bsbt2553-jsnl4lvydk99nsae

The Pulse: February 2026 Healthcare Compliance & Facilities Update

Sat, 28 Feb 2026 12:53:35 GMT

February may be the shortest month of the year, but in the world of healthcare facilities and regulatory oversight, it often feels like the longest. Between the launch of the Joint Commission’s Accreditation 360 and the sudden shifting of federal staffing mandates, your compliance "To-Do" list likely looks more like a "To-Don't-Panic" list. Below is your breakdown of the critical updates, deadlines, and strategic shifts defining February 2026.

Regulatory Roundup: The "Great Repeal" of 2026

The most significant news hitting desks this month is the formal pivot in Long-Term Care (LTC) staffing.

CMS Staffing Mandate Repealed : Effective February 2, 2026 , CMS officially rescinded the 2024 minimum staffing requirements (the 3.48 HPRD mandate).
The Fine Print : While the "one-size-fits-all" numbers are gone, the Enhanced Facility Assessment requirements are still very much alive. Regulators are moving away from rigid ratios toward a "competency-based" model. You must still prove your staffing levels match your specific resident acuity.
What it means for you : It’s time to double-check your assessment documentation. Auditors aren't counting heads as strictly, but they are scrutinizing the logic behind your staffing decisions.

HIPAA & Privacy: The February 16th Pivot

If you haven't updated your Notice of Privacy Practices (NPP) yet, you are officially behind. February 16, 2026, marked the deadline for compliance with the final rule aligning 42 CFR Part 2 (Substance Use Disorder records) with HIPAA.

Lawful Holder Doctrine : Any practice receiving SUD records is now a "lawful holder," triggering new obligations for how those records are handled in legal proceedings.
Reproductive Health Privacy : New prohibitions are in place regarding the disclosure of PHI for investigations into lawful reproductive healthcare.
Security Rule Modernization : Th e HHS Office for Civil Rights (OCR) is phasing out the "addressable" vs. "required" distinction. By late 2026, every safeguard will be mandatory.

Tech & Sustainability: Do Less with Less

The 2026 facility mantra has shifted from "do more with less" to "do less with less"—meaning we are using data to eliminate wasted effort.

Unified Platforms : The era of separate spreadsheets for maintenance, energy, and compliance is over. Integrated CAFM (Computer-Aided Facility Management) tools are now the standard for audit-ready reporting.
The "Heart" of the Facility : Since it’s American Heart Month, it’s the perfect time to run a Life Safety check on AEDs and Cardiac Crash Carts. Ensure your battery replacement logs are digitized—paper tags are so 2024.

A Note on Candor : Let’s be real—the repeal of the staffing mandate might feel like a relief, but it’s actually a trap for the unprepared. Without a fixed ratio to hide behind, your clinical judgment is the only thing standing between you and a "Statement of Deficiencies." Don't let the lack of a mandate lead to a lack of a plan.

The 2026 CMS Mandates: Navigating the New Era of Accountability and Interoperability

Fri, 02 Jan 2026 12:47:53 GMT

A Special Briefing for Healthcare Leaders and Providers

The Centers for Medicare & Medicaid Services (CMS) is ushering in a transformative year with new requirements for Fiscal Year (FY) 2026 that will profoundly impact payment, quality reporting, and administrative processes. For healthcare facilities, understanding and preparing for these changes—especially the launch of a major new payment model and significant new interoperability rules—is crucial for financial health and care delivery.

Here is a breakdown of the key CMS mandates taking effect in 2026

1. Transforming Episode Accountability Model (TEAM): Bundled Payments Go Mandatory

The biggest shift for many acute care hospitals is the launch of the mandatory Transforming Episode Accountability Model (TEAM), starting January 1, 2026.

What it is : TEAM is a bundled payment model that makes selected acute care hospitals financially accountable for the total cost and quality of care for a surgical episode, beginning with the anchor procedure and extending for 30 days post-discharge.
Target Episodes : The model initially focuses on five high-volume, high-cost surgical procedures:
Coronary Artery Bypass Grafting (CABG)
Total Hip and Knee Arthroplasty (THA/TKA)
Spinal Fusion
Major Bowel Procedure
Acute Myocardial Infarction (AMI)
The Mandate : Selected hospitals in specific Core-Based Statistical Areas (CBSAs) will be required to participate.
The Stakes : Hospitals will receive a bundled payment target price. If the actual cost is below the target and quality metrics are met, the hospital earns a share of the savings (upside risk). If costs exceed the target, the hospital may face financial penalties (downside risk), which will become mandatory for most participants after the first year.
 Action Items for Hospitals : Success requires significant investment in clinical redesign and care coordination to manage the entire 34-day episode, especially optimizing post-acute care (e.g., skilled nursing facility, home health) and ensuring strong patient-recorded outcomes (PROs) and proper referrals to primary care post-discharge.

2. Prior Authorization & Interoperability: The Digital Mandate

CMS has finalized rules aimed at streamlining the notoriously burdensome prior authorization process and accelerating digital health data exchange.

Faster Decisions (Starting Jan 1, 2026) : Impacted payers (including Medicare Advantage and Medicaid managed care plans) must process standard prior authorization requests within 7 calendar days and expedited requests within 72 hours.
New Transparency : Payers must provide a specific reason for any denial, regardless of the submission method.
Prior Authorization API (Effective Jan 1, 2027, with some reporting starting Jan 1, 2026) :
Payers are required to implement a Prior Authorization API (Application Programming Interface). While the final API technology implementation deadline is 2027, providers should prepare for this shift. This API is intended to allow providers to:
Determine if prior authorization is required for an item or service.
Identify the payer's documentation requirements.
Send and receive prior authorization requests and responses.
Provider Impact : While the API is a payer requirement, providers will be expected to leverage this technology through their Electronic Health Records (EHRs) for faster, more efficient transactions. Clinicians participating in the Quality Payment Program (QPP) must also attest to their adoption of the Prior Authorization API in 2027.

3. Inpatient & Long-Term Care Payment Update (FY 2026)

CMS has issued its Final Rule for the Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) for FY 2026.

Payment Increase : Acute care hospitals that are meaningful EHR users and submit quality data will see a net payment increase of approximately 2.6%. This update reflects market basket adjustments and a statutory productivity cut.
Quality Program Changes : CMS is refining quality reporting programs by removing several measures that focus on social drivers of health and health equity. Conversely, the agency is increasing its focus on data security, requiring eligible hospitals to attest to completing an annual self-assessment using all eight Safety Assurance Factors for EHR Resilience (SAFER) Guides starting with the 2026 reporting period.

4. Physician Fee Schedule and Quality Payment Program (QPP)

The annual updates for the Medicare Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) continue the transition toward value-based care.

Merit-based Incentive Payment System (MIPS) : The transition to MIPS Value Pathways (MVPs) will continue to expand, with new MVPs proposed for specialties like Diagnostic Radiology, Pathology, and Vascular Surgery.
Payment Conversion Factors : The gap is widening for payment updates between providers in Advanced Alternative Payment Models (APMs) and those under the traditional PFS, further incentivizing participation in APMs.

Preparation is Paramount

The 2026 CMS mandates demand an integrated, organization-wide response. Facilities must focus on:

TEAM Readiness : Identify your organization's exposure to the TEAM model, audit your current episode costs, and begin developing cross-functional care pathways that seamlessly coordinate care from pre-op through the 30-day post-discharge window.
Tech Stack Updates : Work with your EHR and IT partners to ensure systems will be ready to integrate with the new payer APIs to handle interoperability and prior authorization functions by the compliance deadlines.
Quality Program Alignment : Update your quality reporting infrastructure to comply with the new SAFER Guides requirement and align performance efforts with the remaining, modified, and new quality measures across all relevant CMS programs.

The year 2026 is set to solidify the shift toward highly coordinated, financially accountable, and digitally integrated care. Your proactive planning today will determine your organization's success tomorrow.

Be sure to browse Our Website for a full list of services we provide.

Year in Review: Compliance, Quality, and the Path Forward

Wed, 24 Dec 2025 21:54:03 GMT

Compliance, Quality, and the Path Forward

The close of the fiscal year is a critical time for every healthcare facility. It's not just about balancing the books; it's about a mandatory, comprehensive evaluation of our performance, policies, and risks to ensure continued compliance with the Centers for Medicare & Medicaid Services (CMS) , HHS (Health and Human Services) , and state regulations.

The core of this evaluation lies in the Quality Assessment and Performance Improvement (QAPI) program (a CMS requirement for hospitals and long-term care facilities) and the annual Facility Assessment (especially for nursing homes). This detailed look back sets the stage for a safer, more effective next year.

1. Evaluating the Past Year: Achievements and Deficits

A successful end-of-year review requires an honest, data-driven look at the results of your previous goals. This process is not about assigning blame but about system-level analysis to drive continuous improvement.

Goals, Policies, and Performance

Reviewing QAPI Projects (PIPs):
Positive Results: Did your Performance Improvement Projects (PIPs)—focused on high-risk areas like readmission rates, infection control (HAI/CAUTI/CLABSI), or fall reduction—meet their measurable targets? If yes, the successful system changes that led to improvement should be standardized and sustained .
Negative Results: If targets were missed, you must analyze the root causes . Was the policy flawed? Was the training insufficient? Was data collection inaccurate? The QAPI process mandates that facilities not just report failures, but act on them and track performance to ensure improvements are sustained .
Adverse Events and Medical Errors: Review all tracked medical errors and adverse patient events. This mandatory analysis must identify their causes and implement preventive actions across the entire hospital system, ensuring feedback and learning occurs at all staff levels.

Regulatory Compliance and Concerns

Survey Findings: Analyze the results of all CMS and state surveys. Any citation, particularly those categorized as systemic, high-risk, or problem-prone , must become a priority for immediate correction and a focus area for the next year’s QAPI projects.
Data Utilization: Verify that the data collected for required Medicare Quality Reporting Programs (e.g., Hospital Readmission Reduction Program, VBP) is being actively used by the QAPI committee to monitor the effectiveness and safety of services .

2. Mandatory Risk Assessment & Next Year’s Planning

The year-end review culminates in updating the Facility Assessment and establishing new goals that are data-informed, measurable, and aligned with federal and state priorities.

Focus Area

Current Mandate/Guidance (CMS/HHS)

Next Year's Goal Examples (SMART)

Risk Assessment

The assessment must identify facility- and community-risk factors (e.g., natural disasters, infectious disease threats, or local healthcare access issues) and inform staffing decisions based on the patient population's unique needs ().

Goal: By Q3, implement a new EHR module for ligature risk assessment for all admitted mental health patients, resulting in a 100% completion rate upon admission.

Infection Control

Facilities must develop and maintain a robust Antibiotic Stewardship Program in addition to the Infection Prevention and Control Program ().

Goal: Reduce the facility's \text{C. diff} infection rate (a Hospital-Acquired Condition) by compared to the previous year's baseline by implementing a new environmental cleaning protocol.

Quality/QAPI

Priorities must focus on high-risk, high-volume, or problem-prone areas that affect health outcomes and patient safety.

Goal: Decrease the -day readmission rate for patients with Chronic Obstructive Pulmonary Disease (COPD) by by implementing a telehealth-supported post-discharge follow-up program.

Health Equity

Future-looking CMS strategy emphasizes moving all Medicare beneficiaries into accountable care relationships to improve equitable outcomes and lower costs. New models prioritize prevention and data transparency.

Goal: Analyze quality outcome data by patient race/ethnicity to identify a disparity, and reduce the time to follow-up appointment for a high-risk subpopulation by hours next year.

3. Achieving Sustainable Improvement

Moving into the next year, the leadership team must ensure:

Prioritization: Improvement activities must be prioritized based on the severity and prevalence of the problem identified in the annual review.
Resources: Sufficient resources (time, money, and trained personnel) are dedicated to the new performance improvement projects.
Culture: Foster a culture of safety where staff feel empowered to report quality concerns without fear of retaliation, allowing the QAPI program to be truly effective.

A rigorous, data-driven end-of-year evaluation ensures not just compliance, but genuine, sustainable improvement in patient care—the ultimate goal for every healthcare provider .

Safety & Spirit: Navigating Decorations in Healthcare Facilities

Wed, 05 Nov 2025 01:20:40 GMT

The desire to brighten a healthcare environment with decorations—whether for a holiday, a special event, or year-round visual comfort—is understandable and often encouraged for patient and resident well-being. However, in Texas healthcare facilities, this simple act is governed by a critical network of rules from the Centers for Medicare & Medicaid Services (CMS), state regulators like the Texas Health and Human Services (HHSC) / Texas DSHS, and accreditation organizations like CIHQ.

The guiding principle across all these bodies is Life Safety, primarily concerned with fire prevention and patient safety.

Here is a breakdown of the key rules and best practices for decorations in hospitals, nursing homes, and other regulated facilities:

The Paramount Rule: Fire Safety & The Life Safety Code (NFPA 101)

Federal rules (CMS) and state licensing standards often mandate compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) , specifically the 2012 edition. This code forms the backbone of decoration rules.

Electrical Safety: A Major Focus

Electrical decorations, particularly during holidays, introduce significant risk.

Wiring and Lights: Only lights and wiring that are Underwriters Laboratories (UL) listed are permitted. All cords must be in good condition (no fraying or exposed wires).
Extension Cords: Do not use extension cords for decorations. If temporary power is needed, use a UL-listed, hospital-grade Relocatable Power Tap (RPT) (often called a UL 1363 power strip). Daisy-chaining power strips is strictly forbidden.
Trip Hazards: All cords must be placed to prevent trip hazards .

CIHQ and Infection Prevention (IPAC)

Accreditation organizations like the Center for Improvement in Healthcare Quality (CIHQ) focus on safety, often including infection prevention:

Cleaning & Dust: Decorations must be made of materials that are non-porous and can be easily cleaned. Decorations that harbor dust or are difficult to sanitize (like tinsel or dried wreaths) may be discouraged or prohibited, particularly in patient care areas or during outbreaks.
Location Restrictions: Decorations are typically prohibited in high-risk areas like:
Clean and dirty utility rooms.
Medication rooms.
Treatment/procedure rooms.
Sterile reprocessing areas.
Timely Removal: CIHQ and best practices often recommend that temporary decorations be displayed and removed in a timely manner (e.g., within a few working days after a holiday) to prevent dust buildup and reduce potential fire load.
No Attachment to Ceilings: Decorations should never be hung from ceiling tiles or the ceiling grid as this compromises the smoke barrier integrity.

Best Practices for Facility Staff

To ensure a balance of safety and spirit, every Texas healthcare facility should:

Develop a Clear Policy: Have a written, facility-specific policy on decorations that clearly outlines all fire, electrical, and infection control requirements.
Use a Checklist: Require staff to use a "Decoration Assessment Checklist" before placing items to ensure compliance.
Appoint an Inspector: Designate the Safety Officer or Facilities Manager to inspect and approve decorations, documenting the materials' flame-retardant status.
Communicate & Train: Provide annual training for all staff on decoration guidelines, especially before major holidays.

Decorating a healthcare facility can significantly boost morale for patients, residents, and staff. By treating every decoration as a potential safety risk, and following the core rules set by CMS, CIHQ, and applicable state laws, facilities can celebrate safely and stay compliant.

HCE Global customizes services to fit the needs of each client. We pride ourselves on helping our clients achieve & maintain a status of excellence in the healthcare industry. We will work with you to prioritize your most immediate training needs. If you need of program/policy/procedure development, mock surveys, training, corrective action plan assistance, construction or remodel assistance, or ongoing routine support services, we can help!

Be sure to browse Our Website for a full list of services we provide.

Elevate Your Practice: The Lasting Value of Healthcare Conferences

Mon, 13 Oct 2025 00:49:42 GMT

In the dynamic world of medicine, staying current isn't just an advantage - it's a professional necessity. Healthcare conferences and summits, such as CIHQ’s 2025 Accreditation & Regulatory Summit (Oct 21-23) offer a potent blend of education, networking, and rejuvenation that can reshape your career and improve patient care. For any professional questioning the time and investment, here's why attending these events is essential for your long-term success.

1. Stay Ahead of the Curve with Continuing Education

Healthcare conferences provide a direct line to the latest research, treatment protocols, and medical technologies. Instead of relying solely on journal articles, you can participate in hands-on workshops, case-based discussions, and live demonstrations under expert guidance. Many conferences also offer Continuing Medical Education (CME) credits, helping you fulfill licensing requirements while expanding your knowledge. This immersive learning helps you deepen your understanding and apply innovative techniques that directly impact patient outcomes. 

2. Expand Your Network and Foster Collaboration

Conferences are a hub for connecting with peers, mentors, and thought leaders from various healthcare sectors. Face-to-face networking during breaks, meals, and social events is more impactful than virtual interactions and can lead to fruitful collaborations and research partnerships. For solo practitioners or those in underserved areas, this is an invaluable opportunity to share clinical challenges, exchange insights, and build a supportive community.

3. Explore Career Opportunities and Industry Innovation

From startup showcases to exhibit halls filled with the latest medical devices and EMR platforms, conferences offer a comprehensive view of the industry's future. This exposure helps you: 

Assess new technologies for your practice.
Engage directly with vendors and product experts.
Connect with recruiters and potential employers.

Regular attendance demonstrates your commitment to professional growth and keeps you at the forefront of innovation. 

4. Combat Burnout and Reignite Your Passion

Healthcare is a demanding field, and burnout is a very real threat. Conferences offer a refreshing break from the daily routine and a chance for self-reflection and rejuvenation. The energy and inspiration from thought-provoking keynote speeches and success stories can reignite your passion for your work. Engaging with colleagues who share a similar dedication to healthcare can provide a renewed sense of purpose and motivation.

5. Gain Inspiration and New Perspectives

Stepping out of your everyday environment and into a new space can spark creativity and new ideas. Attending sessions on diverse topics—from leadership strategies to patient equity and digital health—can challenge conventional thinking and provide new perspectives. By listening to how others are solving problems, you can gain insights and tactics to implement in your own practice. 

Ready to Make Your Next Move?

Investing in your professional development is an investment in your career, your practice, and most importantly, your patients. If you're a healthcare professional seeking to expand your knowledge, grow your network, or find new inspiration, it’s time to explore the many opportunities that conferences and summits offer, like CIHQ’s annual Regulatory Summit .

See you at a Conference! And please, stop by our booth. We would love to chat!

As always, HCE Global customizes our services to fit the needs of each individual client or system. We pride ourselves on helping our clients achieve & maintain a status of excellence in the healthcare industry. We will work with you to prioritize your most immediate training needs. If you need of program/policy/procedure development, mock surveys, training, corrective action plan assistance, construction or remodel assistance, or ongoing routine support services, we can help!

See you at a Conference! And please, stop by our booth. We would love to chat

Be sure to browse Our Website for a full list of services we provide.

New Hire Orientation

Thu, 04 Sep 2025 03:39:17 GMT

Its that time of year again when the kids are heading back to school. This is also a great time for healthcare organizations to refresh their new employee orientation and annual training programs. Setting calendar reminders can prevent oversight of important initiatives. Having a comprehensive and current orientation program in the key to the beginning of a successful education program for healthcare professionals.

When planning your organization’s orientation program be sure to determine who should have complete oversight. In many cases this person is a Human Resources Director. They typically know when new employees are being onboarded and orientation is planned according as part of the onboarding process for new employees. Development of the content should be a collaborative effort among the following department leaders:

Clinical and Non-Clinical

CEO and or CNO: Introductions and welcome to all new team members

HR: Introductions among new employees and roles, resources, company policies such as payroll, badging access, parking, dress code, time and attendance etc.

Life Safety/EOC Specialist: Fire Safety, Environmental Issues, On call support, Active shooter training, facility “codes” for drills and emergency activation, workplace violence, utility shut down-failures

Supply Chain: How to order supplies, charging for supplies

EVS: How to contact EVS for routine and urgent cleaning

Employee Health: Reporting on the job injuries, Global Harmonization System Training, Eyewash station locations and use, safe ergonomics

Risk Management: Risk reporting trainings and platforms

Quality : Introduction to hospital wide quality assurance initiatives

Infection Prevention: Hand Hygiene training Bloodborne Pathogen training, standard and Isolation precautions

Corporate Compliance Officer: Introduction to Corporate Compliance Program and reporting protocol

Medical Records: HIPAA training, reporting breaches, release of information protocol, approved abbreviations

Bio-Medical Engineering: Reporting faulty equipment and PM’s expired PM’s, lock out tag out protocol

Radiology: MRI Safety, Radiations Safety

Clinical employees

Pharmacy: Access to medication, contact information, bar code scanning, pyxis use, narcotic administration and waste, medication reconciliation during transition of care and discharge, LASA drugs, Antibiotic Stewardship, safe medication storage, home medication policy

Nursing: Safety and care throughout course of patient stay. Blood transfusion safe practices/policies, Suicidal Ideation protocol, restraints and seclusion, Protocols, assessment, safe medication administration, orders, escalation process, EMTALA, Advanced Directives, Accessing delineation of privileges for providers, etc.

Respiratory Therapist: Accessibility, Equipment, Treatments, Protocols, Safety administration.

Lab: Resource available around the clock, waive testing competencies-protocols, safe specimen collection-time parameters from collection to delivery, how specimens should be stored if kept on unit temporarily, Critical results reporting

Radiology: Expand on education concerning radiation safety, services available, turn-around times for results, tele-radiology services if provided, on-call schedules if applicable.

Dietary: Resources, consultations, educational resources for patients and families, enteral feedings and supplements, nourishments and contact information for after hours

Nursing and Clinical Departments: Unit specific orientation should be incorporated as part of onboarding based upon the area nursing personnel will work such as Cath Lab, Dialysis, Emergency Department, Med-Surg, Obstetrics, Pediatrics, Peri-Operative Services and Radiology for example.

Once you have re-vamped and revitalized your new employee and onboarding education process, you should begin to think about annual re-education for all employees. We tend to find organizational deficiencies around various dates that onboarding occurs. If you base annual training a year from the date that an employee is onboarded, you must keep up with those dates. You may also consider using an annual across the board refresh date. In other words, all personnel would be required to complete annual re-education every April for example. It may be less than a year for newly onboarded employees but having education sooner than letter is typically a better scenario. For employees who recently onboarded, you may consider making an exception an rescheduling due dates further out. Your process should be determined by its size, services provided and resources available. Most importantly, you must be able to demonstrate a process that works and is able to demonstrate current competencies for all employees.

An annual skills fair is always very well received. Consider dedicating some time once a year to dedicating a single week (or days for smaller organizations) as a re-occurring calendar invite.

Finally, consideration for record keeping is a must. You must be able to produce employee records that include completion of HR onboarding protocols, credentials, education, experience, current licensure and certifications, references, training and competencies. Is your record keeping organized? Are trainings done via paper as well as electronically? Can you attest to an employee’s acknowledgement of training and education and be able to demonstrate that they have been deemed competent in their roles and responsibilities when asked to produce evidence to a surveyor?

Above reflects an overview of minimal educational requirements for clinical as well as non-clinical staff and is not intended to be a complete list of education requirements for healthcare personnel.

Be sure to browse Our Website for a full list of services we provide.

References:

https://typelane.com/6-steps-to-include-in-your-new-hire-orientation

https://www.linkedin.com/posts/three-rivers-behavioral-health_we-are-pleased-to-introduce-the-january-new-activity-7290730476716130304-Ajru

In Need of Skilled Healthcare Support Staff Now? HCE Global can Help!

Tue, 05 Aug 2025 05:45:45 GMT

In Need of Skilled Healthcare Support Staff Now? HCE Global can Help!

The healthcare industry today seems to be in a never-ending state of flux. High turnover rates and burnout are a very real concern for healthcare organizations. It is more difficult than ever to recruit experienced healthcare professionals let alone retain them. With enrollment in Nursing degree programs at an all time low, healthcare facilities find themselves competing to recruit and retain experienced nurses.

At HCE Global, we understand the frustration this is causing administrators and leaders. This has lead, as we know, to many professionals wanting to leave the healthcare profession for good. We have decided to take a stand to help our weary colleagues work through these challenging times. We have developed comprehensive training programs that provide one-on-one remote as well as on-site training and mentorship opportunities. Our comprehensive training programs will help you to develop your diamonds in the rough into future leaders, reducing stress levels and burnout while improving job satisfaction.

We recognize that healthcare organizations do not in many cases have the personnel or resources to provide comprehensive training programs necessary to meet regulatory requirements for critical healthcare programs. If you are in need of Environment of Care, Life Safety, Infection Prevention, Quality Assurance, Case Management or Utilization Review Managers, we’ve got you covered! We also provide leadership training for healthcare executives.

As always, HCE Global customizes our services to fit the needs of each individual client or system. We pride ourselves on helping our clients achieve & maintain a status of excellence in the healthcare industry. We will work with you to prioritize your most immediate training needs. Whether you are in need of program/policy/procedure development, mock surveys, training, corrective action plan assistance, construction or remodel assistance, or ongoing routine support services, we can help!

Be sure to browse Our Website for a full list of services we provide.

References:

https://www.mercy.edu/academics/programs/nursing-education

https://www.pathlms.com/innsofcourt/courses/21083/sections/22983/links/17699

Medical Record Management: Are You Gambling with Your Patient’s Health Information?

Wed, 16 Jul 2025 02:04:57 GMT

Medical Record Management: Are You Gambling with Your Patient’s Health Information?

When it comes to protecting patient health records, there are many considerations to ensure organizations are not left vulnerable to breaches. Establishing measures to ensure medical records are secure is critical. The Centers for Medicare and Medicaid Services (CMS) has established standards to help organizations safeguard medical records. If you are unsure about how information is being protected in your facility, then we highly recommend doing a deep dive into your facility’s current practices. Here are the areas that should be considered:

Access

It is important for hospitals to establish and control access to current and historical medical records. Restricting access to only authorized individuals is essential. CMS requires that healthcare providers must be able to access historical medical records twenty-four hours a day. Additionally, healthcare providers should be able to access medical records for five years after a patient has been treated by the facility. Retention requirements may vary by state so be sure to know the retention periods required by your respective state. Historical data is essential in understanding past diagnosis, medical treatments and prior patient disposition. Access to information can also be helpful in developing current patient care plans and resources for continuity of care.

Audit

Conducting internal audits to identify potential risks can be helpful in identifying area for improvement in oversight and management of medical records.

Security

Encryption of medical records can help to prevent breaches from happening.
Ensuring reliable server backup for Electronic Health Records is essential. Be sure to investigate systems in place to prevent loss of records. If vulnerabilities are identified, work with vendors and Information Technology specialists to eliminate risk.

Storage Requirements

The condition of medical records storage areas should be protected from risk of water intrusion or fire. When selecting a storage location, healthcare providers should look at potential risk that could compromise the integrity of the records.

Training

Education is a major factor in safeguarding your organization’s medical records. Ensure that team members understand all aspects of medical record management and comply with maintaining organizational safeguards. Release of information requests should be carefully managed by a designated Custodian of Medical Records. Logs should be maintained to reference release of records and known security breaches. If a breach is identified, be sure to immediately consult the Compliance Officer and Risk Management immediately.

Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges.

Whether you are in need of QAPI assistance, mock surveys, leadership training, corrective action plans or ongoing routine support services, we can help!

We pride ourselves on helping our clients achieve & maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

References:

Emergency Preparedness: Is your Facility Ready in case of Disaster?

Wed, 04 Jun 2025 04:13:07 GMT

Emergency Preparedness: Is your Facility Ready in case of Disaster?

With hurricane season fast approaching, emergency preparedness for hospitals is critical to ensure continuity of care, protect patients and staff, and safeguard infrastructure during and after a storm.

A comprehensive plan should follow CMS Emergency Preparedness Rule requirements and include the four core elements: Risk Assessment and Planning, Policies and Procedures, Communication Plan, and Training and Testing .

Here’s a structured guide:

1. Risk Assessment and Planning

Conduct an all-hazards risk assessment , focusing on:

Hurricane storm surge maps, flood zones, and wind exposure
Vulnerabilities in power supply, HVAC, medical gas systems, and IT systems
Potential supply chain disruptions
Surge capacity planning for patient influx

Key Actions:

Identify essential functions and personnel
Plan for shelter-in-place vs. evacuation scenarios
Estimate water, food, fuel, and medical supplies needed for at least 96 hours
Coordinate with local emergency management (LEMA), FEMA, and CMS

2. Policies and Procedures

Develop and document detailed hurricane-specific protocols:

Pre-storm actions: Secure windows, test generators, stockpile supplies, discharge non-critical patients
Staffing: Activate A/B teams (Team A for shelter-in-place, Team B for relief)
Evacuation: Criteria for vertical/horizontal evacuation and full facility evacuation
Include transportation contracts, destination hospitals, patient tracking
Infection Control: Ensure IPC protocols remain operational under limited utilities or compromised infrastructure

3. Communication Plan

Ensure reliable communication with:

Internal staff (call trees, emergency phones, radios)
External partners (EMS, public health, vendors, media)
Patients and families

Required Elements:

Redundant systems (landlines, satellite phones, internet failover)
Integration with local/state emergency operations centers (EOCs)
Procedures for status updates and coordination

4. Training and Testing

Conduct annual hurricane-specific drills (tabletop and full-scale)
Train staff on:
Emergency roles and responsibilities
Evacuation procedures
Use of emergency equipment (generators, radios, etc.)
Incorporate after-action reviews (AARs) from past hurricanes to improve the plan

Additional Considerations

Facilities and Infrastructure

Backup power systems: Test generators under full load
Flood barriers/sandbags
Rooftop equipment secured and water-proofed
Fuel delivery contracts in place

Patient Care

Emergency medical records access (offline/backup)
Plan for vulnerable populations (dialysis, ventilators, behavioral health)
Maintain pharmacy and oxygen supply
Food & Water supply for substantial time off grid/supply

Regulatory Compliance

Meet CMS Conditions of Participation (CoPs)
Align with Accrediting Body EM standards such as CIHQ and TJC
Documentation for FEMA reimbursement (costs, actions taken, damages)

Tools and Resources

HHS ASPR TRACIE Hurricane Playbook
FEMA Continuity Guidance Circular
CDC Shelter-in-Place Checklist for Healthcare
American Hospital Association (AHA) Disaster Readiness Guide

Mitigating Risk in Healthcare: Learning from Bad Outcomes

Thu, 08 May 2025 06:08:08 GMT

Mitigating Risk in Healthcare: Learning from Bad Outcomes

Adverse events include a variety of unintended outcomes that cause patient’s harm. “Every year, millions of Medicare patients experience adverse events and temporary harm events as a result of medical care or in a health care setting.” (OIG, 2023). In such cases, patients may incur prolonged hospitalization/treatment and permanent harm. Patient death is also associated with adverse outcomes. When patient safety is compromised, it is up to the organization to conduct a comprehensive investigation to determine how the event occurred. If concerns are not addressed, the probability of the event reoccurring is highly likely.

Risk Mitigation Strategies

Although hospitals strive to ensure they have a comprehensive Quality Assure Performance Improvement (QAPI) Program, there are several considerations to ensure that such programs are effective. To have a state-of-the-art electronic reporting program is simply not enough. It is important to ensure that that the following elements are in place:

Establishing a culture of safety. Empowering employees to report concerns before they lead to adverse events.
Educating healthcare personnel on how to report risks or concerns.
Following up immediately on events that are reported.
Conducting a root cause analysis or gap analysis to evaluate events preceding an adverse outcome. Findings should be communicated as appropriate to prevent recurrence.
Performance Improvement (PI) measures should be considered using a multidisciplinary approach. Be sure to educate team members on new PI initiatives.
Safety measures should be implemented without delay.
Data collection and ongoing monitoring are critical to ensure that performance measures are effective. In the event that safety measures are not working well, revaluation is required, and new improvement strategies should be considered.
Near-miss events should also be reported and monitored. Establishing or re-establishing standard operating procedures may be necessary to prevent patient harm.

“A coordinated team approach where everyone is on the same team and empowered to express their concerns irrespective of "rank," and members are knowledgeable about their duties, offers the best chance for successful risk mitigation” (McGowan, et al 2023). Establishing and setting the tone for safe culture in healthcare settings is a must. Ongoing training on quality initiatives and process improvement is necessary to promote safe culture. Employees who do not “buy in” may also have a negative impact on their peer’s willingness to report concerns. A leadership team that fosters accountability, teamwork and transparency will have a positive impact on employee engagement and satisfaction.

There is no time like the present to take a closer look at your organization’s risk mitigation strategies. Are you looking for expert guidance on QAPI Program enhancement or Risk Mitigation strategies? HCE Global offers specialized consulting services to help your facility navigate regulatory challenges and achieve operational excellence.

Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges.

Whether you are in need of QAPI assistance, mock surveys, leadership training, corrective action plans or ongoing routine support services, we can help!

We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

References:

McGowan J, Wojahn A, Nicolini JR. Risk Management Event Evaluation and Responsibilities. [Updated 2023 Aug 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559326 , https://oig.hhs.gov/reports/featured/adverse-events

Navigating Compliance in Behavioral Health Hospitals: Key Considerations for Success

Tue, 01 Apr 2025 01:40:01 GMT

Navigating Compliance in Behavioral Health Hospitals: Key Considerations for Success

Behavioral health hospitals play a vital role in addressing mental health and substance use disorders, providing critical care to vulnerable populations. However, ensuring compliance with regulatory standards is a complex and ongoing challenge. From accreditation requirements to federal and state regulations, behavioral health facilities must navigate a dynamic landscape to maintain compliance and provide high-quality care.

Understanding Regulatory Standards

Behavioral health hospitals must adhere to multiple layers of regulations, including:

Centers for Medicare & Medicaid Services (CMS) : CMS sets conditions of participation (CoPs) for psychiatric hospitals, ensuring facilities meet safety, quality, and operational standards to receive federal funding.
Center for Improvement in Healthcare Quality (CIHQ), The Joint Commission (TJC) and Other Accreditation Bodies : Accreditation by organizations such as CIHQ, CARF, TJC, or DNV demonstrates adherence to best practices in patient care and operational efficiency.
State-Specific Regulations : Each state has unique licensing and compliance requirements that behavioral health hospitals must follow.
HIPAA and Patient Rights Laws : Compliance with the Health Insurance Portability and Accountability Act (HIPAA) ensures patient privacy, while laws like the Emergency Medical Treatment and Labor Act (EMTALA) protect patient rights.

Common Compliance Challenges

Behavioral health hospitals face unique challenges in maintaining compliance, including:

Staffing and Credentialing – Ensuring that mental health professionals meet licensing and credentialing requirements can be complex, particularly in areas with workforce shortages.
Patient Safety and Restraint Use – Strict regulations govern the use of seclusion and restraints, requiring detailed documentation and staff training to minimize risks and ensure compliance.
Infection Control and Environmental Safety – Behavioral health settings require specialized infection prevention measures, especially given the unique patient population and facility design considerations.
Documentation and Medical Records Management – Comprehensive and timely documentation is critical for compliance with CMS and accreditation standards.
Quality and Performance Improvement – Continuous performance monitoring and data reporting are necessary to meet quality improvement requirements and demonstrate compliance.

Best Practices for Compliance Success

To maintain compliance and provide high-quality care, behavioral health hospitals should implement the following strategies:

Regular Compliance Audits : Conducting routine internal audits helps identify areas of risk before external surveyors do.
Staff Training and Competency Programs : Ongoing education ensures that all employees understand regulatory changes and compliance expectations.
Policy and Procedure Alignment : Keeping policies updated with current regulations reduces compliance gaps.
Strong Leadership and Governance : A dedicated compliance team or officer can oversee regulatory adherence and foster a culture of accountability.
Use of Technology : Electronic health records (EHRs) and compliance tracking software can streamline documentation and reporting requirements.

Conclusion

Ensuring compliance in behavioral health hospitals requires vigilance, proactive planning, and a commitment to continuous improvement. By staying informed about regulatory updates, investing in staff training, and leveraging technology, behavioral health hospitals can enhance patient safety, improve care quality, and maintain compliance with evolving standards.

Are you looking for expert guidance on behavioral health hospital compliance? HCE Global offers specialized consulting services to help your facility navigate regulatory challenges and achieve operational excellence.

CMS CoPs - Respiratory Care: More than Just Meeting Seasonal Demands

Fri, 07 Mar 2025 05:55:44 GMT

Providing respiratory care services can be a challenge for hospitals, especially during months when respiratory illnesses are at their peak throughout communities. Hospitals spend a great deal of time planning to meet the needs of patients during peak periods as they must prepare for the possibility of a large influx of patients. There are several additional strategies that hospitals must also follow in addition to managing respiratory illness and preventing the spread of respiratory illness.

Reporting responsibilities must also be considered. Failure to report the specified data related to COVID-19, influenza, and respiratory syncytial virus (RSV), including confirmed infections of respiratory illnesses among hospitalized patients, hospital bed census and capacity (both overall and by hospital setting and population group [adult or pediatric]), and limited patient demographic information, including age, may lead to the termination of a hospital’s participation from the Medicare and Medicaid programs.

Hospitals who participate in CMS should ensure that they are meeting reporting requirements for acute respiratory illness such as COVID-19, influenza and respiratory syncytial virus (RSV).

Additional data reporting requirements include patient population affected, demographic data and bed capacity. Participating hospitals should also ensure that respiratory care services are integrated into their respective Quality Assurance Performance Improvement Programs.

If you are uncertain if your organization provides services that quality as respiratory care, CMS provided the following list of examples: Respiratory Care Service

Respiratory Care Services Oversight

Identifying a qualified individual(s) to provide respiratory care services is a requirement for hospitals who participate in CMS, which is just one of the requirements. Respiratory professionals should meet qualifications as determined by the hospital’s medical staff and in accordance with state law. Moreover, hospitals must appoint a Doctor of Medicine or osteopathy to oversee respiratory care services. This individual must be appointed on no less than a part-time basis.

Delivery of Services

Being familiar with CMS requirements for delivery of respiratory care services is another important consideration for participating hospitals. A hospital’s medical staff must develop a written directive outlining how care will be delivered by respiratory professionals. Such directives should specify what supervision is required before respiratory care services can be delivered independently by a healthcare professional.

If lab work is being performed, the collection of such labs must be done in accordance with CMS laboratory service requirements. All respiratory treatments must be documented in the patient’s medical record.

Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges.

Whether you are in need of a mock survey, leadership training, corrective action plans or ongoing support services, we can help!

We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

References:

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-D/section-482.57

NSHN and OSHA Reporting: Prepared to Meet the Deadline?

Mon, 10 Feb 2025 01:48:33 GMT

It is that time of year again. At least for acute care hospitals, long-term acute care (LTAC) hospitals and inpatient rehabilitation facilities (IRF) who report to The National Healthcare Safety Network (NHSN). If annual surveys are not reported by March 1 ^st , then your organization will not be permitted to enter monthly reporting plans until the annual survey has been completed. Although there are just a few weeks to go, early planning is the key.

It is important to consider that responses to the Annual Survey questions are a collaborative effort. Planning a meeting in advance with key stakeholders will help to ease the stress of completing what some may consider to be a daunting task. Be sure to coordinate with Facilities Managers, Pharmacists, Laboratory, Nursing, Infection Prevention and Quality leaders on annual survey responses. Although individuals who are responsible for report submission may find that some of the data has not changed significantly from the previous year, we have identified that some questions have been removed while additional questions have been added.

If you are new to NHSN reporting and have not yet completed an annual survey, you will find an alert reminding you on your dashboard upon logging in. Keep in mind that the survey you are completing requires data from the previous calendar year. You will be submitting data for 2024 due March 1 ^st , 2025. There are a variety of questions that will require information about metrics, facility type, infection prevention practices, laboratory testing methods, water quality management, and antimicrobial stewardship practices for example.

Instructions on completing your organization’s annual survey click on the link below that corresponds with your facility type:

Instructions for Completing Annual Hospital Survey

Instructions for Completing LTAC Annual Survey

Instructions for Completing IRF Annual Survey

OSHA requires the following facilities to complete an annual occupational injury and Illness Report:

Ambulatory Health Care Servies
General Medical and Surgical Hospitals
Psychiatric and Substance Abuse Hospitals
Specialty Hospitals
Skilled Nursing Facilities

For a complete list of facilities required to report annually via electronic submission and for additional information on Standard 1904 Subpart E Appendix B click on the following link: OSHA Injury and Illness Reporting Requirements .

Much like NHSN annual surveys, this reporting is also for the prior calendar year. Your deadline for submission is March 2, 2025. If your organization has not previously been reporting, please note that you will need to set up an Injury Tracking Application (ITA) account. For complete instructions, click on the following link User Guide .

Individuals who are responsible for report completion and submission should have a clear understanding of criteria that constitutes a work-related injury. They will also need to know if the employee missed days of work because of injury or illness. If an employee was restricted from usual work activities or reassigned to a new role as a result of the injury or illness this information must be documented. If an employee required care beyond basic first aid, this will also need to be reported.

Reporters should not include Protected Health Information (PHI). For a brief tutorial on OSHA annual reporting requirements, click on the following link OSHA Injury and Illness Reporting .

Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges.

Whether you are in need of mock surveys, leadership training, corrective action plans or ongoing support services, we can help!

We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

References:

https://www.cdc.gov/nhsn/forms/instr/57_103-toi.pd

https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904SubpartEAppB

https://www.osha.gov/sites/default/files/ita_user_guide.pdf

https://www.osha.gov/sites/default/files/osha_rktutorial.pdf

National Patient Safety Goals: A Glimpse At 2025

Mon, 13 Jan 2025 00:50:59 GMT

In 2002 The Joint Commission (TJC) first established the National Patient Safety Goals (NPSG) Program. In 2003, TJC rolled out the first set of NPSG’s. Each year, TJC prioritizes patient safety goals for various healthcare programs. The goals are prioritized based upon feedback from healthcare providers, stakeholders, purchasers and consumer groups. The intent is to minimize risk to patients. With each goal that is identified, there are also essentials steps detailing how to address each goal to meet a desirable outcome for patients. For healthcare organizations who are accredited by TJC, their accreditation status highly depends on a facilities commitment to meeting NPSG’s with success.

For healthcare organizations who are accredited or who are seeking accreditation by TJC, it is important to stay current with the updated goals each year. Of note, many of the goals that are identified do not change drastically from year to year. This is largely because we continue to see adverse outcomes surrounding the same issues each year in the healthcare industry.

If you are or are planning on becoming a TJC accredited organization, it is imperative that you remain current with each year’s set of established goals. Be sure to update this information throughout your facility. Regardless of the type of healthcare program you have, TJC issues a simplified version of each of the goals sets which can be easily printed off their website and used for team education and promoting awareness. In addition, you can also access chapter versions of NPSG’s that detail Elements of Performance (EPs) for meeting goals and the rationale for why each goal is significant.

Although we do not personally endorse TJC, we appreciate and recognize that the NPSG’s are development with an intent to reduce harm to patients. Therefore, we can all appreciate that this information can be shared universally across all healthcare entities and programs regardless of accreditation affiliation or status. You can reference annual goals on their website The Joint Commission .

One of the primary goals that continues to require attention and focus is patient identification. In our experience, we find that methods used for patient identification methods may vary throughout a single organization. Predominantly, patients are asked to provide their name a date of birth to healthcare workers to aid in establishing proper identity. We encourage you to observe how your team identifies patients within your organization. It may be a good time to review your current policy as well as how staff are educated on proper patient identification methods. The consequences due to improper identification of a patient may include medication administration errors, unnecessary treatment for a diagnosis and unnecessary surgery being performed for example. These are just a few adverse events that may occur in addition to many others.

Another goal that continues to remain an area of concern addresses medication reconciliation. If medications are not reconciled in a structured and routine manner, patients may suffer from overdosing or experience serious and potentially fatal adverse reactions to medication. Medication reconciliation should always include medication name, purpose, dose and frequency. It is imperative that patients understand how to follow their prescribed medication regimen correctly.

Alarms continue to remain an area of concern in healthcare organizations. Working in an environment, particularly with a significant amount of patient safety equipment in use is typically stressful for healthcare workers. Alarm fatigue occurs in these environments due to sensory overload as a result of hearing medical equipment alarm frequently. This often leads to unsafe silencing, changing alarm paraments or simply the shutting off of alarm associated with patient care sensors. Aversion to critical alarms remains a serious concern in healthcare today resulting in significant patient harm and death.

There continues to be a major focus on identifying and managing patients with suicidal ideation, reduction of healthcare associated infections and universal precautions to prevent wrong-site surgeries. Although specific NPSG’s will vary based on each type of healthcare program, the focus continues to be on risk reduction and improving patient safety.

We encourage organizations to take a brief look at TJC’s NPSG’s regardless of your organization’s accrediting body or accreditation status. We further encourage you to review your policies, protocols and training programs that address risk reduction relevant to the recurring and increasing concerns in patient care settings across the globe. Adverse events can easily lead to professional liability claims and revenue loss for healthcare organizations but more importantly significant harm to patients as well as death. The statistics continue to demonstrate that these problems remain prevalent and demand our attention. After all, the goal for all healthcare professionals working in this ever-changing and increasingly challenging industry should be to cause zero harm. This requires establishing, supporting and maintaining a culture of safety.

Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges.

Whether you are in need of mock surveys, leadership training, corrective action plans or ongoing routine support services, we can help!

We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.
Contact us today at +1 (800) 813-7117 to schedule a free consultation.

Radiologic Services: Refresher for Hospitals on CMS Conditions of Participation

Mon, 09 Dec 2024 05:57:20 GMT

When it comes to delivering radiologic and diagnostic services under The Centers for Medicare & Medicaid Services Conditions of Participation, hospitals need to have policies, procedures and safe practices in place that are centered around delivery of patient services, safety of patients and personnel, qualifications of personnel and record keeping practices.

Hospitals should be equipped to provide radiologic or diagnostic services to meet patient needs. If a hospital is not fully equipped, or equipment is being serviced, contingency arrangements should be made in the interest of patient safety.

Protecting patients and personnel is another requirement and should also be at the forefront of any hospital’s radiation safety program. Shielding of both patients and team members is essential to minimize unnecessary exposure to harmful radiation. Furthermore, team members who are routinely exposed are required to wear dosimetry badges to monitor their level of exposure to radiation.

In addition, routine inspections of equipment should be performed to mitigate the risk of hazards associated with exposure to radiation. Additional safety measures must also include safe storage, use and disposal of radioactive materials.

Hospitals must carefully consider the qualifications of those who provide radiology and diagnostic services while adhering to state laws and regulations. Considerations must include not only state law but also consideration for competency with regard to granting clinical privileges. It is not uncommon for hospitals to use teleradiology services to perform diagnostic image analysis remotely. If your facility utilizes these services, be sure that they are vetted through the same credentialing process as per your organization’s Medical Staff and Governing Body’s Bylaws dictate.

According to CMS conditions of participation, imaging records must be kept by hospitals for a minimum of five years. All imaging reports with diagnostic interpretations must be signed by the radiologist or practitioner who provided services to a patient. Be sure to check with your medical records department to determine the duration of time and the process for medical archiving historical medical records.

Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges.

Whether you are in need of mock surveys, leadership training, corrective action plans or ongoing routine support services, we can help! We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

References: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.26

The Holiday Season and Healthcare - Considerations for Healthcare Providers

Tue, 05 Nov 2024 01:49:38 GMT

The Holiday Season and Healthcare - Considerations for Healthcare Providers

The holiday season is a wonderful time to celebrate with family and friends. Depending on your level of enthusiasm, you may be someone who prepares for celebrations’ month in advance. Of course, there are varying levels of cheer and excitement when it comes to holiday planning. It is important to consider that not everyone is as enthusiastic about the holiday season. The rising cost of living and expenses associated with holiday celebrations can contribute to increased stress levels for many. We encourage healthcare professionals to be mindful of others to raise awareness of patients and team members who may be silently struggling around them.

Here are a few tips to help identify those in need of warmth and kindness this holiday season:

Administrators and Leaders

Revisit and repost resources available for inpatients and outpatients who may need follow up care and monitoring. Re-educate healthcare providers on how to reference available resources and contact information if needed.
Check in with your team members. Be sure to ask how they are doing. Acknowledgement of someone’s well-being goes a long way. This is especially important in extremely busy and stressful healthcare settings.
Offer flexible scheduling options and split-shifts, if possible, to allow staff to have a fair opportunity to enjoy even a partial holiday with family.
Allow employees to hold a potluck or a white elephant gift exchange maintaining a minimal cost cap.
Allow team members to decorate in accordance with regulatory compliance standards. Check on out our previously published newsletter for more information. Employee engagement goes a long way when it comes to boosting spirits!
Post information about employee assistance programs or resources available for those who may be struggling with depression during the holiday season.

Healthcare Providers

Be sure to continue to screen patients for depression and risk of suicide. It is okay to deviate from the computer generated EMR tools that you use every day. Feel free to use a warm, more personal touch when talking with patients. There is nothing wrong with asking a patient if there is anything that may be troubling them that they would like to discuss.
If you determine that a patient may be at risk, be sure to enlist the help of additional support services for both in-patients and outpatients.
If you determine that a patient is having suicidal ideation, immediately put the appropriate safety measures in place and providers responsible for the care and safe disposition of the patient.

We have immense gratitude for all healthcare professionals, especially those working long and hard hours during the holiday season to keep us safe. From all of us here at HCE Global, we would like to wish you and yours a joyous and safe holiday season!

Be sure to browse Our Website for a full list of services we provide.

Time to Revitalize Infection Prevention Awareness in Healthcare

Mon, 07 Oct 2024 07:30:13 GMT

Time to Revitalize Infection Prevention Awareness in Healthcare

Those who work in a healthcare setting are well aware of Infection Prevention (IP) strategies. Protecting patients and employees should be at the forefront of all IP Programs in order for them to be successful and minimize risk of harm. Although we are all elated to be now several years post-pandemic, those challenging times have more than taken the wind out of the sails of healthcare professional and IP leaders.

October 13-19, 2024, is International Infection Prevention Week. Although it is just around the corner, there is no better time to celebrate all healthcare workers who dedicate their lives to improving the lives of others. It is also the perfect opportunity to acknowledge the hard work and dedication of our Infection Prevention Leaders. This dynamic group of professionals are committed to keeping organizations safe and compliant. A little effort goes a long way. Planning even small activities and awareness initiatives are a great way for organizations to celebrate team members for their contribution to daily IP practices.

We understand that organizations may be struggling with operational budgets and rising costs but there are some activities that can be planned and are free.

Infection Prevention & You has a variety of puzzles that can be downloaded and emailed out as a fun awareness activity.
There are also coloring sheets that can be sent out for team members to engage in a lighthearted IP activity. Coloring is a healthy way to reduce stress.
Use an empty patient room to encourage staff to discuss hand hygiene practices and cleaning protocols for surfaces and equipment. This is also a perfect opportunity to include your Environmental Services Team and acknowledge them for all their hard work in keeping everyone safe.

If your budget allows for a little more, here are some great activities that require minimal cost:

Glogerm is a fun way to demonstrate efficacy of hand washing and cleaning. Kits can be purchased at a low cost.
What’s Wrong with This Picture is another great activity. Pictures taken from surveillance rounding can be displayed for employees to try to determine what the IP breach is. Depending on the image, this event can be both challenging and a great opportunity for education.
Using a few PPE supplies, have team members identify what supplies should be used for various types of isolation. It is also a great opportunity to discuss proper donning and doffing techniques.
When doing routine surveillance, handing out small awards to those who engage in good hand hygiene practices goes a long way.
Providing small snacks or treats around any activity is an enticing way to encourage team engagement, so break out the Halloween candy!

IP Week is also a great time for administrators to recognize IP Leaders for their commitment to keeping everyone safe and organizations compliant with IP standards and reporting requirements. A personal thank you note, or card is a nice touch to acknowledge your IP. If your IP is working toward a certification or interested in continuing education opportunities, supporting their professional IP goals is a win-win for all.

From all of us here at HCE Global, we wish everyone a happy and healthy Infection Prevention Week! Keep up the great work!!

Be sure to browse Our Website for a full list of services we provide.

New NHSN Reporting Requirements: Confident Your Organization Is Prepared?

Mon, 09 Sep 2024 03:22:58 GMT

New NHSN Reporting Requirements: Confident Your Organization Is Prepared?

“Beginning November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) will require hospitals and critical access hospitals (CAHs) to electronically report information, like confirmed infections and bed capacity, related to flu, COVID-19 and RSV, on a schedule specified by the Secretary of Health and Human Services” (CDC, 2024).

With Flu season in full swing and Covid cases on the rise, it is important to understand updated, mandatory reporting requirements for hospitals as well as critical access hospitals. The National Healthcare and Safety Network (NHSN) is working to prepare facilities for new reporting requirements through web-based education. Individuals who are tasked with reporting quality data into NHSN will need to be prepared to do so in coming months.

The Centers for Disease Control and Prevention (CDC) is providing the following upcoming webinars:

Reporting of Hospital Respiratory Data to NHSN – Data Submission Overview
Wednesday, September 11, 2024, from 1-2pm ET
Register: https://cdc.zoomgov.com/webinar/register/WN_bbJez6ECRpqTvGe7mtnuGA
Reporting of Hospital Respiratory Data to NHSN – Data Submission Overview (Replay)
Thursday, September 12, 2024, from 2-3pm ET
Register: https://cdc.zoomgov.com/webinar/register/WN_aJ3P-EdJRi6nQTRV_PlF3A
You can also click on the link below to view a pre-recorded webinar on demand:
https://www.cdc.gov/nhsn/pdfs/pscmanual/Hospital-Respiratory-Data_Webinar.pdf

Now is the time to ensure that data is being collected daily. In addition, data reports should be shared with the individual who is responsible for NHSN data reporting in your organization. Data points that should be collected include bed capacity, patients admitted and hospitalized with Covid-19, Influenza and RSV along with patient age. Additional reporting requirements such as personal protective equipment supply on hand is optional.

Our experts understand the challenges that healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges. Whether you are in need of leadership training, preparing for a survey or require assistance with a corrective action plan, we can help! We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

References:

https://www.cdc.gov/ncird/whats-new/updated-hospital-reporting-requirements-for-respiratory-viruses.html#:~:text=Beginning%20November%201%2C%202024%2C%20the,Secretary%20of%20Health%20and%20Human

Hazardous Material Disasters: How Safe Are You?

Thu, 22 Aug 2024 03:50:16 GMT

Hazardous Material Disasters: How Safe Are You?

Hazardous Materials are commonly used in the healthcare environment. Safe handling, storage and disposal are key considerations for safe management of such materials. Another important consideration is what personal protective equipment should be worn when handling these items. With a variety of different hazardous materials on hand, it can be challenging to keep up with safe management and storage of these items. Occupational Safety and Health Administration (OSHA) has established standards to help ensure that workers are protected on the job. “All employers with hazardous chemicals in their workplaces must have labels and safety data sheets for their exposed workers and train them to handle the chemicals appropriately” (OSHA, 2012).

Here are a few tips to ensure that your organization is providing protective measures to keep your employees safe from exposure on the job:

Conduct a survey of your facility to identify what hazardous materials are being used.
Verify that the chemical being stored are still being used (if not, discard appropriately)
Ensure that Safety Data Sheets (SDS) are available electronically or in paper form such as a manual. If paper manuals are the preferred method, they must be updated routinely.
All employees must be able to access SDS’s immediately.
Keep spill kits readily available.
Train all employees on safe handling of hazardous materials
Ensure PPE is readily available.
Be sure to perform routine checks on eyewash stations and decontamination showers to ensure they are in good working order in the event of exposure.

SDS sheets have sixteen sections that address various safety measures specific to the chemical it describes. This standardized format was adopted to ensure ease and to minimize barriers to identifying pertinent information about products.

Accumulating hazardous materials can be dangerous. It is common to find that hazardous materials are being stored that are no longer in use. Safe disposal of these products is a must. Having an agreement with a reputable company that is well trained and certified in hazardous waste removal should be an important consideration. If you have not recently looked at your internal processes for safe handling of hazardous waste materials, do not delay any longer.

Our HCE Global experts understand the challenges that healthcare facilities are facing today. We are here to help. We offer a variety of professional development services to help grow your novice professionals into industry experts. Using a customizable approach, we will help you navigate through even the toughest of challenges. We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

References:

https://www.osha.gov/hazcom

Professional Development: What is Your Plan for Sustainability?

Thu, 18 Jul 2024 01:34:18 GMT

Professional Development: What is Your Plan for Sustainability?

If you are in a leadership position in the healthcare environment today, you are no stranger to the issues surrounding staffing shortages. With a lack of qualified applicants and high turnover rates, ensuring safe staffing coverage can seem like an ongoing vicious cycle to many department leaders serving in the healthcare industry today. How are you managing this issue in your facility?

Finding and recruiting new qualified personnel is a never-ending task. Not only must you find individuals who meet educational requirements to fulfill their job duties, but it is also important to ensure that new team members are competent to fulfill the positions for which they were fired. One of the biggest challenges is that healthcare personnel who are well-experienced in their fields are in high demand.

If you are fortunate enough to have these well qualified individuals on your team, it may only be temporary. There is a tremendous amount of recruiting activity happening in the healthcare industry incentivizing your hard-working skilled team members to consider other high-paying positions which include sign on bonuses, generous PTO and benefits packages, continuing education compensation and paid relocation expenses.

It is hard to imagine when or even if this staffing crisis will ever go away. In the interim, high turnover rates and training cost for new staff. “The average cost of turnover for a staff RN increased by 7.5% in the past year to $56,300, with a range of $45,100 to $67,500. The average time to recruit an experienced RN ranges from 59 to 109 days, with the average for 2023 sitting at 86 days - nine days quicker than the year prior” (Beckers, 2024) . This budget busting trend has CFO’s struggling to manipulate day-to-day operational costs along with unanticipated overhead costs to account for the onboarding of new staff in because of high turnover rates.

With no immediate resolution to this post-pandemic staffing crisis. Healthcare leaders are hard pressed to find safe and timely solutions. Many rely on high priced staffing agencies to fill immediate needs. We recommend looking within for highly motivated professionals who may already be a part of your team. Mentoring and training novice individuals may be a great way to combat future staffing issues. Now, more than ever, is the time to rethink recruitment strategies. Spending countless hours, not to mention cost, to recruit experienced help can be futile. Redirecting recruitments efforts to promoting from within may just be the future to sustainment and succession planning.

Be sure to browse Our Website for a full list of services we provide.

Dietary Services: Confident your facility is Survey Ready?

Wed, 12 Jun 2024 03:34:10 GMT

Dietary Services: Confident your facility is Survey Ready?

An area that is sometimes overlooked in hospitals is Food and Dietetic Services. It is important for CMS providers to fully understand the § 482.28 Condition of participation: Food and Dietetic Services requirements. In smaller hospitals, it is not uncommon for these services to be contracted. In addition, hospitals may have agreements with outside facilities on meal preparation and delivery as opposed to preparing meals in house. Regardless of how your organization provides these services, the following criteria must be met:

Standard: Organization.

(1) The hospital must have a full-time employee who—

(i) Serves as director of the food and dietetic services;

(ii) Is responsible for the daily management of the dietary services; and

(iii) Is qualified by experience or training.

(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis.

(3) There must be administrative and technical personnel competent in their respective duties.

(b) Standard: Diets. Menus must meet the needs of the patients.

(1) Individual patient nutritional needs must be met in accordance with recognized dietary practices.

(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals.

(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel.

Aside from having a well-structured Food and Dietary Services Department, it is also important to ensure that kitchen conditions are sanitary, food being served is fresh, food temperature is appropriate for serving and storage and environmental conditionals are safe.

CMS developed a Kitchen/Food Observation Tool to help guide surveyors through dietary surveillance.

Hospitals should be able to demonstrate maintenance of logs for temperature monitoring. How is your facility alerted if temperatures are out of range? Is dishware cleaned at the appropriate temperature to ensure sanitation?

Common questions to ask when conducting surveillance: Is the amount of chemical used for cleaning measured correctly? Can you describe (demonstrate if appropriate) how this is done? How are cookware, dishware and utensils stored when not in use?

If your organization has not incorporated your Food and Dietary Services Department into your hospital’s rounding regimen, then there is a serious risk of not meeting the CMS Conditions of Participation.

Our HCE Global experts understand the challenges that healthcare facilities are facing today. We are here to help. Using a customizable approach, we will help you navigate through even the toughest of challenges. We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

Reference:

https://www.cms.gov/files/document/cms-20055kitchenpdf

https://www.ecfr.gov/current/title-42/section-482.28

The Importance of Evaluating Your Hospital's Environmental Services Program

Thu, 16 May 2024 03:43:13 GMT

The Importance of Evaluating Your Hospital's Environmental Services Program

Environmental Services (EVS) is an essential component of healthcare operations. Maintaining sanitary conditions is a critical element of a successful Infection Prevention Program. It is a very common practice for healthcare facilities to contract these services. Whether your organization uses a third-party vendor or employs your own EVS personnel, make it a priority to evaluate day-to- day operations throughout your facility to ensure patient safety and good infection prevention practices.

Education is the most important consideration for establishing and maintaining a safe and healthy environment. When outsourcing EVS services, it is important to consider if the service provider has experience in the healthcare setting. We have found that some organizations may contract with vendors who have only had general EVS training. Ensuring that EVS workers are trained and competent is critical, specifically when it comes to cleaning isolation rooms and terminal cleaning in the surgical services environment.

Here are a few considerations for evaluating your organization’s EVS Program:

Use of personal protective equipment. Have team members been trained on proper donning and doffing procedures? Is this being done properly between locations/rooms?
Hand Hygiene. Are team members compliant with hand hygiene protocol? Is hand hygiene being performed at appropriate intervals?
Separation of clean and dirty supplies. Are clean materials such as paper products, linen and microfiber cleaning cloths being stored separate from soiled materials?
Cleaning agents. Are team members using products that are safe and approved? Are they familiar with how to safely use cleaning agents? Are they donning required PPE for chemicals being used? Is the cleaning of equipment (if applicable) being done in accordance with the Manufacturer’s recommendations? Have they been trained on Safety Data Sheets? Are cleaning agents being stored safely and securely? Do they know where eyewash stations are located?
Curtains. Are team members trained on policies for removing and cleaning curtains in patient care areas?
Hazardous and biological waste. Are they properly trained on safe handling, removal, and secure storage protocols?
Cleaning logs. Are these being completed and maintained correctly? Do you have the ability to access and recall logs?
Communication. How are requests being made for EVS cleaning? Is there sound communication between departments requesting services as to what specific cleaning requirements are needed in various areas? Examples: terminal cleaning for isolation, operating rooms, cleaning areas where renovation or construction are underway or bed bugs infestations, etc.?

Environmental Services Programs are a critical part of operations in all healthcare facilities. Regardless of whether you directly employee EVS personnel or use contracted services, be sure that a comprehensive training program exists. Are team members properly educated and deemed competent in the duties that they are expected to perform? Training should occur with onboarding of all new team members. EVS should be integrated into your organization’s Infection Prevention Program.

Good environmental service practices are essential for establishing and maintaining sanitary conditions, preventing infection, and ensuring safe conditions for patients and healthcare providers.

HCE Global is Here to Help

Be sure to browse Our Website for a full list of services we provide.

Life Safety 101: Think You are Up to Code?

Wed, 17 Apr 2024 04:37:30 GMT

Life Safety 101: Think You are Up to Code?

NFPA 101 is a set of standards developed to ensure that safety of patients, visitors, and staff in a variety of facilities including healthcare. The National Fire Protection Association (NFPA) established these standards to provide guidance for healthcare organizations to maintain a safe environment.

The following are some of the key components make of the NFPA 101 Life Safety Code:

Means of Egress
Fire Protection Systems
Building Construction and Fire Resistance
Specialized Areas
Emergency Preparedness and Response
Accessibility
Occupation Classification

Developing acceptable means of egress should be incorporated into the original design plans of healthcare facilities. Considerations should include dimensions and evacuation routes relative to corridors, exit doors, ramps, stairways, and elevators. Planning and design of facilities should help to ensure safety and efficiency of evacuation during emergencies.

Healthcare facilities are required to install and maintain fire protection systems inclusive of alarm sprinkler, and smoke detection systems in addition to fire extinguishers. Early detection is the key to minimizing injury, reducing the risk of property damage, and preventing catastrophic events. Additional considerations need to be made for emergency procedures, medical gas and electrical safety in specialized areas including but not limited to surgical suites, imaging departments and laboratories.

NFPA Life Safety Code 101 emphasizes the importance of emergency response and preparedness for healthcare facilities. Key components of being prepared and having a sound response plan should include a comprehensive emergency response plan. Elements of the plan would include protocols for conducting fire drills, evacuation, sheltering in place and medical response under emergent conditions.

Accessibility needs must also be considered under this standard. Provisions must be made for individuals with disabilities such as mobility and hearing impairment or other special needs. Different requirements are in place based upon the type of healthcare occupancy. Each type of healthcare occupancy must adhere to special considerations as outlined by the NFPA.

Adherence to NFPA Life Safety 101 standards is critical. Accredited facilities/organizations are required to comply with these standards to ensure a safe environment for patients, staff, and visitors. Careful adherence to these standards requires commitment and dedication including routine inspections, testing and maintenance.

HCE Global is Here to Help

Our HCE Global experts understand the challenge that healthcare facilities are facing today. We are here to help. Using a customizable approach, we will help you navigate through even the toughest of challenges. We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to browse Our Website for a full list of services we provide.

Considerations for Using Biological Implants in Surgery

Fri, 15 Mar 2024 05:54:08 GMT

Considerations for Using Biological Implants in Surgery

There is no shortage of biological implant products on the market today. In fact, more than 20,000 products to date have been approved for marketing by the Food and Drug Administration (FDA). Although many of these products are highly regarded by surgeons and product manufacturers, it is important to understand the potential risks associated with biological implants.

We have chosen to discuss this topic in our newsletter as it has been our observation and experience that there is a lack of understanding of potential risks associated with biologics and a lack of education available to healthcare professionals.

What are Implants?

According to the FDA, “Medical tissues that are placed inside or on the surface of the body. Many implants are prosthetics, intended to replace missing body parts. Some implants are made from skin, bone or other body tissues.” (FDA, 2019).

Some of the major risks associated with the use of biological implants include infection, risk of rejection, and biocompatibility.

Additional considerations for product usage should be made from a cost-analysis perspective. Although a product may be registered for marketing by the FDA, it is not uncommon for insurance payors to reject claims where biological implants were used. Be sure that prior authorizations include the use biological implants in surgical cases to avoid non-payment from insurance payors.

When dealing with human tissue products, it is essential to make sure that the integrity of the product is maintained prior to implantation. How the product is maintained and transported should be carefully monitored.

Here are a few considerations for policy and procedure development:

Process for ensuring a product is registered with the FDA
The product is not manipulated and is maintained in its original sterile packaging
Temperature and humidity requirements are maintained according to manufacturer instructions
The product is not expired
Patient is fully informed about biological implant and has signed informed consent
A method of tracking is established for all biological and well as medical implants.
Create a log that includes product information and serial numbers
Documentation of biological implant is included in the patients medical record
Healthcare personnel have been educated on “gate-keeping’ strategies prior to biologic implants entering the operating room

In our experience, we have found that it is not uncommon for hospitals and ambulatory surgeries centers to not have policies and procedures in place for regulating the use of biological implants in surgical procedures. It is also not uncommon for Manufacturer Product Representatives to show up with products on the day of surgery wherein it is unclear how and in what condition the product has been transported. Additional observations have included that OR team members were completely unaware that a biologic was even planned to be used in a scheduled procedure.

We would like to emphasize that our intention for writing this article is not to take a position in favor or against the use of biological implants, but to help healthcare professionals have a better understanding of these products and encourage the development of policies and procedure that promote patient safety and help to mitigate risk.

This topic is one that we have done extensive research on. Subsequently, we have determined that there is a significant lack of guidance and educational material to help guide healthcare professional to manage use of biological implants in a safe and compliant manner.

If you find that your organization needs additional support, please contact us for assistance. We can provide education and assist with risk mitigation and policy/procedure development.

HCE Global is Here to Help

Be sure to browse Our Website for a full list of services we provide.

References:

https://www.fda.gov/medical-devices/products-and-medical-procedures/implants-and-prosthetics#:~:text=Medical%20implants%20are%20devices%20or,support%20to%20organs%20and%20tissues.

NHSN Annual Facility Survey

Mon, 12 Feb 2024 01:46:47 GMT

If your facility is enrolled in the National Healthcare Safety Network (NHSN), then submitting an annual facility survey for the previous year is a requirement. If your facility was not operational in 2023 but you are enrolling, this information must be provided at the time of enrollment.

The deadline for completion is March 1 ^st of each calendar year. If your facility has been operational, it is important to update the survey to accurately address various components of the survey based on the previous year. There are a variety of online educational modules available to assist facilities through the completion process. You will also find instructions for completing the survey. You can find this information on the Centers for Disease Control and Prevention (CDC) website

It is best to begin working on the survey well in advance of the deadline for submission.

We recommend reviewing all components of the survey and delegating review and completion to personnel that oversee corresponding departments. Assistance from leadership from the following departments will be needed to complete the survey:

Infection Prevention
Microbiology/Lab
Quality
Pharmacy
Nursing
Facilities
Medical Records
Contractors, if applicable

Facilities will need to provide response to a variety of questions on the following topics:

Type of facility
Services Provided
Volumes
Laboratory testing capabilities and equipment
Infection Prevention Practices
Neonatal/newborn level of care if applicable
Antimicrobial Stewardship Practices
Sepsis Management and Practices
Facilities Water Management

You can preview the various NHSN annual survey questionnaires associated with the corresponding facility types listed below:

We recommend that you check with your NHSN administrator to determine if your facility’s annual survey has been completed and submitted. It may also be a good idea to create a task force that includes departmental leaders. This provides a great opportunity to delegate the task of completion of survey questions relative to their respective departments.

HCE Global is Here to Help

HCE Global understands the challenges that healthcare facilities are facing today. We are here to help. Using a customizable approach, we will help you navigate through even the toughest of challenges. We pride ourselves on helping clients achieve and maintain a status of excellence in the healthcare industry.

Be sure to visit Our Website for a full list of services we provide.

Tips For Your Facilities’ New Year’s Resolutions!

Fri, 29 Dec 2023 07:56:29 GMT

JANAUARY 1, 2024

Tips For Your Facilities’ New Year’s Resolutions!

Don’t break these, your facility needs them!

Setting regulatory compliance resolutions for healthcare facilities is crucial to ensure the delivery of high-quality, safe, and effective healthcare services. Here are some potential New Year's resolutions for your facility in terms of regulatory compliance:

1. Stay Informed about Regulatory Changes:

Resolve to stay updated on any changes in healthcare regulations at the local, state, and federal levels.
Regularly check for updates from regulatory bodies such as the Centers for Medicare & Medicaid Services (CMS), CIHQ, or other relevant authorities.

2. Regular Compliance Audits:

Commit to conducting regular internal compliance audits to identify and address any potential issues before they become larger problems.
Ensure that staff members are aware of compliance standards and actively participate in the audit process.

3. Training and Education Programs:

Develop a resolution to provide ongoing training and education programs for staff to keep them informed about regulatory requirements and changes.
Implement a system to track and document staff training to ensure everyone is up-to-date on compliance issues.

4. Enhance Data Security Measures:

Focus on strengthening data security to comply with regulations such as the Health Insurance Portability and Accountability Act (HIPAA).
Invest in technologies and processes to safeguard patient information and maintain privacy.

5. Improve Documentation and Record Keeping:

Commit to improving documentation processes to ensure accurate and complete record-keeping, which is essential for compliance.
Implement electronic health records (EHR) systems if not already in place to enhance accuracy and accessibility.

6. Ensure Patient Safety Standards:

Make a resolution to prioritize patient safety by adhering to standards set by CMS or accrediting bodies like CIHQ or TJC.
Regularly review and update safety protocols to reflect the latest best practices.

7. Emergency Preparedness:

Develop and/or update emergency preparedness plans in compliance with regulatory requirements.
Conduct drills and training sessions to ensure staff are familiar with emergency procedures.

8. Enhance Quality Improvement Initiatives:

Resolve to actively participate in quality improvement initiatives to enhance patient care and meet regulatory standards.
Use data-driven approaches to identify areas for improvement and implement corrective actions.

9. Engage in Collaborative Partnerships:

Collaborate with other healthcare organizations and professionals to share best practices and stay informed about industry trends and changes.
Attend conferences, workshops, and webinars to network and gain insights into regulatory compliance.

10. Review and Update Policies and Procedures:

Regularly review and update policies and procedures to reflect the current regulatory environment.
Communicate any changes to staff and ensure they understand and follow the updated protocols.

By incorporating these resolutions into your overall operational plan, you can promote a culture of compliance, ultimately benefiting patient outcomes and overall healthcare quality

Regular reassessment and adjustment of these resolutions will contribute to the ongoing success of regulatory compliance efforts.

Navigating the Complex Landscape of Hospital Compliance: A Guide to EOC, Life Safety, & NFPA Regulations for Patient Care

Fri, 22 Dec 2023 05:02:29 GMT

DECEMBER 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

In the ever-evolving landscape of healthcare, ensuring hospital compliance is not just a regulatory requirement but a commitment to providing a safe and secure environment for patients, staff, and visitors. This blog aims to delve into the intricacies of hospital compliance, focusing on the crucial aspects of Environment of Care (EOC), Life Safety, and the National Fire Protection Association (NFPA) regulations that collectively shape the framework for patient care facilities.

1. Understanding Environment of Care (EOC):

Definition and Scope: What constitutes the Environment of Care in a hospital setting? Discuss the various elements such as safety, security, hazardous materials, and emergency management.
Joint Commission Standards: Explore the role of The Joint Commission in setting EOC standards and the impact on hospital accreditation.
Compliance Challenges: Highlight common challenges faced by hospitals in maintaining EOC compliance and strategies to overcome them.

2. Life Safety in Healthcare Facilities:

Regulatory Overview: Provide an overview of the Life Safety Code (NFPA 101) and its significance in healthcare settings.
Fire Prevention and Preparedness: Discuss the specific measures hospitals must take to prevent and respond to fire emergencies, including fire drills, evacuation plans, and fire safety training.
Building Design and Construction: Explore how hospital infrastructure must adhere to Life Safety Code requirements, covering areas such as egress routes, fire barriers, and smoke control.

3. NFPA Regulations and Healthcare:

NFPA 99 (Health Care Facilities Code): Delve into NFPA 99, focusing on its application to healthcare facilities, including electrical systems, gas and vacuum systems, and medical gas requirements.
Integration with EOC: Discuss how NFPA regulations align with and complement the broader Environment of Care framework to enhance overall safety and compliance.
Recent Updates and Emerging Trends: Provide insights into any recent updates to NFPA codes relevant to healthcare facilities and discuss emerging trends in compliance and safety standards.

4. Patient Care Implications:

The Intersection of Compliance and Patient Care: Analyze how adherence to EOC, Life Safety, and NFPA regulations directly impacts the quality of patient care.
Case Studies: Share real-world examples where compliance failures have affected patient outcomes and emphasize the importance of a holistic approach to healthcare management.

5. Best Practices and Recommendations:

Developing a Robust Compliance Program: Offer practical advice on establishing and maintaining a comprehensive hospital compliance program.
Training and Education: Emphasize the role of ongoing training and education for staff to ensure awareness and understanding of compliance requirements.
Continuous Improvement: Discuss the concept of continuous improvement in the context of compliance, encouraging hospitals to adapt to evolving regulations and industry best practices.

In the complex and highly regulated world of healthcare, navigating the intricacies of Environment of Care, Life Safety, and NFPA regulations is essential for ensuring the well-being of all stakeholders. By understanding the interplay between these elements, hospitals can not only meet regulatory requirements but also foster a culture of safety, ultimately enhancing the quality of patient care.

Surgical Implants: Have You Considered ALL Aspects of Safety & Compliance?

Tue, 31 Oct 2023 15:40:00 GMT

How Confident Are You?

November 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

The use of surgical implants in a hospital setting is a critical and highly regulated aspect of patient care. Hospitals typically have specific guidance and protocols in place to ensure the safe and effective use of surgical implants. Below are some key considerations that hospitals may include in their guidance for the use of surgical implants:

Regulatory Compliance : Hospitals must comply with local, national, and international regulations and standards governing the use of surgical implants. This includes adhering to guidelines set forth by regulatory bodies such as the FDA (in the United States), the European Medicines Agency (EMA), or other relevant authorities.
Product Selection and Approval: Hospitals should establish procedures for evaluating and approving surgical implant products for use. This includes vetting suppliers and manufacturers, assessing the quality and safety of implants, and ensuring compliance with regulatory requirements.
Credentialing and Privileging: Hospitals should have a process for credentialing and privileging surgeons and healthcare professionals who are qualified to implant devices. This process ensures that healthcare providers have the appropriate training and experience.
Informed Consent: Hospitals must ensure that patients receive comprehensive and understandable information about the surgical implant procedure, including its risks and benefits. Informed consent is a critical step in the process.
Patient Assessment: A thorough assessment of the patient's medical history, condition, and suitability for implantation is necessary. This includes evaluating the patient's overall health, potential allergies, and any contraindications for the specific implant.

Surgical Procedures: Hospitals should have established surgical protocols for the implantation of devices, including pre-operative, intra-operative, and post-operative procedures. These should ensure aseptic techniques, patient safety, and quality care.
Implant Tracking and Documentation: Proper record-keeping and tracking of implantable devices are essential. This includes maintaining detailed records of the type of implant, its lot number, and its manufacturer. In case of product recalls or adverse events, accurate tracking can be crucial.
Surveillance and Monitoring: Hospitals must have systems in place for monitoring the performance and outcomes of implant procedures. This can include post-operative follow-up, tracking complications or adverse events, and ensuring the long-term effectiveness of the implant.
Infection Control and Sterilization: Strict infection control and sterilization protocols are critical to minimize the risk of surgical site infections and other complications associated with implantation.
Staff Training and Education: Hospitals should provide ongoing training and education for healthcare professionals involved in the implantation process. This ensures that staff members are aware of the latest techniques, safety measures, and best practices.
Adverse Event Reporting: A process for reporting and addressing adverse events related to surgical implants should be in place. Hospitals should follow established procedures for reporting adverse events to the appropriate regulatory agencies and manufacturers.
Patient Follow-Up and Postoperative Care: Comprehensive postoperative care and follow-up protocols are essential to monitor patient recovery, assess the performance of the implant, and address any issues that may arise.
Quality Assurance and Continuous Improvement: Hospitals should have mechanisms for ongoing quality assurance and continuous improvement in the use of surgical implants. This includes regular reviews of implant procedures, outcomes, and feedback mechanisms to identify areas for improvement.

The guidance for the use of surgical implants in a hospital will vary depending on the specific hospital, location, and the types of surgical procedures performed. Hospitals typically collaborate with healthcare providers, regulatory agencies, and professional organizations to develop and refine their implantation protocols and procedures.

In our experience, the biggest challenges surround lack of knowledge. Employees and providers may not fully understand regulatory requirements for using surgical implants. It is important to ask surgical device representatives for all information about products, related research, and FDA approval status in order to make informed decisions about possible risk and safety concerns associated with a product.

Tracking of implants is another critical element that may not be fully understood but documentation is critical in the event there is a product recall. Credentialing is another area that is easily overlooked. Have providers been granted privileges to implant surgical devices?

There is no better time than now to do a deep dive in to your organization’s current practices regarding surgical implants.

Use of surgical implants is one of the most complex topics in healthcare today. There is a high rate of failure associated with meeting regulatory requirements compliance due to an extensive list of criteria that should be considered to ensure that use of surgical implants is safe for patients.

When in doubt, call the experts for help! HCE is Here

Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state-of-the-art project or renovating an existing structure. Be sure to visit Our Website to see a full list of the services that we provide.
Contact us today at +1 (800) 813-7117 for a free initial consultation.

Please join us by clicking on any of our icons below to leave a comment or for more information and updates

Click Here To Subscribe To Our Monthly Newsletter

The Basics of USP 797 & 800

Thu, 05 Oct 2023 15:46:00 GMT

Is Your Organization Prepared?

october 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

USP Chapter 797, Pharmaceutical Compounding: Sterile Preparations, delineates the standards for compounding sterile preparations in all pharmacy settings. USP 800 provides standards for safe handling of hazardous drugs to minimize the risk of exposure to healthcare personnel, patients and the environment. Effective November 1, 2023, changes to these standards will be fully adopted and organization must demonstrate compliance.

One of the first considerations for ensuring compliance with USP 797 and 800 is to evaluate your organization’s current practices. The next most important step is to identify a qualified person to evaluate current practices, implement policies and procedures and oversee training. Conducting a risk assessment of current practices is a great way to begin.

A good approach to beginning to establish or revise a program that manages hazardous pharmaceuticals is to reconcile current medications on formulary. In doing so, you may determine that some of the medications listed are not necessarily being used. This is a common finding when providers who have requested medications be ordered are no longer practice at your facility. Eliminating these medications will not only help to minimize the actual number of hazardous medications but can also lead to tremendous cost savings for organizations.

Another point of focus should be evaluating how these medications are currently being handled within the organization. Handling hazardous medications should be done in a manner that is safe and reduces risk of harm to employees who come into direct contact with these medications.

Having the right equipment, ventilation, personal protective equipment, and cleaning products requires planning and collaboration. For organizations that are performing sterile compounding, we strongly recommend looking at how this work is being performed and identifying breaches in the process. The National Institute for Occupational Health and Safety (NIOSH) has published THIS ALERT that covers risks associated with hazardous pharmaceuticals.

Moving Forward
We highly recommend reviewing this publication which provides a comprehensive overview of topics related to prevention exposure to antineoplastic and hazardous drugs in healthcare settings. You will find helpful recommendations ranging from proper personal protective equipment to waste disposal .

Once all risks have been identified, be sure to work toward corrective actions that will not only mitigate risk but will ensure safety for those who work in these high-risk areas. There are several changes that have been adopted that will be in effect. All hazardous drugs, even if low volume, must be prepared in a negative pressure space.

The Joint Commission has also published a chapter on Revisions to Medication Compounding Requirements . This is another great tool that can be used in determining your organization’s compliance with Medication Compounding revised standards. Whether your healthcare facility is considered a large or small generator of hazardous pharmaceuticals, you will still be held to existing and updated standards concerning hazardous pharmaceuticals.

Now is a great time to take a closer look at your facilities, current processes and make improvements as necessary. We understand that preparation, management, and disposal of hazardous pharmaceuticals can be a complex matter but if not done correctly can cause harm to patients and staff. These types of adverse events can lead to litigation, financial burden and impact reputation and accreditation status for organizations.

When in doubt, call the experts for help! HCE is Here
Healthcare Consulting Experts LLC was built based upon our understanding of the challenges that healthcare facilities are facing today. Healthcare professionals strive to deliver the best possible care to all patients. We can help your facility through the difficult times and put you back on track to a less stressful tomorrow.

Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state-of-the-art project or renovating an existing structure. Be sure to visit Our Website t o see a full list of the services that we provide.
Contact us today at +1 (800) 813-7117 for a free initial consultation.

Please join us by clicking on any of our icons below to leave a comment or for more informati on and updates.

References:

https://www.cdc.gov/niosh/docs/2004-165/pdfs/2004-165.pdf?id=10.26616/NIOSHPUB2004165

https://www.jointcommission.org/-/media/tjc/documents/standards/prepublications/effective-2023/prepub_mc_requirements_for_ome_jan2024.pdf

Click Here To Subscribe To Our Monthly Newsletter

Medical Staff Credentialing

Tue, 05 Sep 2023 23:08:00 GMT

How Do Your Providers Measure Up?

SEPTEMBER 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

“In general, any licensed, independent healthcare professional who has been permitted by law and regulated by a licensing organization to provide services and care without supervision or direction within the scope of the individual’s license needs to be credentialed.” (Patel & Sharma, 2022).

It is all too common for healthcare facilities to become easily overwhelmed with day-to-day operations. Staffing shortages easily contribute to daily stress for all healthcare organizations today. While we strive to maintain safe patient environments, it is easy to overlook essential medical staff credentialing requirements.

Medical staff committee members and governing boards have a responsibility to review applicants requesting privileges. The medical staff committee makes recommendations to the governing board for appointment. The governing board makes the final determination on approval or denial. When determining if applicants should be recommended for privileges to practice, considerations should include education, experience relative to privileges being requested, references, history of malpractice and evidence of ongoing continuing education.

Providers should never be granted privileges that they are not qualified to perform or that would be considered beyond the level of care that the facility can provide.

Medical staff credentialing requires oversight by individuals who are well-versed in credentialing requirements. Using the National Practitioner Database can help facilities to learn more about providers background including history or pending legal action against a provider. When providers are appointed to practice, they should complete onboarding and competency training required by the organization. They should also be apprised and familiarize themselves with medical staff bylaws for which they are subject to follow.

Periodic Review

Healthcare organizations are also responsible for conducting periodic review of all medical staff. Common problems that we find when conducting medical staff audits include expired insurance, certifications and licensure. Establishing a structure to conduct ongoing audits of medical staff files is critical.

“Negligent credentialing lawsuits surface when a patient who has been injured in a hospital sues their medical provider for malpractice and the hospital for credentialing the physician” (Haefner, M. 2019).

Healthcare organizations must demonstrate compliance with federal and state regulations for conditions of participation for medical staff. Understanding federal and state regulations is critical.

Leadership and medical staff should take time to review their current medical staff credentialing practices. Familiarization with organizational by-laws is also necessary for those who have a key role in review and recommendation for credentialing providers.

We recommend meeting with your medical staff credentialing assistant to determine how they are maintaining files, conducting audits and communicating with providers to prevent deficiencies. There are a variety of tools to help streamline the credentialing process. Some examples include standardized applications, electronic record keeping platforms and credentialing specialist services.

Understanding how your organization manages credentialing is essential to avoiding risk of patient harm, litigation and financial penalties.

Be sure to take a deep dive into your current credentialing process today.

At HCE, we understand the nature of the healthcare environment can be stressful and fast-paced. Credentialing is a big part of the survey process and should never be overlooked for the sake of taking shortcuts.

HCE is Here to Help

Healthcare Consulting Experts LLC was built based upon our understanding of the challenges that healthcare facilities are facing today. Healthcare professionals strive to deliver the best possible care to all patients. We can help your facility through the difficult times and put you back on track to a less stressful tomorrow.
Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state-of-the-art project or renovating an existing structure. Be sure to visit Our Website to see a full list of the services that we provide.
Contact us today at +1 (800) 813-7117 for a free initial consultation.

Please join us by clicking on any of our icons below to leave a comment or for more informati on and updates.

References:

Patel R, Sharma S. Credentialing. [Updated 2022 Oct 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519504/
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.22
https://www.beckershospitalreview.com/legal-regulatory-issues/how-hospital-and-physician-leaders-can-prevent-negligent-credentialing-lawsuits.html

Click Here To Subscribe To Our Monthly Newsletter

Fire on the Table

Sun, 13 Aug 2023 19:23:00 GMT

Confident Your Surgical Team is Prepared?

August 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

“Operating room fires are devastating events that occur at least 650 times annually.” (FDA, 2018). Healthcare facilities are required to perform fire drills routinely.

We find that often, the requirement of performing routine fire drill requirements sometimes overshadows the need to perform drills specific to surgical services. Although fires can occur anywhere and at anytime for a variety of reasons, what we do know is that there are three key elements that contribute to an increased risk of fire occurring in a surgical environment.

It is important to also consider that surgical fires can also occur during office-based procedures and therefore fire drills should also be conducted in these settings.

There are three key elements to contribute to the perfect environment for a fire to occur. Fuels, ignition sources and oxidizers are frequently used in combination in surgical procedures. You can see examples of each element below in what is known as the fire triangle:

{continues after in-line photo courtesy of Image Resource - Jones, et al.; 2017}

Fire Risk Assessment and "Time Out"

Performing a fire risk assessment as part of “time out” prior to performing a surgical procedure is also best practice. The Association of PeriOperative Registered Nurses (AORN) has created the following Fire Risk Assessment tool .
It is important to evaluate practices in your organization. Here are a few questions to determine if your organization is truly prepared for this type of disaster:

Are team members including fire risk assessments as part of their time out procedure?
Are dry times for skin preps being properly observed?
Do team members understand the elements that contribute to surgical fires?
Have they been educated on their role in the event of a fire?
How to activate alarm and overhead announcement system?
Who can shut of medical gases and where are the valves located?
How to extinguish a fire?
Where and how to evacuate the area safely?
Do they know how to report an event that has occurred or a near miss?

The Joint Commission (TJC) Environment of Care Standard EC.02.03.01 EP11 requires organizations to:

Periodically evaluate potential fire hazards that could be encountered during operative or invasive procedures

Establish written fire prevention and response procedures, including safety precautions related to the use of flammable germicides or antiseptics

Risk factors should not be overlooked by any member of the surgical team. It is important to consider that patients are often sedated during procedures. Each member of the surgical team has a responsibility to protect the patient from harm. Patients may not be able to respond immediately to a burning sensation.

“Of 114 cases identified involving surgical fires, 60% of these resulted in a median award of $215000 to the plaintiff”. (Choudhry, et al., 2017). Adverse outcomes do not only lead to litigation, financial burdens and poor publicity but can also lead to increased anxiety, low morale, and increased turnover among personnel.

It is important for executive leadership to take a supportive approach regarding fire safety and emergency management planning. It is also important for team members to be able to report concerns that they may have about lack of adherence to safety protocols. Does your organization have a system in which team members can safety report concerns without fear or repercussions?

At HCE, we understand the nature of the healthcare environment can be stressful and fast-paced. Safety should always be a number one priority and never overlooked for the sake of taking shortcuts. We encourage all healthcare leaders to take a deep dive into their organizations’ current practices ensuring that safety continues to be a top priority.

HCE is Here to Help
Healthcare Consulting Experts LLC was built based upon our understanding of the challenges that healthcare facilities are facing today. Healthcare professionals strive to deliver the best possible care to all patients. We can help your facility through the difficult times and put you back on track to a less stressful tomorrow.

Contact us today at +1 (800) 813-7117 for a free initial consultation.

Please join us by clicking on any of our icons below to leave a comment or for more informati on and updates.

References:

https://www.aorn.org/guidelines-resources/tool-kits/fire-safety/tool-kit

Choudhry AJ, Haddad NN, Khasawneh MA, Cullinane DC, Zielinski MD. Surgical Fires and Operative Burns: Lessons Learned From a 33-Year Review of Medical Litigation. Am J Surg. 2017 Mar;213(3):558-564

http://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/PreventingSurgicalFires/default.htm

Jones EL, Overbey DM, Chapman BC, Jones TS, Hilton SA, Moore JT, Robinson TN: Operating room fires and surgical skin preparation. J Am Coll Surg 2017; 225:160–5

https://pubs.asahq.org/anesthesiology/article/130/3/492/19230/Operating-Room-Fires

Click Here To Subscribe To Our Monthly Newsletter

Ultrasound Transducers and Outbreak

Fri, 07 Jul 2023 20:31:00 GMT

Confident Your Organization is Cleaning Correctly?

July 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

“In 2016, The Joint Commission found that 74% of all immediate threats to life were related to improperly sterilized or high-level disinfected equipment.” (1)

There is an increased risk of cross-contamination when a transducer comes into direct contact with blood and body fluids. Subsequently, use of transducer sheaths does not eliminate the need for conducting a decontamination process.
Ultrasound transducers are used to explore and diagnose various conditions as well as vital organ function. While some transducers can perform in-depth exploration using a topical approach, other types of testing may require a more invasive approach.
When a transducer is used in a sterile body cavity or exploration of sterile tissues, sterilization of the transducer is the required method of disinfection. When a transducer is used for exploration that involves non-intact skin or mucous members, then a high-level disinfection process is required for transducers following these types of procedures.
Decontamination levels range from low (non-critical) to high (critical). The method of decontamination of equipment should be identified based upon its Spaulding classification. The chart below outlines the Spaulding classification of equipment decontamination (3):

How confident are you that your team members are performing the required level of disinfection on various types of transducers?
In addition to choosing the appropriate level of decontamination, it is necessary to follow the manufacturer's instructions on appropriate cleaning and disinfection procedures. When it comes to instructions for use (IFUs) from the manufacturer, you should be able to not only find the step-by-step process for cleaning the equipment, but also the appropriate chemicals that can safely be used in the cleaning and disinfection process.

Risks associated with failure to follow IFUs can result in harm to patients, damage to equipment, and voidance of warranties. It is the responsibility of the healthcare facility to ensure policies and procedures are in place that address ultrasound transducer cleaning and disinfection processes.

Training and competency should also be a top priority. A critical part of ensuring these practices are done correctly is establishing competency of team members who are performing these tasks. After initial competency has been established, routine and periodic re-evaluation of performance is critical to ensure continuation of safe practice.

In our experience, we have found that improper cleaning and disinfection of equipment is more common than you might think. We encourage all healthcare organizations to take a close look at staff training, internal practices, manufacturer recommendations and policies/procedures to mitigate risk and harm to patients.

Please join us by clicking on any of our icons below to leave a comment or for more informati on and updates.

References:

Click Here To Subscribe To Our Monthly Newsletter

Food and Nutritional Services

Tue, 06 Jun 2023 17:58:00 GMT

How does your Healthcare Facility Measure Up?

june 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

There is no doubt that some of the most dedicated and hardworking personnel in the healthcare industry work in dietary services. This is often an area that is overlooked in the healthcare industry. Regardless of the type of nourishments your organization provides, if your organization participates in Medicare or Medicaid programs, they are expected to abide by § 482.28 Condition of participation: Food and dietetic services. When was the last time your organization reviewed the standard to ensure that all requirements are being met?
If a facility does not employee a full-time registered dietician, certain criteria must still be met when utilizing outside food management resources. It is possible to meet this condition by employing part-time or consultation services, however, there must be protocols in place in which qualified professionals are available for patient care nutritional needs on a constant basis.

Under CMS Conditions of Participation, a hospital must demonstrate one of the following:

Employ a qualified, full-time, director of food and nutritional services who oversees and is responsible for day-to-day management of all dietary services.
Must demonstrate that a qualified dietician is available for all organizational dietary needs on a full-time, part-time or consultation basis.
Be able to demonstrate evidence of personnel both administrative and technical who are competent to provide food and nutritional support services.

Under CMS Conditions of Participation, organizations must demonstrate that they meet the nutritional and therapeutic dietary needs of patients. The minimum criteria for meeting this condition are as follows:

There must be evidence that dietary requirements are customized to individual patient needs based upon recognized dietary practices.
Individuals ordering diets for patients must be qualified as well as authorized by medical staff. Additionally, such professionals who are authorized to order diets for patients must meet requirements of state law for their respective roles.
Organizations should ensure that a dietary manual has been reviewed and approved by a dietician as well as medical staff. The manual must also be made readily available to nursing, medical, and food service personnel at all times.

Developing policies and procedures for mealtimes, ordering and delivery of meals should also be a top priority. Alternative means of nourishment including various types of parenteral nutrition and nutritional supplements should also be considered when developing policies and procedures for your organization.

There are also additional practices that should be considered with regard to maintaining a sanitary environment in food and nutritional departments. It is well understood that sanitation is critical in any healthcare facility but critical attention to detail should be given in areas responsible for preparing and or providing meals and nourishments. Attention to detail is a must. Having controls in place areas critical. Meticulous hand hygiene practices should be adhered to. Hair nets should be worn by personnel who work in the dietary department. Temperature monitoring is also critical with regard to food storage and water used in sanitation of dietary equipment and re-usable tableware

Food and Nutritional Services should be integrated into your organization Quality Assurance Performance Improvement and Infection Control Programs. Additional considerations should also include food supply for emergency situations, dietary education and counseling for patients and families and utilization of vendors for providing nutritional support services in patient care settings.
Additional areas to consider are how food is being stored. Is there potential for cross contamination between meats and fresh produce? How are expiration dates being monitored? Having a process in place for tracking inventory in the event of a recall is also critical. How is your organization alerted about recalls and managing this process? With food preparation also comes environmental safety concerns. Is there open flame cooking being performed? Are there flammable items being used in the department? Do your team members know how to respond in the event of a kitchen fire?

The following tool from CMS can be used to perform an internal audit of your organization’s Food and Nutrition Department: https://www.cms.gov/files/document/cms-20055kitchenpdf . This can help you to identify areas for improvement. This may be a great time to take to opportunity to focus on how your organization measures up to these requirements.

Please join us by clicking on any of our icons below to leave a comment or for more information and updates.

References:

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.28 https://www.cms.gov/files/document/cms-20055kitchenpdf

Click Here To Subscribe To Our Monthly Newsletter

Using Expired Supplies: Is This the New Normal?

Wed, 26 Apr 2023 18:36:00 GMT

Using Expired Supplies for Patient Care Due to Supply Chain Shortages?

April 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

We are all aware of the pandemic-triggered supply chain shortages and the tremendous impact this has had on the healthcare industry for the last few years. While the majority of healthcare organizations learned to make do with the supplies they had on hand, we may now be facing what has become a new normal by using expired supplies for patient care. Many manufacturers of patient care supplies and pharmaceuticals have issued extended use dates for their products due to shortages.

We found this exact scenario first-hand during an onsite visit to a Cath Lab of an acute care hospital. The staff members were well aware that cardiac stents on hand surpassed their expiration dates. When asked why they had not disposed of the expired equipment, they responded by stating that they were instructed not to by their supervisor. Furthermore, they stated that the manufacturer indicated that it was acceptable to continue to use the expired equipment for patient care due to supply chain shortage of the stents. Ultimately, the team members were able to produce a letter from the manufacturer addressing the extended use date of the stents. We could not help but ask ourselves what now makes this an acceptable practice? If it is acceptable to use products well beyond their expiration dates, then why do products have expiration dates to begin with? Or why does the manufacturer label with a date they know the equipment can function past? Just questions, not conspiracy theories.

In conducting independent research, we learned that there are a little over one hundred drugs, 106 to be exact, on the market wherein the Food and Drug Administration (FDA) has extended "use date" up to one year beyond the original expiration date. There is a database available on the FDA website where you can search through lists of commonly used medication for their extended use dates .
There is a caveat in which the FDA states the following “if replacement product becomes available during the extension period, then the agency expects the lots in these tables will be replaced and properly disposed of as soon as possible” ( FDA, 2023 ). According to the FDA, “A medical product is typically labeled by the manufacturer with an expiration date. This reflects the time period during which the product is expected to remain stable, or retain its identity, strength, quality, and purity, when it is properly stored according to its labeled storage conditions” (FDA, 2023).

So, if it is now acceptable to use products well beyond their original expiration dates, are we lowering the standards for product integrity in patient care? Are we now delivering a message to healthcare workers that it is acceptable to use expired supplies for patient care? With millions of products being used in healthcare settings on a daily basis, how can it be manageable to know which products do in fact have acceptable extended use dates and which products do not? Or now will healthcare workers infer that use of expired supplies is acceptable practice due to supply chain shortages.

While this topic is beyond what we may be able to control, HCE would like to recommend that healthcare organizations should look internally for the impact that supply chain shortages are having on their organization. Furthermore, it is important to reinforce with staff members that using expired supplies for patient care should not be a widely acceptable practice and should only be done if the product has been officially issued an extended use date. We have all been trained to adhere to delivering the best possible care to patients to minimize adverse outcomes.

We urge healthcare leaders to work toward minimizing the use of expired supplies in patient care activities whenever possible. Compromising patient care by using products that may be of inferior quality and integrity should not become the new standard of care. We encourage all healthcare leaders to talk with your Supply Chain Managers, team members and Manufacturer Representatives today to gain a better understanding about what may be occurring in your organization today. While shortages may be the current challenges, we are all facing, it should only be temporary. Monitoring current practices regarding supply shortages will help to ensure that these new, adverse practices do not become the new norm.

HCE is Here to Help
Healthcare Consulting Experts LLC was built based upon our understanding of the challenges that healthcare facilities are facing today. Healthcare professionals strive to deliver the best possible care to all patients. We can help your facility through the difficult times and put you back on track to a less stressful tomorrow.
Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state-of-the-art project or renovating an existing structure. Be sure to visit Our Website to see a full list of the services that we provide.
Contact us today at +1 (800) 813-7117 for a free initial consultation.

Please join us by clicking on any of our icons below to leave a comment or for more informati on and updates.

References:

https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/expiration-dating-extension

https://www.fda.gov/drugs/drug-shortages/search-list-extended-use-dates-assist-drug-shortages

Click Here To Subscribe To Our Monthly Newsletter

Code Alerts: Color vs Plain Language

Thu, 06 Apr 2023 15:59:00 GMT

Confident your Hospital is Prepared to Respond to an Emergency Code?

April 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

You do not necessarily have to work in the healthcare industry to know that if a “code blue” is called, it is to alert healthcare providers that a patient has gone into cardiac arrest. Color codes have been around for decades in healthcare. It is a system used to announce various types of situations that require rapid response, emergency treatment, surveillance and security. Depending on the type of emergency, response to this type of announce may impact a single location or can be a facility-wide catastrophic event.

There has been a deviation from the use of color codes by many healthcare organizations. Plain language codes have not only been adopted by hospitals, but are supported by the US Department of Homeland Security and the American Hospital Association. The U.S. Department of Health & Human Services also supports the plain language movement and has published a white paper on its website that includes this statement:

“There are currently no governmental or regulatory requirements, that the authors are aware of, that mandates the use of plain language in daily operations of individual organizations such as healthcare facilities. However, with new CMS emergency preparedness regulations regarding a healthcare facility’s communication plans complying with all federal and state laws and the facility’s ability to effectively communicate “within the facility, across health care providers, and with State and local public health departments and emergency systems” (Centers for Medicare & Medicaid Services, 2016) it could be argued that a standardization of emergency codes within healthcare facilities is now a mandated step in the emergency communication process.”(Prickett, K.J. and Bellino, J., 2019)

Our HCE professionals have found that although many organizations have adopted the plain language emergency code system, that may not be the majority. It is not uncommon to find that hospitals are still following the color emergency code system. One alleged disadvantage of continuing use color codes include lack of knowledge by personnel of what each of the colors mean.
There has been a great deal of argument that with the increasing number of traveling staff, there is not an opportunity to effectively train interim personnel on the meaning of each of the color codes. When color codes are the emergency code system being used, you will likely find that personnel have a badge buddy reminder to assist them with the definitions of each of the color codes. Ultimately, regardless of the emergency response protocol used, it is only as good as the training that goes along with it.

Our HCE experts found this lack of conformity by all to plain language worth further investigation. In talking with emergency response personnel and law enforcement officials, we learned that they are in support of plain language emergency codes. They emphasized that all people should have an equal opportunity to save themselves. In the tragic event that an active shooter enters a facility, patients and visitors would not necessarily know the meaning of a “code silver”. Although we questioned officials about plain language leading to panic ensuing, we felt that their counterarguments were strong and valid. One emergency response professional responded by saying that healthcare professionals are trained and work hard to save lives, it is not ethical or expected for them to risk life or limb to do so in this situation. Another emergency response trainer also suggested that when calling plain language codes such as bomb threat, active shooter, or a hostage situation that once the plain language code is called, their heightened alertness response by all would actually help to disintegrate the threat faster.

Whether or your organization uses plain language codes or color codes to alert of emergency situations, it is clear that proper training of personnel and performing drills periodically are the best way to prepare your organization for any unplanned emergent event. We understand that healthcare organizations today are facing tremendous pressures just to ensure adequate resources are available for day-to-day operations. But unfortunately, these are the times we are in and being prepared to face these alerts is the duty of the facility and their leadership.
We also know that training and conducting emergency drills have taken a back seat in many facilities while organizational needs are being prioritized. We respectfully request that you make your emergency response plan a high priority before an unplanned event should occur. Our dedicated healthcare heroes out there deserve nothing less.

References:

https://www.medicare.gov https://cdn.ymaws.com/www.iahss.org/resource/resmgr/docs/WhitePaper_Plain_Language_Em.pdf https://www.jointcommission.org /

Click Here To Subscribe To Our Monthly Newsletter

Quality Improvement: Do you have the tools you need?

Thu, 02 Mar 2023 15:28:00 GMT

Fortunately, We Provide 5 Tips to Help

march 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

There is no shortage of quality metrics that require monitoring in healthcare. Developing and maintaining a top-notch quality program is no small task. It is also a very necessary one. It is important to remember that having a good quality plan and program in place equates to improved patient outcomes, patient satisfaction, employee satisfaction, improved efficiency, engaged leadership, and increased revenue. Here are a 5 key topics/tips to help improve your organization’s Quality Program and reap the benefits of what having a good plan and program in place can do:

Plan: Establish or review your organization’s approved plan and program. Does your current program address safe culture, chart review, surveillance, education, risk assessments, communication, benchmarks and reporting? If not, now is a good time to correct this. Keep in mind that this should be done no less than annually. The purpose of an annual review is to determine what worked well and what could be improved.

Oversight: It is not always easy in healthcare today to retrain or recruit experienced healthcare professionals. Practical planning is always a good strategy. Be sure that team members who oversee your quality program are educated and stay current on updates and trends. It is important for them to be knowledgeable of evidence-based practices, quality measures, gathering/review data, conducting a root cause analysis and reporting all findings to the facility’s governing body, local, state and federal agencies as appropriate.

Change Management: It is important to consider that having a successful quality improvement program is NOT the role and responsibility of the Quality Manager or Director alone. Education and planning are essential elements of change management. A facility-wide approach is necessary in order for any quality program to be successful. Empower you team members with the tools that they need to impact change and improve the quality of care provided.

{continues after in-line diagram courtesy of CMS.gov}

Review: While a top-notch quality plan requires a proactive approach, it is critical to conduct time sensitive reviews when an adverse event occurs. One of the easiest diagrams to use when conducting a root cause analysis (RCA) is the fishbone diagram. CMS released a revised document on how to use the fishbone tool diagram. Another tool that may be used is failure mode and effects analysis (FMEA). The RCA should be done as close to the time of the event as possible. This will help with recall of the actual events that occurred. It is important to emphasize that the review is non-punitive, and the purpose is to gather information that will be used to identify areas where process improvements may be necessary.

Reporting: Be sure to report metrics, outcomes, successes and failures in a timely manner. Delays in reporting can lead to repeat occurrences of adverse outcomes, negative impact on employee morale and a decrease in revenue. It is also important to keep in mind that your outcomes may also become public information. Specifically, if you are a CMS provider, have you looked at your facility’s data lately? Check out Medicare.gov’s Quality of Care search or The Agency for Healthcare Research and Quality’s (AHRQ) toolkit .

Worth the review, Harvard Business School published five key steps for implementing change management . Before any healthcare organization can have a successful Quality Program, there may be some underlying changes that must occur first.

HCE is Here to Help

Please join us by clicking on any of our icons below to leave a comment or for more informati on and updates.

References:

https://www.medicare.gov/care-compare/?providerType=Hospital&redirect=true

https://www.ahrq.gov/evidencenow/tools/keydrivers/implement-qi.html

https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdf

https://asq.org/quality-resources/fmea

https://online.hbs.edu/blog/post/change-management-process

Click Here To Subscribe To Our Monthly Newsletter

Ransomware: Is Your Healthcare Organization Prepared For An Attack?

Thu, 02 Feb 2023 16:16:00 GMT

In Most Cases, Unfortunately The Answer Is No.

February 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

The impact of a cyberattack on any organization can be detrimental. The healthcare industry has become a popular target for ransomware attacks.

It is important to understand that these types of attacks are not typically done by random, tech savvy individuals. On the contrary, cyberattacks are executed by large corporations in a number of different countries across the world who orchestrate ransomware attacks on a daily basis.

Cyberattacks in the healthcare industry are becoming more common than every before:

Listed as Number One hazard in Top 10 Health Technology Hazards for 2022 (ECRI 2022 - The Joint Commission Tabletop Exercise 1/31/23)
555 Healthcare data breaches from hacking/IT incidents in 2022 (HIPPA Journal, 1/24/23 - The Joint Commission Tabletop Exercise 1/31/23)
Ransomware attacks on healthcare organizations increased by 94% year over year, according to the 2022 State of Ransomware Report from cybersecurity firm Sophos” (HIPAA Journal, 2022) .
86% Increase against Healthcare Organizations in 2022 vs 2021 (Check Point Research, 1/5/23 - The Joint Commission Tabletop Exercise 1/31/23)

Impact of Cyber-attacks on Healthcare Delivery Organizations: (Ponemon, Sept 2021 - The Joint Commission Tabletop Exercise 1/31/23)

70% Delays in procedures and tests have resulted in poor outcomes
36% Increase in complications from medical procedures
22% Increase in mortality rates

What makes healthcare organization a popular target is the knowledge that healthcare providers strive to keep patient records confidential. Additionally, providers are held accountable when protected health information is breached. In such cases, healthcare organization not only face legal and financial consequences and can suffer from bad press related to such events leading to loss of credibility in a highly competitive healthcare market.

We may never be fully prepared to ward off these types of attacks but there are some measures that can be taken to reduce the risks associated with cyberattacks. Your IT Department is likely already knowledgeable of safeguards needed for protection but it is critical to ensure that software backups are in place and that devices and networks are protected.

Education of staff is another key element to protecting your organization. Development of policies and procedures is a must when it comes to software security and safe practice. Another important consideration is to practice down-time drills. Training your staff to be able to continue care when systems are down will help to prepare for the real experience. It seems like a simple drill but it is important to consider that this can be anxiety producing for team members who have only been trained on to work on electronic devices.

Being held hostage by attackers is likely one of the most stressful events a healthcare organization can experience. The threat of breaching countless medical records containing personal and protected health information can create major anxiety for any healthcare facility or system. When this occurs, demands for astronomical payments for the release of records comes at an unaffordable cost to victims.

Aside from the unimaginable stress associated with these types of events, organizations should be prepared to ensure extended periods wherein they are forced to operate in down-time mode while recovery efforts are in progress.

There are a variety of security risk assessment tools on the market today. Some are offered for a fee and others are available in the form of a free trial. HealthIT.gov offer this security risk assessment tool which can be easily downloaded.

Whatever method you choose, there is no time like to present to begin protecting your organization from a brutal ransomware attack. You can’t afford to get caught unprotected. Start planning today.

References:

https://www.healthit.gov/topic/privacy-security-and-hipaa/security-risk-assessment-tool

https://www.hipaajournal.com/healthcare-ransomware-attacks-increased-by-94-in-2021/

The Joint Commission - Cybersecurity Tabletop Exercises, 1/31/23

Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state of the art project or renovating an existing structure. Be sure to visit Our Website to see a full list of the services that we provide.
Contact us today at +1 (800) 813-7117 for a free initial consultation.

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Joint Commission 2023 Patient Safety Goals

Tue, 03 Jan 2023 20:05:00 GMT

Highlighting TJC Priorities for Healthcare Facilities

January 2023

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Happy New Year to all healthcare professionals from HCE!
We are excited for 2023 and looking forward to helping our fellow colleagues work toward a more focused approach to bringing healthcare back to some normalcy after what we all know has been a rocky road over the last few years.

With a fresh new year ahead of us we thought it would be a great time to take a look at The Joint Commission’s (TJC) National Patient Safety Goals (NSG) for 2023. Now is the time to remove the 2022 version from your facilities and familiarize your team members what TJC has identified as high priority safety concerns in health care today.

As you review the new lists of goals you will likely find that the goals have not changed. Essentially, the issues impacting patient safety continue to occur and therefore need to be addressed by healthcare facilities to prevent perpetual reoccurrence of preventable events. TJC publishes a list of goals annually for each of the following health care settings

Ambulatory Healthcare
Assisted Living
Behavioral Health and Human Services
Critical Access Hospitals
Home Care
Hospital
Laboratory Services
Nursing Care Center
Office-Based Surgery

National Patient Safety Goal 01.01.01 pertains to proper identification of a patient. Although it seems simplistic in nature this continues to be a major area for concern. Two patient identifiers should always be used prior to administering any medication or treatment to a patient. Using a patient’s location or room number should never be considered one of the identifiers. Verifying a patient’s name and date of birth are a good practice for avoiding patient identification errors. Be sure your organization’s policy address the method to be used to identify patients.

National Patient Safety Goal 03.04.01 addresses medication safety in healthcare setting where procedures are performed. Any medication that may be used in must be labeled correctly. Syringes, cups, basins or other apparatuses that hold medication must never enter a surgical or procedural field without being properly labeled. Be sure your organization addresses labeling, and team members are well trained on labeling. It is always good to perform random audits to ensure that these practices are being followed consistently.

National Patient Safety Goal 03.06.01 is another important medication safety goal. It is critical to obtain, reconcile and report a patients medication regimen with accuracy. Documentation is critical. When new medications are prescribed for patients, the patient should also receive written instruction about the medication, including how to take the medication, frequency and side effects associated with the new medication to name a few. Patients should also be instructed to keep up to date lists of all medications they are on.

National Patient Safety Goal 07.01.01 pertains to infection prevention. The focus for this goal is hand hygiene. Organizations should develop goals to improve adherence to good hand hygiene practices among health care workers. How is your organization monitoring hand hygiene compliance? Be sure to establish training programs to enforce the danger associated with non-compliance to good hand hygiene practice. Another consideration is to determine if the number of hand washing sinks and hand sanitizer dispensers are adequate for your facility.

National Patient Safety Goal 15.01.01 pertains to reducing risk for suicide. “Suicide is a major public health concern. Suicide is among the leading causes of death in the United States”, (NIIMH, 2022). Prevention efforts should not be overlooked. This goal applies to hospitals and behavioral health settings. Be sure that environmental risk assessment is completed to identify risk factors in patient care settings. Development or revision of existing policies and procedures concerning suicide are critical. Be sure that team members are well educated on identifying risk factors associated with suicide. It is also imperative to utilize a comprehensive screening tool to identify patients to exhibit risk factors associated with suicidal ideation.

For a complete list, visit TJC National Patient Safety Goals for 2023 where you can find more information on all NPSG’s for 2023. TJC provides simplified PDF versions based on facility type. You can also download chapter versions which provide a greater insight into each specific goal including rationale and elements of performance to help your organization with reduce risk that results in patient harm.

From all of us here at HCE, we would again like to wish you and yours a Happy, Safe, and Prosperous New Year!

References:

https://www.nimh.nih.gov/health/statistics/suicide

https://www.jointcommission.org/standards/national-patient-safety-goals/hospital-national-patient-safety-goals/

HCE is Here to Help
Healthcare Consulting Experts LLC was built based upon our understanding of the challenges that all healthcare facilities are facing today. Healthcare professionals strive to deliver the best possible care to all patients. We can help your facility through the difficult times and put you back on track to a less stressful tomorrow.
Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state of the art project or renovating an existing structure. Be sure to visit Our Website to see a full list of the services that we provide. Contact us today at +1 (800) 813-7117 for a free initial consultation.

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Stumped on New Year's Resolution For Your Organization...

Sat, 03 Dec 2022 20:26:00 GMT

Try Evaluating Your Current QAPI Program

December 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

As we approach the end of the year, our experts here at HCE thought it would be a good time to look at performance improvement initiatives within healthcare organizations. With the day-to-day operational struggles that healthcare organizations are facing today, we have identified through surveillance that it is not uncommon for performance improvement projects to have taken a back seat to more pressing issues.

If your healthcare facility participates in Centers for Medicare and Medicaid (CMS) programs, then your facility must be able to demonstrate that it has a Quality Assessment and Performance Improvement (QAPI) Program in place. There are several criteria that must be met for an organization to demonstrate that it meets § 482.21 Condition of participation: Quality assessment and performance improvement program requirements.

Now is a great time to revisit your organization’s program to ensure that focus has been regained on all matters related to patient safety.

Here are a few items to consider to refresh or jump start an effective and compliant QAPI Program:

Governing Boards should ensure that the scope of its program is facility-wide. They should also be prepared to allocate resources as needed for these programs. The Governing Board should approve the number of projects that will be implemented as well as determine the frequency of data collection. Clear expectations of program requirements should also be communicated to the organization’s respective team members.

The scope of an effective program should include criteria focused on reduction of medical errors and improving outcomes. Performance improvement initiatives should include data that is measurable. This enables the organization to gain a clear understanding of whether the program is or is not effective. Evaluation is based on measurable outcomes being analyzed and improvement strategies identified to help improve the organization's performance.

It is important to consider when evaluating organizational performance to include contract services. Contracted service providers should be integrated into Quality Assessment and Performance Improvement Programs. Organizations that do not incorporate contract services into their QAPI Programs would not meet the requirements of the QAPI standard according to CMS Conditions of Participation.

CMS offers the following tools to help organizations create a solid foundation for developing a success QAPI Program:

QAPI Process Tool

QAPI at a glance

While understanding what it takes to develop a success QAPI Program for your facility is critical, it is not enough to ensure the success of the program itself. As facility-wide performance improvement projects are identified, approved, and analyzed, they are sure to be ineffective in the absence of a culture that holds safety in the highest regard.

Establishing a culture of high reliability is another key component towards achieving organizational performance improvement goals and reducing medical errors. Team members who feel safe to speak out about concerns will help to shed light on safety issues that may otherwise not be brought forward. Educating, empowering, and supporting healthcare personnel is a must. Without establishing a culture of trust, you cannot expect to be successful in improving performance and reducing risk within an organization.

Aside from the immediate metrics being analyzed, a successful QAPI Program will reap additional benefits for organizations who are committed to these facility-wide safety-driven programs. One consideration for improving patient outcomes is that it instills confidence in patients, personnel, communities and partnering organizations. Another consideration is reduction and elimination of incidences of patient harm. There are financial incentives for improved performance outcomes that are vital to maintaining an organization's financial health.

Finally, when an organization supports safe culture, there is a greater likelihood that they will not only attract talented healthcare professionals to join their team but will be able retain them on staff as well eliminating high turnover rates.

While there are many more advantages that can be named, we have highlighted those that we feel are a win-win for all. Take a few minutes to dust off your organizations last QAPI and evaluate if it is well understood and has proven to be effective.

Now is a great time as we approach 2023 to hit the refresh button and re-vitalize your organization’s existing, and potentially, outdated program.

From all of us here at HCE, we would like to say Happy Holidays and stay safe.

References:

https://www.govinfo.gov/content/pkg/CFR-2018-title42-vol5/xml/CFR-2018-title42-vol5-sec482-21.xml

https://www.law.cornell.edu/cfr/text/42/482.21

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

A Time And A Place For Everything ...

Tue, 01 Nov 2022 17:10:00 GMT

What Is Your Organization’s Social Media Policy?

november 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

The popularity of social media platforms is something that we are all familiar with. It is difficult to find any business today that does not utilize some type of social media platform to promote goods and services. Additionally, use of social media has become common place for people of all age groups. New platforms continue to be created in hopes of becoming the latest and greatest trend. While at times it may be mind boggling to keep up with what is happening in the social media of the world today, use of social media in the workplace has become an enormous challenge for businesses, in particular the healthcare industry.

At HCE, we have recently polled healthcare executives to elicit feedback on this topic. Although most healthcare administrators attested to having a social media policy in place, some were not sure if a policy existed for their organization. In our experience, lack of knowledge of company policy is not uncommon. Regardless of which social media platform you might access, a simple search can lead you to a healthcare worker on the job dancing and singing on TikTok or making Facebook videos while at work. During the pandemic we discovered countless images of healthcare workers on duty wearing some form of personal protective equipment. The common place of social media in society has raised serious concerns in healthcare today.

While a concern for organizations is employees “stealing time” by utilizing personal social media platforms on “company time”, a greater concern should be the risk to the patient and the organization. Patient Privacy cannot be overstated. A team member could publish videos, images or content that contains patient information without ever intending to breach patient privacy. Another concern is personal cell phone use in patient care settings.

When conducting a risk-assessment we recommend that you determine if policies and procedures in place to restrict or limit the use of personal electronic devices in the workplace. If you discover that this type of policy does not exist, we strongly encourage you to create one to help protect your organization from litigation for inappropriate use of personal devices. In our experience, we have found an astonishing number of breaches by employees using their personal electronic devices in patient care areas. Employees must be well educated on company policy and procedure to prevent these types of occurrences.

Banner Photo found through image search ( owner posted on April 27, 2020) In-line Photo found through image search ( twitter posting on April 26, 2020)

An article published by renalandneurologynews.com in 2021 referenced the following instance wherein a nurse inappropriately used social media while at work. “In 2018, a pediatric nurse at Texas Children’s Hospital lost her job after she posted details about a toddler’s measles diagnosis on an Anti-Vaxxer Facebook Page”. The article also stated “In some cases, clinicians have faced criminal charges. But this happens in the worst cases, such as a nurse or aide posting videos to social media, showing elderly people as they are taking showers or even having sex”. It is never safe to assume that team members understand the consequences of what they may believe is their right to express themselves on social media. According to hipaajournal.com “staff at the Autumn Care Center in Newark, Ohio, were found to have taken a video of cognitively impaired patients who had been trained to sing degrading song lyrics. The video was then distributed via Snapchat. The act was deemed to have resulted in “intentional humiliation” and “psychological harm” being caused. In total, six residents were reviewed for abuse at the facility.”

Social media has many positive attributes when used appropriately in the healthcare industry. “Social media tools such as Facebook, Twitter, and YouTube have been used to train medical personnel, provide information to patients, and allow rapid communication in times of crisis” (AAMC 2022). Many organizations have their own Facebook, Instagram and Twitter accounts for example. LinkedIn is another platform used by countless healthcare organizations. It is not uncommon to find organizations routinely post announcements on social media such as hiring for positions, team celebrations, team member promotions, or services they provide. It is a great way to network with other professional. You can also easily find education sessions available to discuss hot topics in healthcare today or open forums wherein healthcare workers discuss what is going on in the industry today.

Regardless of what you may use social media for, it is critical for businesses regardless of the type of industry to address the topic of social media. Developing a policy and procedure for your organization to control how social media is used is essential to mitigating risk and liability for any organization. Having a policy is not enough to mitigate risk, however. It is crucial to ensure that team members are well educated on policies and procedures concerning social media. It may also be beneficial to include a competency quiz to validate that policies and procedures are well understood.

The American Hospital Association (AMA) has created a guide to help healthcare leaders develop social media policies for their respective organization. The U.S. Department of Health and Human Services has developed a checklist to help with development of social media policies and procedures.

The topic of social media is nothing new. There are a variety of tools to assist organizations with policy and procedure development. We encourage those in healthcare leadership roles to evaluate existing policies and update as necessary to address areas of concern. If it is discovered that policies and procedures do not exist, it is critical to make policy development and employee education a top priority.

As with the two photos posted within this newsletter, there are numerous examples of social media breaches available if you choose to search the web for examples. Don’t allow your organization to vulnerable. There are not only legal and financial implications to consider, but the reputation and community stewardship of any organization could be tarnished for many years to come.

From all of us here at HCE, we would like to say post away. Just remember... there is a time and a place.

References:

https://www.hipaajournal.com/nursing-home-snapchat-photo-sharing-scandal-uncovered-8229/
Journal of the Association of American Medical College 2022, https://journals.lww.com/academicmedicine/fulltext/2013/09000/social_media_use_by_health_care_professionals_and.46.aspx
American Hospital Association, 2022. https://www.aha.org/standardsguidelines/2018-04-02-hospital-leadership-guide-digital-social-media-engagement https://www.renalandurologynews.com/home/departments/hipaa-compliance/health-providers-must-use-social-media-cautiously-to-avoid-violating-hipaa-rules/ (July 2021).
The U.S. Department of Health and Human Services, 2019, https://www.hhs.gov/web/social-media/policies/index.html

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

How Safe Are Your Decorations?

Sat, 08 Oct 2022 16:10:00 GMT

Tips and Suggestions for Decorating Your Facility Safely and Within Guidelines

october 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

As many across the globe begin to look forward to holiday celebrations, it is important to consider the risks associated with decorating. Although decorating in the healthcare setting is not forbidden, it is important to evaluate decorations for potential safety risks prior to displaying them.

When it comes to celebrating holidays, spirits are high. Many employees like to participate in decorating events and there is a lot to be said about how a change of scenery can significantly boost the morale of patients as well as healthcare providers.

While we love and support the spirit of the holiday season, in our experience there have been many occasions in which we have had to address decorations due to safety risks associated with the type or location of celebratory decorations.

Here are a few tips to keep your facility safe and compliant for any holiday you and your team members choose to celebrate:

Decorations should not interfere with the ability to open and close doors.
Combustible decorations should be kept to a minimum
Keep decorative coverings over windows and doors to a minimum
Do not hang decorations from sprinkler heads.
Decorations should be flame resistant. Manufacturer recommendations (MFRs) should be followed if decorations are covered in an approved fire-resistant coating. If re-application of such a material is recommended, the facility must provide documentation that re-application has been done according to the MFR (NFPA 701).
Decorations shall not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system.
Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved automatic sprinkler system.
Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms, having a capacity not exceeding four persons, in a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system.
The decorations exhibit a heat release rate not exceeding 100 kW when treated in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20-kW ignition source.
Avoid the use of unapproved electrical power strips.

Education

Additional considerations for decorating should include developing a policy that addresses decoration for your facility. Be sure to incorporate guidance or restrictions based on Life Safety, Environment of Care and NFPA standards. It is always a good idea to include your facilities’ plant ops and bio-med technicians when planning holiday or celebratory decorating. They can provide valuable input on restrictions and identify issues that may lead to potential safety risks in your facility.

From all of us here at HCE, we would like to wish you a happy and healthy holiday season.

References:

NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. NFPA 289 Standard Method of Fire Test for Individual Fuel Packages

https://www.nfpa.org/codes-and-standards

TJC LS 02.01.10- Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. https://www.jointcommission.org/search/#q=02.01.10&t=_Tab_All&sort=relevancy&f:_SitesOrganizations=[The%20Joint%20Commission

HCE is Here to Help
Healthcare Consulting Experts LLC was built based upon our understanding of the challenges that all healthcare facilities are facing today. Healthcare professionals strive to deliver the best possible care to all patients. We can help your facility through the difficult times and put you back on track to a less stressful tomorrow.

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Alarm Fatigue ... Don't Get Caught Being Silent

Wed, 31 Aug 2022 17:20:00 GMT

Considerations For Facilities to Successfully Battle Alarm Fatigue

august 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Alarm fatigue is not a new phenomenon. This occurs in a variety of setting but is more common in critical care settings when clinicians become desensitized by countless alarms, many of which are false or clinically irrelevant. Technological advancements continue to evolve in the health care industry. With numerous monitoring devices to assist with patient care, it is important to consider the risk associated with utilization of monitoring devices.

The development of alarm fatigue is not surprising. In this c ited study ⁽¹⁾ , there were nearly 190 audible alarms each day for each patient. Here are a few examples of contributing factors:

Multiple monitoring devices being used simultaneously
Incorrect alarm parameters
Poor connection of monitoring equipment
Responding to false alarms
Insufficient staff education on safe monitoring practices

Focus on alarm fatigue may be glazed over in clinical settings today while recent emergent matters have received greater attention. The Joint Commission (TJC) made alarm safety a National Patient Safety goals in 2014 and it continues to be considered a high priority. National Patient Safety Goal 6 - Reduce Patient Harm Associated With Clinical Alarm Systems - is still in effect today. The objective of NPSG.06.01.01 is to improve the safety of clinical alarm systems ⁽²⁾ . Patient harm and even death continue to occur today in patient care settings due to alarm fatigue.

Considerations for Developing Safe Practices
Leadership accountability is becoming even a greater focus in the healthcare industry today. Development of policies and procedures concerning alarm safety is critical. It is important for those in leadership roles to be involved in all matters related to alarm system safety. Another consideration is to obtain input from providers on safe parameters for patients who require monitoring. For example, a patient who is tachycardic or hypertensive may need to have alarm parameters adjusted, as they may never achieve normal range parameters which could essentially lead to constant alarming.

Areas that should be addressed when creating or revising policies and procedures:Range settings for equipment

Personnel authorized to adjust equipment parameters
Preventative maintenance check frequency
Personnel authorized to silence alarms
Personnel authorized to turn off equipment parameters
Guidance for safely setting up and using patient care equipment

It is Never Acceptable to Silence Alarms Without Evaluating the Cause of an Alarm.

Education
In order to prevent adverse events from occurring, staff education must also be included in alarm safety programs in all facilities. Developing policies and procedures system may not be enough to engage end-users in alarm system safety best practices. Eliciting feedback from staff on alarm frequency and false alarms is important. If concerns go unheard or are not addressed, staff may disengage due to lack of concern from leadership.

Staff should not only be educated on equipment but also deemed competent on safe use of equipment. As part of taking over a patient assignment at change of shift, a routine check of all monitoring equipment should be done by the nurse taking over care. Bedside reporting can help to provide oncoming nurses with a better understanding of equipment in use. Ideally, patients should be included in the plan of care. This provides a better understanding of why equipment is being used and what the patient is being monitored for. If there is an audible alarm and the patient is not in distress, if there is not a response to the alarm, the patient can be instructed to use a call light to alert nursing personnel.

Patients should always be assessed for worsening conditions of health so that life saving interventions can be initiated immediately. If a patient is not in distress upon assessment, then an evaluation of equipment connections and equipment should be completed. If it is discovered that any form of patient equipment is not working correctly, then equipment should be replaced with equipment that is working properly. Faulty equipment should be tagged-out of service and Bio-Med should be notified immediately.

Not addressing alarm fatigue will be sure to lead to more alarm fatigue nursing burnout and an increased risk of patient harm and death. Technology will continue to have a major role in patient care. Medical equipment and monitoring devices will continue to evolve and emerge. It is critical that healthcare leaders take the time to develop an alarm system safety program. If a program is already in place, then it is important to conduct a risk assessment of your organization to determine how effective the system truly is.
We can help! Let our experts help you to avert risk of burnout and harm. Contact HCE for a free consultation.

References:

Drew BJ, Harris P, Zegre-Hemsey JK, et al. Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. PLoS One. 2014;9:e110274.
www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/simple_2022-cah-npsg-goals-101921.pdf

Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state of the art project or renovating an existing structure. Be sure to visit Our Website to see a full list of the services that we provide. Contact us today at +1 (800) 813-7117 for a free initial consultation.

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Point-of-Care Testing ... Challenges For Your Facility

Fri, 05 Aug 2022 19:04:00 GMT

Considerations For Performing POCT Correctly

august 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Many organizations have integrated Point-of-Care Testing (POCT) into their daily operations. You will find POCT technology used in medical offices as well as acute care settings. Testing devices are typically small machines that can be transported by hand or easily moved around patient care locations on small carts. There are a variety of laboratory tests that can be performed by healthcare personnel at the bedside.

Advantages
One of the biggest advantages to point of care testing is that it offers immediate results that can alert care providers to critical clinical events. One of the most commonly used POCT devices is the glucometer. These are also very commonly used by diabetic patients at-home to offer immediate results. Another example of POCT is the iSTAT. This handheld machine provides instant results for blood gas, cardiac enzyme, and coagulation levels. This type of technology can assist health care providers with early results enabling them to provide rapid treatment for emergent medical conditions. Another point- of-care test commonly used in healthcare settings is electrocardiogram also known as ECG or EKG. Once conduction leads are placed on a patient and cables are connected, a comprehensive analysis of cardiac rate and rhythm can be obtained in seconds. This type of analysis is a key component of a cardiac work up in every emergency room today.

Another advantage for POCT is the convenience for both the patient and healthcare personnel. POCT can provide diagnostic testing at a reduced cost. Testing performed may be less invasive for patients. Immediate results can provide information that may assist treating providers with early identification of a change in a patient’s condition.

Disadvantages
It is important to understand to risks that can be associated with POCT. One of the areas that our consultants find deficiencies is with staff competency. Healthcare organizations must be able to demonstrate that healthcare personnel have been properly trained to perform POCT. Competency should include key elements such are quality control testing, proper patient identification, unique user identification, aseptic technique and use of appropriate personnel protective equipment depending on the type of testing being performed. Competency should also include a return demonstration of all steps to the qualified trainer. Employers must be able to demonstrate proof of competency for trained personnel who perform POCT. Competency testing should be done for all new team members performing testing and no less than annually.

All equipment used should be properly maintained according to the manufacturer’s recommendations. A log should be kept providing evidence that required maintenance in being performed. In larger healthcare facilities, the Bio-Medical technician oversees servicing and maintenance of this type of equipment and maintains records and log of preventative, routine maintenance, and service for all medical equipment in use and out of service.

Many of the POCT machines that are used at the bedside also require additional quality assurance (QA) measures. For example, a glucometer may require a QA test to be done on the machine every twenty-four hours. This often includes performing a test using reagents that will produce results that mimic a high or low blood sugar result. If not performed, the end user will likely discover that the machine is locked and they are not able to use the machine until a proper QA test is performed. ECG machines typically have a limited storage capacity and patient information should be properly secured or backed up in order not to lose critical information.
Other considerations include how results are being recorded into the patient’s medical records if results are obtained at the bedside. Ideally this type of equipment will store results which are then uploaded safely and securely into the electronic medical records system before this information is accidently deleted.

Like with all technology, equipment malfunction can be a very serious reality. The Manufacturer and User Facility Device Experience (MAUDE) database is maintained by the Food and Drug Administration (FDA). It is a database wherein providers can report instances of equipment malfunction associated with adverse outcomes or death. This website is intended to encourage reporting of adverse events related to medical equipment or devices. There are cases in which POCT equipment did not provide accurate test results when validated by traditional venous or arterial blood testing methods. In many cases patients were incorrectly diagnosed and treated as a result. The National Institutes of Health referenced this article from the National Library of Medicine detailing the evolution of POCT.

In summary, POCT is certainly not going away but will continue to be essential in the fast-paced, demanding healthcare climate of today. We at HCE would like to remind healthcare providers to consider all advantages and disadvantages associated with POCT. Be sure you enlist the support of qualified personnel to oversee maintenance of medical equipment in your organization. We cannot stress enough how important it is to have a thorough training program for healthcare personnel who will perform POCT and to be able to demonstrate these individuals are competent to perform these duties. It is critical to have well written policies and procedures outlining critical results reporting and validation of test results. Finally, documentation and reporting of adverse events is important to not only notify manufacturers of equipment malfunction but also prevent future instances by reporting such matters. For guidance regarding reporting these events, click here for more information.

Contact HCE today to see how our experts can assist you with ensuring that your organization is providing safe and compliant POCT. Call us today at 1(800)813-7117 for a free consultation. We are here for you!

References

https://www.fda.gov/medical-devices/postmarket-requirements-devices/mandatory-reporting-requirements-manufacturers-importers-and-device-user-facilities#3

https://www.fda.gov/regulatory-information/search-fda-guidance-documents/questions-and-answers-about-emdr-electronic-medical-device-reporting-guidance-industry-user

HCE is Here to Help
Healthcare Consulting Experts LLC was built based upon our understanding of the challenges that all healthcare facilities are facing today. Healthcare professionals strive to deliver the best possible care to all patients. We can help your facility through the difficult times and put you back on track to a less stressful tomorrow.

Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state of the art project or renovating an existing structure. Be sure to visit our website at www.healthcareconsultingexperts.com to see a full list of the services that we provide. Contact us today at 1(800) 813-7117 for a free initial consultation.

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Is Your Team Ready To Respond To An Imminent Disaster?

Sat, 02 Jul 2022 17:32:00 GMT

Have You Reviewed/Practiced Your Emergency Preparedness Plan Lately?

july 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

As a healthcare administrator you should ask yourself how confident you are that every team member knows what to do when you are faced with a true emergency of any kind. Would they know how to shelter in place? Are you confident they know evacuation routes and plans to move patients to safe locations? Would they know the difference between a tornado warning and a tornado watch if announced? Would they respond appropriately according to your organization’s written plan? Do you have teams or personnel on staff that are fully trained and prepared to respond to emergencies? With staffing shortages, high turnover rates and lack of qualified personnel throughout the industry today, we strongly encourage organizations to make emergency preparedness a top priority before a disaster actually occurs.

In the event that your organization is impacted by disaster conditions does your organization have critical supplies such as food, water, medication, medical gas and emergency power supply back up in place? Have you established an emergency call list to enlist the help of relief staffing? Are all contact phone numbers current? Do you have adequate sleeping arrangements in place for staff who may not be able to leave the facility? Are you ready to stand up a fully operational incident commend center in the wake of a true disaster? These are just a few examples of questions that should be considered when evaluating how well your organization is prepared for a true emergency.

Although not all states are impacted by severe weather during hurricane season, the beginning of hurricane season 2022 is a great time to re-evaluate your facility’s emergency preparedness plan. In addition to severe weather conditions, there are a number of other ways that your organization could be faced with imminent harm. A few examples include disease outbreak, chemical spills, radiation emergencies, natural disasters, or bioterrorist attacks.

The following are a few examples of standards outlined by Centers for Medicare and Medicaid Services (CMS) that must be met in order to comply with CMS conditions of participation:

Risk assessment
Establish a comprehensive communication plan
Develop emergency preparedness policies / procedures
Ensure training-testing programs are in place
All of these must comply with both federal and state law.

Another consideration not required but strongly encouraged that is to formulate coalition plans within your community. Working with local emergency response personnel is a great way to establish supportive relationship with trained professionals. When disasters strike it affects the community at-large; therefore, working together on tabletop strategic planning exercises at least annually is also strongly encouraged. Working with advisory committees in you region is an excellent way to assist with emergency preparedness planning. Our team has found that they have an extensive number of resources available for assisting with plan development and will even conduct onsite staff training upon request.

It is not enough to just have a written plan, however. If your facility’s emergency preparedness plan only exists on paper and is not rehearsed or well-known to staff, the outcome of the disaster you face may be a horrific tragedy. There are a great number of resources readily available to assist healthcare providers with Emergency Preparedness Planning and training. CMS offers interpretive guidance for Emergency Planning Conditions of Participation for Healthcare Providers . We also encourage you to look at Emergency Response Resources for your individual state. The Department of Homeland Security also provides a Comprehensive Toolkit to assist with emergency response planning and training. The Occupational Safety and Health Administration (OHSA) provides an Emergency Action Plan Checklist that provides step by step planning guidance on how to develop and implement and emergency action plan for your organization. In addition, they also provide a variety of resources to help organizations determine if they are compliant with OSHA Emergency Standards .

Let our Healthcare Consulting Experts (HCE) assist your organization with review, revision, or development of a safe, compliant, and customized emergency preparedness plan today. We understand the work that goes into developing a plan that will truly protect your organizations team members, patients, and community when disaster strikes. Leave it to our experts to assist! Contact us today.

References

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_z_emergprep.pdf https://www.usa.gov/state-emergency-management

https://preptoolkit.fema.gov/documents/1269813/1269861/HSEEP_Revision_Apr13_Final.pdf/65bc7843-1d10-47b7-bc0d-45118a4d21da

https://www.osha.gov/etools/evacuation-plans-procedures/eap/develop-implement/checklists
https://www.osha.gov/etools/evacuation-plans-procedures/emergency-standards

Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state of the art project or renovating an existing structure. Be sure to visit our website at www.healthcareconsultingexperts.com to see a full list of the services that we provide. Contact us today at 1(800) 813-7117 for a free initial consultation.

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Confident Your Facility is Protected from a Legionnaires’ Outbreak?

Tue, 31 May 2022 17:54:00 GMT

Often Underdiagnosed, The Potential For Risk Is Much Greater.

May 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

If you are an Infection Preventionist (IP) who has experienced a Legionnaires’ outbreak in your facility, then you can likely recall how stressful this type of event can be. Regretfully, without having a good understanding of risk factors that can contribute to these situations, it may only be a matter of time before you are managing an internal investigation in your own facility. Having knowledgeable IP’s and plant operations technicians on your team will help to mitigate risk in your organization.

The most important thing to know about Legionnaires’ bacteria is that although it is present in soil, it is also a hearty water-borne bacteria that can rapidly contaminate reservoirs and environments that contain moisture. It is also important to understand that a diagnosis of Legionnaires’ pneumonia carries a 10% mortality rate for those infected. In 2018, there were roughly 10,000 cases of Legionnaires’ disease reported in the United States alone, which was believed to be a low estimate due to underdiagnoses (CDC, 2021).
Equipment that can contribute to this type of outbreak includes cooling towers, hot water heaters, fountains, and birthing tubs. When contaminated water is vaporized and inhaled, individuals in affected areas are predisposed to infection.

Common symptoms of infection include shortness of breath, coughing, headache, muscle aches and fever. The most common types of tests used to diagnose patients with Legionnaires’ Disease include chest x-ray and urine or sputum culture and sensitivities.
The CDC has published a great resource to help with recognition of risk factors, signs and symptoms and treatment for Legionnaires’ Disease ( https://www.cdc.gov/legionella/downloads/fs-Legionnaires’s.pdf ).

We encourage facilities to conduct a risk assessment to determine if you are at risk for developing an outbreak. Healthcare organizations who operate under Centers for Medicare and Medicaid conditions of participation are required to complete an annual risk assessment. A helpful tool that may be used to conducted a risk assessment comes from the CDC and is referred to as Legionnaires’ Environmental Assessment Form (LEAF) - https://www.cdc.gov/legionella/downloads/legionella-environmental-assessment-p.pdf .

Because our team members at Healthcare Consulting Experts (HCE) have been directly involved with the traumatic impact that a Legionnaires’’ outbreak can cause, we encourage you to prepare your team members with information that can help mitigate the risk of an outbreak. Not only can reducing risk save lives but the financial burden associated with such an outbreak can be crippling to any organization. We are here to help! Whether you are in need of staff education or onsite surveillance, our experts help your organization avoid this type of catastrophic event. Contact us today at www.healthcareconsultingexperts.com or (800) 813.7117 for your free consultation.

References

https://www.cdc.gov/legionella/fastfacts.html

https://www.cdc.gov/legionella/downloads/fs-Legionnaires’s.pdf

Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state of the art project or renovating an existing structure. Be sure to visit our website at www.healthcareconsultingexperts.com to see a full list of the services that we provide. Contact us today at 1(800) 813-7117 for a free initial consultation.

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

How Safe Is Your Medical Equipment?

Fri, 22 Apr 2022 20:57:00 GMT

How Safe Is Your Medical Equipment? Here Are A Few Tips To Consider To Prevent Injury

april 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE CEO

and Founder

If your organization is fortunate enough to have an organized Biomedical Equipment Technician on staff than chances are your organization is compliant in managing your healthcare equipment. All healthcare facilities rely on a wide variety of equipment that can be used to assist with monitoring, providing care to patients and communicating vital information. Not all equipment used in a healthcare setting remains stationary.

Keeping a current inventory log is not only a requirement by the Centers for Medicare and Medicaid Services (CMS) but will also help with tracking. It is not uncommon for equipment to go missing. Having a high-tech asset tag system in place can help minimize loss.
During the course of a CMS survey, you can anticipate a surveyor asking for your inventory list. The complete list should include a location of the equipment, description, and identification number. This list should also include the manufacturer, model and serial number of all pertinent equipment. It must indicate an acceptance date and any information that is pertinent to safe use of the equipment.

The World Health Organization published Introduction to Medical Equipment Inventory Management. Your can download the manual for free here: https://www.who.int/publications/i/item/9789241501392 .

The manual provides an overview of the key elements that should be included in all healthcare facilities to ensure a successful and safe medical equipment program is in place.

When dealing with any equipment use in healthcare, best practice is to always abide by the manufacturers recommendation for use, cleaning and preventative maintenance. It is critical for organizations to educate team members about manufacturer recommendations (MFR’s). It is not uncommon for new equipment to be damaged by using the wrong disinfectant to clean or to void a warranty due to not performing requirement preventative maintenance on equipment.

Subsequently if a patient is injured by equipment that has not been properly maintained, a facility may face significant legal and financial consequences. If a patient does sustain an injury involving medical equipment, the healthcare facility is required to report any injury or death that occurred as a result under the Safe Medical Device Act of 1990.

Another key element to having a safe and effective medical equipment program is implementing a lockout/tagout system. Education is key to ensuring that equipment that is not working or not working properly be removed from general use until it has been properly repaired or replaced by a Biomedical Equipment Technician or an engineer. Having a method in place to clearly identify faulty equipment is critical in a healthcare environment and should not be overlooked. Make lockout tags readily available to team members and verify that they understand how to report faulty or broken equipment immediately when the situation occurs.

Whether your organization is just getting started or in need of guidance to help ensure your facility has a safe and effective medical equipment program, we can help. Contact us today at www.healthcareconsultingexperts.com for a free initial consultation.

Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state of the art project or renovating an existing structure. Be sure to visit our website at www.healthcareconsultingexperts.com to see a full list of the services that we provide. Contact us today at 1(800) 813-7117 for a free initial consultation.

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Healthcare Construction: A Few Things to Consider

Tue, 29 Mar 2022 01:16:00 GMT

Has Healthcare Expansion Added to the Stress Already Existing in the Industry?

march 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

As we continue to evolve to meet the increasing demand for healthcare services, we find ourselves experiencing a new growth spurt more commonly known as healthcare construction and expansion. According to Becker’s Hospital Review there are seven new hospital construction projects in works in the United Sates planned for 2022 with each project costing $600 million. (M. Plescia, 2022).

There is currently a significant growth trend in healthcare facilities both large and small. For many years we have been made aware that healthcare providers would be hard pressed to provide vital services to a variety of rapidly growing patient populations. Although telehealth service lines helped providers to manage an increasing number of sick patients during the pandemic, telehealth services cannot provide optimal care to acutely ill patients.

Today there are a growing number of healthcare facilities of all varieties being newly constructed or renovated. The industry continues to struggle with service line shortages predominantly in the area of behavioral health. Regardless of the type of the facility being constructed or renovated, here are a few considerations that investors and healthcare administrators should consider.

Balancing Staffing Shortages and Healthcare Facility Expansion

Hearing about healthcare staffing shortages is stressful to any healthcare professional working in the industry today. We are all well aware of the challenges and anguish that the pandemic has placed upon all healthcare professionals. Mega hospital systems continue to expand and grow at rapid rates. New healthcare facilities are also being constructed on a regular basis.

While there is a definite need to provide more access to healthcare services, can we ensure that we can staff these newly resurrected facilities? In many cases, the sparkling new healthcare setting will be quite an attractive option to those who have been stretched thin in their old familiar healthcare facilities throughout the pandemic. Salaries are more competitive than ever before, which in turn, leaves healthcare CFO’s wondering how they can adequately budget for safe staffing levels.

Will this expansion drive of future, state of the art healthcare facilities place an even bigger wedge between experienced healthcare professionals and demanding fast-paced high-stress positions that are even today nearly impossible to fill? These may be just a few things to consider when contemplating what the future of healthcare will look like.

Infection Control
Not every professional in the healthcare industry equates construction with infection prevention risks. If you are in facility who has an experienced Infection Preventionist (IP) on your team, you are in luck! IP’s know this routine well.

Here at HCE we understand the importance of having someone with this experience to assist with risk mitigation. Prior to beginning a new project your IP would meet with administrators, engineers and contractors on any planned construction or renovation project. From there, they identify possible risk factors the work could create in the patient care setting and identify measures to be taken to control harm from occurring. Personal protective equipment, containment measures and paths of egress for debris removal are just a few things to consider.

Your IP will devise a form known as the Infection Control Risk Assessment (ICRA). The IP consults with workers and contractors about the safety measure that should be taken throughout the course of the project. The conditions of the ICRA are finalized by the IP who will routinely conduct rounds to ensure that all safety measures are being taken. When deficiencies are identified, revision and reeducation are necessary.

Supply and Demand
We are all very much acquainted with the supply chain shortage. The same is true for securing experienced contract labor. Under optimal conditions, there are strategic steps that are taken when hiring a contractor to construct a new healthcare facility or renovate an existing structure. With ongoing supply and demand struggles, finding an available contractor that is also well-versed in healthcare physical environment requirements can be an even greater challenge.

This is an area that we strongly advise where you should not take short cuts. Although you may have a project deadline in mind, cutting corners when it comes to healthcare construction should never be an option. Deficiencies identified during initial or repeat surveys in addition to any rework that will be required is never worth the risk.

We recommend investor and administrators follow their normal process for vetting contract labor. We also recommend that you have flexibility with your construction deadlines due to labor demand. It is always prudent to exercise a little patience to ensure the best possible and safest outcome for all; not to mention, avoiding unnecessary additional costs.

Don’t take chances! Our experts can assist with regulatory compliance requirements for whether you are building a new, state of the art project or renovating an existing structure. Be sure to visit our website at www.healthcareconsultingexperts.com to see a full list of the services that we provide. Contact us today at 1(800) 813-7117 for a free initial consultation.
Don’t leave it to guesswork - Leave it to the experts!

References

https://www.beckershospitalreview.com/capital/7-hospital-construction-projects-worth-600m-or-more.html

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Spring is in the Air !

Tue, 01 Mar 2022 22:13:00 GMT

Four Tips for Restoring Healthcare Operations from a Fresh Perspective

march 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

As we near the spring of 2022, it may be a good time to do some housekeeping in your healthcare facility. It is important for all organizations to enter into a new calendar-fiscal year with the mindset of improving upon prior year outcomes. Whether or not your organization is a Centers for Medicare and Medicaid Services (CMS) facility or an independent healthcare provider, here are a few best practices that can help to improve the quality of the services provided to patients, reduce cost, and improve day-to-day operations for any healthcare facility.

Annual Review of Policies and Procedures – Empower Your Staff
There is no time like the present to begin an annual review of policies and procedure. An organization’s policies and procedures outline how an organization operates. In the past two years we have all experienced policy change at a rate making day-to-day operations confusing to front-line healthcare professionals. In many cases, there may even be reluctance to begin reviews due to fear of new changes to practice requirements determined by regulatory agencies. Nonetheless, it is best to take a proactive approach in conducting these reviews. It is important to consider what has changed since the last time a policy was reviewed when conducting a retrospective review. and make sure that the policy and or procedure fits how your facility currently provides services. In our experience, we have found it to be helpful to elect team members to champion these reviews. As an administrator or leader, you may be apprehensive about assigning additional tasks to team members who have been experiencing work related stress, but it may surprise you that delegating even a single policy for review empowers team members to work autonomously. This allows team members to have input, conduct independent research and helps to promote team engagement. It is our recommendation to prioritize reviews and continue the process gradually. Be sure that all recommendations for revision are carefully reviewed and that proposed changes are aligned with current evidence-based practices. Keep in mind that all revisions must be reviewed by the individuals or committees who are authorized to approve such changes for your organization.

Records, Records, Records ….
Whether your healthcare facility utilizes paper or electronic charting, spring is an is ideal time of year to conduct an internal sweep of how protected health information (PHI) is managed. The larger the size of a facility, the greater the risk of PHI traveling from one location to another. Even if your organization only uses electronic charting, most organizations still find that it is virtually impossible to get rid of paper documents and records completely. Conducting surveillance is critical in identifying PHI security breaches. Examples may include PHI found in unsecure locations, computer stations being left unlocked or improper disposal of health information. Fax machines can be another contributor to The Health Insurance Portability and Accountability Act (HIPAA) breaches, particularly those that are not in a secure location. In our experience, we have found medical records left on fax machines in plain view and faxes being sent out of organizations that did not include coversheets with breach disclosure statements. We have found that this can be a common problem for many organizations and can be easily prevented by ensuring that all team members are well-trained on HIPAA compliance practices. Be sure to conduct annual reviews and training with your team members and survey your facilities to prevent potential major infractions.

Quality Assurance Performance Improvement (QAPI) Plans
Having QAPI plans in place in not only best practice but also a condition of participation for CMS. Data is collected throughout the year. This vital information is reported national databases for public reporting. QAPI should be shared with personnel from the front-line workers to the governing boards of healthcare facilities. Reports include goals, benchmark data and overall performance metrics. The purpose of having a well-reviewed plan in place is not just to demonstrate that we have collected data but to reflect upon how we can improve performance. QAPI plans should include an annual review. This is an opportunity to review what measures did or did not work for the organization. Identifying areas of vulnerability provides a great opportunity to explore new ideas. Be sure that any changes made to the plan are integrated into organizational policies and procedures as applicable. Other examples of programs requiring annual review are Infection Prevention and Emergency Preparedness Programs. The following attachment from CMS is a great resource on how to structure a successful QAPI program: qapifiveelements.pdf (cms.gov)

Contract Services
Contracted services are an area often overlooked in many healthcare organizations. Subsequently, these types of services may be more commonly used in smaller privately-owned facilities. It is critical to review contracted services periodically. Be sure the services being provided meet the agreed-upon contractual obligations. If a service provider is not meeting the service commitment, then the matter should first be addressed with the contractor. Too often, contracts auto-renew or are not reviewed by an organization. Both of these matters can lead to excessive cost and poor outcomes for healthcare facilities. If you are contracting for licensed professional services, be sure that you can prove that the service providers are qualified and credentialed to perform the duties agreed upon by both parties.
If you are contracting construction services, for example, can you be sure that contracted personnel have been properly trained on safety measures? It may be good to inquire if the contractor is familiar with working in a healthcare environment especially within patient care areas and are familiar with med gas safety measures. When considering contract labor, be sure that you are protecting your organization from potential risks. Engage key stakeholders in the selection and review process for all contract services. Conducting concurrent review will help protect your organization from unexpected legal and financial implications.

In summary
Here at HCE we recognize the daily challenges and increasing workloads that all healthcare providers are faced with today. Spring 2022 is a great time to embark on a fresh start and cleanse your organization from the aftermath of the pandemic. We hope that you will find these tips and reminders helpful and can incorporate fresh, new ideas into your day-to-day routines.

HCE is here to help! Contact us today for to discuss how we can help your organization get back on track in 2022. Thanks to all healthcare professionals for your commitment to caring.

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Medical Device and Pharmaceutical Recalls: Is Your Organization 100% Protected?

Mon, 07 Feb 2022 18:39:00 GMT

It May Be Time to Evaluate How Recalls are Being Identified in Your Healthcare Facility

february 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Pharmaceutical and medical device recalls are nothing new in the healthcare industry. It is important to understand that recalls may happen for a variety of reasons. It is also important to understand that the level of risk associated with the recalled medication or equipment is categorized based on the level or risk associated with the product. This is to help communicate from how minor to how dangerous the product is if used in a conventional manner. Although the Food and Drug Administration (FDA) enforces standards for recalling vaccines, medical devices, and pharmaceuticals; the responsibility is that of the manufacturer of these types of devices to report information about quality concerns of the products that have identified. The FDA does however have the authority to issue a mandatory recall based upon the severity of risk associated with any of these products.

Once a manufacturer has determined that a medication or device needs to be recalled for review, modification or removed from the market completely, the manufacturer should then immediately notify not only the FDA but all clients who may have purchased the item(s) in question. Notification letters should include a priority status. If a device or medication could potentially cause serious harm or even death, it would be classified as a Category 1 risk by the FDA and marked urgent by the sender of the notification. For moderate risk, items or medications would be labeled as a Category 2 risk which can still lead to health risks that do not result in irreversible harm or fatality. Category 3 risks are considered to be minor. These may be associated with a mere design flaw but in no way are expected to result in adverse outcomes if they do reach the patient.

It may be a good time to familiarize your pharmacists and supply chain team members with the FDA’s recall websites listed under resources below. The list includes an eye-opening number of medical device and pharmaceutical recalls in addition to non-medical products recalled. It may also be a good time to conduct a risk assessment for your organization to determine how recalls are managed on a day-to-day basis.

There are a variety of sophisticated informatics systems that help healthcare organizations communicate this vital information to key stakeholders upon receipt of the information. In the consulting world, we often encounter a variety of issues resulting in vital information not being communicated properly or effectively. Inefficient or broken lines of communication and/or not updating current contact information for essential personnel can result in serious risk to patients. Inefficient or ineffective communication of recalls can easily open organizations up to financial and legal consequences. We know how overwhelming the constant influx of information is in the healthcare world right now. We are always here to help! Let us help your organization get back on track today.

From all of us here at HCE, we are extremely grateful for all you do, and we hope you all are staying safe out there!

Please join us by clicking on any of the icons below to leave a comment or for more informati on and updates:

Click Here To Subscribe To Our Monthly Newsletter

Telehealth: Familiar with the Advantages but it may be time to consider the Disadvantages

Sat, 01 Jan 2022 17:51:00 GMT

Has the time come to reconsider best practices for optimal patient outcomes?

january 2022

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Having been in the midst of the pandemic in a busy acute care setting, I too have welcomed telehealth technology. Although we are still dealing with the day-to-day pressure that Covid-19 has created for the healthcare industry, including exhausted healthcare personnel, it may be time to reevaluate the utilization of telehealth/telemedicine to ensure that we are providing the best possible care for patients.

As clinicians, we understand that in order to optimize patient care we should implement and adhere to evidence-based practices regarding the care that we provide to patients. We all know that prior to the pandemic, use of telehealth technology in a healthcare setting was not utilized nearly as frequently as it is today. Has the time come to reevaluate adherence to evidence-based practices for optimal patient outcomes?

If a provider is not able to auscultate heart or lung sounds through direct patient contact, he or she may not be able to correctly diagnose a patient’s medical condition. I was recently made aware of a scenario wherein a patient who was suspected of having a stroke was evaluated using telehealth technology. During the course of the patient's hospitalization, a neurologist conducted a neurological exam only utilizing “face time” from his remote location which did not include a hands-on physical examination of the patient. Knowing what a true head-to-toe neurological evaluation entails, this caused me to question if this type of telehealth examination could be considered comprehensive, thorough in nature, and more importantly, provide optimal patient care.

Another area to consider when reevaluating the utilization of telehealth in day-to-day practice should be how medications are being prescribed. Prior to the pandemic healthcare providers were expected to adhere to antimicrobial stewardship best practices. The need for antimicrobial stewardship (ASP) measures have been widely adopted and are well recognized by infection prevention regulating authorities such as the Centers for Medicare and Medicaid Services (CMS) The Joint Commission, and Centers for Disease Control and Prevention (CDC), for example.

The reason for the adaptation to ASP best practices is because of the growing number of multidrug resistant organisms (MDRO) that are widespread throughout communities and healthcare facilities along with a growing number of newly emerging MDRO’s. A few well-known examples of these MDRO’s include Clostridioides difficile (C.difficile) and Methicillin-resistant Staphylococcus aureus (MRSA). Both of these bacteria are highly transmissible and commonly associated with healthcare associated infections in healthcare settings. MDRO’s are believed to be associated with greater than 20,000 deaths per year in the United States alone.

Pharmacists and microbiologists must be actively involved in antimicrobial stewardship programs in order for them to be successful. Has telemedicine utilization throughout the Covid-19 pandemic allowed us to revert back to the old days when antibiotics were easily prescribed for any ailment you may have had? Are providers who are evaluating patients via telehealth prescribing antibiotics to treat a patient's symptom prior to lab work being done and blood culture results evaluated?

In order to ensure that the antibiotic being prescribed is appropriate for bacteria identified, blood cultures would be drawn to identify how a patient should be treated. Antimicrobial stewardship committees should include microbiologists, pharmacists, and clinicians. As part of the ASP team microbiologists communicate with clinicians about abnormal blood culture results that are identified. If an antibiotic was prescribed that would not be appropriate for treating the bacteria identified, the pharmacist would also communicate with the ordering provider offering guidance on what antibiotic selection would be most appropriate for treating the patient. By deviating from these best practices, we could potentially be taking steps backwards in our efforts to reduce the number of MDRO’s as well as prevent the evolution of newly emerging MDRO’s.

Telehealth has been part of the healthcare industry for decades. Technological advances have helped telehealth to be what it is today. There are a substantial number of benefits as a result of being able to utilize telehealth technology. One of the major advantages include being able to provide access to care for people who live in remote areas. Telemedicine visits can be conducted by providers wherein they can interact with patients both verbally and through real time video enabling providers to be able to conduct an overall patient assessment. In some institutions, there are actual robots which are utilized to conduct physical assessments of patients in healthcare settings. Information is communicated in real time. This can be beneficial if providers are not immediately present in a healthcare facility. Other advantages include eliminating the need for travel to healthcare facilities which can be a significant hardship on patients, their care providers and loved ones. Finally, there is certainly an advantage to the cost saving aspect to be considered such as the cost of transportation, ancillary staffing required for conducting a traditional office visit. Overall telehealth has been an amazing technological advancement in the healthcare industry.

Telehealth was and still is very widely used to evaluate patients throughout the ongoing Covid-19 pandemic. Telemedicine has allowed providers to conduct wellness checks on patients remotely. The advantages of being able to conduct visits and assessments remotely has been recognized by governing authorities as a perfectly acceptable means of providing care for patients. Overall, this practice eliminated or significantly reduced the need for providers to have direct contact with patients who were known to be Covid positive or have been identified as a person under investigation (PUI) for Covid. Utilization of telehealth technology has helped us to preserve and protect our healthcare providers from contracting Covid during a time when healthcare providers are already in short supply.

In summary, I would like to emphasize that the point of this communication is strictly to raise awareness for organizations to evaluate how they are delivering care to patients via telehealth technology. I do not suggest that precautions should not be taken or to eliminate the utilization of telehealth technology. It is most important to ensure that everyone is able to perform their duties in the safest possible manner. The purpose of this communication is to remind all healthcare professionals that deviation from evidenced-based best practices could potentially have a significant impact on overall public health in the near future. I recommend evaluating how your organization is utilizing telehealth technology in the delivery of patient care, engaging your leadership teams, and evaluating the risk vs. benefit of adhering or deviating from evidenced-based practices in your organization.

From all of us here at HCE, we are extremely grateful for all you do, and we hope you all are staying safe out there!

Please join us through any of the links below to leave a comment and for information updates:
https://www.linkedin.com/company/healthcare-consulting-experts-llc/?viewAsMember=true https://www.facebook.com/HealthcareConsultingExpertsLLC https://twitter.com/HealthcareCons4 https://www.instagram.com/healthcareconsultingexperts/

Click Here To Subscribe To Our Monthly Newsletter

Infection Prevention & Quality Improvement Tips

Wed, 01 Dec 2021 18:27:00 GMT

December 2021

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

We would like to take a moment to raise awareness to the following healthcare related events for December 2021: World AIDS Day – Dec. 1, National Handwashing Awareness Week – Dec. 5-11 and National Influenza Vaccination Week. We wish all of our hard working healthcare professionals out there a joyous holiday season from HCE!

Greetings

We hope that everyone is enjoying a wonderful, joyous and peaceful holiday season. Thank you for your ongoing support. We are committed to helping healthcare organizations achieve and maintain ongoing service excellence. We commend all of you for your commitment to quality improvement and patient safety. Each month, we share helpful tips which are based upon ongoing observations by our HCE professionals. We find that these topics are not often understood. Therefore, we share information that we hope will help others.

Infection Prevention Tips

Transportation is typically not the first thing that comes to mind when discussing infection prevention matters. In the world of healthcare however, these two topics are often directly related. It is not uncommon for healthcare facilities to transport instruments or equipment between multiple inter-organizational locations. Facilities can reduce costs by sharing resources such as personnel and equipment. It is important to keep in mind that these practices must comply with AAMI, ANSI, DOT and OSHA standards. It is critical for organizations to develop policies and procedures that meet all requirements. It is also critical to ensure that team members who will be involved in the transporting process are properly trained and have been deemed competent to perform these tasks in a safe and compliant manner.

Vehicles used in the transporting equipment must have a clear separation between clean and dirty items. It is also important to ensure that items being transported are properly labeled. Instruments soiled with blood or bodily fluids should be transported in containers appropriately labeled as "Biohazard". When selecting containers for transport, be sure to choose containers that are leak proof as well as puncture proof. Vehicles transporting soiled instruments should also be equipped with personal protective equipment and spill kits. Be sure to review your state's specific DOT requirements. Vehicles must also be able to maintain acceptable temperature and humidity ranges. Extreme heat or humidity levels can compromise the integrity of sterile instruments which increases risk of infection if instruments are then used in patient care.

We recommend reviewing your facility's current workflow for transporting instruments between facilities. Be sure to develop, review or revise existing policies to ensure current practices are compliant with regulating agencies. Evaluate workflows and interview employees to ensure that they are following safe practices and have a good understanding of your organization's policies and procedures concerning transportation of medical instruments and equipment.

Healthcare Quality Improvement Tips

A Workplace Violence Prevention Program should be included as part of your organization's Quality Assurance Performance Improvement Plan. There are a variety of factors that exist in a healthcare setting that promote an increased risk for workplace violence to occur. Holidays, although joyous, are also stressful at times. This is why we decided to include workplace violence as a topic in our monthly newsletter to raise awareness about workplace violence.

In order to have an effective Workforce Violence Prevention Program, you must have team members who are well educated about the risk factors and appropriate response methods when faced with potentially violent situations. Such situations when they arise tend to escalate very quickly so effective and timely response to these matters are critical. The National Institute for Occupational Safety and Health (NIOSH) offers plenty of free educational materials that can be utilized for training purposes. Active shooter incident planning should also be incorporated into your Emergency Preparedness Plans. Free training materials are easily available through the Department of Homeland Security. You can also consult the Regional Advisory Committee (RAC) in your area for training help and support.

In order to have an effective Workplace Violence Prevention Program, organizational leaders must be invested in promoting the plan by providing a comprehensive education program for all team members and performing drills within the organization. This will help employees be better prepared when faced with these unfortunate and horrifying events.

A few key points to include within your program are education on awareness of behavior that can lead to violence, training employees on how to respond when faced with potentially violent situations, training employees on how to elicit help a situation arises, review of escape routes for employees to safely remove themselves from a situation if necessary and how to barricade themselves for protection if unable to escape and an active shooter has entered the building. We recognize that the concern for violence in the workplace is very real. It is up to each organization to do their part in keeping everyone safe. It is also important for all employees to feel safe on the job. Having an effective Violence Protective Program will ensure that team members feel secure and know exactly what to do when facing a hostile situation that arises.

In Summary

We hope that you find our tips helpful. Regretfully, in the healthcare industry, some of the topics that must be discussed can create a certain level of anxiety for healthcare workers. Ultimately, having well established policies, procedures and educational programs in place can help reduce anxiety across the board for the entire healthcare team.

Get in Touch

Here at HCE we recognize that there are so many challenges healthcare entities face on an ongoing basis and the healthcare climate is changing rapidly and drastically. We continue to encounter challenges as a result of the COVID-19 pandemic. Whether you are attempting to put your facility back on track or opening a new healthcare entity amongst these challenging times, you are likely managing a fair number of challenges. HCE can help! Contact one of our experts today. Tell us your needs and we will customize a plan to assist you and your organization eliminate your day-to-day operation stress.

Happy holidays to you and yours from all of us here at HCE!

Click Here To Subscribe To Our Monthly Newsletter

Single Use and Manufacturer Recommendations

Mon, 01 Nov 2021 21:53:00 GMT

Two Definitions Your Staff Needs to Understand

november 2021

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Happy National Hospice & Palliative Care Month, National Patient Transport Week Nov. 1-7, Allied Health Professionals Week Nov. 6-12, National Radiologic Technology Week Nov. 6-12, National Nurse Practitioner Week Nov. 13-19 and Perioperative Nurses Week Nov. 13-19 from HCE!

Greetings

It is holiday time once again. With nationwide staffing shortages, the day-to- day challenges continue to grow. We would like to express our gratitude to all healthcare workers for their ongoing commitment to patient care. We hope this communication finds you and your families happy and healthy.

Infection Prevention Tips

Single use means single use! This is a controversial matter that commonly pops up in many healthcare organizations. Be sure to review the products that your organization uses to determine whether they can be properly cleaned and sanitized or if they are truly intended to be single use. This simply requires review of the manufacturers packaging. Although it seem pretty straight forward, if employees are not aware that items should be disposed after use, they will find creative ways to "clean" equipment and reuse items.

We have observed this behavior on countless occasions. It does not necessarily mean that there is ill intent or a lack of concerns on the employees behalf, they are simply not well informed or have not been educated about single use items. One observation always comes to mind with regard to single use. While conducting surveillance in a pediatric clinic, we interviewed a nursing assist who was "cleaning" otoscope covers. She went through her ten minute process with great pride and explained how she would soak the covers in hydrogen peroxide, rinse with water and leave them to dry. I thanked her for her thorough explanation an proceeded with the Director of Nursing to the supply closet to validate that the process was being done according to manufacturer recommendations. Upon review of the packaging we found that it was clearly labeled that the covers were intended to be single use only items. The Director of Nursing promptly educated her team about single use only items and disposal after use. The Nursing Assistant truly believed that she was effectively cleaning the otoscope covers. There was no ill intent just lack of education.

You will also hear employees discuss reuse of items to "save money". In a busy pediatric clinic where many children are seen for ear infections, you can imagine how quickly infection might spread due to reuse of covers that were never intended to cleaned or reused. Be sure to check you supply closets and educate your team members!

Healthcare Quality Improvement Tips

Manufacturer Recommendations are also commonly not followed in healthcare facilities. Once again, this is not because team members disregard the recommendations; they are simply not aware or have not been educated on the topic. One item that comes to mind is reusable blood pressure cuffs. Not all facilities are equipped with single use cuffs. These items are okay to be reused but facilities must comply with the manufacturer's recommendation for proper cleaning of the equipment. This process typically requires soaking or rinsing the item in a cleaning solution for several minutes and then allowing it to air dry. In a busy healthcare setting this is not practical. You will commonly find team members wiping these items with Sani Wipes. Although there is good intent to clean and sanitize these items, keep in mind that they are covered in nylon cloth and bacteria will seep through the material. Wiping the exterior surface with a Sani Wipe will not achieve the manufacturer's recommendation for proper cleaning and disinfection.

Manufacturer recommendations will also dictate if preventative maintenance is required on equipment. Additionally, these recommendations might also include the frequency in which the maintenance should occur. Be sure to review these requirements and document when the maintenance has been completed. You will be asked to produce this documentation during a survey but more importantly you will be able to demonstrate that you are adhering to manufacturer recommendations in the interest of patient safety.

Please also keep in mind that if your facility does not adhere to manufacturer recommendations, you may also void any warranties you have on the equipment. Our colleagues in a very large health system faced this same issue. After purchasing equipment for a new hospital, improper cleaning of the new equipment voided the warranty and damaging the equipment purchased for $100k after only six months!!

In Summary

We are here for you! We understand the challenges that healthcare organizations face on a daily basis. Let us know how we can help your organization improve. To all the healthcare heroes out there, we want to wish you and your families a very Happy (and safe) Thanksgiving!

Click Here To Subscribe To Our Monthly Newsletter

Prevent Adverse Outcomes Through Development of Infection Prevention and Quality Improvement Program

Fri, 01 Oct 2021 21:48:00 GMT

Helpful reminders that can help to ensure safe patient outcomes and reduce risk of infection in your healthcare facility

october 2021

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Happy International Infection Prevention Week Oct 17-23, National Healthcare Quality Week Oct 17-23, National Health Education Week Oct 18-22, Respiratory Care Week Oct 24-30, Medical Ultrasound Awareness Month, National Breast Cancer Awareness Month and National Physical Therapy Month from HCE!

Infection Prevention Tips

Although we cannot say enough about the importance of good hand hygiene compliance, we can assure you that in general, compliance rates have gone up significantly throughout the course of the Covid-19 pandemic. This is truly something to celebrate! It is still critical to ensure that employees are well trained on proper hand hygiene technique, however. For instance, do staff understand when to wash their hands with soap and water vs. hand sanitizer? It seems simple, but we can assure you that when asking this question, you will get an even mix of responses.

Hand sanitizer is perfectly acceptable when performing most general duties. It is quick, requires very little activity and studies suggest that this method is 99.99% effective in preventing the spread of germs and infection. Be sure employees do understand that this is not an acceptable method of cleaning their hands when dealing with any blood or bodily fluids. The soap and water method are considered to be most effective when caring for patients who are on enteric isolation precautions. If your organization has a well trained Infection Preventionist on staff, then rest assured that there is a good chance that your employees are aware of which method to choose when providing day to day care to patients.

It is important to incorporate this training into your existing infection prevention program. This education should be done as a part of any new employee orientation as well as on an annual basis. Never assume that even your most seasoned healthcare team members understand which method to choose when incorporating best practice into their daily routine.

Healthcare Quality Improvement Tips

Proper identification of a patient would seem to most a simplistic of tasks for most employees to be able to complete. This continues to be a point of focus with regulatory agencies because of the inconsistencies in methods used to obtain proper identification of patients. Incorrect identification of a patient can lead to a multitude of errors including, but not limited to medication errors, incorrect diagnosis, patients undergoing unnecessary treatments and or procedures. There is also the risk of patient health information being wrongfully released from the healthcare facility. These types of errors stemming from incorrect patient identification can lead to significant legal and financial implications for any healthcare entity.

These errors does not stop just with the patient. Many times you will hear incorrect patient identification information exchanged between departments.

Remember, there are only two data points recognized as acceptable methods of identifying patients. These include verification of a patient's name and date of birth . Once again, not only is this education critical for all new employees, but we cannot emphasize enough the importance of annual and ongoing training.

In Summary

It is hard to believe that we still continue to miss the mark on what would seem to be some of the most simplistic tasks, but the fact is that we continue to do so. Adverse outcomes can be prevented and eliminated through development of comprehensive Infection Prevention and Quality Improvement Programs in addition to new and ongoing employee education.

Click Here To Subscribe To Our Monthly Newsletter

Creative Ways to Battle Staffing Shortages

Wed, 01 Sep 2021 21:48:00 GMT

Two Ways Can Be Alleviated - Academic Community and Open-House Recruiting

september 2021

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Pure exhaustion of healthcare workers is one of the major reasons that so many healthcare professionals are leaving the industry. The time has come to bring in the reinforcements! Two ways this can be alleviated are by involving the academic community and open house recruiting. Many institutions of higher learning are desperately seeking clinical experiences for students who are interested in entering the healthcare field. Clinical experiences help students to gain the essential practical and critical thinking skills necessary to become competent in the profession. This is an ideal opportunity for all healthcare administrators to consider hosting clinical experiences for students. Despite the possibility of initial resistance and apprehension of your clinical team members who may be reluctant to precept students in the clinical environment; rest assured, the benefits will most certainly outweigh concerns. It is time to mold a new generation of healthcare professionals to support the tired and weary through these difficult times. Open house recruiting is another opportunity to recruit a variety of talented and skilled healthcare workers. This is one method that many larger healthcare facilities have moved to but the size of the facility does not necessarily matter. The issue that most healthcare facilities are dealing with today is that despite applicants applying for positions, Human Resources personnel are not able to effectively manage the constant staff turnover as well as the onboarding of new staff members from day to day. Having a scheduled open house event to recruit new team members can be a much more efficient way to capture the interested of the many talented healthcare workers seeking a new opportunity in what has become a very competitive healthcare market. Additionally, this will enable organizations the opportunity to fill vacancies in a much more efficient and timely manner.

Click Here To Subscribe To Our Monthly Newsletter