Learning the Regulations - What's the Best Way to Learn Them?

[Mozzie]

Hi,

I know that if a facility does not have quality they are facing risk issues and I am trying my best to connect the dots. I really need a mentor and it has been difficult to find at the place where I'm working currently.

I started a position a few months ago in Risk Management which is under the Quality Department. I am also the Safety Officer (both Patient Safety and Environment of Care Safety). Any Medical Malpractice Cases - I work with legal on either locally or at corporate. The med mal stuff - I think I am getting okay and work well with the attorneys. However.........

.......However, I am trying to learn the regulations that "govern health care facilities". They seem to come from different sources and address different issues. I do not know where to go for what. My CQO is very smart and knows them inside and out - however, I don't feel that she is doing very well at showing me where she gets her information.

We are a Joint Comission hospital - and I have looked up a few regs on there and on our state regs. But there are other things for example that I can not find. Here is the first example:

I went on environment of care rounds with a group of people. The manager asked me a question inregards to alcohol hand rubs located in a carpeted area (I guess there was question as to whether ornot this would be a fire hazard).

My CQO received the question via e-mail and answered it - extensively - but did not cite the information.(BTW - the answer was yes, alcohol rubs can be located in carpeted areas as long as the rooms have sprinkler systems) - I eventually found this information on a CMS web site - but it was dated from 2005.And of course I question these answers because I don't know if they are the most current regs.

Here is a second example:

We built a new building for a cardiac rehab unit. We are only renting the space - we do not own the building and it is connected to the hospital in the medical office area right next to the hospital. However,this is a service line that will be billed under the same medicare number as our facility and there was question to how to handle any "Code Blues" - if they should occur. Now - I did not know the answer to this question - however - My boss knew that in order to run this service line that we as a hospital needed to respond to codes in that department because we are billing under the same medicare number. And of course it was the the right thing to do -which we all support.

Anyways, this is a problem for me - I want to learn these regs and which regs pertain to what issues. Also, what reg dates do we go by? How often are they updated. However, I feel that this information is not explained well or withheld. ~OR~ maybe - there are other things going on that I don't know about.

My CQO has been in quality for some time now - she and the case manager "job shared" the risk management role with responsibilities divided between the two of them. So my boss knows part of the job and the other person knew the other part. However, it has been difficult to put the whole picture together with some things.

I really need someone to plug in to. Our new quality director is learning also - but her role is much different than mine.

If anyone feels that they can spare some information to start with - I would be so greatful and would do what I could to return the favor.

Thank you all for taking the time to read this.

Sincerely,

Mozzie

[smc]

I have been working in this field for about 6 years. There are many great resources on the JC from HCPRO. I really like the book on Joint Commission standards crosswalked with CMS conditions of participation. Also, I recommend that you subscribe to Briefings on the Joint Commission by HCPRO and Joint Commission Perspectives from JCR.

Many times people will say, "The Joint Commission says you have to do xyz.....", and that is not always the case. Many times those myths come from previous JC surveyors so you really have to read the standards and elements of performance. Also during surveys you will be held to your own policy so it is wise not to hold you facility to a higher standard than is required. Hope this helps

[Mozzie]

Dear SMC,

Thank-you so much for sharing. If I can return the favor I will - Just let me know.

I have looked up this book and it looks like a great place to start. I agree with the policy thing - as I go through ours - I notice elements of some that apply to other policies that read differently - you are soooo right about being careful about policies - they can bury you if you are not careful.

SMC - are you willing to be a mentor?

Thanks again,

Mozzie

[3rdcareerRN]

Although I do not work fulltime in QI/QA, I've run across a few resources that may be useful :

OSHA's eTools and Electronic Products for Compliance Assistance -- an easy way to navigate their massive resources/regulations:

http://www.osha.gov/dts/osta/oshasoft/index.html

Medicare/Medicaid (CMS) starting point:

http://www.cms.hhs.gov/home/regsguidance.asp

Lab accreditation/standards (may apply to your hospital's lab):

http://www.a2la.org/medical/medical.cfm and http://www.aacc.org/gov/gov_affairs/Pages/regulatory.aspx

FDA's site for medical/rad. devices:

http://www.fda.gov/cdrh

Med instruments:

http://www.aami.org/

building fire safety (your local fire chief is an even better resource)

http://www.nfpa.org/

General safety issues and regs:

http://www.nsc.org/

Another site for radiological safety but also has QI resources:

http://www.rsna.org/

Good luck!

[newQAnurse]

Do you know if there is a review courses out there to learn about all the regulations???