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Tips For Your Facilities’ New Year’s Resolutions!
JANAUARY 1, 2024
Tips For Your Facilities’ New Year’s Resolutions!
Don’t break these, your facility needs them!
Setting regulatory compliance resolutions for healthcare facilities is crucial to ensure the delivery of high-quality, safe, and effective healthcare services. Here are some potential New Year's resolutions for your facility in terms of regulatory compliance:
1. Stay Informed about Regulatory Changes:
- Resolve to stay updated on any changes in healthcare regulations at the local, state, and federal levels.
- Regularly check for updates from regulatory bodies such as the Centers for Medicare & Medicaid Services (CMS), CIHQ, or other relevant authorities.
2. Regular Compliance Audits:
- Commit to conducting regular internal compliance audits to identify and address any potential issues before they become larger problems.
- Ensure that staff members are aware of compliance standards and actively participate in the audit process.
3. Training and Education Programs:
- Develop a resolution to provide ongoing training and education programs for staff to keep them informed about regulatory requirements and changes.
- Implement a system to track and document staff training to ensure everyone is up-to-date on compliance issues.
4. Enhance Data Security Measures:
- Focus on strengthening data security to comply with regulations such as the Health Insurance Portability and Accountability Act (HIPAA).
- Invest in technologies and processes to safeguard patient information and maintain privacy.
5. Improve Documentation and Record Keeping:
- Commit to improving documentation processes to ensure accurate and complete record-keeping, which is essential for compliance.
- Implement electronic health records (EHR) systems if not already in place to enhance accuracy and accessibility.
6. Ensure Patient Safety Standards:
- Make a resolution to prioritize patient safety by adhering to standards set by CMS or accrediting bodies like CIHQ or TJC.
- Regularly review and update safety protocols to reflect the latest best practices.
7. Emergency Preparedness:
- Develop and/or update emergency preparedness plans in compliance with regulatory requirements.
- Conduct drills and training sessions to ensure staff are familiar with emergency procedures.
8. Enhance Quality Improvement Initiatives:
- Resolve to actively participate in quality improvement initiatives to enhance patient care and meet regulatory standards.
- Use data-driven approaches to identify areas for improvement and implement corrective actions.
9. Engage in Collaborative Partnerships:
- Collaborate with other healthcare organizations and professionals to share best practices and stay informed about industry trends and changes.
- Attend conferences, workshops, and webinars to network and gain insights into regulatory compliance.
10. Review and Update Policies and Procedures:
- Regularly review and update policies and procedures to reflect the current regulatory environment.
- Communicate any changes to staff and ensure they understand and follow the updated protocols.
By incorporating these resolutions into your overall operational plan, you can promote a culture of compliance, ultimately benefiting patient outcomes and overall healthcare quality
Regular reassessment and adjustment of these resolutions will contribute to the ongoing success of regulatory compliance efforts.
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.
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