First Healthcare Compliance CONNECT- February 2018

®
CONNECT
An Exclusive Monthly Publication for Clients
February 2018
Get the
Flu Facts!
Measure
your Quality
of Care
Get compliant
with Hand
Hygiene!
Are you a
Compliance
Super Ninja?

January
2
January
18
February
1
March
1
February April
1
Important Compliance Dates
Starting January 2, 2018, through February 28, 2018, Critical
Access Hospitals and Eligible Hospitals attest for EHR Incentive
through QNet.
As of January 18, 2018, WCAG 2.0 AA Website accessibility and
Section 508 compliance for any organization receiving federal
healthcare dollars. MIPS Improvement Activities - accessibility.
Applicable organizations post OSHA 300A information for employees
through April 30, 2018.
Organizations must report all breaches under 500 for CY2017 by
March 1, 2018.
April 1, 2018 begins the transition period for claim submissions with
new Medicare Cards. Cards will be mailed to beneficiaries April
2018-2019.
Compliance Super Ninja
Terri Councilor
Office Coordinator
Gary S. Ruoff D.O.
How would you describe your experience with First Healthcare Compliance?
Our experience has been excellent. The program has worked very well for us and they are good at getting back to us
with information. The training has also been beneficial for us - I don’t have to go searching for it, it’s all right there.
What do you enjoy most about working with your office?
We are a busy office with an exceptional group of people. They are all team players and what we foster within our team
transcends out to our patients. We prioritize consistent availability to our patients through a team effort.
Would you rather be completely invisible for one day or be able to fly for
one day?
I would rather be able to fly for one day. There are a lot of things I haven’t seen
and this way I could take it all in from a different perspective.
July
1
February October
1
By July 1, 2018 for organizations with 20-249 employees in high
risk NAICS and ≥250 employees must electronically submit 2017
OSHA 300A form.
By October 1, 2018 Bundle Payments for Care Improvement
Advanced Voluntary Bundled Payment Model.
Each month we highlight one exceptional compliance
professional chosen by our client services team. If our team
notices your compliance chops, you might be the next Ninja!
In This Issue:
Important Compliance Dates
Compliance Super Ninja
Get the Flu Facts!
How to Prevent Noncompliance with Hand Hygiene
Quality Measurement in Practice with Reid Kiser
System Updates
Conquer Patient Safety Challenges with CRPs
Upcoming Learning Opportunities
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By Jill Brooks, MD, CHCO
• High number of opportunities for hand hygiene per
hour of patient care
Self-reported factors
• Handwashing agents cause irritation and dryness
• Sinks are inconveniently located/shortage of sinks
• Lack of soap and paper towels
• Often too busy/insufficient time
• Understaffing/overcrowding
• Patient needs take priority
• Hand hygiene affects healthcare workers relationship
with patient
• Low risk of acquiring infection from patients
• Wearing of gloves/belief that glove use obviates need
for hand hygiene
• Lack of knowledge of protocols/guidelines
• Not thinking about it/Forgetfulness
• No role model from colleagues or superiors
• Skepticism regarding the value of hand hygiene
• Disagreement with the recommendation
• Lack of scientific information on definitive impact
First and foremost, a culture of patient safety must be
adopted by the entire organization. Hand hygiene must
be an organization-wide priority. Staff training should
include the importance of hand hygiene in the healthcare
setting and the use of appropriate engineering and
work practice controls. Frequent reminders are always
helpful -signage, staff meetings and emails – to promote
the significance of hand hygiene to the organization and
patient safety. Periodic monitoring of each individual’s
hand hygiene techniques should be incorporated into
the program to achieve success. Individual and organizational
compliance with hand hygiene practices should
be recognized and rewarded, and noncompliance should
be addressed with sanctions. Continuous evaluation of
the organization’s hand hygiene program is necessary to
assess the effectiveness of the program, revising policies
and procedures when necessary to improve compliance.
Need information on proper hand hygiene techniques?
First Healthcare Compliance offers the following
resources for your hand hygiene program and patient
safety posters.
The Centers for Disease Control and Prevention (CDC) reports approx-
Time’s up for each healthcare worker to be aware of their significant
imately 1.7 million health care-associated infections (HAIs) each year,
role in prevention of HAIs with diligent hand hygiene. As of January 1,
many of which are attributed to transmission by health care person-
2018, surveyors for The Joint Commission focus on noncompliance
nel. All health care personnel must be compliant with hand hygiene to
prevent avoidable health care- associated infections (HAIs). However,
implementation of a hand hygiene program in a healthcare facility
is only the first step– but that alone will no longer meet compliance
requirements. The Joint Commission’s heightened focus on hand
hygiene this year will require further efforts for both employers and
employees.
It’s been over a decade since The Joint Commission established the
National Patient Safety Goal (NPSG.07.01.01) for healthcare organizations,
requiring compliance with the CDC or World Health Organization
hand hygiene guidelines. Specifically, this NPSG includes the following:
• implement a hand hygiene program
• set goals for improving compliance with the program
• monitor the success of those plans
• steadily improve the results through appropriate actions
with Infection Prevention and Control Standard IC.02.02.02, EP2, citing
accredited programs for any individuals failing to perform hand hygiene
while involved with direct patient care.
Healthcare organizations must address any barriers to an effective
hand hygiene program, particularly those that may result in an individual’s
suboptimal or lack of hand hygiene during patient care activities.
According to the CDC’s Guideline for Hand Hygiene in Health-care
Settings, the following factors are associated with poor adherence to
hand hygiene practices:
Observed risk factors
• Physician status
• Nursing Assistant status
• Male Sex
• Working in an ICU
• Working during the week
Join us on Social Media!
System Updates
We are excited to announce new features coming soon to the
1st Premium solution!
• 24/7/365 anonymous hotline to
reduce the risk of whistleblowers
• Additional reporting via secure url
• Secure document upload,
organization, and storage
• Messages, e-mails, and documents
easily distributed to employees for
attestation and documentation
• Incident reporting and management
across the organization with realtime
updates
Since 2004, The Joint Commission citations primarily focused on
organizations demonstrating a pattern of noncompliance, but this is
• Wearing gowns/gloves
• Automated sink
Contact us today and upgrade your solution!
no longer the case.
• Activities with high risk of cross-transmission
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Podcast
Get the eBook!
Quality Measurement in Practice with Reid Kiser
Catherine Short, Partnership Marketing Specialist at First Healthcare Compliance, hosts Reid Kiser,
Founder and CEO of Kiser Healthcare Solutions, LLC, strategic and business operations consulting
services to healthcare industry stakeholders, for an interactive discussion on “Quality Measurement
in Practice.”
This podcast will provide attendees with an increased understanding of quality measurement so that
they can effectively identify and use measures to improve the quality of care, while keeping in mind
industry’s value-based goals.
When a patient safety incident, medical error or adverse event occurs, patients are
rarely the only victims. Join us to explore the impact on caregivers and understand
the lasting damage to those providers.
®
Objectives:
1. Define quality measurement and today’s drivers of measurement
2. Describe the types of quality measures and practical uses for measures
3. Discuss opportunities to maximize improvement with quality measurement
Looking for the latest compliance insights?
Subscribe to our listen and learn podcasts and don’t miss a thing!
Patient Safety Gaps
Medical Errors and Second Victims
By David M. Sommers MD JD LLM
Read more about:
• Background of Patient Safety Gaps
• Scope of the Problem
• Medical Errors and Accountability
Listen to the First Healthcare Compliance podcast!
Download your copy today!
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COMPLIANCE WORD SEARCH
Join us for The Healthcare
Compliance Symposium 2018!
Thought leaders will provide meaningful insight
on time-sensitive topics including: elements
of a compliance program, HIPAA Privacy and
Security, OSHA, and Human Resources for
compliance. Attendees are eligible to receive CME,
CLE, and CEUs while networking with industry peers.
Register now for Early Bird Pricing!
10 First Healthcare Compliance, LLC © 2018
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The most comprehensive healthcare
compliance course yet!
Improving patient safety, decreasing rates of error, and minimizing
medical liability costs are important objectives of health care reform
in the United States. Many experts believe that to accomplish these
goals, organizations must adopt principles of transparency and just
culture, and engage in effective and honest communication with
patients and families as well as proactively seek early resolution of
claims after adverse events caused by inappropriate care. In recent
years, forward-thinking health systems and liability insurers have
developed communication and resolution programs (CRPs) designed
to encourage full disclosure of unintended patient care outcomes to
patients and their families. Such efforts involve an investigation of the
incident, an apology, an explanation with complete revelation of the
facts, and when appropriate, reimbursement or compensation. These
programs represent a systematic strategy to respond to patients when
something goes awry, and are integral to patient quality and safety. In
part, they are founded on the principles of respect, transparency, and
honesty and may improve patient safety outcomes and quality of care
by providing an introspective review of the occurrence and promoting
learning opportunities from any mistakes, errors, or near misses. CRPs
meet the needs of patients, their families, and caregivers when an
adverse event occurs in patient care, and address any identified patient
safety and quality gaps.
Alternatives to Medical Malpractice Litigation
Many patient safety leaders view these programs as an alternative
to the costly and lengthy malpractice litigation process which fails to
answer fundamental questions about the nature of the harm and basic
details of the incident. Often, the traditional response to patient harm
involves the disclosure of limited information and avoidance of admissions
of fault–a “deny and defend” model. These interactions quickly
turn adversarial, and the open communication normally accorded the
patient-physician relationship is abandoned. For health care providers,
the “deny and defend” paradigm provides little incentive for investigation
of the event because of the fear that a compensable error might
be revealed. Thus, there is no analysis of the event and organizations
are unable to learn how to prevent a similar catastrophe. This loss of a
learning opportunity can derail efforts to improve patient care.
One of the seminal communication and resolution programs was
developed and implemented at the University of Michigan Health
System (UMHS). This “Michigan” model and other programs, mostly
notably the “Seven Pillars” approach at the University of Illinois Medical
Hospital and Health Sciences System (“UIH”), changed the way these
organizations responded to patient injuries and medical malpractice
claims. These programs are known collectively as early settlement
models as opposed to another model involving limited reimbursement,
which typically covers nominal out-of-pocket expenses and loss
of time, and may adjust the billing for services. UMHS’s efforts were
driven by three guiding principles: (1) compensate quickly and fairly,
(2) vigorously defend appropriate care, and (3) reduce patient injury
and claims by learning from mistakes. The health system sought open
communication with patients about an adverse event but also critically
investigated the incident to assess whether the care comported
with the standard of care and was reasonable, offered an apology, and
provided an early offer of compensation when the care fell below the
standard of care or was unreasonable in the circumstances. A multidisciplinary
internal committee reviews the event to determine if the care
provided was medically reasonable and whether the care negatively
affected the outcome. If warranted, peer review, quality improvements,
or additional education and training may be recommended. This program
has successfully reported a reduction in claims, malpractice
lawsuits, median time to claim report to resolution, defense costs, and
average settlement amounts.
UIH adopted a related approach premised upon similar underlying principles
as well as the CANDOR program (communication and optimal
resolution program developed by the Agency for Healthcare Quality
and Research). The “UIH’s Seven Pillars” strategy is characterized
by prompt reporting of the incident, rapid review and investigation by
safety and risk management, early communication with patient and
family (within 15-30 minutes of the unanticipated event), full disclosure,
apology, and a rapid remedy (holding hospital and professional
fees), a focus on learning opportunities and system improvement, data
tracking and evaluation, and education and training. The results of this
program have been profound. Having open and honest communication
with patients and their families and offering an early financial resolution
package after an adverse event has not resulted in significant
liability concerns but has actually led to lower claims, legal fees and
expenses, costs per claim, settlement costs, self-insurance costs, and
mean times to claim closure. These findings closely track the UMHS
experience.
The Fundamentals is a user-friendly, four-module course designed
to help healthcare professionals understand the
essential principles and practices of compliance.
Visit 1sthcc.com/shop to
register today!
Written by our “dream team” of
healthcare providers and attorneys,
The Fundamentals Course is packed
with useful, easy-to-understand
information that covers HIPAA, OSHA,
employment law and enforcement of
Federal healthcare laws. The course
takes less than four hours to complete.
The Compliance Certification Board
(CCB)® has approved this event for up
to 4.4 non-live CCB CEUs.
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Join Us for These Upcoming
Learning Opportunities!
Complimentary CEU Webinars
February 20th @ 12pm ET
Sexual Harassment in the #MeToo Era: What
You Need to Know to Protect Your Business
Lauren E.M. Russell, Esq.
Young, Conaway, Stargatt, and Taylor, LLP
Listen and Learn Podcasts
March 6th @ 12pm ET
Trendspotting- False Claims Act
Enforcement in Health Care
Sean McKenna, Esq. and
Michael McCarthy, Esq.
Featured February 12th
Quality Measurement in Practice
Reid Kiser
Kiser Healthcare Solutions, LLC
Featured February 27th
Medical Waste FAQ
Matt Georgov
ChoiceMed Waste
Now available in our training zone!
CEUs from the following organizations:
AAPC
ADCA
AHCAE
AHIMA
APMBA
ARHCP
HBMA
MAB
NAMAS
NHCLA
PAHCOM
PAHCS
PHIA
PMI
PMRNC
POMAA
Contact our Client Services Team with any questions!
888.54.FIRST or clientservices@1sthcc.com
14
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