Your Complete Policy Management Partner
Everything your healthcare organization needs to confidently maintain accreditation compliance.
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Simplify & automate policy access, review and approval across your organization
Web-based library of more than 18,000 customizable policy documents
Instantly access up-to-date policies, procedures & forms authored by MCN experts
Automated regulatory notification system of daily email or mobile alerts
Keep current with regulatory changes from more than a dozen federal regulatory bodies, including TJC & NIAHO
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MCN Healthcare has been indispensable to our accreditation compliance efforts. With Policy Manager, Policy Library and StayAlert!, we have peace of mind that our policies will always be up-to-date and easy to locate.
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Helpful MCN Healthcare Resources
The US Food and Drug Administration (FDA) is alerting the public, including women and health care providers, that a nipple aspirate test is not a replacement for mammography, other breast imaging tests, or breast biopsy, and should not be used by itself to screen for or diagnose breast cancer. The FDA is not aware of any valid scientific data to show that a nipple aspirate test by itself is an effective screening tool for any medical condition including the early detection of breast cancer or other breast disease.
Certain manufactures are promoting the use of nipple aspirate tests as a stand-alone evaluation tool for screening and diagnosing breast cancer, claiming they are an alternative to biopsy or mammography. They also claim that a nipple aspirate test can detect pre-cancerous abnormalities and diagnose breast cancer before mammography with just a sample of a few cells. The FDA is concerned that women will believe these misleading claims about a nipple aspirate test and not get mammograms and/or other needed breast imaging tests or biopsies. This may lead to serious adverse health consequences.
Possible health consequences include false negative test results, indicating the absence of breast cancer when cancer exists, and false positive test results, indicating the presence of breast cancer when none exists. False negative results may lead to delayed diagnosis and/or delayed treatment of breast cancer, with increased risk of serious illness or death. False positive results may lead to needless patient anxiety, along with unnecessary additional testing and treatment.
The National Comprehensive Cancer Network (NCCN) 2013 guidelines state that the clinical utility of nipple aspiration is still being evaluated and it should not be used as a breast cancer screening technique.
The FDA recommends that the nipple aspirate test not be used as a substitute for mammography or by itself for breast cancer screening or diagnosis.
Read the MedWatch Safety Alert, including a link to the FDA Safety Communication, at the link below.
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.
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 »