QOTW – QUESTION OF THE WEEK: Changes in Standards for Diagnostic Imaging Services

What is the implementation date for The Joint Commission standard changes for diagnostic imaging services?

The first effective date for standard changes is July 1, 2014.  Other changes in requirements will be phased in by 2015.  These changes affect hospitals, critical access hospitals and ambulatory care healthcare organizations that provide diagnostic imaging services.

The changes in requirements effective July 1, 2014 include CT, nuclear medicine, PET, and MRI services.  Changes in standards that will be phased in by 2015 include fluoroscopy, qualifications for those radiology technologists and cone beam CT.

MCN’s StayAlert! will be reviewing these standard changes as well as providing applicable policies and procedures

Related Products from MCN:
Imaging Services Policy and Procedure Manual

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MCN Learning: Surge of Violence

Nursing social media sites have been buzzing about the recent attention being given to bullying in healthcare. But now a new issue has surface – violence against nurses. Recently two events occurred in California where nurses were stabbed by patients. One of these nurses is in critical condition. The other has non-life-threatening injuries.

Regardless of the level of injury, attacks being made on nursing staff are an issue that cannot be ignored. Many healthcare organizations have security checkpoints, similar to airport security checkpoints, where anyone who comes into the hospital has to be cleared prior to gaining access to the facility. Apparently these security checkpoints are not enough.

Just a few weeks ago several nurses were attacked by patients in hospitals in New York City. One of these nurses has a critical head injury. The frequency of these attacks is unsettling. What once may have been considered a relatively “safe” industry to work, healthcare is quickly mirroring the overall increase of violence in society.

Fortunately individual states have acted on this increase in violence to nurses. Twenty states have passed laws that inflict penalties on individuals who assault nurses. But only seven states provide educational sessions to help hospital employees recognize potentially violent patients.

However there is another part to this issue that is not universally discussed. Bullying in nursing has been occurring for decades. Oftentimes bullying has been ignored or treated as a “rite of passage” within the profession. Additional studies are being conducted by nurse researchers to try to understand why bullying occurs and what can be done to combat it. Until additional information is available, the epidemic of bullying continues.

Bullying has been identified as the reason for school students to “act out” with violence against other students and school teachers. Now, bullying is being used as a reason for violence against nurses. It appears that society is becoming more, and not less, aggressive and violent.

As a fellow nurse, it is disheartening to read and learn of the extent of violence to nurses. Nurses are self-sacrificing individuals who put the needs of others before their own. Besides being unique, they are expected to provide care to all walks of life, regardless of the situation or health condition. And in doing so, nurses often place their own health in jeopardy in order to support someone else.

Even though Nurse’s Day is a still a few weeks away, I think that it is time for more people to acknowledge the role of the nurse – not just in healthcare but in society. Regardless of the setting, nurses bring to the table compassion, understanding, and empathy. Nurses approach issues and situations methodically and strive to solve problems and challenges with the least amount of stress and angst to others. Nurses do not deserve to be physically attacked, by anyone for any reason.

I realize that violence against any particular societal subset is unacceptable; however very few people will learn about these attacks on nurses through the mainstream media. One or two nurses being attacked is not newsworthy enough for prime time. I disagree. Any attack on any nurse should be broadcasted to any and all who want to listen.

As usual there are no easy answers to this issue. Nurses work in a variety of settings and have, for years, been instructed and counseled on ways to ensure personal protection. In the past, this education had been sufficient. Unfortunately today that is not the case.

Hopefully with more states getting involved the frequency of violence against nurses will subside. One can only hope that this reduction will then be mirrored by society and civility will become the rule instead of the exception. Until that happens, embrace the day!

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QOTW – QUESTION OF THE WEEK: ASC’s Governing Body and ASC Policies

What is the CMS regulation that addresses the responsibilities of an ASC’s Governing Body and the ASC’s policies and procedures?

CMS (§416.41) requires Ambulatory Surgical Centers (ASC) to have a governing body that assumes full legal responsibility for determining, implementing, and monitoring policies governing the ASC’s total operation.  The governing body is responsible for establishing the ASC’s policies, making sure that the policies are implemented, and monitoring internal compliance with the ASC’s policies as well as assessing those policies periodically to determine whether they need revised.

The governing body has oversight and accountability for the quality assessment and performance improvement program, ensures that the facility policies and programs are administered so as to provide quality healthcare in a safe environment, and develops and maintains a disaster preparedness plan.

The regulation particularly stresses the responsibility of the governing body for:

  • Direct oversight of the ASC’s quality assessment and performance improvement (QAPI) program
  • The quality of the ASC’s healthcare services
  • The safety of the ASC’s environment; and
  • Development and maintenance of a disaster preparedness plan

In the case of an ASC that has one owner, that individual constitutes the governing body.

Delegations of governing body authority should be documented in writing.

Related Products from MCN:
Ambulatory Surgical Center and Outpatient Surgery Department Policy and Procedure Manual

Policy Manager Automated Workflow Software

Posted in CMS - Centers for Medicare and Medicaid Services, MCN Healthcare, QOTW - Question of The Week | Leave a comment