Hawai'i-Pacific Chapter
A quarterly e-newsletter for the Hawai'i Pacific Chapter of ACHE Winter 2015 Newsletter
In This Issue
Message from your ACHE Regent, Winter 2015
Message from the Chapter President
Recent Chapter Events
AONE Conference, 2015: Leadership in Action
News from the Education Committee
Membership: New Fellows, Members, and Recertified Fellows
Calendar of Events for Winter 2015
Education Calendar for Winter 2015
Winter 2015 Financial Report
National News - Winter 2015
News from Guam ACHE
Joint Commission Accreditation Process Updates for 2016
Leveraging Electronic Health Records to Promote Population Health
Humanitarian Medicine and the Lesson of Sustainability
Career Development
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Which healthcare issue do you feel is most important to address in 2016?
Primary Care Physician Shortage
Nursing / Assistant Shortage
Long-term care
Universal Coverage / Payor
Tort Reform
Medicare / Medicaid


Jen Chahanovich, FACHE

Gidget Ruscetta, FACHE

Art Gladstone, FACHE

LT Joseph Fromknecht


Selma Yamamoto

Natalie Pagoria

Art Gladstone, FACHE

Micah Ewing

MAJ Charlotte Hildebrand, FACHE

Lt. John Piccone

Nick Hughey

Jennifer Dacumos

Stella Laroza


Darlena Chadwick, FACHE


Joint Commission Accreditation Process Updates for 2016
Richard Giardina RN, MPH, CIC, FACHE

Even if it is not your survey year, we all should be aware of what the Joint Commission (TJC) expects from our facilities during their visit.  Annually, expert consultants from Joint Commission Resources travel to Hawai‘i to provide the latest revisions to the Hospital Accreditation Standards (HAC) and anecdotes from surveys to help have a successful survey at our facilities.  Here are the major points discussed during the TJC session for 2016:

  1. Revised agenda for the Life Safety surveyor:  This used to be the Life Safety Surveyor (LSS) role was played by the Nurse or Physician Surveyor.  The LSS is now part of the survey team for all days during the survey.  TJC now employs engineers to fulfill that role; in fact, this new role is the most dynamic of all three.  Immediately upon arrival and skipping the opening conference altogether, the LSS will hit the ground running and proceed directly to the Operating Suite to review temperature, humidity, and pressure gradients.  The reason being that infractions of these standards should be addressed and remedied immediately rather than waiting for day 4 of the survey as in the past.

  2. Revised criticality:  TJC uses icons in its Hospital Accreditation Standard manual to denote criticality; meaning, how ‘close’ does the finding come to patient.  Currently a standard is scored as an ‘A’ or ‘C’ (there is no ‘B’) determining how many times an issue has to be addressed before it triggers an RFI. After careful review, TJC is developing a grid looking at probability of harm and how often an event is observed in a facility.  This revised criticality scheme remains in development at this time.  The good news is the icons will disappear from the manual.

  3. Electronic survey findings and interpretation:  There can be a certain level of variability and subjectivity in surveyor standard interpretation.  Particularly when placing a finding into a certain standard.  TJC has developed an electronic database that is driven by keywords in the observation.  The intent is to have agreement between the surveyor findings during survey and the final report that arrives from TJC headquarters post survey, boosting confidence in the consistency of the accreditation process.

  4. 2016 National Patient Safety Goals:  The purpose of the National Patient Safety Goals is to improve patient safety.  The goals focus on problems in health care safety and how to solve them.  The major change for 2016 is, NPSG.06.01.01, use alarms safely, make improvements to ensure that alarms on medical equipment are heard and responded to on time.  Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly managed, they can compromise patient safety.  This is a multifaceted problem.  In some situations, individual alarm signals are difficult to detect.  At the same time, many patient care areas have numerous alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals or even disable them.  Other issues associated with effective clinical alarm system management include too many devices with alarms, default settings that are not at an actionable level, and alarm limits that are too narrow.  These issues vary greatly among hospitals and even within different units in a single hospital.  There is general agreement that this is an important safety issue.  Universal solutions have yet to be identified, but it is important for a hospital to understand its own situation and to develop a systematic, coordinated approach to clinical alarm system management.  Standardization contributes to safe alarm system management, but it is recognized that solutions may have to be customized for specific clinical units, groups of patients, or individual patients.  This NPSG focuses on managing clinical alarm systems that have the most direct relationship to patient safety.  Starting January 2016, hospitals must implement their plan for reducing alarm fatigue that was required to be completed in 2015.  This can be a daunting task since hospitals are plagued with multiple alarms for a number of medical devices.

In summary, Life Safety is the primary focus of surveys in 2016.  In 2015, 8 of the top 10 findings fell under the category of Life Safety.  Your Life Safety Team at your hospital can benefit by using valuable resources on the Joint Commission Connect website at http://www.jointcommission.org/ to develop a gap analysis and action plan to address potential risks in the Life Safety domain.

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Save the Date

2016 Congress on Healthcare Leadership: 

Date: March 14-17, 2016
Place: Hyatt Regency, Chicago, Illinois.


HFMA Panel Discussion (1 Education Credit)

The Hawai'i Chapter of Healthcare Financial Management Association (HFMA) hosts their annual 2016 conference. Dr. Kenric Murayama will host a panel discussion entitled, "Engaging Physician Leaders: The 'What's In It For Me (WIIFM)?' Problem.

April 21, 2016, 2:00PM
: Ala Moana Hotel



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