Center for Improvement in Healthcare Quality Newsletter
January 2022

News You Can Use

January Compliance Tip of the Month

January’s tip of the month is focused on the standard/requirements regarding emergency medications. Specifically, for the treatment of Malignant Hyperthermia.
Organizations can be cited by surveyors when they are unable to demonstrate that the necessary medications and supplies can be provided to the bedside within 10 minutes as required by the Malignant Hyperthermia Association of the United States (MHAUS). It is most often cited in areas outside of the surgical services department such as radiology other procedure type suites where anesthesia gases are used.
Both the CMS and CIHQ standards/requirements have been included for reference.


MM-11: Emergency Medications
The organization must assure that medications are readily and immediately available to meet the emergent care needs of the patient.
  1. The organization assures that emergency medications are stored throughout the facility and can be accessed in a timely manner (within five minutes of identified need).


§482.25(b) Standard: Delivery of Services
In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.
According to MHAUS, “the exact incidence of MH is unknown. Epidemiologic studies reveal that MH complicates one in about 100,000 surgeries in adults and one in about 30,000 surgical procedures in children”.
It is recommended that the organization have a mechanism in place to react and respond to this emergent and potentially fatal condition. There should also be a process in order to determine if the supplies and medication can be retrieved and provided within the 10-minute timeframe. The recommendation is that the organization conducts drills to assure that this is possible. It is also recommended that the drill be conducted after regular working hours when staff may be more limited. Documentation of the drill including any opportunities that present themselves along with actions taken to address them will eliminate any question regarding compliance.
For a complete list of the MHAUS recommendation for preparing an MH cart click on the following link.
ARS resources to assist with compliance:
Reference Library – Other Regulatory Reference Entities
  • Malignant Hyperthermia Association of the United States (MHAUS)

A New Way to Achieve Healthcare Accreditation Certified Professional (HACP-CMS)

Becoming and maintaining HACP-CMS certification just got easier! It is the only certification based 100% in the CMS Conditions of Particpation.
Historically, candidates or existing HACP-CMS holders could attend the in-person course/test administration which preceded the annual CIHQ Accreditation & Regulatory Summit each year or purchase the study guide and/or practice exam, study independently and then register and take the examination.
Technology is our friend and there is a new online video course. The course consists of 8 video classes in which you will be able to hear and see Rick Curtis as he teaches the regulations. Then you will be able to take the exam, achieve or renew certification and receive CEU’s. The study guide and practice exam are optional but are still available for purchase.
Regardless of you learning preferences, CIHQ-HACP has provided you with the tools to join the ranks of over 1000 HACP holders across our nation and abroad.
If you want to learn more just go to

CIHQ has Joined the Texas Organization of Rural & Community Hospitals (TORCH)

CIHQ is proud to announce our Corporate Membership with the Texas Organization of Rural & Community Hospitals (TORCH) whose vision is to provide rural Texas access to the highest quality healthcare. The mission of TORCH is to be the voice and advocate for rural and community hospitals, and to provide leadership in addressing needs and issues that arise. We believe this partnership will serve CIHQ and TORCH through shared values of providing the best customer service, using data as a basis for setting policy and improving outcomes, and an open dialogue. CIHQ and TORCH strive to be prepared for changes, maintain growth and to build strategic relationships that enhance effectiveness.