May PHC Newsletter

by dawnconrey
Patton Healthcare Consultants

Accreditation – Compliance – Patient Safety

May 2020

Inside This Issue

  • Returning to Normalcy?
  • Perspectives
    • ORYX Temporary Modifications
    • Direct Data Submission Program
    • Perinatal Care Delay
    • Consistent Interpretation
    • Face Masks
    • Emergency Management Note
  • EC News
    • Special Pathogens, Emerging Infectious
    • Disease Program
    • COVID-19, Patient Separation and Preparedness
  • CMS
    •  Freestanding EDs
    •  EM Critique Form

May 2020 PHC Newsletter

Returning to Normalcy?

Hopefully by now things are either calming down in your area and/or your elective business is restarting. We also hope that you and your families have stayed well personally during the pandemic. A hot topic during the crisis has been waivers, and CMS continues to add to them.  The list of all program waivers is now up to 36 pages long. The entire list remains available at:

These waivers continue as long as the national emergency continues, and we hear rumors that some may become permanent changes even after the national emergency ends.

We participated in the Joint Commission’s consultant forum at the end of April and it looks like they will not resume normal volume of surveys for quite some time. As you would expect, they are looking for ways to evaluate the safety of the area and organization where surveys are due and how to protect your organization by maintaining a healthy surveyor workforce. We will employ similar strategies when we resume our onsite consultations.

The best news we heard during that forum is that when surveys do restart, the surveyors will not be looking at any records during the national emergency.

One of the issues we have been anticipating when surveys restart is a potential enhanced focus on the EM and IC chapters relative to an influx of infectious patients. TJC confirmed during the forum that they are indeed analyzing these very same issues. One of the opportunities that will arise from implementing your disaster plans during the COVID-19 outbreak is the opportunity to do a thorough evaluation of your disaster response.

While that might sound tedious, if you do a thorough critique it will eliminate one of this year’s disaster drill requirements; and since this was a community wide actual emergency, it eliminates the more elaborate community-wide drill requirement. You can of course still proceed with your two drills to test the improvements you design after the evaluation of your COVID-19 response.

To help with your evaluation, we have created a template evaluation tool that may be helpful to you (see “EM Critique Form” in the CMS section) . The most important thing from our tool, or others you may have used previously, is to identify what could have been better and what needs to change.


ORYX Temporary Modifications:

The May edition of Perspectives describes temporary modifications to the performance measurement requirements (ORYX) for the purpose of burden reduction. They are making the submission of chart abstracted measures optional at this time.

This optional feature applies to 4th quarter 2019 and 1st and 2nd quarters of 2020. If you have been maintaining your abstraction and want to optionally submit your data, there will basically be a one quarter extension on the deadline to do so.

Direct Data Submission Platform:

2019 was the last year for submission by performance measurement vendors. In 2020, TJC has a new platform for electronic submission they call their Direct Data Submission Platform, or DDS Platform. TJC will be providing a webinar on this on June 9th. If interested in participating in this webinar, take a look at their website and Performance Improvement page for additional information.

Perinatal Care Delay:

TJC also announced a delay in public reporting of their perinatal care measures due to the optional nature of the 4th quarter 2019 data submission. A date when public reporting will now start was not identified.

Certification programs have similar modifications with the 4th quarter 2019 and 1st and 2nd quarters of 2020 being optional. If you do choose to submit anyway, there is no deadline by which that data should be sent.

Face Masks:

face masksPerspectives includes some CDC information describing current thinking on when to use surgical masks and when to use N95 respirators. In addition, TJC has an announcement stating that staff may wear homemade, cloth masks as an extreme measure if the hospital is unable to supply the PPE that is commensurate with the risks to which the staff are exposed. Staff may also bring in their own medical grade PPE if the hospital is unable to supply them. Some staff may want to wear a mask throughout the day and this is also permissible.

Our advice on this guidance is that it should be treated like a time limited waiver used for the duration of this crisis, but not a new policy that will be applicable long term.

Emergency Management Note:

In our March Newsletter we had described the standards changes TJC would be making as a result of the Federal “burden reduction” changes made by CMS. These are summarized in the May edition of Perspectives and the EM changes are the focus of an article in the May EC News. TJC describes that a note that had been unintentionally dropped from EM.03.01.03, EP 3 has been added back in. This standard describes the requirement for a hospital to conduct two emergency management drills a year. As we mentioned earlier in this newsletter, at least one of these drills must be a community-wide exercise. Note 3 for EP 3 states that: “Staff in freestanding buildings classified as a business occupancy, that do not offer emergency services nor are community designated as disaster receiving stations need to conduct only one emergency management exercise annually.”

Unrelated to the Perspectives article we also wanted to point out Note 1 for EP 3. Note 1 states: “If the hospital experiences an actual emergency (natural or man-made) that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale, community based or facility based, functional exercise following the onset of the emergency event.” Thus, the very real experience many of you just went through with COVID-19 can eliminate the community-wide drill for many organizations.

Consistent Interpretation:

Coincidentally this month’s column features 2 elements of performance in EM.03.01.03, EPs 5 and 14 and EP 5 from EM.02.02.15. The guidance/interpretation column identifies what TJC is looking for on survey, but what is really remarkable is that these EPs were scored in only 0.78%, 0.71% and 0.07% of actual TJC surveys last year. In fact, EM.02.02.15 EP 5 was only scored in one hospital survey out of 1412 total surveys in 2019. We anticipate that scoring in this chapter will be substantially higher in the coming year.

EC News:

Special Pathogens, Emerging Infectious Disease Program:

covid ballThe lead article in this month’s EC News is authored by the Senior Assistant VP for Emergency Management in the NYC Health and Hospitals System, an organization that was heavily impacted by the pandemic. He describes that they had developed a special pathogens or emerging infectious disease program in his system. They had gotten ready using patient actors presenting with fictitious symptoms to help the staff understand their roles and responsibilities in caring for patients with such infectious disease symptoms.

 COVID-19,  Patient Separation and Preparedness:

The next article deals more specifically with COVID-19 and provides guidance on keeping infectious patients presenting to the organization separate from noninfectious patients. One TJC suggestion is to design separate emergency room entrances and interior spaces during construction or renovation projects. They also suggest that if patient demand for airborne isolation exceeds capacity, rather than converting single patient rooms into negative pressure rooms, establish a temporary suite and convert an entire multi-bedded suite to airborne isolation.

TJC also provides a preparedness checklist from one of their publications for high consequence infectious diseases. This checklist is designed to help organizations critique their emergency operations plan for emerging infectious disease


Freestanding EDs:

CMS published one new QSO memo on April 21, QSO 20-27. This discusses freestanding emergency departments, not affiliated with a hospital, which only exist in four states, Colorado, Delaware, Rhode Island and Texas. The memo addresses additional flexibilities that might be available for these entities to provide inpatient care during the national emergency by affiliating with a hospital or temporarily applying to Medicare to provide this care during the emergency.

EM Critique Form:

Many of the drill evaluations we have seen during consultations are very similar to the EC management plan evaluations some organizations prepare, basically stating that everything worked perfectly. We have heard of many organizations really rallying to the challenge of COVID-19, and rapidly reconfiguring, changing and elevating, or expanding services due to innovative thinking, and long and hard hours on the job. We assume there are many important lessons to be learned from this experience and opportunities to improve the preparation roadmap called an emergency operations plan as a result.

Consultant Corner

Dear Readers,

We give continued thanks to all essential workers and healthy wishes for you, your family, and colleagues.  We are now offering a new program called “Back to Basics:  Survey Readiness Plan.”  This is a hybrid virtual/online support program to assist with assessment and education to meet your needs going forward after this national emergency.  We understand the need for assistance without disrupting your organization or extensive costs, so this program is designed specifically for that purpose.  Contact us today!

Jennifer Cowel, RN MHSA

Kurt Patton, MS RPh

John Rosing, MHA

Mary Cesare-Murphy, PhD