Your Complete Policy Management Partner
Everything your healthcare organization needs to confidently maintain accreditation compliance.
Robust document control and workflow management software solution
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.
Beverly McKenzie, Compliance Programs Director, IASIS Healthcare
Helpful MCN Healthcare Resources
Unintended Retention of a Foreign Object Tops Joint Commission List of Most Frequently Reported Sentinel Events in 2014
The Joint Commission recently released its Sentinel Event statistics summary for 2014. Unintended retention of foreign object was reported 112 times between January 1, 2014 and December 31, 2014 making it the most often reported sentinel event for this time period. TJC's root cause analysis identified Leadership issues as the top contributing factor for this Sentinel Event.
According to TJC, "Leadership" encompasses areas including but not limited to:
- Organizational planning
- Organizational culture
- Standardization (e.g., clinical practice guidelines)
Unintended retention of foreign objects can have catastrophic consequences including the need for additional surgery or even death. Best practices to consider for the prevention of unintended retention of foreign body include:
- Using a multidisciplinary team to develop policies and procedures that are applicable to all operative and other invasive procedures.
- Ensuring policies are evidenced based using resources published by organizations such as TJC, the World Health Organization, the American College of Surgeons and the Association of periOperative Nurses, No Thing Left Behind.
- Ensuring policies and procedures address the following topics:
o Standardized Counting Procedure
o Wound Opening and Closing Procedures
o Intra-operative Radiographs
o Effective Communication
o Appropriate Documentation
o Safe Use of Assistive Technologies
Included with today's notice are example policies and procedures related to the prevention of unintended retention of a foreign object.
FDA Safety Communication: Problem with Quality of Mammograms at Coastal Diagnostic Center in Pismo Beach, California
The US Food and Drug Administration (FDA) is alerting patients and health care providers who may have referred patients who had mammograms at Coastal Diagnostic Center located in Pismo Beach, California anytime on or after February 24, 2013, about possible problems with the quality of their mammograms.
According to the FDA the results of the mammograms are not necessarily inaccurate, but patients should consider having their mammograms re-evaluated at a Mammography Quality Standards Act (MQSA)-certified facility to determine if the patients need a repeat mammogram or additional medical follow-up.
Patients have the right to request their mammogram and copies of their medical reports from Coastal Diagnostic Center.
The FDA recommends the following for patients who had a mammogram at Coastal Diagnostic Center any time on or after February 24, 2013:
- If you have had a more recent mammogram at a MQSA-certified facility since then, you should follow the recommendations from that facility.
- If you have not had a mammogram at an MQSA-certified facility since then, follow these guidelines:
Please follow the link below for additional information.
- Talk with your health care provider as soon as possible about the need for a follow-up exam.
- If your health care provider recommends a repeat mammogram, it should be done at an MQSA-certified facility to ensure quality and accuracy. A database of MQSA-certified facilities in your area is available online or by calling the National Cancer Institute's (NCI) information number at 1-800-422-6237.
- If you need a repeat mammogram and your health insurance will not pay for it, you can call the National Cancer Institute's (NCI) information number at 1-800-422-6237 for a listing of MQSA-certified facilities near you that will provide free or low- cost mammograms
CMS Issues Proposed FY 2016 Rule for Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System
The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule to update fiscal year (FY) 2016 Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS). The proposed rule, which would apply to approximately 3,400 acute care hospitals and approximately 435 LTCHs, would affect discharges occurring on or after October 1, 2015.
According to CMS, the proposed rule proposes policies that continue a commitment to increasingly shift Medicare payments from volume to value. In addition to updating payment rates, highlights of the proposed rule CMS include:
- An update to the measures used in the Hospital Inpatient Quality Reporting (IQR) Program. CMS proposes to add a total of eight new measures for the FY 2018 payment determination and subsequent years (five clinical episode-based payment measures, one patient safety measure, and two coordination-of-care measures). CMS also proposes to remove nine measures, two of which are suspended, for the FY 2018 payment determination and subsequent years, as well as refine two previously adopted measures to expand measure cohorts.
- CMS proposes to continue updates to the Hospital Value Based Purchasing Program and to expand the number of measures including the addition of a care coordination measure to the FY 2018 program year and a 30-day mortality measure for chronic obstructive pulmonary disease to the FY 2021 program year.
- The proposal of an expanded population for two measures that are already included in the Hospital Acquired Conditions (HAC) Reduction Program, an adjustment to the relative contribution of each domain to the Total HAC Score, and an extraordinary circumstances exception (ECE) policy.
- For the Hospital Readmissions Reduction Program CMS proposes the implementation of a refinement of the pneumonia (PN) readmission measure to expand the measure cohort and the formal adoption of an extraordinary circumstance exception (ECE) policy.
Featured Policy Library Manuals
MCN's NEW Ambulatory Surgical Center/Outpatient Surgery Department Policy and Procedure Manual is cross referenced to TJC standards, AAAHC standards and CMS regulations. Policies and procedures meet AORN and CDC recommendations and guidelines. This comprehensive reference guide has over 290 policies and procedures that are ready to customize to your organization. See also the Administrative Manual for Ambulatory Care Facilities and the Ambulatory Services EOC Manual.Read more »
MCN Healthcare’s Home Health Policy and Procedure Manual provides over 400 policies and procedures addressing administration, emergency management, human resources, medical records, infection control, safety and security, equipment management, medication management, performance improvement, patient rights and responsibilities, waived testing as well as patient care. The Home Health Policy and Procedure Manual is cross referenced to CMS regulations, TJC, ACHC, and CHAP standards.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 »