Accreditation & Regulatory Journal
December 2023

News You Can Use

A Christmas Message from CIHQ

It’s hard to believe that 2023 has just about come and gone. Seems like yesterday we welcomed in a new year and in a few short weeks we’ll do it again.
It’s traditional this time of year to talk about giving thanks and offering best wishes to one and all. It’s a fair question to ask whether there is anything to be thankful for? Our nation is in turmoil. Forces are trying to drive us apart rather than bring us together. After years of battling the effects of the pandemic - we’re simply exhausted; And if all this wasn’t enough, have you seen your grocery bill lately!
It’s tempting – and understandable – to not quite have that “holiday cheer” this year. But I would like to suggest that we still have a lot to be thankful for. Our family, our friends, and – as importantly – each other. As healthcare workers you share a bond that is both unmistakable and unbreakable.
You fight the good fight. You risk your own health and safety for the sake of helping others. You’re the brave few that care for those in their most dire time of need. You celebrate the victory and mourn the loss. Yes, as far as I’m concerned, each of you are truly heroes.
So, this holiday season I do give thanks. I give thanks for the honor and privilege of working with each of you in our collective mission to improve the lives of the people we touch. My sincere wish is that this holiday season brings you and your loved one’s joy, peace, and good health.
Rick Curtis, CEO
Center for Improvement in Healthcare Quality

Compliance Tip of the Month

Winter Is Coming - What You Can Do To Prepare
Billy Kinch – MHA, HACP-PE
It seems like this year has just flown by. The winter season is coming soon. It is probably my favorite time of the year, mainly because of the holidays. There are many good things that occur during this time of year; however, winter can bring with it some not so fun times as well. I live in Texas, and we have experienced some unusual winters recently and we are not built for it. I wanted to talk about a couple of key systems in a hospital that could pose an issue during the winter months. They are the hospital’s emergency generators and fire sprinkler system.
Emergency Generators
Think of your generators like you do your own vehicles. Your vehicle can sometimes be difficult to start during very cold days. The same is true for your generators. Here are a few reasons why your generator may not start during the winter:
  • Cold oil
  • Cold battery
  • Cold electronics
  • Air blockage
  • Exposure to weather elements
As you enter the winter months here are some things that an organization can do to prepare your generator:
  • Inspect and clean your generator – While this is already a regulatory requirement to inspect the emergency generator weekly, it is especially important to make sure you inspect the air vents. During the fall, you can get leaves and twigs blowing around and they will commonly get stuck around the air vents of your generators. Make sure the vents are clean and clear. Check for loose wires and other parts to make sure there are no signs of corrosion.
  • Run the generator regularly – While it is no longer a code requirement to run a generator weekly, during the winter months is a good time to do this. Running the generator allows for the moving parts to become lubricated, and it maintains the seals in the generator.
  • Use an engine block heater – Having an engine block heater, also called a water jacket heater, can prevent dangerous cold starts by keeping the engine oil warm when the generator is idle. An engine block heater can combat the issue that cold temperatures present for starting generators. Another consideration is to install a coolant heater, air inlet heater and control panel heater if your generator faces freezing temperatures.
  • Change to a winter-grade oil – You can lessen the friction and make it easier for your generator to start if you utilize a thinner oil that is designed for winter use. You can then change back to the typical oil once the temperatures start warming up.
  • Warm the batteries and keep them charged – Most of the emergency generators in hospital use lead-acid batteries. The cold weather can adversely affect those batteries. Sometimes the below freezing temperatures can reduce the functionality of the battery to less than half of its capacity. Keeping the batteries warm can be performed with a thermostatically controlled warming blanket. This blanket can be plugged into the same power source you are using for the engine block heater.
Fire Sprinkler Piping
Freezing sprinkler piping during the winter months can cause a huge flooding issue in hospitals. According to NFPA 110, wet fire sprinkler systems require freeze protection if any portion of the sprinkler system is in spaces where temperatures cannot be maintained at or above 40 degrees Fahrenheit. One of the ways that the code permits to prevent freezing is the use of an antifreeze solution. However, the solution must be in compliance with your local and state fire codes. Before utilizing any type of antifreeze solution, it is very important to consult with your fire sprinkler system professionals, including your local fire authorities. This is to make sure that the solution you are using does not create additional fire risk in the event that the sprinkler system is activated during a true fire. Some solutions have been known to create a fire risk when used in sprinkler systems. There are new products on the market that meet a UL listed standard for use in fire sprinkler systems as an alternative to antifreeze solutions. It is important to understand all the requirements that would be needed to be followed in the event that an organization utilizes this type of solution. Please refer to NFPA 110-2010 7.6 for requirements, as well as local fire authorities. I hope that you all have a safe winter season and always be prepared.
 

CIHQ Expansion of Accreditation Programs – Update

CIHQ is expanding its accreditation programs to Acute Psychiatric Hospitals. The application has been approved and the virtual office review has been completed. The final decision to accept the application was published in the Federal Register on September 29, 2023. We are excited about welcoming Acute Psychiatric Hospitals to the CIHQ family of accredited organizations. You can find this exciting announcement in the Register at https://www.federalregister.gov/documents/2023/10/02/2023-21724/medicare-and-medicaid-programs-application-from-the-center-for-improvement-in-healthcare-quality-for
Will you be the first acute psychiatric hospital to be accredited by CIHQ? You can open an account and apply today at CIHQ.org click on “Hospital Programs – United States”, select “Acute Psychiatric Hospitals” and then “Apply for Accreditation” in the blue navigation bar or click HERE. Our standards, policies and survey activity guide are available free of charge on the website.

Conferences and Sponsorships

CIHQ Announces Plans for 2024 Accreditation & Regulatory Summit
Save the dates: September 24 – 26, 2024
Location: San Antonio, Texas at Pedrotti’s Ranch
The 2023 CIHQ Accreditation & Regulatory Summit was a HUGE success. It was the largest summit in our history with over 500 in attendance. If you attended, then I am sure that you would agree that it was a great event and valuable to all. If you were not able to attend, then know you were missed.
Everyone, hang on to your hat as we unveil the plans for the 2024 summit! CIHQ is inviting you to help us celebrate our 25th Anniversary Jubilee. Yes, CIHQ will be a quarter of a century old in 2024 and we plan to throw a Texas-sized conference and celebration.
Save the dates: September 24 – 26, 2024
Location: San Antonio, Texas at Pedrotti’s Ranch (click to check it out)
The summit will be packed full of relevant topics in the accreditation and regulatory environment. In addition, we are planning to make this the most fun conference you will attend all year. The theme will be a 25th Jubilee Texas style complete with encouragement to dress western (optional) and attend our complimentary rodeo show. Education and fun will be had by all.
CIHQ was the fourth deeming authority to be approved by CMS for Hospitals
In celebration of our 25 years in business we will be hosting a game session during which participants will be teamed up to see who knows the most about CIHQ and its 25-year journey. You may feel you are at a disadvantage. Fear not!
Beginning in January, there will be facts about us published each month in our CIHQ Accreditation & Regulatory Journal. The facts will be in different locations withing the journal but will all be housed in a box with a game-themed border. Here is an example of the border. Search the journal to learn interesting facts. At the summit teams will compete against each other for the level of knowledge and the team that knows the most will win a fun and exciting prize.
Stay tuned in to your journal for facts and fun about us! We can’t wait to see all of you at the summit! More summit information will be sent as it is finalized and made available. This is the event that you won’t want to miss!
Here is some feedback from the 2023 Summit:

2023 CIHQ Accreditation & Regulatory Summit – Feedback from a Speaker
My name is Jason Little, and I am the Director of Hospital at Home, Remote Patient Management, and Lifeline at Roper Saint Francis Healthcare in Charleston South Carolina. It was a pleasure to be included as one of the speakers for the CIHQ Summit. I thoroughly enjoyed sharing our Hospital at Home program, the new standard for acute care. It was also extremely beneficial to learn more about CIHQ and all its participating members. The attendees were so engaging and definitely welcomed innovation and future movement of care to home. I loved all the questions received following the presentation. In addition, the accommodations, scheduling, topics, and venue were perfect for optimal collaboration and networking. I would be honored to speak in the future at another CIHQ Summit or event. Thank you”.
Jason Little, MBA, PMP
Hospital at Home Director