increase in both responsibilities and pay. accreditation...

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Briefings on Accreditation and Quality

Continuing Education ObjectivesAfter reading this article, you will be able to:

• Discuss changes to the requirements for swing beds

• Identify the areas of care affected by the changes in

Appendix A

• Identify the areas of care affected by the changes in

Appendix W for critical access hospitals

CMS earlier this year published revised guidelines for both Appendix A—Survey Protocol, Regulations and Interpretive Guidelines for Hospitals and Appendix W—Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAH) and Swing-Beds in CAHs. The hospital revisions went into effect April 1, 2015, and the CAH revisions went into effect April 7.

The revisions to the hospital manual under Appendix A addressed only a few changes such as outpatient orders, radiopharmaceuticals for nuclear medicine, and dietary. However, one-third of the CAH manual has been completely revised. Revised sections include pharmacology, nursing, rehabilitation, and drugs and biologicals. New sections to the CAH manual include

CMS updates hospital and CAH guidelines

Behavioral health in the hospital settingEven with Joint Commission require-ments for behavioral health assessments in the ED and beyond, hospitals still struggle in this area. What is your organi-zation doing to improve behavioral health integration into the continuum of care?

Annual salary surveyAccreditation professionals see an increase in both responsibilities and pay.

Antibiotic stewardship programsBOAQ advisor Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, takes a closer look at the elements of antibiotic stewardship programs.

AAAHC acquires HFAPMeg Gravesmill discusses the transi-tion process and future of AAHHS.

What should I be doing now?In the final column of her 12-month series, Jodi Eisenberg, MHA, CPMSM, CPHQ, CSHA, reviews the benefits of the accreditation survey process.

P3

P6

P10

P12

P8

IV medications and blood and blood products. Many of these standards also exist in the hospital manual.

What do these changes mean for healthcare pro-viders and surveyors? “It’s a good thing; most of the changes made are the same standards they have for hospitals, or they’re a shortened version of those stan-dards,” says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCMSP, president of Patient Safety and Healthcare Consulting, Inc. “I think that’s good because a lot of hos-pitals are in systems now. I think it’s going to be easier for the surveyors. It never made sense that the two hospital manuals have so many differences.”

RadiologyCMS has changed the wording in the radiology section

of Appendix A so that a doctor or pharmacist does not need to be present for a trained nuclear medicine technolo-gist to push the contrast during the nuclear medicine test.

“This makes a lot of sense, especially on evenings and weekends when physicians or pharmacists may not be available,” says Dill Calloway. “They removed the term ‘direct’ from supervision, so the technicians will still

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be under supervision, but the pharmacist doesn’t have to be in the department at the time of administration.” Also, hospitals should be aware that CMS issued a memo dated May 15, 2015, that rewrote most of the radiology and nuclear medicine sections in the hospital Conditions of Participation manual under Appendix A.

DietaryThis section was updated in both manuals, with slightly

shortened standards in the CAH manual. Medical staff can now credential and grant privileges to qualified dieti-tians or nutrition professionals if permitted by state law. Some states refer to this person as a registered dietitian or licensed dietitian.

The qualified dietitian will be able to write diets (e.g., supplemental, therapeutic, total parenteral nutrition, etc.) for patients as well as order lab tests as they relate to dietary needs without the supervision of a physician or another healthcare practitioner.

CMS added two new provisions to this standard. The first states that all hospital patients must have their nutritional needs met in a manner consistent with

Briefings on Accreditation and Quality (ISSN: 1941-5877 [print]; 1941-5885 [online]) is published monthly by HCPro, a division of BLR®. Subscription rate: $429/year or $772/two years. Back issues are available at $30 each. • Briefings on Accreditation and Quality, 100 Winners Circle, Suite 300, Brentwood, TN 37027. • Copyright © 2015 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978-750-8400. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of Briefings on Accreditation and Quality. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Briefings on Accreditation and Quality and HCPro, a division of BLR, are not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Briefings on Accreditation and Quality is available online. Please call 781-639-1872 for more information.

EDITORIAL ADVISORY BOARD

Sue Dill Calloway, RN, MSN, JD, CPHRMChief Learning OfficerThe Emergency Medicine Patient Safety Foundation Columbus, Ohio

Joseph L. CappielloChief Operating OfficerHealthcare Facilities Accreditation Program Chicago, Illinois

Sharon Chaput, RN, CSHABrattleboro Retreat Brattleboro, Vermont

Jean Clark, RHIA, CSHAConsultantHollywood, North Carolina

Elizabeth Di Giacomo-Geffers, RN, MPH, CSHAHealthcare ConsultantTrabuco Canyon, California

Jodi Eisenberg, MHA, CPMSM, CPHQ, CSHAPrincipal Consultant, Accreditation and Clinical Compliance ServicesUniversity Healthsystem ConsortiumChicago, Illinois

Renee H. Martin, RN, JD, MSNTsoules, Sweeney, Martin & Orr Exton, Pennsylvania

Patrick Pianezza, MHAManager of Patient Experience VEP Healthcare Walnut Creek, California

Diane RogierFormer PresidentNAHQ Glenview, Illinois

Erin CallahanVice PresidentContent Development & Product [email protected]

Michelle ClarkeManaging [email protected]

This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.

Follow UsFollow and chat with us about all things healthcare compliance, management, and reimbursement. @HCPro_Inc

recognized dietary practices. The second requires that all patient diets must be ordered either by a practitioner caring for the patient or by a qualified dietitian as autho-rized by the medical staff.

Outpatient servicesIn Appendix A, CMS has revised the orders for

outpatient services standards so that the healthcare practitioner must be licensed in the state where he or she provides patient care, even if the patient is in another state for a short period of time. For example, if a patient lives in one state and receives a prescrip-tion for a medication and needs a blood test to moni-tor the effects and then the patient goes on vacation, the local hospital could decide to run the test.

Drugs and biologicalsThis section is new to the CAH manual, and the

content varies slightly from the hospital manual. A CAH must have written policies for the administration of all drugs and biologicals based on widely accepted stan-dards of practice and both federal and state law.

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Abraham recommends working with staff to engage with the patient to get to the heart of his or her story.

“We recommend this, particularly if the person is someone we’ve seen before, what I call a frequent flyer,” says Abraham. “A lot of times you can pick up on additional stressors or other factors that make this new admission different.”

And it’s not only beneficial to the patient to realize if there are some new factors in his or her latest visit to the hospital—you’ll need to make sure it’s part of the patient’s plan of care.

“The plan of care—and this is where I see issues—has to be relative to the assessment you’ve done on the patient,” Abraham says. “It has to be a plan you’ve worked out with the patients or their loved ones.”

It begins at admission but carries through until the patient leaves the hospital and beyond—something most professionals know, but may not always follow through on.

“The continuum of care is now scrutinized more than it ever has been in the past,” says Abraham.


• Describe why it is important to identify new stressors in a

returning behavioral health patient

• Identify which departments face the most common

challenges with behavioral health patients

• Describe ways for staff to interact with behavioral health

patients that can improve their care

With CMS and The Joint Commission increasingly push-ing to make sure facilities are following requirements and standards regarding mental health, now is a good time to assess your own facility’s mental health resources. But what happens when you’re in a facility without a behavioral health services unit? How do you keep patients and staff safe?

You’ve got to start right when the patient arrives at the hospital, says Isaac Abraham, RN, MSN, senior consultant with Compass Clinical.

“You want to make sure you’re really involving the patient throughout the entire continuum of care,” says Abraham. “It starts with admission.”

Behavioral healthcare in hospitalsMeeting requirements with limited resources

Drugs and biologicals can be administered either by or under the supervision of the MD, the DO, the registered nurse (RN), or, if permitted by state law, the physician’s assistant (PA). Although medication admin-istration should be based on a written order, CMS does not prevent CAHs from using either verbal orders or standing orders. In both cases, the practitioner respon-sible for the patient must put the order in writing as soon as possible.

It’s important to note that if a CAH has a psychiatric and/or rehabilitation unit, the CAH must follow the CMS hospital Conditions of Participation for all services in those units, including verbal and standing orders.

NursingCMS significantly revised the nursing section with

seemingly commonsense updates, Dill Calloway says. Revisions include mandating that CAHs iden-tify an individual, an RN such as the chief nursing

officer, who is responsible for nursing services, including the development of policies and proce-dures for nursing services.

The CAH should have a sufficient number of supervisory and non-supervisory nursing personnel for both inpatient and outpatient services. Staffing schedules will need to be monitored to ensure patient needs are met.

CAHs should also have procedures for assigning and coordinating nursing care for every patient, says Dill Calloway. The RN should consider the capabilities of the nursing staff and assign appropriate tasks while creating assignments. CMS does not want to interfere in staffing assignments, provided the employee meets all educa-tional, training, and experience criteria, and the assign-ment is in compliance with state law.

Patient care at every CAH will have their care supervised by either an RN or a PA where permitted by state law. H

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“We’re not doing it for The Joint Commission or CMS, we’re doing it for the patient,” Abraham says.

The organization needs to have a vision that is under-stood and supported by everyone.

“If you start off there, every meeting should begin with what is our vision,” says Abraham. “And you have to keep that fresh in staff members’ minds.”

Leadership buy-in can make the training process eas-ier through support, both financial and cultural. Leaders need to be at the forefront of improving the facility’s culture of safety.

“We train staff on how to hold a patient, or restrain them, and that’s important to keep them safe—but if you can prevent it from happening at all, that’s better,” says Abraham.

A common theme with behavioral health and the continuum of care is what happens once the patient leaves the facility. Without proper discharge planning and follow-up, behavioral health patients can get looped into a cycle of readmission.

“Patients come into the hospital and haven’t been tak-ing their medication. You get them back on that medi-cation regimen. This goes for all health issues, not just behavioral,” says Abraham. “If I don’t take my insulin, my diabetes will get out of control. The same holds true for psych patients.”

Everyone needs to work together The best situations Abraham has encountered for tak-

ing care of patients from intake to discharge have been team efforts engaging state institutions, private hospitals, community organizations, and more.

“The best models I’ve seen and been involved with have everybody working together,” says Abraham.

These group efforts have community services boards and some way for behavioral health patients to find help 24 hours per day. Access to assistance earlier can keep these patients from returning to the ED when they have nowhere else to turn, he notes.

Those hotlines “may send someone to check on the patient, may see what’s going on, and they may send me to the ED or suggest I come in the next day, but” there is a more diverse continuum of care at work, Abraham says.

“Working together is crucial, and that’s what’s missing in a lot of places,” he adds.

The big issue Abraham is encountering that comes into play with behavioral and mental health is the increased focus by The Joint Commission and CMS on patient rights.

“We’re doing better as a country, but a lot of times patients are labeled as behavioral health patients” and issues arise, Abraham notes.

As recently as a few years ago, use of restraints without legitimate reason was still a common practice, something that The Joint Commission and other regulatory require-ments improved.

“If you use restrictive methodology, you have to be justified in doing so,” says Abraham.

To comply with these standards, Abraham works with organizations with training, particularly in the emergency department (ED), labor and delivery, and other areas where mental health patients are frequently seen and can quickly become a risk to themselves and to others.

“Staff tell me they don’t feel comfortable, that the training they’ve received in school [for dealing with behavioral health] wasn’t hands-on enough. So we coach them on how to deal with behavioral health patients,” says Abraham.

Now, he says, all healthcare facilities have to take the time and effort to train staff to make sure they have the ability to prevent, and when needed, de-escalate behavior.

“This is an expectation from CMS and The Joint Commission,” says Abraham. “You use the least restric-tive methodology when working with any patients, espe-cially psych patients. You have to make every effort to keep the patient as well as others safe. Restrictive meth-ods should be used only as a last resort, and documenta-tion should reflect the process.”

Of course, while the emphasis across the country has been to eliminate or reduce the use of seclusion or restraint, this requires a combination of resources, support from leadership, and training to properly implement.

“The organization must have the reduction of seclu-sion and restraints as part of their vision and mission in order to create a safe environment. This is being done across the country,” says Abraham.

When visiting organizations, Abraham starts by doing an assessment of the units, looking at how the teams work together. He says the best places have the same philosophy on behavioral healthcare.

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The private sector can’t operate alone. Not only are there fewer hospitals than in years past, there is also the unfortunate reality that behavioral health is not profitable.

“They could use those beds and units for other medi-cal problems,” says Abraham.

Which is why hospitals and communities need to work together.

“Together we can come up with ways to help patients transfer from the ED to a crisis stabilization level,” says Abraham. “People need to sit down at the table and say, ‘What can we do to use less expensive, less restric-tive methodology to treat patients and keep them out of the hospital?’ ”

While hospitals can be the initial spark for these discussions, they don’t have to be. Abraham has encoun-tered a police chief in one community who was invested and wanted to create a partnership with other institu-tions, for example.

“It’s about people being willing to invest the time,” says Abraham.

This particular police chief worked with professionals like Abraham and a community board to help train his officers, who are often approached in behavioral health situations, to give them better de-escalation skills.

“This sort of project can be initiated from anywhere,” says Abraham.

In other communities, state behavioral health insti-tutions work out relationships with private hospitals to help their patients get back into their lives after hospitalization.

“If we started moving patients into the community right away, we knew they would have relapses,” says Abraham. “Our goal was, if they were hospitalized, have them at a private hospital and treated so they didn’t have to come back in unnecessarily.”

The ED and behavioral health No matter what else changes, behavioral health con-

tinues to be a central part of day-to-day life in the ED. “This has been a hot item for the last couple of years,”

says Abraham. In the wrong situation, behavioral health patients

could end up boarded or held in the ED for days for their own safety.

“You could be there the whole weekend,” says Abraham. “The Joint Commission said this boarding has got to stop.”

Crisis stabilization units can help with this, for example. At another institution Abraham worked with, four rooms next to the ED were dedicated for mental health patients.

The ED physicians had to assess and do triage, but a psych nurse and a psychiatrist on call were available after the ED ruled out anything medical that needed to be addressed.

What can be done to helpIn a time when approximately 50% of American

patients will have some sort of mental health issue diagnosed in their lifetime, there are concerns across the continuum as every unit in a given hospital will at some point need to address mental health concerns with their patients.

Staff need to be prepared and supported regardless of their unit or role.

Where can healthcare organizations take immediate action to improve how they handle behavioral health in their facilities?

First, begin by looking at how your staff speak to and with the patient.

“One facility I worked in, for example, used too much medical jargon,” says Abraham. “You’ve got to keep it short and simple for the patient. The patient should be able to tell you what I’m there for and what I’m working on.”

Help staff learn that what sounds good on the chart might not be practical for use with the patient to com-municate his or her own care.

This isn’t just a role for nurses or physicians, either. “You need everybody working together. It’s what

CMS is looking for: multidisciplinary approaches involv-ing doctors, social workers, everyone working to give the patients what they need,” says Abraham. “They provide all the therapeutic modalities and service the patients need to get their care met.”

And these staff members have to understand their audiences.

“We put it down on paper in medical jargon and if I’m a CMS surveyor and I see it in medical jargon, that’s what I’m going to think you’re saying to the patient,” says Abraham. “It needs to be simplified.”

The other issue is timing of treatment plans. Behavioral health still suffers from not receiving the same immediacy of care other areas do.

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HCPro’s first salary survey of accreditation profes-sionals in three years found growth in both compensa-tion and job responsibilities. Eighty-two accreditation professionals responded to the survey, up slightly from 74 respondents in 2012.

There has been some improvement in terms of sal-ary increases in 2015. Forty percent of respondents reported receiving a 2% or less salary increase, com-pared to only 31% who reported receiving a 2% or less increase in 2012. The number of people reporting no salary increase at all decreased slightly to 33% (vs. 35% in 2012).

Interestingly, the median income of $50,000 to $50,999 has decreased slightly to 8% (vs. 10% in 2012), but salaries exceeding $100,000 (38%) are higher than they were three years ago (29%).

See Figure 2 for the full picture of salary increases for 2015.

Salary survey shows accreditation professionals see increase in pay, responsibilities

We also asked respondents if they were eligible to receive a bonus. Unfortunately, a whopping 65% said they were not eligible for a bonus this year. The remaining respondents answered:• 24% said they were eligible for a bonus based on

the performance of the organization• 11% said they were eligible for a bonus based on in-

dividual performance

Annual salaries on the riseThe most anticipated question: What is the expected

salary for this role? Approximately 50% of respondents reported salaries

in the $60,000–$99,999 range. The largest percentage of respondents (17%) fell in the $70,000–$79,999 range, a slight increase from 16% in 2012. In 2012, the larg-est percentage of respondents (18%) reported making $80,000–$89,999, compared to only 11% in 2015.

On the flip side, organizations need to address what happens when the patient leaves the organization.

“You’ve got to start thinking about the discharge plan right away. Nobody wants the patient to have to stay unnecessary days,” says Abraham.

The industry as a whole is doing better with dis-charge planning, Abraham notes, but there is still often an issue of resources once a behavioral health patient leaves the hospital.

“You need the right place for the right treatment,” he says. Without some kind of guidance, patients are destined

to fall off track with their care once they leave the hospi-tal. Whether it’s some sort of group home, a “club house” setting, or a program teaching social or technical skills, something to keep these patients on track after they leave the hospital can help prevent readmissions.

“We really do need a continuum of services that meet the needs of the patients,” says Abraham. “They leave the ED, they have a follow-up visit, [and] we make sure they stay on target. It’s a matter of having these resources in place. We’ve got to work with the patients; otherwise, it’s out of sight, out of mind.” H

“If I as a patient walk in on a weekend, I can’t sit until the behavioral health team comes in on Monday,” says Abraham.

He compares it to a cardiac issue. There is a physician they can call immediately to the ED, where an initial treatment plan can be started. The patient will be started on necessary medications.

“You’ve got to show how this patient came in on Friday and this is what you did to keep him safe,” says Abraham. “If I come in with a heart attack, I’m not going to wait for a cardiologist on Monday.”

Abraham says The Joint Commission has done a good job pushing for initial suicide risk assessments, which can help identify other mental health issues dur-ing intake.

“You have to ask everybody. People may be upset or suicidal, and there are psychosomatic disorders when people are having a lot of physical issues,” Abraham says. The piling on of physical ailments, pain, and discomfort can lead to depression or more, and these can be identified and assessed by talking with the patient.

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While participants report their median salary has dropped by $10,000, 36% of accreditation professionals are reporting salaries of $100,000 or higher compared to 23% reported in 2012. Additionally, only 14% of respondents reported salaries less than $59,999, which is a significant decrease from 2012 when 21% reported making less than $59,999 per year.

See Figure 1 for a full salary breakdown.

Who are our respondents?In addition to asking about salary, we also asked

respondents to identify their age, experience, and gender to get a better sense of who is in the accredita-tion market.

An overwhelming proportion of accreditation professionals are female. Approximately 93% of all surveyors are female, a 2% increase from 2012.

There are still more novice survey coordinators, who have worked in the field less than two years (28%), than there are veteran coordinators, but the veterans are catching up. Twenty-four percent of respondents

have been working for more than 10 years, which is a huge jump from 14% just three years ago.

The majority of respondents (36%) fall into the 51–60 age range, followed closely by those in the 41–50 age range (30%). Only 18% of the respondents fall in the 31–40 age range.

Curiously enough, the percentage of survey coor-dinators in the field for two to five years decreased to 28% (vs. 41% in 2012). We don’t have an explanation for that decrease as the percentage of surveyors in the field for six to 10 years also decreased, although not as substantially (20% vs. 24% in 2012). It could be surmised that those coordinators aged into the over-10-year group.

Seventy-four percent of respondents said they oversaw preparation for multiple settings. Approximately 58% reported being responsible for

Figure 1: 2015 salary ranges

20%15%10%5%0%

Less than $30,000

$30,000–$39,999

$40,000–$49,999

$50,000–$59,999

$60,000–$69,999

$70,000–$79,999

$80,000–$89,999

Figure 2: Percentage of accreditation professionals who received a raise

No raise

More than 10%

7%–8%

9%–10%

5%–6%

3%–4%

2% or less

0% 10% 20% 30% 40% 50%

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The nuts and bolts of antibiotic stewardship programs


• Discuss the need for antibiotic stewardship programs

• Identify the core elements of hospital antibiotic stewardship

programs

• Explain optimal antibiotic use policies

Editor’s note: Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, is a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor.

The creation and expanded use of antibiotics has allowed for the successful treatment of routine infec-tions and safer surgical procedures. However, there has also been overuse and, in some cases, misuse of antibiot-ics. This has led to the rise of antibiotic-resistant infec-tions, making antibiotics less and less effective.

Last month, the White House convened a special forum on antibiotic stewardship attended by more than 150 healthcare organizations, including the Centers for Disease Control and Prevention (CDC) and The Joint Commission, and announced increased efforts to

multiple acute care settings, more than their counter-parts (45%) in 2012.

Many respondents wear multiple hats and oversee more than one organizational function. The largest percentage, 64% (vs. 48% in 2012), also oversees facility quality improvement. Survey coordinators also oversaw safety, nursing, medical staff, and risk management. See Figure 3 for additional hospital functions and departments.

In addition to our usual suspects, 36% indicated they were responsible for other areas not identified on the survey. The top three write-in responses for additional responsibilities include infection control, compliance, and licensure.

Other topics included:• Policy administration• Employee health• Patient experience• Patient-family relations• Core measures• Support services• Durable medical equipment

The Joint Commission continues to be the primary accrediting body most hospitals use (holding steady at 91%), but the number of facilities using alternative accreditors is climbing. A few respondents are with DNV-GL/NIAHO (8% vs. 1% in 2012) and HFAP (3% vs. 2% in 2012). H

Figure 3: Oversight of additional functions/departments

Medical staff

Nursing

Quality improvement

Risk management

Other

Safety management

0% 10% 20% 30% 40% 50% 60% 70%

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promote effective antibiotic stewardship within health-care facilities.

There is growing evidence that hospital-based pro-grams dedicated to improving antibiotic use, referred to as antibiotic stewardship programs (ASP), can strengthen treatment as well as reduce antibiotic-related adverse events, according to a report issued by the CDC last fall. The report, Core Elements of Hospital Antibiotic Stewardship Programs, highlights the needed components for a successful stewardship program.

Core elements of ASPs The elements discussed in this article are designed

to complement existing guidelines from organizations such as the Infectious Diseases Society of America and The Joint Commission. There isn’t a “one size fits all” approach to optimize antibiotic prescribing in hospitals. Hospitals will need to determine what works best for them given their resources and finan-cial capabilities.

Leadership commitmentNot surprisingly, leadership commitment is key to the

success of stewardship programs, according to the CDC report. Leadership can show support in a number of ways, such as:• Issue formal statements supporting efforts to im-

prove and monitor antibiotic use• Include stewardship-related duties in job descrip-

tions and performance reviews• Ensure staff has enough time to contribute to

activities• Ensure participation from hospital groups that can

support stewardship activities

Accountability and drug expertiseThe leadership of the stewardship program should

include someone, such as a physician, who is respon-sible for the program outcomes. There should also be a pharmacy leader who will colead the program. Both leaders should have training in infectious diseases and/or antibiotic stewardship from either the CDC or other formal organizations.

The stewardship committee should be a multidisci-plinary committee composed of members of key hospi-tal groups.

Actions that support optimal antibiotic useHospitals will need to create and put in place policies

that support optimal antibiotic use, such as document-ing dose, duration, and indication. This ensures that antibiotics can be easily identified, modified as needed, and/or discontinued.

Additionally, develop and implement facility-specific treatment recommendations based on national and state guidelines. This will help optimize antibiotic selection and duration, particularly for common usage scenarios like community-acquired pneumonia, intra-abdominal infections, urinary tract infections, and skin and soft tis-sue infections.

Interventions to improve antibiotic useThe aim of the interventions is to improve antibiotic

use and increase quality of care. Interventions should be divided into three categories: broad, pharmacy-driven, and infection- and syndrome-specific.

Broad interventions encourage the use of antibiotic timeouts, prior authorization, and drug-related audit and feedback. The use of an antibiotic timeout 48 hours after the initial order reminds the physician to revaluate the order to determine the continuing need for the drug and whether the correct antibiotic was initially chosen.

Prior authorization by an antibiotic expert is required some antibiotics whose use may be restricted by spectrum

Core elements of hospital antibiotic stewardship programs

• Leadership commitment

• Accountability

• Drug expertise

• Action

• Tracking

• Reporting

• Education

Source: CDC. Core Elements of Hospital Antibiotic Steward-ship Programs. Atlanta, GA: US Department of Health and Human Services, 2014 (www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html).

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AAAHC moves into hospital accreditation market with HFAP acquisition

In early October, the Accreditation Association, the parent company of the Accreditation Association for Ambulatory Health Care (AAAHC) announced it had acquired the Health Facilities Accreditation Program (HFAP) from the American Osteopathic Association (AOA).

“This acquisition promises to be one of the most exciting developments in the world of healthcare accreditation today and in the years ahead for ASCs, hospitals, and laboratories,” said Stephen A. Martin, Jr., PhD, MPH, AAAHC president and CEO, in a release.

“It brings together two well-known, highly respected healthcare accreditors that share organizational philoso-phies and cultures that are extremely compatible. These combined teams and resources will allow us to deliver the highest quality of services and results to clients.”

The Accreditation Association announced in 2012 that it would be launching The Accreditation Association for Hospitals/Health Systems, Inc., a hospital accreditation program. HFAP, created in 1945 to review osteopathic hospitals, has had deemed status from CMS since 1965 to review all types of hospitals.

of activity, cost, or other associated issues. Pre-authorization of the therapy needs to be completed in an appropriate time frame.

Prospective audit and feedback differs from the anti-biotic timeout in that staff other than the treating team reviews the antibiotic therapy to ensure its effectiveness. This intervention has proven effective in the treatment of critically ill patients.

Pharmacy-driven interventions may include automatic changes from intravenous to oral antibiotic therapy in appropriate situations, which improves patient safety if there is no longer a need for intravenous access. Other pharmacy interventions include:• Dose adjustments and optimization• Time-sensitive auto stop orders• Prevention/detection of antibiotic-related drug-drug

interactions

Infection- and syndrome-specific interventions discuss treatment for specific syndromes, but should not inter-fere or preclude treatment for severe infection or sepsis. Recommended interventions for select issues include:• Community-acquired pneumonia—focus on cor-

recting recognized problems in therapy, including improving diagnostic accuracy and tailoring the ther-apy to culture results

• Urinary tract infections—focus on avoiding unnec-essary urine cultures; ensure patients receive appro-priate therapy for the recommended duration

• Empiric coverage of methicillin-resistant Staphylo-coccus aureus (MRSA) infections—stop therapy if patient doesn’t have MRSA or change to beta-lac-tam if the cause is methicillin-sensitive Staphylococ-cus aureus

• Clostridium difficile infections—review antibiotics in newly diagnosed patients to identify possible use of unnecessary antibiotics

Tracking and reporting A successful stewardship program should measure

both the evaluation of the process as well as the out-come to determine any opportunities for improve-ment when administering antibiotics, according to the CDC.

The committee should ask questions that range from determining if policies are being followed as expected to evaluating whether the interventions put in place have improved antibiotic use and patient outcomes.

EducationASP committees should share regular updates on

antibiotic prescribing, resistances, and infectious disease management at both the national and state levels with the healthcare organization. Sharing this information on a routine basis promotes improved prescribing and increased patient safety.

For the full list of references, visit Accreditation & Quality Advisor at http://blogs.hcpro.com/acc/. H

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“If anyone was to switch over from HFAP to Joint Commission or some other deemed accreditor, they would have to go through an initial survey. They won’t have to do that with us. That’s of historical importance with this acquisition.”

CMS approvalThe acquisition has been approved by CMS and is the

first time two organizations with deeming authority will transition to single ownership.

CMS approval “is a lengthy process, because it’s a seri-ous issue,” Gravesmill says. “First you have a discussion with CMS, followed by an in-person discussion complete with a Q&A session to address any additional questions they might have.”

They were very responsive and receptive to the idea of the acquisition, she adds.

The future of the AAHHSFirst, the ambulatory care component of HFAP

is going to transition slowly to the AAAHC so that there will just be one ambulatory product, according to Gravesmill.

As time goes by, what can we expect from the AAHHS? “When the AAHHS was started, we focused on small and rural hospitals, but knew we would eventually grow to a larger health system,” Gravesmill says. “Joining with HFAP has allowed us to get to that larger health system; we’ve got some wonderful relationships with some big health systems throughout the United States.”

This merger “will allow us to still maintain our rela-tionship with small rural hospitals, which have a unique way of doing business that is different from the way larger medical systems do business, so we’re not going to lose that,” Gravesmill adds.

“Our staffing has increased in that we have a group of people that have been very dedicated to AOA and HFAP and understand the process for these differ-ent organizations, and now we’re joining with them to emphasize the same important things, such as educa-tion and interpretation on the latest CMS standards,” she says.

“We really want to be a partner with hospitals and health systems,” Gravesmill says. “We’re there to help you get over the bumps you might [find] within your organization.” H

As of October 14, HFAP is being managed and oper-ated under the direction of AAHHS.

Transition processOne might expect the transition process between two

accrediting bodies to be difficult, but an AAHHS execu-tive says that won’t be the case.

Explains Meg Gravesmill, vice president and general manager of AAHHS, “The AAHHS hasn’t swooped in to say, ‘Here are new practices.’ We’re continuing with what HFAP has started. We’re building this transition process for these organizations to be successful; it should be very smooth sailing for everybody.”

HFAP-accredited hospitals won’t experience jarring changes, she adds.

“When folks call up and ask questions, they’ll follow the same process and get their responses the same way and from the same person they’ve always worked with,” Gravesmill continues. “It’s a seamless process for all of the organizations.

“Our goal was that the organizations received the same customer focus and customer friendliness they expected from HFAP—that is going to continue through this whole process,” she says.

Full deeming authorityFull deeming authority of critical access hospitals,

laboratories, and the other three deemed programs will transition from HFAP and AOA to AAHHS, Gravesmill says.

“It’s going to take a few years to fully transition, as some organizations have just gone through an HFAP accreditation survey and their accreditation doesn’t expire for three years,” she says. “We’re not going to ask them to go through another survey.”

The AAHHS plans to “develop a process to transi-tion organization as they make the move from HFAP to AAHHS. We’ll tell them, here’s how the standards are set up for HFAP, and here’s how the standards are set up for AAHHS, and here’s how you can move forward and here are the similarities so that you can be successful on your next survey with AAHHS,’ ” she explains.

“The really key thing that we found for our organi-zations is that they don’t have to go through an initial Medicare deemed status survey,” Gravesmill says.

Complimentary Issue


What should I be doing now?

Month 12 post-survey tips

Editor’s note: Each month, advisor Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, manager of accredita-tion, clinical compliance, and policy management for Northwestern Memorial Healthcare in Chicago, explains the steps and goals survey coordinators will want to take at a given point in their survey cycle. For this month, the last in her series, Eisenberg examines month 12 post-survey.

Every healthcare organization has a process for annual performance appraisals; in fact, it is a requirement. The strategy, implementation, and functional steps in any annual performance appraisal process or system are innately similar to the focused standards assessment that is used to assess performance against the Joint Commission standards. The responsibility to initiate the review rests squarely on the accreditation professional. The accredita-tion professional generally helps to determine everything from the level of compliance with the standards to the action plan and monitoring that must be implemented to achieve improvement where necessary. For month 12, I felt it was appropriate to review the benefits of this process.

Benefits for the accreditation professionalWhether conducted for CMS, the state department of

public health, The Joint Commission, or any of a number of regulatory bodies that hold healthcare organizations accountable for compliance with regulations and stan-dards, an annual assessment of an organization’s compli-ance status is an indicator of the stability of systems that are in place to provide reliable, safe, and quality care to every patient every day. The assessment, if done well, can provide current compliance status, but it can also reveal areas that need attention—perhaps areas that are not out of compliance but regardless need to be strengthened or developed. Benefits for the accreditation professional include understanding the full scope of standards and the development of key relationships with operational part-ners and content experts within his or her organization.

Organizational benefitsFor the organization, the annual assessment can

reinforce corporate goals and provide information

for thorough resource planning regarding purchasing new equipment, staff recruitment, training and devel-opment, and performance improvement initiatives. Involving frontline staff in the assessment process as well as the process to correct, improve, and achieve compliance can have a positive impact on staff satisfac-tion as well as patient satisfaction. The key is to con-duct a thorough assessment, identify gaps in systems and issues in compliance, and work to improve and correct these issues.

Benefits for the staff and managementPerformance appraisals can be more effective if con-

ducted as a counseling session, rather than a review of performance. It is beneficial to use that same approach when conducting an organizational compliance assess-ment. Rather than sitting at a desk and checking the boxes, get out and talk to staff and managers. Involve staff and managers in the assessment process. Conduct tracers to validate compliance. The value in the tracer actually comes less from identifying gaps in performance and more from connecting with the staff, helping them to feel comfortable with the process. When the accredita-tion professional involves others in the process, there is potential for the managers to improve their management skills and to develop better relationships with staff. This assessment process using the tracer methodology can also be used throughout the year to monitor the training and development needs of staff. As Ben Franklin said, “Tell me and I forget. Teach me and I remember. Involve me and I learn.”

Optimizing benefitsFeedback, whether positive or negative, is extremely

important. Results of the assessment should be com-municated back to the staff and managers as well as up to senior leadership. At the staff level, whether it is an opportunity to chat with your reviewer or a path to improving compliance, approaching the process with an attitude open to learning will help you to walk away feeling that the assessment was time well spent … and you might just learn something along the way! H

increase in both responsibilities and pay. accreditation...

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