As reported last week in the KHA News blog (article 1, article 2), the United States Pharmacopeia (USP) notified stakeholders that it is postponing the official effective dates of several new and revised standards pertaining to pharmaceutical handling until further notice while it reviews appeals to the standards. KHA urged the USP to delay this implementation and has also urged the Kentucky Board of Pharmacy not to adopt the new USP standards at this time.

The Joint Commission has released an official statement regarding the USP delays:

The Joint Commission is aware of the United States Pharmacopeia (USP) statement released on September 23 regarding the delay of implementation...

As reported yesterday in the KHA News blog, the United States Pharmacopeia (USP) notified stakeholders that it is postponing the official effective dates of several new and revised standards pertaining to pharmaceutical handling until further notice while it reviews appeals to the standards. KHA contacted the Joint Commission this morning to clarify how this would impact their surveys.

Their official statement has not yet been released; however, until the Joint Commission knows more about the delay in implementation of USP 797 and 800 standards, there will be no changes to the way they survey medication compounding.

KHA will distribute any updated information to members as soon as it is available.

On February 19, KHA will host a webinar on Ligature Risks:Ensuring Compliance with the CMS Hospital CoPs and TJC Requirements. This a hot topic, and there is a great deal of survey activity around prevention of suicidal patients from harm or strangulation.

The Joint Commission announced that this is one of the four top areas of focus. The Centers for Medicare and Medicaid Services (CMS) has promulgated requirements for hospitals to prevent ligature risk and self harm from patients that are suicidal. A 13-page memo was issued and the hospital manual was amended on December 29, 2017, to implement these changes. Any hospital that received Medicare, which is most hospitals in America, must implement these changes for all patients.

View the brochure for details and a program agenda. Online registration...

This one-day program will provide valuable information for those individuals who are responsible for creating the best possible Environment of Care and Life Safety programs and must understand the Joint Commission survey methodology and recent changes to the standards. Attendees will be able to implement a practical, continuously compliant program for health care facilities to achieve maximum performance while effectively preparing for unscheduled Joint Commission and Centers for Medicare and Medicaid Services (CMS) surveys. Participants will also receive specific guidance in how to understand and interpret the most serious deficiencies that are common in surveys. Sufficient time will also be provided for questions and discussion.

The event will be held February 27 at the Hilton Garden Inn Northeast in Louisville.

View the brochure...

The Kentucky Society for Healthcare Engineers is hosting a special event on December 7 featuring John Maurer with The Joint Commission and Sharon S. Gilyeat with Koffel Associates where participants will take a deep dive into the current code updates and standards that impact hospital facility managers and engineers in Kentucky.

Major changes  from the Centers for Medicare and Medicaid Services (CMS) have resulted in new and expanded accreditation requirements, and the Joint Commission has just released a number of new standards for 2018. This event will provide insight into how to address these changes.

This will be one of John D. Maurer's first Joint Commission update presentations since becoming director of the accrediting organization. Sharon Gilyeat will provide valuable Life Safety code and compliance updates to help ensure your organization's success.

For more information on registration and sponsorship opportunities, visit https://kshe.site-ym.com/page/lets_talk_code....

Throughout 2017, many changes have and are expected to occur in The Joint Commission Accreditation process and the effects it will have on accredited organizations. With the implementation of the Project REFRESH SAFER Matrix for scoring and the changes related to Pain Management, there will be some interesting challenges for all health care organizations. The Joint Commission Update 2018 on December 12 in Louisville will provide information needed to understand and manage these accreditation process changes. 

Topics to be discussed are:

The Project REFRESH and the SAFER Scoring Matrix Survey Preparation/Tracer Prep, Antimicrobial Stewardship Suicide Risk and Psychiatric Unit tracer information frequently cited and challenging standards 2018 Requirements for Education and Identification of important Electronic Medical Record Navigation Points. View the brochure...

On November 1, KHA will host a webinar to assist hospital staff learn more about the regulations and laws that surround The Joint Commission (TJC) Standard 01.07.01, and help make sure they are in compliance. TJC Leadership Standard 01.07.01 requires the board, senior managers and leaders of the medical staff to have knowledge of various health care laws and regulations.

Because of the health care reform federal law changes, this program will cover the important laws that every hospital should be aware of. It will provide information on how to locate a copy of the laws and the importance of updating policies and procedures to be compliant with these federal laws. This session will also discuss some of the many changes in federal regulations and interpretive guidelines by the Center for Medicare and Medicaid Services (CMS) regarding the hospital conditions of participation (CoPs) which must be followed by every hospital that accepts Medicare or Medicaid.

View the program brochure...

On October 20, KHA will host a seminar to get hospitals up to date on the latest changes in Joint Commission accreditation. The event will be held at the Hilton Garden Inn Louisville Northeast.

Many changes are occurring in the Joint Commission Accreditation process through January 2017, and the changes will have a great deal of impact on accredited organizations. With the implementation of the Project Refresh SAFER Matrix for scoring and the changes related to management of the Plan for Improvement associated with the Statement of Conditions, there will be some interesting challenges for all health care organizations. The Joint Commission Update 2017 seminar will provide information needed to understand and manage these accreditation process changes. Topics to be discussed include the Project Refresh and the SAFER Scoring Matrix, The Plan for Improvement portion of the Statement of Conditions post survey, frequently cited and challenging standards and High Reliability.

The event brochure...

KHA will host a seminar on the Joint Commission Environment of Care (EOC) Standards on March 29 at the Hilton Garden Inn Northeast in Louisville.

This one-day program will offer valuable information on how to use the Environment of Care Committee to improve facility environment of care safety and compliance with the Joint Commission. A well-developed Environment of Care Committee can make a measurable improvement to the safety of hospitals and in outcomes from surveys.

For details, view the brochure. Registration for all KHA events is available by clicking "Events" on the KHA home page, www.kyha.com.

If you need additional information, contact Carol Walters at KHA (cwalters@kyha.com).

The Joint Commission has released its annual Top Performers on Key Quality Measures List, and 24 Kentucky hospitals were recognized for 10 different categories in the report.

Heart Attack

• Baptist Health Madisonville
• Frankfort Regional Medical Center
• Meadowview Regional Medical Center
• Owensboro Health Regional Hospital
• St Elizabeth Edgewoord
• St Elizabeth Florence
• St Elizabeth Fort Thomas
• UK Chandler Medical Center

On May 18, KHREF will host Getting Survey Ready in 2015 for the Physical Environment at the Crowne Plaza Louisville Airport. This one-day program will provide valuable information for those individuals who are responsible for creating the best possible environment of care, emergency management and life safety programs and must understand the 2015 Joint Commission survey methodology.

View the program for detailed information, including the agenda and registration.

If you have any questions, please contact Carol Walters at KHA (502-426-6220 or 800-945-4542 or via email at cwalters@kyha.com).

The Joint Commission and Centers for Medicare and Medicaid Services (CMS) are now focusing on some specific standards that continue to be problematic. These standards make it necessary and timely to present a program on the essentials of Joint Commission readiness. This two-day program, offered by the Kentucky Hospital Research and Education Foundation (KHREF) on November 13-14, will provide a comprehensive review of the accreditation manual for hospitals focusing on such specific problematic topics as National Patient Safety Goals, infection control and leadership/human resources. Attendees will gain a better understanding of how The Joint Commission and CMS are interrelated; where the problematic areas are; and how to have a flawless survey through proper front-end preparation.

For a complete overview of the conference, and to learn how to register, please see the brochure.

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On April 15, KHREF will host Implementing the Best Practices and Programs: Getting "Survey Ready" at the Hilton Garden Inn Louisville.

This one-day program will provide valuable information for those individuals who are responsible for creating the best possible Environment of Care, Emergency Management and Life Safety programs and must understand the 2014 Joint Commission survey methodology and changes to the standards. Information will be provided so attendees will be able to implement a practical, continuously compliant program for health care facilities to achieve maximum performance while effectively preparing for unscheduled Joint Commission and CMS surveys.

View the program brochure for program details. Online registration is available at https://secure.kyha.com/meetingregistration.asp.

For further information, please contact Carol Walters at KHA (502-426-6220 or 800-945-4542 or via e-mail at cwalters@kyha.com).