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Keep current with regulatory changes from more than a dozen federal regulatory bodies, including TJC & NIAHO
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Helpful MCN Healthcare Resources
As StayAlert reviewed earlier this year, the Joint Commission (TJC) has implemented a new National Patient Safety Goal (NPSG.06.01.01), effective January 1, 2014, which requires hospitals and critical access hospitals to improve the safety of clinical alarm systems. NPSG.06.01.01 has a two phase implementation and organizations must be in compliance with Elements of Performance 1 and 2 in 2014. Today's notice reviews these first two EPs.
According to TJC, this NPSG addresses clinical alarms that can directly affect patient care, IV machines, ventilators, cardiac monitors, etc. The goal of the first phase is to increase awareness of the risks associated with clinical alarms.
As of July 1, 2014, NPSG.06.01.01 EP 1 requires organizations to establish alarm system safety as a hospital priority.
NPSG.06.01.01 EP 2 requires organizations, throughout 2014, to identify the most important alarm signals to manage based on the following:
- Input from the medical staff and clinical departments
- Risk to patients if the alarm signal is not attended to or if it malfunctions
- Whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue
- Potential for patient harm based on internal incident history
- Published best practices and guidelines
Included with today's notice are tools to assist with compliance with these two Elements of Performance.
The National Coordinator for Health Information Technology (ONC), which coordinates the adoption, implementation, and exchange of Electronic Health Records (EHRs), contracted with RTI International (RTI) to develop recommendations to enhance data protection; increase data validity, accuracy, and integrity; and strengthen fraud protection in EHR technology. The Office of the Inspector General has released a new report, Not All Recommended Safeguards Have Been Implemented in Hospital EHR Technology, that presents the findings of a study evaluating how hospitals receiving EHR Medicare incentive payments, administered by the Centers for Medicare & Medicaid Services (CMS), have implemented the RTI recommended fraud safeguards for EHR technology.
The study found that nearly all hospitals with EHR technology had RTI-recommended audit functions in place, but were not always using them to their full extent. Other finding included:
- All hospitals employed a variety of RTI-recommended user authorization and access controls.
- Nearly all hospitals were using RTI-recommended data transfer safeguards.
- Almost half of hospitals had begun implementing RTI-recommended tools to include patient involvement in anti-fraud efforts.
- Only about one quarter of hospitals had policies regarding the use of the copy-paste feature in EHR technology.
According to OIG, because many hospitals cannot customize the copy-paste feature in EHR technology, the need for policies to govern its use is elevated. OIG acknowledged that the copy and paste feature can be used appropriately and enhance efficiency; however, this feature also poses risks. In the study OIG recommends that CMS work with ONC and hospitals to develop guidelines for using the copy-paste feature in EHR technology. CMS has agreed with this recommendation and states that it will develop guidelines to ensure the feature is used appropriately.
Once CMS issues guidance, StayAlert will publish additional information and applicable policies and procedures.
The Centers for Medicare & Medicaid Services (CMS) has proposed a new timeline for the implementation of meaningful use for the Medicare and Medicaid EHR Incentive Programs and the Office of the National Coordinator for Health Information Technology (ONC) proposed a more regular approach to update ONC's certification regulations.
Under the revised timeline, Stage 2 will be extended through 2016 and Stage 3 will begin in 2017 for those providers that have completed at least two years in Stage 2. The goal of this change is two-fold: first, to allow CMS and ONC to focus efforts on the successful implementation of the enhanced patient engagement, interoperability and health information exchange requirements in Stage 2; and second, to utilize data from Stage 2 participation to inform policy decisions for Stage 3. The phased approach to program participation helps providers move from creating information in Stage 1, to exchanging health information in Stage 2, to focusing on improved outcomes in Stage 3.
According to CMS, this approach allows CMS and ONC to support an aggressive yet smart transition for providers.
Since the American Recovery and Reinvestment Act - which included the creation of the Medicare and Medicaid EHR Incentive Programs - was signed into law, the nation has seen unprecedented growth in the adoption and meaningful use of electronic health records (EHRs). Between 2009 and 2012, EHR adoption nearly doubled among physicians and more than tripled among hospitals. Every month, thousands of providers join the ranks of hospitals and professionals that have adopted or are meaningfully using EHRs. As of October 2013, 85 percent of eligible hospitals and more than six in 10 eligible professionals had received a Medicare or Medicaid EHR incentive payment. Moreover, nine in 10 eligible hospitals and eight in 10 eligible professionals had taken the initial step of registering for the Medicare or Medicaid EHR Incentive Programs as of October 2013.
Featured Policy Library Manuals
MCN Healthcare’s HIPAA Guidelines Policy and Procedure Manual provides policies and procedures addressing the HIPAA Privacy Rule, the HIPAA Security Rule, Notification of Breach of Protected Health Information (HITECH), and Transactions and Code Sets as mandated by the federal government. Policies and procedures include the changes covered in the Omnibus Final Rule, January 2013.Read more »
The Medical Office Policy and Procedure Manual is cross referenced to Joint Commission standards for Ambulatory Care and Primary Care Medical Homes and NCQA standards for Patient Centered Medical Homes. This manual includes policies that meet OSHA requirements for safety and infection control, Human Resources policies and Medical Office Compliance Plan and much more!Read more »
Be sure your organization is in compliance with Joint Commission’s National Patient Safety Goals with MCN's quick, easy-to-use and proven reference guide that addresses each NPSG and associated Elements of Performance. This comprehensive resource tool includes over 140 policies, procedures, forms and implementation tools. Includes policies and procedures for the NEW NPSG.06.01.01!Read more »