Looking forward: Expect the next decade to focus on coping with new technology and old problems
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January 12, 2020
by A.J. Plunkett (firstname.lastname@example.org)
Healthcare compliance changed quite a bit in the last decade. For one thing, fire safety moved into the current millennium with the adoption of the 2012 versions of NFPA 101 Life Safety Code® (LSC) and NFPA 99 Health Care Facilities Code®.
OK, technically only the use of the 1999 version of NFPA 99 qualified as the last millennium, but using the 2000 version of NFPA 101 was close enough to the last millennium to have endlessly frustrated facilities managers and accreditation professionals who had to juggle other jurisdictions having authority that had adopted later versions. CMS did finally catch up with the formal adoption of the 2012 versions of both fire safety codes in 2016.
That was just one of the key challenges of the decade spanning 2010-2019. There was the push to reduce hospital-acquired conditions, highlighted by what seemed like an all-out war with infections such as Clostridium difficile (C. diff), influenza, Staphylococcus, Legionella, molds, and any and all microorganisms clinging to life on various hard-to-clean medical devices like endoscopes and surgical instruments. There were concerns about sterile compounding and the safety of medication administration.
Then there were the outside infections that prompted what sometimes seemed like extreme measures throughout healthcare systems: the many varieties of influenza, then Ebola, then measles, and back to influenza.
There were the natural and not-so-natural disasters that prompted an overhaul of emergency preparedness in healthcare: the terrorist attacks at the Boston Marathon; the hurricanes and storms named Maria, Michael, Sandy, and Harvey, as well as the dozens of others that flew in and out. And there were the wildfires and the snowstorms and the flooding.
Hospitals and other healthcare organizations fought for balance in an economy that produced a necessary but imperfect overhaul of how the nation pays for its healthcare. They also found themselves in the middle of other battles within their communities: a rising suicide rate, a shocking addiction to opioids, and an epidemic of mass-casualty shootings.
All of those battles dwarfed what should be the focus of healthcare compliance—patient safety initiatives such as:
- Ensuring patients don’t fall during their hospital visits (or at home afterward from a misunderstanding of medications)
- Reducing the number of alarms that keep those patients awake and the staff numb to hearing real dangers
- Improving the medical plans for patients upon discharge to keep them on the road to recovery and out of the hospitals for readmission
- Preventing adverse events with medication and in surgical suites that do more harm than good
- Keeping up with technological advances such as electronic health records and cybersecurity
- Working to keep hospitals cleaner and hands consistently washed to prevent the spread of infections
So what of the 2020s? There will be many things that will build on past accomplishments—and challenges. And there are already new patient safety initiatives.
Here are some thoughts on what you can expect going forward.
The growing use of technology in medical care and compliance will continue to provide improvements and challenges for healthcare providers.
One of the biggest changes in the last decade was “the widespread shift to use of technology for medical records—including electronic order entry and documentation of medication administration as well as credentialing and privileging. Each of these has had a significant impact with mixed results for standards compliance,” said Karen Beem, MS, RN, and Deanna Scatena, RN, with HFAP Standards Interpretation, via email.
“For example, the documentation of patient care, which was a largely manual process, is now a mostly electronic process. Among the beneficial results are the speed and standardization of documentation, the reduction of errors due to transcription and legibility issues, improvement in multidisciplinary care through accessibility, and better control of confidential information. The challenge of limiting access with paper charting is largely solved by electronic charting that embeds better controls for restriction of use to authorized individuals,” noted Beem and Scatena.
“In the past decade, mergers and acquisitions of individual hospitals by healthcare systems have led to standardization of operations, policies, practices, training, and even accreditation activities. The credentialing and privileging of professional staff which had always been a challenge, for example, is increasingly coordinated through a centralized and integrated process.”
“All in all, this shift to greater use of technology has led to largely improved compliance with documentation requirements. Remaining challenges include inevitable human error, as when a ‘copy and paste’ approach to data entry results in the advancement of inaccurate information. And overreliance on electronic documentation also has the potential to shift focus from the patient to the screen. HFAP is always looking for evidence of patient-centered care through direct observation and interviews,” said the HFAP executives.
The future holds even more challenges, they said.
For instance, consider “the adoption of technology such as blockchain for demonstrating compliance in areas like credentialing and privileging of medical staff. This technology has potential to improve a highly redundant process, but the capabilities are yet to be fully realized by healthcare,” Beem and Scatena wrote.
Expect technology to have a growing impact on the physical environment as well.
“Certainly, innovations in technology (for those that can access it) have been a big part of the picture, from tablet-based apps that can be used for documenting rounds and follow-up to ‘smarter’ building systems that allow much greater flexibility in providing a safe, comfortable environment,” said Steve MacArthur, safety consultant for The Greeley Company.
Meanwhile, the growing use of electronic devices, both personal and as part of the job, will continue to be a challenge for cybersecurity, infection control, and overall patient safety.
ECRI Institute identified home healthcare devices as one of the top technology hazards for 2020. “Interruption in transfer of patient monitoring data from cybersecurity issues can lead to misdiagnosis or delayed care,” warned ECRI.
Dan Scungio, MT(ASCP), SLS, laboratory safety officer for Sentara Healthcare, notes new technology is great in the laboratory setting, but it’s also an infection control challenge.
Personal electronic devices—specifically smart watches and fitness trackers—“along with cell phones, remain a source for lab-acquired infections, though are largely unreported,” said Scungio.
“As technology moves along, what new devices will be used and how will we use them in the lab? For example, people want to use tablets to perform audits, but those items shouldn’t be brought in and out of lab areas. What new items will emerge?”
While the 2012 versions of the NFPA’s key healthcare fire codes were adopted in 2016, expect accrediting organizations (AO)—The Joint Commission (TJC), the Healthcare Facilities Accreditation Program (HFAP), DNV GL, and the Center for Improvement in Healthcare Quality (CIHQ)—to keep making changes to the standards at CMS’ request.
CMS also will continue to put pressure on AOs to find more physical environment and fire safety problems in hospitals as the agency evaluates the AOs’ work and reports to Congress.
“The biggest change over the last decade (and this covers pretty much all of healthcare) is the focus on the management of risk in the physical environment as a cornerstone of regulatory survey activities,” says MacArthur.
“It is difficult to quantify the level of knowledge on the part of the surveyors. The agencies will tell you that their surveyors are quite competent in providing oversight in the physical environment; the organizations being surveyed will likely continue to be underwhelmed by the knowledge and skills of the surveyor cadres. However, the reality is certainly somewhere in the middle and probably closer to the lower end of the scale than is useful, but I guess you can’t improve if there are no improvements to be made. However, it is clear that safety in all its permutations will continue to be a focus for the foreseeable future,” MacArthur said, via email.
“I think issues relative to environmental quality (water, air, etc.) are going to continue to be potential hot-button areas for consideration,” he said. “I guess the overarching thing is that keeping up to date on the ever-changing regulatory landscape is going to be more important than ever.”
“While many people may say that the change from the 2000 edition of the LSC to the 2012 edition of the LSC was the biggest change in healthcare life safety (and it certainly was a major change),” says Brad Keyes, CHSP, owner of Keyes Life Safety Compliance. “I believe the biggest change is how CMS has stepped up to take control of the way the LSC is being enforced by the accreditation organizations.”
“For years, the AOs (The Joint Commission, HFAP, DNV, AAAHC, etc.) have been surveying healthcare facilities with little more than a cursory nod toward life safety compliance, which resulted in a false sense of belief by hospital, nursing home, and surgery center administrators that their facilities were in excellent shape. These same healthcare facilities that received such positive reviews by the accreditation surveyors began to receive scathing surveys from the state agencies, who survey on behalf of CMS, and rightfully so,” said Keyes.
“The state agencies were finding deep-seated problems with compliance with the LSC, such as incorrect construction types, dead-end corridors that exceeded the maximum length allowed, and improper usage of magnetic locks on doors as the means of egress.”
“Now, CMS has cracked down on the AOs and are holding them accountable for failing to cite life safety deficiencies that the state agencies find only weeks later. This has resulted in tougher life safety surveys by the AOs during the past decade, and will likely only get more difficult for healthcare in the years to come,” said Keyes.
The focus on ligature risk will also likely be a CMS priority.
Look for regulations from CMS and other agencies to continue to be updated and implemented, especially in areas around medication management and worker safety.
The past decade has seen the push for (and the final publication late last year) of EPA regulations to manage the disposal of hazardous waste pharmaceuticals. While some parts of the EPA rule have already gone into effect, requirements for state adoption will mean a slow rollout of all the new regulations over the next couple of years.
Meanwhile, the U.S. Pharmacopeia (USP) is implementing revisions and new standards on sterile and non-sterile pharmaceutical compounding as well as the protection of staff in the handling of hazardous drugs.
Expect “clearer and more unified safety regulations across regulatory agencies,” warned Scungio. “CAP standards should better match OSHA, for example. It would be great if new safety documents create clearer guidelines for certain safety issues. For example, define clean and dirty spaces, etc.”
As regulations continue to change, there could also be problems with surveyors from different organizations in how those requirements are assessed.
Over the past few years, there have been “inconsistent editions of codes/standards being enforced,” said Paul Dzurinda, CFPS, CHSP, director of life safety and quality at RPA.
“Since it takes so long for CMS to adopt newer editions of codes, there are oftentimes conflicts in requirements between state codes (IBC, IFC) and the LSC and those standards referenced by the LSC,” he said.
“Another challenge is the inconsistent interpretation and application of codes/standards among AHJs [authorities having jurisdiction]. There are wasted dollars spent on remediating ‘deficiencies’ cited by AHJs for items that are not true violations of the codes/standards. Increased education for AHJs will help with this problem,” Dzurinda said.
Antimicrobial stewardship will continue to take more resources as the CDC, CMS, and AOs continue the charge to reduce the use of antibiotics that is creating “superbugs” resistant to their effectiveness.
Conditions of Participation (CoP) revisions published in September revised and added to the Infection Control CoP—now called Infection Prevention and Control and Antibiotic Stewardship Program. The expanded CoP calls for hospitals to have a documented antibiotic stewardship program that “must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable,” and must include collaboration “with the hospital-wide quality assessment and performance improvement (QAPI) program.”
In November, a CDC report found that antibiotic-resistant (AR) bacteria and fungi cause more than 2.8 million infections and 35,000 deaths per year in the U.S., and warned that the rate of deaths from AR infections was nearly double what CDC originally reported in 2013.
Meanwhile, the FDA continues to explore and approve new medical devices that are easier to disinfect, even as it clamps down on the industry to ensure safer devices.
Look also for TJC and other AOs to continue to push infection control as not just a clinical but overall physical environment and hospital concern.
The more things change ...
Expect the 2020s to also be more of the same, even as there are changes, the experts say.
“Not new, but an ongoing concern, especially in an era of trying to do more with less, is oversight of contracted services,” said HFAP’s Beem and Scatena. “Specifically, healthcare organizations need to attach quality metrics to contracted services and monitor these performance indicators through the QAPI program.”
Quality monitoring will factor into more survey concerns, as CMS continues a trend of pushing for more evidence-based performance improvement.
Marshalling information on an array of improvements across the hospital and getting it into the hands of those who need it will also be a key challenge.
“Hospitals have always been data-rich environments,” said Beem and Scatena. “Avoiding siloes of those who work with data and those who work with patients is a communications challenge that will need to be met. Integrating communications between patient care services, IT, and leadership up to and including governance is critical to quality – which is the ultimate goal of compliance.”
Resources to do all these things will remain tight, however, especially as facilities need to update buildings and services.
“Renovating our facilities and continuing healthcare construction projects is going to be a challenge. Budgets are tight and many of our existing facilities are aging and need rehabilitation or even replacement,” said Alex Zivnuska, PE, CHFM, project manager at Code Consultants.
“I personally see rehabbing our facilities and the systems in our facilities as a direct contribution to patient care. From our out-of-date patient wings, to our aging building infrastructure, to the expansion of technology, an investment in the more than 75 million baby boomers needing care is an obligation we all share.”