August 2023 | Issue 29

WHAT'S NEW IN SUSTAINING COMPLIANCE?

CMS Memo Regarding Inconsistencies in Survey Processes | Review CMS memo

As many of you have inquired, The Joint Commission received a transmittal on June 16 from CMS,

which addresses changes to survey processes. CMS has asked all accrediting organizations to evaluate and change processes for pre-survey notifications, avoid dates and complaint investigations. These changes

would apply to all deemed programs (excluding Laboratory) and to all accreditors. 

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CAH Revisions from CMS Review Go into Effect August 27 | Learn more

Effective this Sunday, Aug. 27, the Joint Commission is making several changes to the elements of

performance (EPs) for critical access hospitals (CAHs) to better align with CMS Conditions of Participation.

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The Joint Commission Eliminates Additional Standards across all Accreditation Programs

Get the details

The Joint Commission recently announced it will eliminate and consolidate a second section of standards, following the first major reduction announced late last year. The more than 200 eliminated and

consolidated standards, also effective this Sunday, Aug. 27, will streamline requirements and make them

as efficient and impactful on patient safety and quality as possible. 

IHS PARTNER SPOTLIGHT

PATH Training Inspires Support among Non-hospital Service Units

TAKE 5 FOR SAFETY

Detecting Harm with Trigger Tools

Research shows only 10-20% of errors are ever reported in voluntary event reporting systems. Lack of reporting can be due to system culture, fear of blame or staff not knowing what should be reported. Trigger tools are an additional resource to identify harm in your facility and address safety concerns.  

Triggers are specific occurrences that signal the need for a more intensive record review to determine if harm occurred. Trigger tools are not standalone solutions. They are part of a comprehensive patient safety program. When harm is identified, the health care team can take appropriate actions to improve patient safety and quality and prevent harm. 

Various types of trigger tools are available from The Institute for Healthcare Improvement (IHI), including the IHI Global Trigger Tool for Measuring Adverse Events. These tools are used to enhance measurement of the overall level of harm within an organization. 

Follow these steps to implement trigger tools: 

1. Determine the type of trigger tools to use (general, specialty or location-specific). 
2. Review records and gather data according to trigger tool criteria and instructions.  
3. When a trigger is identified, a multidisciplinary team should review the record to confirm an event occurred. Once an event is confirmed, conduct a root-cause analysis (RCA) to determine reasons for the event. 
4. Develop and implement strategies to address the identified safety concerns and prevent future occurrences.  
5. Provide ongoing education and training to health care staff regarding patient safety best practices, the use of trigger tools and the importance of reporting safety events and concerns.  
6. Continuously measure and monitor the effectiveness of the implemented corrective actions. 
7. Foster a culture of safety, which includes open communication, non-punitive reporting of safety concerns, and a focus on continuous improvement. 
8. Collaborate with other health care institutions and organizations to share best practices and lessons learned in using trigger tools effectively for patient safety. 

Resources: 

• Agency for Healthcare Research and Quality (AHRQ): Triggers and Trigger Tools 
• Developing and Evaluating an Automated All-Cause Harm Trigger System 
• Institute for Healthcare Improvement Trigger Tools 
• Office of Inspector General (OIG): Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018 
• OIG: Incidence of Adverse Events in Indian Health Service Hospitals, 2020

PATH EVENTS

IHS Opioid Surveillance Dashboard Office Hours | Register Now

Every third Wednesday September through November

2-3 PM ET | 1-2 PM CT | 1-12 PM MT | 11 AM-12 PM PT

Join the IHS National Committee on Heroin Opioids and Pain Efforts (HOPE Committee) and PATH for open office hours sessions on the use of IHS Opioid Surveillance Dashboards (OSD). This call will support IHS users of the IHS OSD through

• discussing dashboard functionality and use cases;
• responding to dashboard questions;
• providing a forum to discuss requests, recommendations or enhancements;
• highlighting techniques to get the most out of this dashboard.

(This event is free and open to IHS staff only.

Registration is required to receive the call-in information.)

Understanding Indigenous Drivers of Health

PATH and IHS leaders, Dr. Phillipe Champagne, MD, MPH, IHS Physician Senior Advisor, and CAPT Jana Towne, RN, BSN, MHS, Director, IHS Office of Quality (Acting), hosted a timely event last month. The session highlighted The Joint Commission (TJC) requirements to reduce health care disparities, provided guidance on implementing a health equity program, shared creative ways to use electronic medical records (EMRs) to assess and document social drivers of heath and more. If you missed the session or would like a refresher, you can listen to the event recording and view the Indigenous Drivers of Health PowerPoint slides.

Check out these resources:

• PATH: Understanding Indigenous Drivers of Health Key Takeaways
• CMS: Using Social Determinants of Health Z Codes
• CMS: Framework for Health Equity 2022-2032
• U.S. Department of Health and Human Services (HHS): Addressing Social Determinants of Health in Federal Programs
• PATH: Generic Community Resource Guide you can use to build a comprehensive guide to use across your organization. 

Did You Know?

We know life happens, and though you may have wanted to attend a live event, a time conflict or any other many possible reasons kept you from it. Many of our past event recordings, key takeaways, flyers and resources can be found on our event page on our website. 

Please feel free to check out our PATH Events page if you missed an event or would like a refresher. While you are there, check out some of our other postings and materials available to you.

New NIHCM Infographics on Combination Drug Use Overdoses

Earlier this week, the National Institute for Health Care Management (NIHCM) released excellent infographics on the Latest Data: Combination Drug Use Increases Overdoses. Data are provided by the Centers for Disease Control and Prevention (CDC).

The majority of methamphetamine and cocaine deaths involve a synthetic opioid. Deaths involving opioids and meth are highest among American Indians or Alaska Natives.

Yet another reason to provide your community with naloxone access and training.

HOPE and PATH have developed several tools and resources for you to use. Access them on the IHS website:

• Download, print and share within your facility and with community partners: Naloxone Keeps the Circle Strong poster.
• Use this training PowerPoint to help community members understand naloxone: Naloxone Community Training slide deck.
• Find an IHS naloxone mentors in your area.
• Utilize the HOPE Committee’s website for a variety of tools and resources to impact drug harms in your community.

HOPE and PATH offer many more resources on this critical issue. Please reach out to us for tailored tools and trainings at [email protected].

This material was prepared by Comagine Health for the American Indian Alaska Native Healthcare Quality Initiative under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. NQIIC-AIHQI-413-08/21/2023