Center for Improvement in Healthcare Quality Newsletter
September 2021

2021 Accreditation and Regulatory Summit

“Virtual for One More Year” Airing September 21 - 23, 2021

This will take the place of the annual in-person CIHQ Accreditation & Regulatory Summit as we go “Virtual for One More Year”. Each session will air live just like the monthly webinars and will have a question-and-answer session following each one. CEU’s will be awarded based on your registration/attendance.
Accredited Hospial Registration: Check your hospital extranet site for the registration link.
Not a Accredited hospital (Non-Client Registration): CLOSED

Featured Speakers & Topics

September 21, 2021 - Tuesday

0900 – 1000 CT
Special Session with CIHQ Partner – Spend Mend
Everything you need to know to prepare for an OIG Audit of your hospital’s Explant Warranty Credit Program
Presenter: Alan Brander, RN, FACHE MBA/HCM
Implantable medical devices occasionally fail and must be replaced. If devices fail while under warranty, credit is due from the manufacturer. If credits are equal to or greater than 50% of the device cost, the credit must be returned to Medicare. In a recent review of 911 hospitals, the OIG found that every audited hospital had some mismanaged cardiac device warranty credits. In all, nearly 50% of qualifying credits were not paid back. Regardless of intention, this is Medicare fraud. CMS and OIG estimate hospitals have underpaid credits by at least $30 Billion and have committed to recoup billions in unpaid credits Your hospital will likely fall into their scope. It’s crucial you become compliant Or you’re risking penalties, fines, being designated an excluded provider and even jail time. Learn what the expectations are and how to prepare.
1100 – 1200 CT
CMS Survey & Certification Process – The Basics
Presenter: Richard Curtis RN, MS HACP
New to regulatory compliance? Been awhile since CMS knocked on your door? Maybe you just want to validate that you’re still on top of your game? If the answer to any of these questions is yes, then this webinar is for you. Join us as we systematically review the basics of the CMS Survey & Certification Process.
1300 – 1400 CT
Life Safety Code Compliance for Business Occupancies
Presenter: William Kinch MHA, HACP-PE
CMS has given accrediting agencies their marching orders: start surveying business occupancies for life safety code compliance! Expect surveyors trained in life safety to do much more than just look at methods of egress. This webinar will cover important aspects of the NFPA 101 Life Safety Code for business occupancies. To be for-warned it to be for-armed!
1500 – 1600 CT
Medication Orders – The Do’s and Don’ts
Presenter: Ann Martin MSN, RN
Titration orders, range orders, duplicate therapy… the requirements never seem to end, and neither do the citations! This webinar will address the requirements for complete and accurate medication orders, the most common deficiencies cited during survey, and strategies to hard-wire compliance.

September 22, 2021 - Wednesday

0900 – 1000 CT
Special Session with CIHQ Partner – BDA – Dunbar & Associates
Productive Conflict – The Power of In-The-Moment Conversations
Presenter: Nick Dann - Managing Director, Dunbar Organizational Health / BDA Health Informatics
This session will focus on the objectives below and how you can apply these to your organization.
  1. Learn why great leaders are both conflict avoiders and conflict seekers.
  2. Understand which commonly accepted behaviors in the workplace are actually destructive responses to conflict.
  3. Discover how practicing In-The-Moment Conversations with your team members can lead to lifelong leadership lessons.
1100 – 1200 CT
How to Prepare & Manage the Survey Process
Presenter: Gina Miller, MSN, RN, HACP
It’s said that preparation is the key to success. It’s also said that without execution, preparation is meaningless. Both are true when it comes to succeeding in the survey process. From document preparation to dealing with the unexpected, this webinar will provide a wealth of practical advice on how to prepare and manage your hospital’s survey.
1300 - 1400 CT
Food Storage Practices – The Kitchen & Beyond
Presenter: Paula Sims, MSHA, BSN, RN, HACP
How long can food be stored in a refrigerator? What does the term “hazardous food” mean? Why do some foods have a special outdate? Kitchens and nourishment areas on patient care units frequently get cited because such questions are left unanswered. This webinar will focus on food storage requirements for healthcare facilities. Time to get those questions answered!
1500 – 1600 CT
Dissecting NFPA-99
Presenter: William Kinch MHA, HACP-PE
Most facility staff have a pretty good knowledge about the NFPA-101 life safety code. But how knowledgeable is your hospital’s staff on NFPA-99. CMS and accrediting agencies require compliance to both. This webinar will systematically explore NFPA-99, identify major compliance challenges, and discuss strategies for success.

September 23, 2021 - Thursday

0900 – 1000 CT
Special Session with CIHQ Partner – RL Datix
Instructions for Use and Record-keeping in the Sterile Processing Department and Beyond. Building "Pillars" to Form a Strong Base of Patient Safety
Presenter: David Jagrosse, CRCST, CHL
Efficient, accurate, updated, and accessible information on reprocessing, staff training, and competencies within the Sterile Processing Department and beyond is the key to safely reprocessing medical devices and keeping our patients safe. We will explore how manual and automated systems can be leveraged to build the strongest foundations for patient safety throughout the process.
Join us for this informative webinar as we:
  • Discuss instructions for use and their importance
  • Identify "pillars" of a good system
  • Understand what accreditation surveyors look for in the department
  • Outline current standards that apply
  • And much more...
1100 – 1200 CT
Antibiotic Stewardship – Is Your Hospital Compliant?”
Presenter: Paula Brinn, MBA, BSN, RN, HACP
The requirements for a robust and comprehensive antibiotic stewardship program aren’t just a regulatory expectation, they’re an integral part of high-quality patient care. This webinar will provide a systematic top-to-bottom review of what CMS and accrediting agencies look for when assessing your hospital’s antibiotic stewardship program.
1300 - 1400 CT
Charting by Exception & Other Documentation Pitfalls
Presenter: Kimberly McGuire, MSN, RN, HACP
Charting by exception is a growing, and problematic, practice in healthcare. But there’s more… block charting, electronic copy forward capability, and boiler plate records all combine to result in multiple deficiencies during a survey. This webinar will explain the challenges with medical record documentation and how to avoid them.
1500 - 1600 CT
CMS Update – What does the Future Hold?
Presenter: Richard Curtis RN, MS, HACP
The Center for Medicare Services (CMS) continues to make significant changes to its standards and survey & certification process. These changes impact hospitals regardless of who acts as their accrediting organization (AO) CIHQ staff routinely meet with top CMS officials. You’ll receive the latest information on what CMS is up to, the impact on your hospital, and much more.