Accreditation update: Moving to high reliability

Karyn Temte Lloyd, RN, BSN
Quality management coordinator

Dec. 4, 2013

Let’s begin this new series with a question: Why should we be concerned about accreditation?
Facility accreditation through The Joint Commission and Centers for Medicare & Medicaid Services ensures that we’re following the highest standards for patient care. Failing to meet these standards not only affects reimbursement to providers and our facilities, it falls short of the expectations that we place on ourselves at Providence.

The Joint Commission surveyed five of our hospitals this past year, as well as hospice, home care and medical equipment services. Their reports were generally positive, reflecting our high quality of care. Surveyors, however, are now drilling deeper into every aspect of process improvement and patient safety, giving us opportunities to improve in some key areas.

Infection prevention
In surgical suites, remember that:

  • No personal items are allowed.
  • All hair, including facial hair, must be covered.
  • Hand hygiene should be observed before, during and after care, and after removing gloves.

Isolation techniques:

  • Follow appropriate isolation precautions as noted in signs outside of the patient environment.
  • Here too, proper hand hygiene is required before, during and after care, and after removing gloves.

Procedural time outs
To prevent wrong-site surgeries, every team member must:

  • Follow the time out protocol for every invasive procedure for inpatients and outpatients, including incision and drainage, chest tube, circumcision and fine needle aspiration.
  • Pause and confirm the correct patient, correct procedure and correct site, including laterality.
  • Clearly document informed procedural consents. Specify date and time and avoid acronyms.
  • Document the procedural time out in the patient’s record. Your nurse can help with this.

New! The two-midnight benchmark
As Dr. Bradley Bryan wrote in the October issue of Pulse, CMS requires new documentation for all inpatient hospital admissions involving patients with Medicare Advantage Plans. This includes:

  • A physician certification of medical necessity for inpatient services. This begins with a completed, authenticated order in the medical record before discharge or transfer certifying that services are appropriate for inpatient admission according to the two-midnight benchmark.
    The order must include:
  • The reason for inpatient services, such as inpatient medical treatment or medically required diagnostic study, or special or unusual services for cost outlier cases under the inpatient prospective payment system.
  • Supplemental documentation in physician notes or discharge planning instructions that supports the necessity of inpatient treatment.
  • Critical access hospitals must certify that the patient may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission. See illustration.

Look for more accreditation updates every other month in Pulse, or email Karyn Temte Lloyd with questions.