The Consultant Forum also provided insight into the increased number of adverse decisions, PDA and AFS, as well as immediate threat to life.
They supplied data on the numbers of PDA, AFS and ITL from 2013 through early July 2018. We noted the ratio of AFS to PDA’s has changed from more AFS to more PDA and the total number of PDA’s has grown each year. In 2017 there were 54 PDA decisions and in the first 6 months of 2018 there have already been 66.
Here is the good news. The Joint Commission improved the process for a time limited PDA. In the past, the PDA led down the path to denial of accreditation absent a successful review hearing panel.
Going back to the 411 discussion above, every PDA decision we have seen did involve problems with high level disinfection or sterilization. In fact, many involved suicide risks and quite a few involved sterile compounding. We have seen dialysis problems much less often, but that may be the newest hot button issue soon to expand.
We should also note every one of the PDA’s we have seen did involve some aspect of pre-cleaning of surgical instruments. They often included the same issue noted above on which they seem to have reversed course.
Also, here is another but much less impactful change we noted. There are an increasing percentage of hospital surveys identified where one or more Medicare Conditions of Participation are noncompliant. This increased from 31% in 2016 to almost 52% in 2018.
Here Is The Good News
But, there is good news. This should lead to increased consistency on validation surveys conducted by the states for the CMS. And, almost all organizations we have worked with were able to clear their condition level findings on the first try.
Joint Commission also announced a change on validation surveys. What’s more, they are conducting some concurrent validation surveys with CMS instead of the usual retrospective validation surveys. They find the consistency increases when the teams are simultaneously evaluating the organization. Thus far CPHQ and DNV have not been part of the pilot. But, CMS perceives the outcome as very positive. So, we expect the future process to include this concurrent activity.
Patton Healthcare Consulting provides Joint Commission Compliance Assistance and a full range of pre-survey and post survey services to healthcare organizations. Contact us to learn more.