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From the C&A Classroom: Getting Up to Speed: Mid-Year Update on TJC & CMS New Requirements and Hot Topics


Jill Ryan, Chief Executive Officer of Courtemanche & Associates, with contributions from Marty Piepoli, Senior Consultant, hosted the June webinar – Getting Up to Speed: Mid-Year Update on TJC & CMS New Requirements and Hot Topics. The webinar focused on four key aspects of accreditation and regulatory compliance – the disparity rate between accrediting organizations and CMS, what’s’ new from CMS, recent FAQs from TJC and a review of TJC’s Top 10 list.

According to CMS, the accepted disparity rate between accrediting organization surveys like TJC, HFAP, DNV and CMS surveys is 20%. Compare that to the fact that the TJC disparity rate in 2013 was 41%, HFAP 67% and DNV 64%, well above 20%. What does this mean? It means that CMS will continue to enhance its oversight of accrediting organizations and hospitals can continue to expect very rigorous surveys. Recent survey activity also demonstrates that there is an increase in repeat findings from previous surveys. Organizations need to know the requirements and standards, especially those top scoring ones.

CMS has recently published several new and revised requirements. A snapshot of these include:

  • In May of 2015, CMS published a new memo on radiologic and nuclear medicine services
  • CMS has issued a temporary withdrawal of requirements for blood and glucose monitoring
  • CMS issued an update on relocatable power strips

TJC issues frequently asked questions (FAQs) on their public access website. Jill Ryan encourages organizations to check the site regularly to learn about key standards interpretations. One recent FAQ pertained to texting of orders. The answer was clear. Texting of orders is not allowed under any circumstance. In HR, there was an update on the requirements for criminal background checks for staff and students and volunteers who function as staff. Visit the TJC FAQ page for more information.

Knowing what is new is key, but there needs to be a refresher on what has been trending frequently. TJC’s “Top 10” scoring was shared and nor surprisingly environment of care, life safety and infection prevention top the list. Whether it is maintaining egress, developing alarm management policies, or having fire safety plans in place, these areas are all highly scrutinized.

All of these standards and requirements help us to keep patients safe. Compliance is the backbone of safety for patients and staff.

Coming Up:

Pre-recorded session to be released August 17, 2015

Getting on Track with the Provision of Care (PC) Requirements: Tackling Those Long-Standing Issues
Healthcare organizations have dedicated intense focus and efforts to improving processes related to falls, restraints, care planning and pain; however, these issues still prevail. This webinar will address the intent of the requirement and provide practical methods for compliance and improved patient outcomes.

Visit C&A’s all-new eClassroom for more information on our current online course offerings!

Jill Ryan

Author Jill Ryan

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