December 2008 Joint Commission Online Now Available

The December 2008 issue of Joint Commission Online is now available. Updates in the latest issue include:

• Accreditation changes effective January 1, 2009 to comply with CMS application for continued deeming authority;
• No new National Patient Safety Goals (NPSGs) will be created for 2010 in order to review the 2009 NPSGs;
• The elimination of "thresholds" in Conditional Accreditation (CA) and Preliminary Denial of Accreditation (PDA) decisions;
• The announcement that organizations will receive their National Quality Improvement Goal data in March;
• The announcement of five new members to The Joint Commission Board of Commissioners.

Click here for the full issue of Joint Commission Online:
http://www.jointcommission.org/Library/jconline/jconline_dec_2008.htm

Rhode Island Begins Electronic Credentialing System January 1

On January 1, 2009, the Rhode Island Department of Health (HEALTH) will no longer issue wallet cards to new or renewing licensees. All primary source verification will be conducted through HEALTH's online system.

When a license is first issued, HEALTH will send written notification containing the license number, expiration date, and information on how to use the online system in lieu of the wallet card.

If you have any questions about the new system, contact Charlie Alexandre at charles.alexandre@health.ri.gov.

Click here to visit HEALTH's online license verification system:

http://www.health.ri.gov/hsr/professions/license.php

OIG Releases Two Studies on Adverse Event Reporting

The Department of Health and Human Services Office of the Inspector General (OIG) has released two studies on how hospitals and states are collecting and utilizing data on adverse events.

In the study titled, Adverse Events in Hospitals: Overview of Key Issues, the OIG identifies adverse events as "any harm to a patient as a result of medical care, such as infection because of contaminated equipment." The study also notes that while better reporting of adverse events will lead to a higher quality of care, there are several barriers to proper reporting. For example, the report states that hospital staff may be too busy and forget to report an incident. Others may be hesitant to report an adverse event, fearing that it will lead to legal action.

The OIG's second study, Adverse Events in Hospitals: State Reporting Systems, examined the 27 states that have established adverse event reporting systems. Although each state has a different reporting system, they have all been using their data to make quality improvements in their healthcare systems.

To read the OIG's studies, click here:

Adverse Events in Hospitals: Overview of Key Issues
http://www.oig.hhs.gov/oei/reports/oei-06-07-00470.pdf

Adverse Events in Hospitals: State Reporting Systems
http://www.oig.hhs.gov/oei/reports/oei-06-07-00471.pdf

Source: BNA

More States Moving Toward Health IT Implementation

According to a report by the National Conference of State Legislatures (NCSL), more states are moving toward health IT (HIT) implementation, recognizing its impact on improving the quality of care, while lowering costs.

The report shows that between 2007 and 2008, more than 370 HIT bills were introduced at the state level, three times more than the number introduced between 2005 and 2006.

Supporters of HIT cite improvements it can make in patient record-keeping and the prevention of duplicate records.

Source: Healthcare IT News
http://www.healthcareitnews.com/story.cms?id=10590&fromRSS=true

AOIA Announces First Subscriber to XML-Based Physician Profile Service

The American Osteopathic Information Association (AOIA) has announced that Collaborative Fusion, Inc. (CFI) is the first subscriber to its XML-Based Physician Profile. CFI customers can use the service to conduct automated primary source verification of physician specialty information within the AOIA database.

AOIA developed the system to aid with emergency response efforts as part of the Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP).

CFI customers will be able to access the service as part of the CORES Platform. CORES reports provide information such as certification histories that can be used for primary source verification.

Source:
American Osteopathic Information Association
Contact: Annette Gippe
agippe@osteotech.org

CMS Renews TJC's Deeming Authority for Ambulatory Surgical Centers

The Centers for Medicare & Medicaid Services (CMS) has renewed The Joint Commission's (TJC) deeming authority for ambulatory surgical centers for the maximum term of six years.

TJC is one of four accrediting bodies granted deeming authority by CMS. Organizations wishing to enter the Medicare program must first be surveyed by one of these four accrediting bodies. Once certified, they can opt to have future surveys conducted by one of the accrediting bodies or by CMS state surveyors.

Source: The Joint Commission
http://www.jointcommission.org/NewsRoom/NewsReleases/nr_121208.htm

Section 1921 Implementation Delayed

The Practitioner Data Bank branch of the Health Resources and Services Administration (HRSA) has announced that implementation of Section 1921 of the Social Security Act has been delayed. The final rule was returned to the Secretary of Health and Human Services without any action from the Office and Management and Budget (OMB).

Section 1921 would require the NPDB to be queried for all licensed healthcare professionals including chiropractors, podiatrists, pharmacists, physician assistants, ophthalmologists, professional and paraprofessional nurses, physical therapists, respiratory therapists, and social workers.

It is expected that Section 1921 and other pending final rules from HRSA will be held for review by the incoming Secretary of Health and Human Services.

For more information on Section 1921, click here:
http://www.npdb-hipdb.hrsa.gov/about1921.html

The Joint Commission Issues Sentinel Event Alert on Healthcare Technology

NEWS RELEASE

Media Contact:
Ken Powers
Media Relations Manager
630-792-5175
kpowers@jointcommission.org

Joint Commission Alert: Prevent Technology-Related Health Care Errors

(OAKBROOK TERRACE, Ill. – December 11, 2008) Technology is often touted as the “cure” for health care, but a new Joint Commission Sentinel Event Alert issued today warns that implementation of technology and related devices is not a guarantee for success, and may actually jeopardize the quality and safety of patient care.

The Joint Commission’s Alert urges greater attention to understanding when a technology may (or may not) be applicable, choosing the right technology, understanding the impact technology can have on the quality and safety of patient care and attempting to quickly fix technology when it becomes counterproductive. The Alert makes clear that the overall safety and effectiveness of technology in health care ultimately depend on its human users, and that any form of technology can have a negative impact on the quality and safety of care if it is designed or implemented improperly or is misinterpreted.

The Alert notes that there is very little data on the number of errors directly caused by the increasing combined use of health information and devices. As an example, however, root cause analysis of errors shows that computerized medication orders and automated dispensing cabinets for medications are frequently involved. In addition to specific recommendations contained in the Alert, The Joint Commission urges health care organizations to use its Information Management accreditation standards to improve patient safety while using technology. Since technology is so common in health care—from admitting patients to the operating room to ordering and administering medication—any Joint Commission accreditation standard can be tied to technology.

“Innovations in technologies and information systems are vitally important to improve health care quality and safety, but we must be mindful of the safety risks and preventable errors that these implementations can create or perpetuate” says Mark R. Chassin, M.D., M.P.P., M.P.H.., president, The Joint Commission. “The strategies contained in this Alert give organizations and caregivers guidance that can help prevent patient harm and maximize the beneficial impact of these innovations.”

The Alert notes that the implementation of technology can threaten care and patient safety when:

· Clinicians and other staff are not included in the planning process;
· Providers do not consider the impact of technology on care processes, workflow and safety;
· Technology is not fixed when it becomes counterproductive; and
· Technology is not updated.

To reduce the risk of errors related to health information and technology, The Joint Commission’s Sentinel Event Alert recommends that health care organizations take a series of 13 specific steps, including the following:

· Look for possible risks in how caregivers carry out their work and resolve these issues before putting technology into place;
· Involve the caregivers who will ultimately use the technology;
· Train everyone who will be using the technology and provide frequent refresher courses;
· Make clear who is authorized and responsible for technology—from putting it into use to reviewing safety; and
· Continually seek ways to improve safety and discover errors.

Other strategies for reducing technology-related errors include avoiding distractions for staff using technology, monitoring and reporting errors and near misses to find the causes, and protecting the security of information.

The warning about preventing technology-related errors is part of a series of Alerts issued by the Joint Commission. Previous Alerts have addressed anticoagulants, wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm.

Source:
http://www.jointcommission.org/NewsRoom/NewsReleases/nr_12_11_08.htm