According to Becker's Health It, the state of Connecticut has scrapped a software program it spent $20 million developing that was intended to exchange health information and was run by the University of Connecticut, despite the high amount of money that was used in the development and that was promised to be an excellent project for the health system, the Office of Health Strategy canceled the project permanently. At the moment, Connie (Connecticut Health Information Exchange) is using the same software that was developed for the Maryland health system which costs $1 million a year, which is less than what they spent to develop their own system, but, in the end, it is still a high cost.
A hospital information management system doesn’t necessarily have to cost millions of dollars to be excellent, and at MediMizer we have demonstrated an experienced vendor can create affordable software and develop projects tailored to the client which can include from an equipment inventory to IoMT security solutions with really great prices and, above all, excellent results.
In the biomedical and hospital field, much is said about medical devices, maintenance, new medical technology, management, and parts; engineers, technicians, and other staff are also related to the term "nomenclature" specifically to identify medical devices, each medical device in the world regardless of the brand or model has its own identifier code (UDIs), but, who is in charge to establish that codes? Well, the FDA is in charge of that, which is based on the GMDN (The Global Medical Device Nomenclature) that works as an international standard (ISO 15225) and is a non-profit association, whose function is to create a system of agreed descriptors to identify medical devices, which will subsequently receive a UDI.
The GMDN is managed by the GMDN Agency, which is made up of a group of regulators, manufacturers, and providers of medical devices, which are in charge of standardizing the naming and grouping of devices, all in order to improve communication in the hospital environment and help regulators to understand better the use of medical equipment while supporting patient safety.
A UDI is an identifier code created in a readable way for humans and machines that serves to modernize the surveillance of technology and its management, also to facilitate the whole part of marketing and innovation of devices, in order to generate a UDI it is required a GMDN, that is to say, that it is within a very specific category, a UDI, as its name suggests, is unique, however, hundreds of UDIs can share the same GMDN term or code. A GMDN term represents a group of generic medical devices in a database and allows these to be harmonized. A UDI cannot have more than one GMDN term or code, so they try to generate them as detailed as possible.
GMDN term lists and databases are updated daily, new terms are added based on requests from users developing new technology, and some existing terms may be modified to broaden the scope of the term or to indicate that the term became obsolete in case it no longer accurate to describe a product. if you are registered with the GMDN and have a list with the terms that you requested or simply match your interest or products, if they are modified or become obsolete, you will be notified via email. The lists of each licensee or client are private, encrypted with a password, and cannot be seen or accessed by another licensee, likewise, as a user, you do not have access to see the complete list of terms within the GMDN database, rather, it shows you the most relevant codes or that can be useful to you according to your range of products, if you require the more than 24,000 terms within the database, you must request special access, in which you will be granted a 5-digit code to access the full list of terms.
In order to label a medical device with its UDI, the FDA requires that the GMDN term to which the UDI is linked be current, that is, not obsolete. If the equipment was already labeled with its UDI previously and some time has passed and the GMDN term of the UDI becomes obsolete, it is not necessary to relabel the device, it is only necessary to notify the FDA about the new GMDN term in which said medical device is found, In this way, the FDA will update its GUDID (Global Unique Device Identification Database) and the expenses relabeling costs will be avoided.
In the summer of 2021, the FDA released a draft of what would be the final guide for UDIs, after eight years of launching the UDI Rule, aimed at manufacturers (labelers) and issuing agencies accredited by the FDA, the final guide describes the requirements and recommendations so that they meet the objectives of the device identification rule, in the document you will be able to observe the two forms in which a UDI is presented, which are the easy-to-read form and the automatic data capture form through of technology. However, this new guide rejects requests from manufacturers which include changing the way data is displayed and removing data delimiters since the UDI should be the most important data in the label and precede other data. In the new guide, you can also find recommendations for independent software labeling requirements. This restructuring of the guide for IDUs was carried out as a result of hundreds of medical errors that occurred as a result of the incorrect identification of medical devices, which caused confusion about how to use them.
In this post, CMS proposed "public reporting of clinical quality measure data", specifying limited criteria for each type of organization.
According to NPR Health News, April 18, 2017, "The move follows steps CMS took several years ago to post government inspection reports online for nursing homes and some hospitals." Nursing Home Inspect at http://projects.propublica.org/nursing-homes/ allow the public to review deficiencies.
In response, The Joint Commission responded, "The Joint Commission is opposed to the CMS proposal to make all accreditation survey reports (including statements of deficiencies) and acceptable plans of correction publicly available on the websites hosted by accreditation organizations."
We observed on the ProPublica page that the data is not shown relative to patient count, actual incidents, benchmarks or other factors. This does support TJC arguments that it would inhibit participation and cause hospitals to seek deeming organizations that present the friendliest findings.
If the information presented is not uniform and educational, it is possible a member of the public could choose to travel 30 minutes further for a critical heart procedure because an exit door was inappropriately left open or locked according to a report. An assortment of comments on Yelp can be very helpful when selecting a care-giver for dentistry or dermatologist. For critical and long term care, it is good there is a healthy debate taking place about the nature of information to be reported. Maybe the deeming agencies need to be proactive about working with AAMI and similar organizations to standardize public reporting before they are ordered to do so.
Many arguments have been made in support of "transparency."
Whatever reporting is required, the expected benefit should be supported by evidence.
According to the CMS post, these accreditation organizations are affected:
Under CLIA (Clinical Laboratory Improvement Amendments), additional organizations are recognized:
For now, the change is on hold indefinitely. CMS.gov posted on 8-2-1017 in a fact sheet (CMS-1677-F):
"After consideration of the public comments received, CMS decided that it would be best if the proposal was not finalized and instead, the proposal was withdrawn. CMS is committed to ensuring that patients have the ability to review the findings used to determine that a facility meets the health and safety standards required for Medicare participation. However, we believe further review, consideration, and refinement of this proposal is necessary to ensure that CMS establishes requirements, consistent with our statutory authority, that will inform patients and continue to support high quality care."
This single matrix is now used to evaluate risk instead of various criteria that varied by EP. It is a simple 3 level risk evaluation relative to a 3 level scope. The new evaluation has no effect on events that are an immediate threat to life and therefore this is shown above the matrix.
Placement on the matrix is based on surveyor experience, definitions, context and team discussion. "Anchors" are specific examples which have been compared to a pain scale indicating the examples have various levels of severity. We read one report that a "library of anchors" will be produced by TJC over time. (Compass Clinical Consulting, Feb 20, 2017)
If there is an ITL (Immediate Threat to Life), the organization has 72 hours to eliminate the ITL. If it can not be eliminated in that time, an emergency plan that can take up to 23 days (including the 72 hours) to complete.
In all other cases, there are 60 days to show evidence of compliance, including Who, What, When and How.
For non-compliance in the red or dark orange regions, the evidence much also include leadership involvement and preventive analysis. Also these will be consider for special consideration in future surveys through the next full survey.
Leadership involvements looks first at the sustainability of changes and support from the top levels of leadership. Examples give of support are providing resources, speaking out on behalf of the change and establishing plans for period measurement of and reporting on the changes.
Preventive analysis assures that the corrective action is global and not only a solution for the specific case. The analysis reviews underlying reasons. The focus is in preventing future incidents.
The SAFER matrix applies to the entire organization and results will be included in the report as the EC (Environment of Care) rules cited displayed on the matrix. If examples or one EP fit into more than one risk group, it will appear in the most severe group.
Initial evaluation (June 2016) roughly estimated about a fifth of findings were in the widespread and about 2/5ths were limited. The JC Extranet site further defines Likely as harm that can happen at any time without any contributing factors. Moderate likelihood may require other contributing factors or conditions.
(Key Sources: Presentations by George Mills and Caroline Heskett of The Joint Commission 2016-2017)
Relevant information presented by TJC (The Joint Commission) before 2017:
For the past several years, facilities management and hospital safety have been under a microscope during Joint Commission surveys, particularly since the addition of dedicated Life Safety Code surveyors whose sole responsibility is to review the physical environment for compliance with safety standards. Joint Commission surveys are no longer on a set schedule--while they are approximately triennial, surveyors can arrive unannounced and without warning at any time, requiring organizations to be in a state of continual readiness. Leadership needs to acknowledge that Joint Commission surveyors can arrive when they themselves are not present, and must make sure that their staff members, from the ground floor up to unit directors, are prepared for survey.
This is particularly challenging in the area of medical equipment and what the responsibilities are for staff from top to bottom. George Mills, MBA, FASHE, CEM, CHFM, director of the Department of Engineering at the Joint Commission, spoke recently at the Association for the Advancement of Medical Instrumentation (AAMI) conference on what the Joint Commission survey process is with inspection of medical instrumentation and what surveyors will be looking at.
To begin with, surveyors will examine the inventory, looking to see if the work has been done according to schedule and what the organization has determined for frequency of inspections.
Department leaders should be not only qualified, but must know how the inventory of devices was created. If organizations are using Alternate Equipment Management (AEM) processes, department leaders should understand and evaluate the monitoring process as well as its effectiveness. What is the organization’s criteria? What is the completion rate for the AEM processes?
Equipment maintainers must have a working understanding of the process and strategy of equipment maintenance, both according to manufacturer guidelines and AEM processes if used. They must be prepared to address the completion of scheduled work and how to address repeated work orders if asked by surveyors.
Equipment users must also be prepared to demonstrate a high level of knowledge. They should be able to address the reliability of the equipment, know what the response time is when the equipment fails, and have an understanding of the organization’s culture of safety.
Equipment users should be trained on equipment use, and be prepared to address customer satisfaction within the department.
Surveyors are going to look at policies and procedures, Mills said. Specifically, they will ask how equipment is evaluated to ensure there is no degradation of performance and how to identify and address if there are any mis-calibrations.
Policies and procedures should address how equipment is tested for calibration.
Surveyors will also look at errors and near misses. How are incidents investigated, according to your policies and procedures? Was an equipment failure preventable? Did the use of AEM processes contribute to the equipment failure? And how do your policies and procedures dictate how potentially unsafe equipment will be sequestered to avoid further potential harm?
Surveyors will want to know how an organization evaluates potential modifications to its medical device and equipment maintenance strategy.
They will also examine the accuracy of an organization’s inventory, with focus on evaluation of High Risk and Life Support equipment. How the organization indicates the use of AEM for specific equipment is a necessary requirement. Staff should be prepared to answer the question: is grouping of like equipment acceptable?
Lastly, when evaluating the organization’s inventory, the question should be addressed: are the imaging/radiological devices and medical laser devices exempt from AEM?
Surveyors will have a focus on High Risk equipment, and will expect that appropriate manuals are available. Documentation of inspections, tests, activities, and frequencies of use should be accurate and readily available--documentation issues have been one of the most-cited standards for 2013 and even earlier, a challenge which many organizations still struggle mightily with.
Staff should be prepared to discuss organizational strategies for equipment maintenance and explain how current policies are appropriate and effective in order ensure that medical equipment on site is reliable.
Lastly, Mills mentioned some of the most challenging standards for 2013, all of which organizations are still struggling with even as 2014 comes to a close. These include many physical environment issues, including corridor clutter, ventilation, fire barrier penetration, documentation of inspections and testing, smoke barrier penetration, maintenance of an 18” clearance from the ceiling, and unsafe environment standards.
Leadership would do well to maintain a firm understanding and keen eye on medical equipment policies, procedures, and processes as well as staff awareness and training in preparation for upcoming Joint Commission surveys.
" ... Including about 100,000 annually at a cost of $30B in North America alone. ... Inadequate hand hygiene remains a frequent and modifiable contributing factor, as established from hospital outbreaks of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and other hospital-acquired infections. ... ... A classical study, for example, found that physicians had about half the rate of compliance when compared with nurses (30% vs 52%, p<0.001). ... Here, we explore a different account for why the problem might not be solved by changing the personalities or motivations of physicians. Specifically, we suggest that the circumstances surrounding physicians in hospitals are rife with behavioral factors conducive to failures of hand hygiene."
Why even good physicians do not wash their hands.
The Center for Devices and Radiological Health (CDRH), which is a part of the Food and Drug Administration (FDA), is responsible, in conjunction with the Standards Management Staff (SMS), for the development and implementation of both national and international medical device consensus standards. This involves working closely with the Standards Developing Organizations (SDOs) and advertising standards liaison representative positions to maintain an appropriate standards database. SMS publishes updated medical device standards no less than twice annually.
See organizational and contact information for the SMS below or visit: http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/Standards/default.htm:
Recognized Consensus Standards The FDA’s database of recognized consensus standards can be accessed at www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfStandards/search.cfm
Procedures for the Use of Consensus Standards
The CDHR and SMS believe that conformance to their domestic and international consensus standards ensures the safety and/or effectiveness of a health device. Designers and manufacturers of new health devices can benefit from conformance to these standards since such conformance often eliminates the need to review the test data that applies to the standards when seeking regulatory approval. It should be noted, however, that conformance to the consensus standards will not always be a satisfactory basis for waiving regulatory decisions about a new device.
The CDHR and SMS believe that compliance with their consensus standards represents “the least burdensome approach in all areas of medical device regulation,” but also encourages those who believe an alternative approach would be less burdensome to contact the CDHR Ombudsman at this email address: CDRHOmbudsman@fda.hhs.gov. More information about the office of the Ombudsman can be found at www.fda.gov/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/CDRH/CDRHOmbudsman/default.htm.
General Use of Consensus Standards in the Premarket Applications Review Process
Section 510(k) of the Food, Drug and Cosmetic Act requires device manufacturers who must register, to notify FDA of their intent to market a medical device at least 90 days in advance. Conformity to the recognized standard should, in these cases, minimize the amount of data and documentation needed in the 510(k) submission to demonstrate substantial equivalence and, thus, streamline the premarket review process.
Applicants referencing a national or international standard should include a completed Standards Data Form for 510(k)s (FDA Form #3654, Form Approved OMB #0910-0120) as part of their 510(k).
Declaration of Conformity
If a manufacturer decides to conform to one or more recognized consensus standards in its premarket review process for a new device, the manufacturer must submit a “declaration of conformity” to the standards. A manufacturer can use in-house testing or third-party analysis to determine a device’s conformance to consensus standards. The manufacturer is also expected to maintain all records relating to its compliance with the standards.
The FDA recommends that submissions showing a device’s compliance with a consensus standard indicate “yes,” “no,” or “not applicable” for all sections of that standard. Any deviation from the standard should also be clearly indicated.
The FDA states that a declaration of conformity to a recognized consensus standard should do the following:
Review of Documentation
When a manufacturer’s declaration of conformity is deemed to conform adequately to FDA-recognized consensus standards, the aspects of the device addressed by the consensus standard are acceptable. There are, however, occasions in which a reviewer may have specific concerns and request additional information from the manufacturer.
Recognition of New and Revised Consensus Standards
To recognize a new standard or a new version of an existing standard, the FDA will post updated information in one of the Supplemental Information Sheets on CDRH's internet page and publish a notice in the Federal Register. The FDA will accept a declaration of conformity to a standard after it is recognized.
Scott Colburn, Director, Standards Management Staff, Office of the Center Director (OCD), is available to answer questions on consensus standards and issues related to declarations of conformity. He can be reached at (301) 796-6287.
Jon Stewart interviewed Atul Gawande on this book "Being Mortal". Gawande reports that a group of cancer patients choosing palliative care at end of life lived 25% longer than those choosing more severe medical care. The study was of stage 4 lung cancer patients. The discussion of end-of-life tradeoffs started with the statement that 17% of people die at home and most die in other institutions. There was some mention of his previous book, "Checklist Manifesto" which sounds like a book we need to pick up. The importance of planning medical checklists can be and will be followed is important.
The Joint Commission
The Joint Commission is an independent (not government), not-for-profit organization which accredits and certifies more than 20,500 health care organizations and programs, including hospitals, doctors’ offices, nursing homes, behavioral health facilities, office-based surgery centers and home-care services.
The purposes of The Joint Commission include helping health care operations improve the quality and safety of the care they provide, as well as reduce the risk of adverse outcomes.
In 2002, in keeping with its mission to continuously improve health care for the public, The Joint Commission launched a National Patient Safety Goals (NPSGs) program to address specific safety concerns.
The Patient Safety Advisory Group
A Patient Safety Advisory Group was formed – a panel of prominent safety experts composed of nurses, physicians, pharmacists, risk managers, clinical engineers and other professionals with hands-on experience addressing patient safety concerns in a variety of clinical settings. The panel’s purpose is to advise the Joint Commission on the development and updating of the NPSGs, the first of which became effective January 1, 2003.
The Patient Safety Advisory Group works with the Joint Commission to identify emerging safety concerns. They seek input from practitioners, care-providing institutions, consumer groups and other entities invested in patient safety. The Patient Safety Advisory Group uses the information to advise the Joint Commission in the effective use of NPSGs, standards, surveys, performance measures, educational materials, Sentinel Event Alerts and The Joint Commission Center for Transforming Healthcare (to be discussed.)
2014 National Patient Safety Goals (NPSGs)
There are different sets of NPSGs for particular settings, including:
Some of the goals are applicable to all settings. The full text containing the NPSGs can be purchased from Joint Commission Resources, http://www.jcrinc.com
Sentinel Event Alerts
An additional safety operation of The Joint Commission is the management of what the commission calls sentinel events; reports of the events are called Sentinel Event Alerts.
A sentinel event is an unintentional, unexpected, occurrence which results in death, serious physical and/or psychological injury, or confers the risk of serious adverse outcome if the event were to recur. These events are not related to the natural course of the patient’s disease or condition. Inherent to the definition of adverse outcomes is loss of life, limb or function.
Such events demand immediate attention and responses. They differ from medical errors, although some errors may trigger sentinel events, and sentinel events can increase the risk that medical errors will occur.
The Joint Commission, during the accreditation process, critiques the organization’s response to sentinel events. Already accredited organizations will have periodic, scheduled reviews, as well as random, unannounced reviews and for-cause investigations.
Accredited organizations are expected to respond appropriately with timely, credible analysis, to find the root cause of the adverse event. The analysis focuses on procedures and systems, not on individuals. The organization then must develop a plan for action, to reduce the risk of recurrences.
Some of the sentinel events that are reviewable under The Joint Commission’s Sentinel Events Policy include (not all inclusive):
Examples of sentinel events which are not reviewable, under the same Joint Commission policy include (not all inclusive):
Procedures for Implementing the Sentinel Event Policy
The Joint Commission staff will determine whether an event is reviewable based on available information they received about the event. Urgent threats to health or safety are referred to Joint Commission Executive Leadership for authorization to conduct an immediate, unannounced for-cause survey. The organization of interest must submit the complete root analysis and the action plan within 45 days from the date the event was reported.
The Joint Commission staff assess the acceptability of the organization’s response to the reviewable sentinel event. If the root cause analysis information and action plan are deemed to be thorough and credible, the organization is assigned one or more Sentinel Event Measures of Success (SE MOS). An MOS is a numerical or quantifiable measure that determines if a planned action was effective and sustained.
If the response is unacceptable, Joint Commission staff will provide consultation to the organization on the unmet criteria and extend an additional 15 calendar days beyond the original submission date for the organization to demonstrate acceptable analysis and an appropriate plan for action.
If the amended report does not meet established criteria, or The Joint Commission determines that the organization has not made serious improvement efforts, accreditation may be affected.
If the report is acceptable, The Joint Commission determines appropriate follow-up – usually reassessment in four months.
Universal Protocol for Preventing Wrong-site, Wrong-procedure, Wrong-person Events
The Joint Commission’s Universal Protocol applies to all invasive procedures. Those which place the patient at the most risk involve general anesthesia or deep sedation. The protocol is based on the following principles:
The Universal Protocol is most effective in environments which promote teamwork, and all members are empowered to pursue patient safety.
Timing and location of preprocedure verification of patient identity and site marking must be determined by an individual organization. The frequency and scope of preprocedure verification is determined by the type and complexity of the procedure. Preprocedure verification, site marking, and time-out procedures must be as consistent as possible throughout the organization. Site marking is not required when the person performing the procedure is with the patient from the time the decision to do the procedure is made, through to completion of the procedure.
Joint Commission Center for Transforming Healthcare
The Joint Commission, in 2008, created a Center for Transforming Healthcare, to tackle the most critical healthcare quality and patient safety problems. With the NPSGs, core measures, and high standards for accreditation, hospitals and other organizations that deliver healthcare can determine where to focus their resources, to have the greatest impact on quality and safety. However, some major shortcomings in quality and patient safety persist, despite considerable efforts to find solutions, including hand hygiene, wrong-site surgery and hand-off communication. The demand is great for more specific, effective and durable solutions.
The Center participants – some of the nation’s leading hospitals and health systems - are using a systematic approach to analyze the underlying causes of dangerous breakdowns in care, and to develop proven solutions to the more complex problems.
The Joint Commission makes available the proven solutions to the more than 20,500 healthcare organizations it accredits and certifies. With the proven solutions, significant advances in safety for all have been made in health systems and processes of care.
In September 2010, the Targeted Solutions Tool (TST) was introduced. The Joint Commission Center for Transforming Healthcare developed the application. It guides healthcare organizations through a step-by-step process to accurately measure their organizations’ performance, identify the barriers to excellent performance, and direct them to proven solutions that are customized to address the particular barriers of each organization.
The TST currently provides targeted solutions for hand hygiene, wrong-site surgery, and hand-off communications. Targeted solutions for surgical site infections, heart failure hospitalizations, patient falls, sepsis and others will be incorporated into the TST as the center completes their development.
National Patient Safety Foundation
The National Patient Safety Foundation (NPSF) is a not-for-profit organization dedicated to identifying problems in safety and creating solutions for both patients and healthcare workers. The NPSF, although it has a similar mission to that of The Joint Commission, it is entirely independent, with no affiliation to the commission.
The NPSF partners with patients, families, communities, healthcare workers and institutions to address safety issues, solve problems, and provide education in regard to patient and healthcare worker safety.
Among its educational resources is the NPSF On-line Patient Safety Curriculum. The 10 – module course is approved for continuing education credit by the Joint Commission and the American Board of Medical Specialties. The NPSF can be reached at (617) 391-9900 and www.npsf.org.
Institute of Medicine: www.iom.edu
The Joint Commission: www.jointcommission.org
The Joint Commission Sentinel Events: www.jointcommission.org/sentinel_event_policy_procedure
The Joint Commission: Patient Safety: www.jointcommission.org/topics/patient_safety.aspx
The Joint Commission Resources: www.jcrinc.com
The National Patient Safety Foundation: www.npsf.org
The Center for Transforming Healthcare – Joint Commission: www.centerfortransforminghealthcare.org