The Reinertsen Group, Alta, Wyoming, and senior fellow, Institute for Healthcare Improvement, Cambridge, Massachusetts, states that “The study reaffirms it would be a good idea to develop more capable boards, both by recruiting board members with expertise in quality and safety, and by offering all board members the opportunity to ground themselves in serious knowledge of quality and safety concepts and methods. But it is even more important that we establish practices—at the board level, and at the quality/safety committee level—that allow our board members to apply their knowledge effectively.”

Goal Revisions for Healthcare-Associated Infections NPSGs from The Joint Commission

National Patient Safety Goals (NPSG)
Standard NPSG.07.03.01   Implement evidence-based practices to prevent health care– associated infections due to multidrug-resistant organisms in acute care hospitals. Note: This requirement applies to, but is not limited to, epidemiologically important organisms such as methicillinresistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), carbapenemresistant enterobacteriaceae (CRE), and other multidrugresistant gram-negative bacteria.
Elements of Performance for NPSG.07.03.01  Based on the results of the risk assessment, eEducate staff and licensed independent practitioners about  health care–associated infections, multi-drug-resistant organisms and prevention strategies at hire and annually thereafter. Education occurs upon hire or granting of initial privileges and periodically thereafter as determined by the organization.  Note: The education provided recognizes the diverse roles of staff and licensed independent practitioners and is consistent with their roles within the [critical access] hospital organization.  Implement a surveillance program for multidrug-resistant organisms based on the risk assessment.  Note: Surveillance may be targeted rather than [critical access] hospital-wide.  Measure and monitor multidrug-resistant organism prevention processes and outcomes, including the following:   Multidrug-resistant organism infection rates using evidence-based metrics    Compliance with evidence-based guidelines or best practices    Evaluation of the education program provided to staff and licensed independent practitioners Note: Surveillance may be targeted rather than [critical access] hospital-wide.
Standard NPSG.07.04.01 Implement evidence-based practices to prevent central line– associated bloodstream infections.    Note: This requirement covers short- and long-term central venous catheters and peripherally inserted central catheter (PICC) lines.
Element of Performance for NPSG.07.04.01 1.  Educate staff and licensed independent practitioners who are involved in managing central lines about central line– associated bloodstream infections and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities or granting of initial privileges and periodically thereafter as determined by the organization.    Conduct periodic risk assessments for central line– associated bloodstream infections, monitor compliance with evidence-based practices, and evaluate the effectiveness of prevention efforts. The risk assessments are conducted in time frames defined by the [critical access] hospital, and this infection surveillance activity is [critical access] hospital-wide, not targeted.
                 Use a standardized supply cart or kit that contains all necessary components for the insertion of central venous catheters.   Perform hand hygiene prior to catheter insertion or manipulation.  .  Use a standardized protocol for maximum sterile barrier precautions during central venous catheter insertion. .  For adult patients, do not insert catheters into the femoral vein unless other sites are unavailable.   Use an alcoholic chlorhexidine antiseptic for skin preparation during central venous catheter insertion that is cited in scientific literature or endorsed by professional organizations. *unless contraindicated.
    *: A limited number of National Patient Safety Goals contain requirements for practices that reflect current science and medical knowledge. In these cases, the element of performance refers to a practice that is cited in scientific literature or endorsed by professional organizations. This means that the practice used by the hospital must be validated by an authoritative source. The authoritative source may be a study published in a peer-reviewed journal that clearly demonstrates the efficacy of that practice or endorsement of the practice by a professional organization(s) and/or a government agency(ies). It is not acceptable to follow a practice that is not supported by evidence or wide-spread consensus. During the on-site survey, surveyors will explore the source of the practices the hospital follows

Suicide Prevention by Courtemanche & Associates


Suicide Prevention “ Ligature Risks and More  May 4, 2017

  • According to the National Alliance on Mental Illness (NAMI), 1 in 5 adults experience mental illness and over 20 million adults have a substance abuse disorder.  Behavioral Health issues in healthcare have been on the radar by The Joint Commission, since the formation of the first National Patient Safety Goal for behavioral health released in 2007. Patient Suicides account for over 10% of all reported Sentinel Events.  One of the highlighted points from the Sentinel Event Alert #56, released earlier this year, was that 21.4% of behavioral health settings and 5.14% of acute care settings were not in compliance with Safety Goal 15.01.01, EP1 in 2014.  This safety goal was focused on identifying specific patient characteristics and environmental features that may increase or decrease the risk for suicide.
  • By now, everyone should be aware of the renewed focus during surveys around preventing suicides and eliminating ligature points.  What better month than National Mental Health Month to take a moment to focus on Suicide Prevention in its entirety. Ensuring that your organization has completed a thorough and credible self-assessment is vital for Patient Safety.  Here are the steps:

    Step 1:  Identify areas (dedicated and non-dedicated) where psychiatric patients are cared for

    Step 2:  Conduct a robust environmental risk assessment. This is best accomplished by a multi-discipline team comprised of senior (C-suite) leadership, behavioral health team experts, facilities management, and local department staff.

    Step 3: Based upon your Risk Assessment, determine your mitigation strategies

    • Short term “ immediately reduce risk
    • Long term “ capital investment. Remember, for every long term strategy, you need to have a short term fix that will reduce the risk while waiting for implementation of the long term strategy.
      • Short term strategies might include: (1) Relocating the service to safer area (2)Providing additional staff (3) Increasing the monitoring of patients (4)Re-consideration of services provided

    Step 4:  Review processes & policies on patient screening, assessment/reassessment, placement of patients and resource allocation.

    Step 5:  Review staff education- have you offered programs to staff on providing care to patients with behavioral health issues, how to de-escalate and evolving situation and how to stay safe when de-escalation is ineffective.  Have you provided education on how to provide sitter services to patients with behavioral health needs?  The education content for behavioral health sitting maybe very different than risk for fall sitting services. Does the education include content around suicide risk awareness? Who have you educated?  Is the scope broad enough and include ancillary staff such as radiology, phlebotomy and respiratory staff?

    Step 6:  Assess competence of those staff assigned to provide care, treatment and services to patients with behavioral health needs.  Criteria could include their ability to assess the physical environment for risk.  Assure appropriate committee involvement.

    Step 7:  Document, document, document. Make certain your risk assessment is documented and up-to date.  Keep minutes of the team meetings, decisions and actions taken. Utilizing evidence based practices to assess and design your services is vital.  To assist you, here are several links: Some of the commonly referenced tools related to patient screening are as follows:  Patient Health Questionnaire (PHQ-9), ED-SAFE Patient Safety Screener, and for the Emergency Department, the Suicide Behaviors Questionnaire-Revised (SBQ-R).

    Use the most current edition of the Psychiatric Design Guidelines (2017) to assist you with identifying behavioral health approved products.

    Attached some tools (General) and Emergency Dept.)to help in the rounding process in addition to a risk assessment tool related to environmental issues