HCPro.com: Ambulatory Quality and Compliance Insider

Whether you're complying with The Joint Commission's National Patient Safety Goals, meeting CMS requirements, or overcoming AAAHC survey challenges, maintaining highquality patient care is no small task. Every issue of Ambulatory Quality and Compliance Insider is packed with field-tested compliance tips you can implement right away and how-to advice from ambulatory experts across the country.

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September 2008 (Volume 8, Issue 9)	view entire issue

New Joint Commission standards change scoring and eliminate FMEAs
Surgery centers accredited by The Joint Commission will face two seismic changes come January 1, 2009. The new standards will no longer require surgery centers to conduct Failure Modes and Effects Analysis (FMEA), and the scoring process will now factor in the severity of violations. And if noncompliance with even one standard poses an imminent risk of patient death, the surgery center could face an expedited preliminary denial of accreditation. "They have a priority tier," says Jan Allison, RN, director of quality and accreditation at Surgical Care Affiliates in Birmingham, AL, who serves on the ASC Advisory Task Force for The Joint Commission and took part in calls on the Standards Improvement Initiative (SII).

Joint Commission cracks down on disruptive clinicians
Dictatorial docs who demean, bully, or otherwise behave badly may want to get in touch with their kinder, gentler side. Beginning January 1, 2009, new standards from The Joint Commission (formerly JCAHO) will require ambulatory surgery centers (ASC) to have protocols to put cantankerous clinicians in their place-or else. The accreditor issued a Sentinel Event Alert in July warning that disruptive behavior by physicians, or any clinicians for that matter, pose a threat to patient safety.

Proposed CfCs, public reporting top list of ASC concerns
As ambulatory surgery centers (ASC) prepare to implement new Conditions for Coverage (CfC) and report on new quality measures, several concerns are weighing on ASC administrators' minds, including quality improvement, data collection, and policy changes. The Centers for Medicare & Medicaid Services (CMS) proposed new CfCs in 2007 and is expected to release the finalized version this fall. Waiting for the finalized version to be released can be unnerving, especially when implementation dates of the new conditions are unknown.

Teamwork helps prevent surgical fires in ASCs
The American Society of Anesthesiologists (ASA) has published a new advisory that aims to help organizations prevent surgical fires. Although the comprehensive advisory is primarily aimed at anesthesiologists that the ASA represents, its recommendations are also pertinent to other healthcare workers. It is particularly important for ambulatory surgery centers (ASC), which are required by Joint Commission National Patient Safety Goal #11 and Requirement 11A to educate clinicians and anesthesia providers about how to manage heat sources and fuels. The Joint Commission (formerly JCAHO) also mandates that facilities establish guidelines to minimize oxygen concentration under surgical drapes.

Other recently-published articles from Ambulatory Quality and Compliance Insider:

Beating CFCs to the punch

Surgical smoke raises safety alarms

OSHA citations are down, but fines carry weight

Preparing for the challenges of Medicare fee changes

Bone up on respiratory hygiene, cough etiquette to prevent spread of infection

Pathology -project, diabetes program win QI awards

AAAHC’s Chapter 5 proposal worries some facilities

Vigilance needed on reproductive hazards in healthcare

Tackle disruptive clinician behavior early and often

How to conduct an effective root cause analysis

Flash sterilization stirs up debate in ASCs

Save time, money by asking doctors’ offices for info

Universal Protocol: Q&A with Peter B. Angood

Timeouts need to include the entire surgical team

Teamwork helps prevent surgical fires in ASCs

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