Despite state and federal regulations, and private hospital accreditation programs that try to ensure high-quality care, errors occur in hospitals that result in patient injuries. Many errors are due to process failures rather than unpredictable accidents. Process failures can result in harm or, at best, missed opportunities to provide good care. Managers must remain vigilant by employing comprehensive monitoring programs that ensure protocols don’t slip.
The Joint Commission recently released a new chapter to the Comprehensive Accreditation Manual for Hospitals (CAMH) entitled Patient Safety Systems. The chapter is intended to encourage organizations to build more high-reliability environments, specifically working to promote and foster high quality, safe patient care.
By Cary D. Gutbezahl, MD Because of the financial challenges that hospitals face, they have been obsessed with managing productivity (a code word for staffing based on workload units). Many hospitals have spent a substantial amount of money measuring staff productivity based on workload units such as occupied beds, radiology tests, and patient days. Staffing […]
CMS develops Conditions of Participation (CoPs) that health care organizations must meet in order to participate in the Medicare and Medicaid programs. According to CMS, these health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries. In September 2014, Joint Commission Resources hosted its first CMS Hospital Update providing an overview of the most challenging CoPs, unique aspects of the CoPs related to specific challenging chapters, and a focused discussion on Immediate Jeopardy.
Of course, we all want to provide safe, quality care to patients, but do we need to be associated with an accreditation brand to demonstrate that we do?When considering the costs of accreditation, leaders should ask the following questions…
Would you ever do business with an industry if you knew the equivalent of 160 losses would occur each month?
The latest CMS Update included a discussion of immediate jeopardy triggers hospitals should be aware of. CMS defines immediate jeopardy as “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.”
Briefings on the Joint Commission: Organizations are taking a much more critical look at their infection control programs, as are surveyors, not just looking at the infection control plan and risk assessment, but also at the program leadership within the organization,
Regardless of choice — including the option of not seeking accreditation and instead gaining approval through survey by the state agency responsible for CMS oversight — selecting an accreditation source is a strategic decision meriting leadership consideration for an appropriate organizational fit. Because these are choices with real differences, executives should select an accreditation vendor based on criteria. But what criteria make one organization a better fit than the others?
The “Accreditation Options” series from Compass Clinical Consulting being featured on Becker’s Hospital Review magazine has thus far evaluated the strengths and limitations of the four predominate accrediting organizations with deemed status from CMS: Healthcare Facilities Accreditation Program, The Joint Commission, Det Norske Veritas Healthcare and the Center for Healthcare Improvement.
One additional but rarely used option is to eschew using any external accrediting body and instead selecting state-based review for Medicare/Medicaid approval of Conditions of Participation. There are advantages and costs associated with all options, but few organizations understand, much less consider, the state option.
Emergency departments across the nation have been challenged by rising volumes. ED crowding is exacerbated by the increase in the number of patients with mental disorders, substance abuse problems or both, who present with acute problems. Besides the mental health conditions such as schizophrenia, mood disorders, anxiety disorders, alcohol and drug disorders and intent to self-harm, these patients often have other medical problems including diabetes, liver disease and various infections.
Frequently, all it takes to achieve big gains in hospital efficiency and quality is a change in personnel.
Cary Gutbezahl, CEO of Compass Clinical Consulting, sat down for an in-depth “Profile in Healthcare Leadership” interview with Mr. Dennis Vonderfecht, President and CEO of Mountain States Health Alliance (MSHA), the largest healthcare system serving Northeast Tennessee, Southwest Virginia, Southeast Kentucky and Northwest North Carolina. The topics was ‘how do you create and communicate a patient-centered care culture?’
Compass Clinical’s Victoria May Fennel, PhD, RN-BC, CPHQ, is featured in Beckers Hospital Review for her latest article “Accreditation options: Understanding the Center for Improvement in Healthcare Quality.” Written by Victoria May Fennel, PhD, RN-BC, CPHQ The newest hospital accreditation option is the Center for Improvement in Healthcare Quality. Originally formed in 1999 as a […]
When looking for the right people for your healthcare organization there are four things that you cannot teach that the right people already have. They are…
First and foremost remember that the least important part of the organization is the people who are in the C-suites. The most important people are the people who are delivering the care. I don’t ever want anyone to forget in executive leadership that we are here to support the people at the bedside. That’s the only reason we’re here. It’s the only reason we have jobs. It’s the only reason, presumably, that we’re…
For healthcare executives, the question is, how do we ensure that we do not uncover a defect until it is associated with patient harm?
Are there “ignition switch defects” in your hospital? How do we ensure that we do not uncover a defect until it is associated with patient harm?
Often, inpatient areas outside the main OR and sterilization processing department (SPD), clinics, and other outpatient areas process items—such a vaginal speculum or probes, ophthalmology and dental instruments, and other re-usable equipment—using steam sterilization or high-level disinfection that may not meet industry standards.
The spotlight is on sterilization and high-level disinfection (HLD) processes during accreditation surveys, and many organizations struggle with ensuring compliance in all areas across the organization. Often, inpatient areas outside…
Cary Gutbezahl, CEO of Compass Clinical Consulting, sat down for an in-depth “Profile in Healthcare Leadership” interview with Mr. Dennis Vonderfecht, President and CEO of Mountain States Health Alliance (MSHA), the largest healthcare system serving Northeast Tennessee, Southwest Virginia, Southeast Kentucky and Northwest North Carolina. The topic was, ‘how do you take the board from thinking at the hospital level to thinking more like a real healthcare system?’
As you look into the future and see the changes occurring where population health becomes a bigger issue for health systems and there’s a migration away from what has always been the cash cow of healthcare – the hospital – how do you manage that financial change as it occurs and keep the whole enterprise afloat? A Profile in Healthcare Leadership with leadership profile features Mark Frey, President and Chief Executive Officer, Alexian Brothers Health System.
Compass Clinical’s Victoria May Fennel, PhD, RN-BC, CPHQ, article, Understanding Det Norske Veritas Healthcare’s National Integrated Accreditation for Healthcare Organizations program, is featured in Becker’s Hospital Review. In 2008, Det Norske Veritas Healthcare, Inc. received notification that it had been approved by the CMS to deem hospitals in compliance with the CMS Conditions of Participation for […]
Mark Frey, President and Chief Executive Officer of Alexian Brothers Health System, discusses the the dramatic changes their organization went through in adapting to healthcare reform with Compass Clinical CEO Cary Gutbezahl.
Healthcare providers do not have to wait for the analytics—case managers can be recruited to identify high-risk populations early in a patient’s enrollment into a healthcare network. See how in Compass Clinical’s Terri Marshall, RN, MS, CCM and Cary Gutbezahl, MD featured article “A Guide for Identifying High-Risk Patients Through Hands-on Case Management,” in the July 2014 issue of Dorland’s Case in Point Magazine.