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It is that time of year again. At least for acute care hospitals, long-term acute care (LTAC) hospitals and inpatient rehabilitation facilities (IRF) who report to The National Healthcare Safety Network (NHSN). If annual surveys are not reported by March 1 st , then your organization will not be permitted to enter monthly reporting plans until the annual survey has been completed. Although there are just a few weeks to go, early planning is the key. It is important to consider that responses to the Annual Survey questions are a collaborative effort. Planning a meeting in advance with key stakeholders will help to ease the stress of completing what some may consider to be a daunting task. Be sure to coordinate with Facilities Managers, Pharmacists, Laboratory, Nursing, Infection Prevention and Quality leaders on annual survey responses. Although individuals who are responsible for report submission may find that some of the data has not changed significantly from the previous year, we have identified that some questions have been removed while additional questions have been added. If you are new to NHSN reporting and have not yet completed an annual survey, you will find an alert reminding you on your dashboard upon logging in. Keep in mind that the survey you are completing requires data from the previous calendar year. You will be submitting data for 2024 due March 1 st , 2025. There are a variety of questions that will require information about metrics, facility type, infection prevention practices, laboratory testing methods, water quality management, and antimicrobial stewardship practices for example. Instructions on completing your organization’s annual survey click on the link below that corresponds with your facility type: Instructions for Completing Annual Hospital Survey Instructions for Completing LTAC Annual Survey Instructions for Completing IRF Annual Survey OSHA requires the following facilities to complete an annual occupational injury and Illness Report: Ambulatory Health Care Servies General Medical and Surgical Hospitals Psychiatric and Substance Abuse Hospitals Specialty Hospitals Skilled Nursing Facilities For a complete list of facilities required to report annually via electronic submission and for additional information on Standard 1904 Subpart E Appendix B click on the following link: OSHA Injury and Illness Reporting Requirements . Much like NHSN annual surveys, this reporting is also for the prior calendar year. Your deadline for submission is March 2, 2025. If your organization has not previously been reporting, please note that you will need to set up an Injury Tracking Application (ITA) account. For complete instructions, click on the following link User Guide . Individuals who are responsible for report completion and submission should have a clear understanding of criteria that constitutes a work-related injury. They will also need to know if the employee missed days of work because of injury or illness. If an employee was restricted from usual work activities or reassigned to a new role as a result of the injury or illness this information must be documented. If an employee required care beyond basic first aid, this will also need to be reported. Reporters should not include Protected Health Information (PHI). For a brief tutorial on OSHA annual reporting requirements, click on the following link OSHA Injury and Illness Reporting . Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges. Whether you are in need of mock surveys, leadership training, corrective action plans or ongoing support services, we can help! We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry. Be sure to browse Our Website for a full list of services we provide. Contact us today at +1 (800) 813-7117 to schedule a free consultation. References: https://www.cdc.gov/nhsn/forms/instr/57_103-toi.pd https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904SubpartEAppB https://www.osha.gov/sites/default/files/ita_user_guide.pdf https://www.osha.gov/sites/default/files/osha_rktutorial.pdf

In 2002 The Joint Commission (TJC) first established the National Patient Safety Goals (NPSG) Program. In 2003, TJC rolled out the first set of NPSG’s. Each year, TJC prioritizes patient safety goals for various healthcare programs.

When it comes to delivering radiologic and diagnostic services under The Centers for Medicare & Medicaid Services Conditions of Participation, hospitals need to have policies, procedures and safe practices in place that are centered around delivery of patient services, safety of patients and personnel, qualifications of personnel and record keeping practices.

The holiday season is a wonderful time to celebrate with family and friends. Depending on your level of enthusiasm, you may be someone who prepares for celebrations’ month in advance.

Those who work in a healthcare setting are well aware of Infection Prevention (IP) strategies. Protecting patients and employees should be at the forefront of all IP Programs in order for them to be successful and minimize risk of harm.

With Flu season in full swing and Covid cases on the rise, it is important to understand updated, mandatory reporting requirements for hospitals as well as critical access hospitals. The National Healthcare and Safety Network (NHSN) is working to prepare facilities for new reporting requirements through web-based education.

Hazardous Materials are commonly used in the healthcare environment. Safe handling, storage and disposal are key considerations for safe management of such materials. Another important consideration is what personal protective equipment should be worn when handling these items.

If you are in a leadership position in the healthcare environment today, you are no stranger to the issues surrounding staffing shortages.

An area that is sometimes overlooked in hospitals is Food and Dietetic Services. It is important for CMS providers to fully understand the § 482.28 Condition of participation: Food and Dietetic Services requirements. In smaller hospitals, it is not uncommon for these services to be contracted.

Environmental Services (EVS) is an essential component of healthcare operations. Maintaining sanitary conditions is a critical element of a successful Infection Prevention Program. It is a very common practice for healthcare facilities to contract these services.

NFPA 101 is a set of standards developed to ensure that safety of patients, visitors, and staff in a variety of facilities including healthcare.

Considerations for Using Biological Implants in Surgery

If your facility is enrolled in the National Healthcare Safety Network (NHSN), then submitting an annual facility survey for the previous year is a requirement. If your facility was not operational in 2023 but you are enrolling, this information must be provided at the time of enrollment. The deadline for completion is March 1 st of each calendar year. If your facility has been operational, it is important to update the survey to accurately address various components of the survey based on the previous year. There are a variety of online educational modules available to assist facilities through the completion process. You will also find instructions for completing the survey. You can find this information on the Centers for Disease Control and Prevention (CDC) website It is best to begin working on the survey well in advance of the deadline for submission. We recommend reviewing all components of the survey and delegating review and completion to personnel that oversee corresponding departments. Assistance from leadership from the following departments will be needed to complete the survey: Infection Prevention Microbiology/Lab Quality Pharmacy Nursing Facilities Medical Records Contractors, if applicable

JANAUARY 1, 2024 Tips For Your Facilities’ New Year’s Resolutions! Don’t break these, your facility needs them!

In our final issue for 2023, we focus on guidelines and basics for patient safety regarding EOC, life safety, and NFPA regulations. Start your New Year off by checking off these important reminders

In our November Edition, we highlight the safety & compliance aspects of Surgical Implants. We discuss regulations and the challenges associated with this growing field and what topics or questions should be addressed by the hospital/facility.

In our October Newsletter, we provide an overview of compliance for USP 797 & 800 that you must be in compliance with starting November 1st. We also provide a couple of documents from Agencies or Accrediting Bodies that can assist you in your mission.

In our September issue, we discuss why Medical Staff Credentialing is so important for the provider AND the facility. We share evidence of shortcuts taken and the result in not just financial terms but also patient and staff safety.

In this month's newsletter we discuss and provide resources for handling a fire on the table and ways to prevent them.

For this month, we decided to focus on ultrasound disinfection and to revisit the idea of your facility following best practice and the manufacturer's IFUs. Do not forget to take a moment and view your own policies and procedures.

For our June newsletter, we offer information and tips on an often overlooked department and service... Nutritional Service

In this month's edition, we discuss the current trend of using expired medical supplies and give some questions that facilities and leadership should ask before using them.

In our April issue, we discuss the two main code alerts being used in healthcare along with our findings and further research summaries.

In this month's newsletter, we discuss topics and tips for implementing and reviewing your Quality Improvement plan. The five topics are broken down and also give tools for your facility to utilize in order to have a more structured and thorough plan.

In our February newsletter, we discuss Ransomware in the healthcare industry. We highlight why and offer a few suggestions including Education and Training for when a down-time occurs. Links to assessment tools are also provided.

In the first newsletter of 2023, we discuss The Joint Commissions updated patient safety goals for healthcare facilities. We highlight a few and encourage you to familiarize your team members with what the TJC deems high priority.

In our final newsletter of 2022, we discuss the reasons to evaluate your current QAPI Program and the benefits than can come from the review.

In our November newsletter, we discuss Social Media policy, procedures, and considerations for your facility, patients, and workers.

In our October newsletter, we detail suggestions and considerations for your facility when decorating for the holidays.