This March, the California Department of Public Health (CDPH) will launch its new general acute care hospital relicensing survey, which will merge California’s licensing requirements with elements of the Medication Error Reduction Plan and Patient Safety Licensing Surveys. As all facilities can expect to be surveyed every three years, it is important that hospitals understand the changes that were made, what to expect when a survey team visits and how to prepare in advance for the survey process.
The Centers for Medicare & Medicaid services will host a Dec. 14 webinar on the Hospital Value-Based Purchasing (VBP) program, addressing surgical site infection rates for colon surgeries and abdominal hysterectomies within the Hospital VBP program. The webinar will include health care-associated infection standard population updates from the Centers for Disease Control & Prevention and methods to improve surgical site infection standardized infection ratios. Webinar slides will be available for download from www.qualityreportingcenter.com under “Upcoming Events” the day before the presentation. Registration is available online.
The California Department of Public Health (CDPH) will launch its new general acute care hospital relicensing survey in March 2016. The new relicensing surveys will be unannounced and hospitals will be surveyed every three years, as required by law. Learn about the new survey process, as well as how you can prepare in advance for a surveyor visit.
The California Department of Public Health’s (CDPH) Healthcare Associated Infection (HAI) program has implemented a voluntary surgical site infection (SSI) validation program. The program aims to help hospitals better assess the quality and accuracy of their SSI data.
All hospitals are eligible to participate; CDPH will identify hospitals as participating or non-participating in the next HAI report, published in the fall of 2016. When the report is published, CDPH will request a site visit at each hospital that did not participate in validation, as well as at each hospital in need of surveillance and reporting assistance, as indicated by the validation findings. The deadline to sign up and submit validation reports is Dec. 4. For information about the 2015 SSI validation process, visit www.cdph.ca.gov/programs/hai/Pages/2015SSIvalidation.aspx. For questions, contact HAIProgram@cdph.ca.gov.
Gov. Brown has signed into law AB 679 (Allen, Chapter 778, Statutes of 2015), extending the deadline for registering with the Controlled Substance Utilization Review and Evaluation System (CURES). Previous law required that all pharmacists and health care practitioners who are authorized to prescribe, order, administer, furnish or dispense Schedule II, III or IV controlled substances register with CURES by Jan. 1, 2016. Practitioners now have until July 1, 2016 to register. More information is available on the California Prescription Drug Monitoring Program website.
California Public Protection & Physician Health, Inc. (CPPPH), in collaboration with the UC San Diego Physician Assessment and Clinical Education (PACE) program, has announced its 2015 project on evaluations of physicians. The project includes a workshop that will be offered in both northern California (Nov. 21) and southern California (Dec. 5), as well as a certificate of completion for those who prepare evaluations and wish to show that they have completed all steps of the CPPPH project. CHA is a joint founder of CPPPH, along with the California Medical Association, the California Society of Addiction Medicine and the California Psychiatric Association. The organization was founded to address the need for focused education, technical advice and consultation for medical staff and medical groups in support of physician health activities. For more information on the workshops and CPPPH, see the attached brochure.
The Food and Drug Administration (FDA) has notified providers that it has resolved technical problems with the Clozapine Risk Evaluation and Mitigation Strategy Program, and that prescribers and pharmacies should now be able to complete their online certification for the program. Clozapine is a medication for schizophrenia, and last month the FDA issued new monitoring, prescribing, dispensing and receiving requirements, attempting to address concerns about a serious blood condition called neutropenia that is sometimes associated with the medication. If prescribers or pharmacists encounter additional problems with the program, they should contact the FDA at (844) 267-8678.
An HVAC task force, whose members include the American Hospital Association’s American Society for Healthcare Engineering (ASHE), has issued the attached interim guidance to help health care facilities maintain appropriate temperature and humidity control in operating rooms and sterile processing departments while it works to achieve consensus on conflicting standards. Among other actions, the task force said it plans to explain the conflicting standards to accreditors and state licensing agencies and ask them to work with health care organizations to establish a plan for resolving variance.
In addition to ASHE, task force members include the American Society of Heating, Refrigerating and Air-Conditioning Engineers; Association for the Advancement of Medical Instrumentation; Association for Professionals in Infection Control and Epidemiology; Association of periOperative Registered Nurses; and the Facility Guidelines Institute.
The Joint Commission yesterday released a Sentinel Event Alert examining the contributing factors to patient falls and offering suggested solutions health care organizations can implement to help reduce them. The Joint Commission defines a sentinel event as a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm or severe temporary harm where intervention is required to sustain life.
The Jefferson College of Population Health (JCPH) is now accepting applications for the Hearst Health Prize for Excellence in Population Health. Finalists for the award, which recognizes outstanding achievement in managing or improving population health, will be invited to present their project at next year’s Population Health Colloquium in Philadelphia. The Hearst Health Prize was created to discover, support and showcase the work of an individual, group or institution that has successfully implemented a population health program that has made a measurable difference in improving health outcomes. For more information and to apply, visit the JCPH website.
The Joint Commission Center for Transforming Healthcare last week debuted the Preventing Falls Targeted Solutions Tool (Preventing Falls TST) to help hospitals reduce the number of patient falls. Over the past four years the commission has worked with several hospitals, including one in California, to develop a system for assessing whether a patient is at risk for falling and created 21 different solutions to address the common risk factors associated with falls. Using the Preventing Falls TST, pilot hospitals were able to reduce all falls by about 35 percent and those resulting in injury by 62 percent. More information is available on the Joint Commission website.
The Centers for Disease Control and Prevention (CDC) will host a clinician call Aug. 20 to discuss work being done to implement a coordinated approach to protect patients from carbapenem-resistant Enterobacteriaceae (CRE) and Clostridium difficile (C. diff). The call, titled “CRE and C. difficile: Is Your Healthcare Facility Implementing the Necessary Approach to Stop the Spread?”, is open to all hospitals and will feature testimony from clinical experts on preventing antibiotic-resistant infections and improving antibiotic stewardship. For more information, visit http://emergency.cdc.gov/coca/calls/2015/callinfo_082015.asp.
The Centers for Medicare & Medicaid Services (CMS) has updated the Law and Policy page on its Open Payments website with information about new reporting requirements for continuing medical education (CME) in the 2015 Medicare physician fee schedule final rule. In October 2014, CMS eliminated the exemption for payments or other transfers of value made to physician speakers at certain accredited continuing education events.
The result of this change is that, starting in 2016, when an applicable manufacturer provides an “indirect payment” or other transfer of value to a continuing education organization for a continuing education event to physicians, and that manufacturer knows or finds out the identity of the physician attendees/speakers within the reporting year or by the end of the second quarter of the following reporting year, that payment must be reported to CMS in 2017. A payment is considered “indirect” when a manufacturer directs, instructs or otherwise causes a third party to provide payment to a covered recipient.
The attached Survey and Certification memo from the Centers for Medicare & Medicaid Services (CMS) updates the infection control surveyor worksheet in the state operations manual for ambulatory surgery centers (ASC). Intended to help surveyors better understand infection prevention and control issues in the ASC setting, the worksheet changes align with current nationally recognized standards of practice and clarify some questions surveyors have had. In addition, CMS has added to the worksheet questions about the practice of immediate-use steam sterilization (IUSS) to help surveyors assess compliance with recently released IUSS guidance.
The Centers for Medicare & Medicaid Services (CMS) has issued the attached survey and certification letter updating the interpretive guidance in Appendix A of the State Operating Manual for hospital conditions of participation for radiologic and nuclear medicine services. The updates reflect current standards of practice and provide more detailed instructions for compliance assessment. Included in the update is a description of the types of radiologic/nuclear medicine services provided and discussion of safety precautions hospitals are expected to take to decrease radiation exposure risks.
The National Healthcare Safety Network (NHSN) has announced that the annual deadline for ambulatory surgical centers (ASCs) to submit data on influenza vaccinations among health care personnel (ASC-8: Influenza Vaccination Coverage among Healthcare Personnel) has been extended from May 15 to Aug. 15. The extension is intended to assist as many ASCs as possible in meeting the requirement during its initial implementation year. To submit data, ASCs must enroll in NHSN at least eight weeks before the Aug. 15 deadline. For additional information, visit https://images.magnetmail.net/images/clients/AHA_11/attach/NHSN_ASCUpdate.pdf.
Gov. Brown has appointed Karen Smith, MD, MPH, as director of the California Department of Public Health (CDPH). Dr. Smith has been medical staff for infectious disease at Queen of the Valley Medical Center since 2012, has served as public health officer and deputy director at the Napa County Health and Human Services Agency since 2004 and has been a faculty consultant at the Francis J. Curry International Tuberculosis Center since 1997. In addition, Dr. Smith is a liaison to the Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response Board of Scientific Counselors, and is president-elect of the California Conference of Local Health Officers. She served as assistant section chief at the California Department of Health Services Tuberculosis Control Branch from 2000 to 2001.
“CHA congratulates Dr. Smith on her appointment to this important position and looks forward to working with her,” said CHA President/CEO C. Duane Dauner.
The Centers for Medicare & Medicaid Services (CMS) released on Jan. 30 a Survey and Certification Letter providing revised guidance for rule changes to the Conditions of Participation affecting hospitals, ambulatory surgical centers, rural health clinics and federally qualified health centers.
CMS adopted its Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction; Part II final rule on May 12, 2014, and since then has issued several other Survey and Certification Letters with revised guidance. Affected organizations should review their policies and procedures to ensure compliance.
You’ve received a licensing violation. You may have been expecting it from a recent survey, or it may have come as a complete surprise. One thing is for certain, survey activity — and subsequent violations — will be more common now that California Department of Public Health (CDPH) has issued new regulations for hospital penalties, including non-immediate jeopardy violations.
The CHA Joint Committee on Accreditation & Licensing is currently accepting new member applications. The committee, which meets quarterly in Sacramento, addresses hospital accreditation, regulatory and licensing issues and makes policy recommendations to the CHA Board of Trustees. To be eligible to serve on the committee, individuals must be employed with a CHA member hospital and serve as liaison for accreditation and licensing issues at their facility. To apply, send a biography to Lori Woolsey at email@example.com by April 4.