If hospital survey results during the past year are any indication, 2019 should be a very busy and challenging year for hospitals across the country. For CMS: Greeley has seen an uptick in EMTALA citations and we continue to see termination actions focused on infection prevention and the care of suicide patients. The Joint Commission… [Read More]
A second “time out” is required by NFPA 99 for some surgical procedures
Bud Pate, Vice President, Content; Steve MacArthur, Consultant, The Greeley Company Joint Commission representatives have begun emphasizing the need for an additional “NFPA Time Out” for some surgical cases. This time out is not required by the Joint Commission’s Universal Protocol, but it is referenced in the NFPA (National Fire Prevention Association) standards. We’ve received… [Read More]
When exactly is “Bylaws Season”?
Hospitals seem to have a season for everything. There are preparations and protocols and promotions for the onset of tourist- and flu-seasons. There are awareness days, weeks, and months for every imaginable body part, cancer, and disorder. There are business seasons for year-end, budget planning, and performance improvement benchmarks and goal-setting. There are appreciation days… [Read More]
Focusing on High-Level Disinfection
Among the topics slated for “enhanced” attention during Joint Commission surveys are high-level disinfection and sterilization, which continue to be problematic for hospitals across the country. Issues related to disinfection usually lead to condition-level findings, sometimes placing the hospital into “Immediate Threat to Life” or “Immediate Jeopardy” status. Background In early 2012 the FDA issued… [Read More]
Policy, Procedure, or Guideline?
If you are looking to make a change at your hospital to define or revise the way you do or should be doing things, be sure you understand whether the change should be made in policy, procedure, or guideline, or to what extent in each. Policies are broad expressions of the intent or desired outcome… [Read More]
Mock Surveys: Helpful, or Not So Much…?
There are two types of recommendations that can come out of a mock survey: good recommendations and unhelpful recommendations. If you’ve had a mock survey before, it may have been delivered with recommendations like: “Staff should be educated…,” “Be sure to remind the physicians…,” or “Don’t do this anymore!” Two of these are “managed loose”… [Read More]
Areas of Focus: Enhanced Joint Commission Survey Process
If your hospital is accredited by The Joint Commission (TJC), your CEO recently received a letter. That letter alerts the CEO that Joint Commission surveyors have been given additional training in four subjects to focus on when they arrive at your door for a survey. These subjects are: high-level disinfection and sterilization; sterile compounding of… [Read More]
Pain Points in the Opioid Epidemic… for Hospitals and Physician Practices
No more Mr. Niceguy. It started as “better guidance” for prescribers as concerns mounted that the over-prescription of opioid pain medications was feeding a sharp rise in addiction to illicit forms, including street-sourced pills and heroin. But it has turned into well-coordinated federal and state enforcement actions against physicians and nurses, as well as their… [Read More]
Marijuana in the Hospital Environment
As more states legalize marijuana, more physicians have begun recommending cannabis to their patients for the management of pain, nausea, anxiety, and loss of appetite. Recent literature also suggests that cannabis may be effective in treating other conditions. For example, the Federal Food and Drug Administration (FDA) recently approved a drug whose active ingredient is… [Read More]
Still “laundry list” privileging? Let’s talk about OPPE and FPPE.
If you are still using “laundry list” privileging as opposed to core privileging, you are likely struggling to perform meaningful OPPE and FPPE. If a laundry list for a typical specialist includes 60-80 privileges, how do you determine current competence for each? In order to prove current competence, you need data. And performance on only… [Read More]
