Archive for the ‘Licensing’ category

Compliance v. Enforcement

April 21st, 2014

compliancevenforcementThose of you in Public Health Licensing have heard me talk about the difference between compliance and enforcement more than once.  They’re 2 different things. Compliance means that a licensed healthcare, residential or childcare facility meets our standards and expectations.  Enforcement is an action that we occasionally take in order to get a facility into compliance.

In other words, our goal is always compliance- not enforcement.  The most cost effective way to achieve compliance is to provide clear and understandable customer assistance, provide education during on-site surveys, set clear expectations, and work effectively with our licensees and associations to make sure they understand what we expect.  When customer assistance, education and clarity aren’t enough to get compliance, we sometimes need to resort to enforcement actions to move a licensee into compliance.

The bottom line is that while we sometimes need to take enforcement actions to incentivize a facility to become and/or stay compliant- it’s usually the least cost-effective tool in our toolbox.

Regulatory Reform Improves Health & Wellness in AZ

April 18th, 2014

web regulatoryreform Three years ago we made the commitment to overhaul the way we regulate Arizona’s 5,500 licensed healthcare facilities.  Our goal was to move from the existing prescriptive regulations to a new set of outcome-based rules.  The idea was to shift from the former 2-dimensional standards to a deeper set of 3-dimensional regulations.

The final regulations that we’re publishing at the end of April are tied to outcomes.  The model puts more responsibility on the facility’s managers to ensure that they’ve developed policies and procedures to ensure they’re meeting the needs of the people they serve.

The new model basically sets some prescriptive minimum standards- and then requires facility operators to develop an additional set of policies and procedures to ensure patient and resident health & safety.  Facilities are also required to measure patient and resident outcomes.  If they have bad (preventable) outcomes- our survey teams will determine whether they weren’t following their policies and procedures, had inadequate policies and procedures, or both.

The new final regulations aren’t the finish line.  Our next task is to educate and train our survey teams and regulated healthcare facilities on the new regulations.  Because the final rules depend largely on outcomes and solid policies and procedures rather than just static standards- this effort won’t happen overnight.  It’ll probably take about 18 months to get everybody up to speed on the new expectations.

Congratulations to our committed Stakeholders and Team ADHS for collaborating on the development of regulations that’ll be improving Health and Wellness for all Arizonans for years to come.

Healthcare Associated Infections Progress Report

April 8th, 2014

haiprogressreportHealthcare-Associated infections are a major (often preventable) threat to patient safety. Last week the National and State Healthcare Associated Infections Progress Report expanded on previous reports- detailing progress toward the eliminating healthcare-associated infections.  The HAI Progress Report found significant reductions for nearly all infections- including in AZ. Central line-associated bloodstream infections and surgical site infections continued to approach the 5-year goals set in the National Action Plan to Prevent Health Care-Associated Infections.

Arizona’s public health system takes a layered approach to preventing HAI’s in our state.  It starts with our Licensing team- who regulates the healthcare institutions where the care happens.  Our Medical Facilities Licensing team and our HAI Program collaborate to ensure the safety of patients in Arizona by jointly providing technical assistance and guidance to licensed healthcare facilities in response to identified infection control breaches.  The next layer is our network of public health disease detectives.  Our Healthcare-Associated Infections Program and the counties conduct epidemiologic investigations when we get reports of unsafe injection practices affecting multiple patients.

Our HAI Program and Advisory Committee also generate guidance documents for healthcare facilities and provide best practices for infection control and injection safety like materials produced through the CDC’s One and Only Campaign and Arizona’s Stakeholder-driven No Place Like Home initiative- which partners with the national Partnership for Patients: Better Care, Lower Costs project.

Now Hiring – Licensing Assistant Director

March 26th, 2014

Once in a while we have a tremendous opportunity for a great leader to join our team, but not very often.   We just posted the Assistant Director for Public Health Licensing.  The person we’re looking for will be able to take a great team and make it better.  This person will be collaborating with partners on the local, state and national level on everything from reducing healthcare-associated infections to quality improvement to managing a $17 million dollar budget.

This position is a real leverage point for improving public health outcomes in Arizona.  Our licensing area handles most of the licensed facilities in the department including medical, long-term care and residential facilities and childcare homes and centers.  There are also a few specialty licenses that fall into the division like speech-language and hearing therapists and midwives.  

If you feel you’re the right person at the right time, visit and check out the Assistant Director posting.

Arizona State Hospital In Good Standing

March 14th, 2014

Last September the Arizona State Hospital (ASH) was inspected (surveyed) for the Centers for Medicare and Medicaid Services (CMS). The survey team can review over 20 different areas and three were identified that we needed to address: Governing Body, Patient Rights, and Nursing Services.   In December, we developed and implemented a Plan of Correction which was submitted to CMS.  Some people think certification or licensure surveys are something to fear.  At the Arizona Department of Health Services (ADHS) and particularly at ASH we take a different approach.  Surveys are an opportunity.  They are part of the quality improvement process that health care facilities employ to make sure patients receive high quality care.  

A few weeks ago we had a return visit from CMS surveyors to verify whether we executed our Plan of Correction.   The entire team at ASH did a great job during the inspection- ensuring that the surveyors had everything that they needed to meet their objectives.  The required documentation was easy to find, and the surveyors got to see how well our team works together.  Today we received good news from CMS.  They’ve concluded that we’re satisfying their requirements, and that the Arizona State Hospital is in good standing, including our Deemed Status as a result of our Joint Commission Certification.  Congratulations Team ASH. 

Having external entities such as CMS and the Joint Commission (JC) review your organization creates an exceptional opportunity to get a fresh set of eyes on what a facility is providing for services.  If you think about it in the quality realm, the survey is an evaluation using evidence based practices.  Survey and accreditation standards are built to determine whether programs are delivering services in accordance with the accepted “Standards of Care” that have been developed from years of surveys, experience, research and best practice from regulators, clinicians, academics, legal analysis and patient experience.  Why would a program not want to have an opportunity to be evaluated according to these standards? 

So while some people look at surveys and their results as a negative reflection on the program we need to reframe that look from the lens of quality.  We want quality services and outcomes for patients.  Learning from both internal and external quality processes helps organizations meet those goals.  Continuous quality improvement only happens when you continually evaluate the services through the quality lens.  The team at ASH and ADHS is proud of the work that staff at every level are doing to meet the needs of some of Arizona’s most vulnerable citizens and fulfill our requirement of delivering high quality care. 

BTW: You can read more about some of our initiatives to improve the quality of care at the State Hospital here and here.

Planned Parenthood v. Humble

March 11th, 2014

We were served Wednesday with a lawsuit seeking declaratory and injunctive relief from our new Abortion Clinic Regulations that are scheduled to go into effect on April 1.  The new regulations were in response to HB 2036, which was passed and signed during the 2012 legislative session…  tasking us with several things related to the regulation of abortions.  Among them was a requirement that we adopt new Rules for abortion clinics and outpatient treatment centers that provide abortion services.  The statute was very prescriptive, so our Rules basically mirror the Law.  

The primary complaint from Planned Parenthood of AZ, Inc. is centered around our upcoming requirement that any medication used to induce an abortion be administered in compliance with the FDA protocols as outlined in the printed label instructions (many clinicians currently use the medication “off label”).  

The new regulations are scheduled to apply to the 4 abortion clinics (3 in Phoenix and 1 in Tucson) and 5 outpatient treatment clinics authorized to perform abortion services (2 in Phoenix, 1 in Glendale, 1 in Tempe, and 1 in Tucson) beginning April 1, 2014.

Licensing & Rulemaking

March 10th, 2014

Our Licensing & Rulemaking teams have spent the past two years working with numerous associations and stakeholders from various licensed facilities as part of our regulatory reform initiative. The last legislative session extended our “exempt” rulemaking authority through April of 2014. This gave us the unique opportunity to live with the new rules for a little while to find out what worked and what didn’t. Our integrated rules officially went into effect on October 1, 2013, but since then, we’ve been continuing to work on incorporating stakeholder and surveyor feedback into the 18 Articles of regulations for Healthcare Institutions and Court Ordered Program Approvals and ensure consistency throughout the packages.

Our teams have been busy going through the comments to develop the new draft Rules, which are now posted online for our final comment period. The drafts and comment surveys will remain up for the next 30 days, giving our team a chance to review and incorporate appropriate feedback before the rules become final in April. We’ll file the final rule packages on April 30, 2014 and have a July 1 implementation date on each of the packages. That’ll give our licensees a chance to learn the new rules and changes before they’re expected to comply with them, and it’ll give our surveyors time to learn the new rules so we can survey to them properly. It’s been a long road- and we’re in the (final) final-stretch now.

National Audit: Room for Improvement at Skilled Nursing Facilities

March 6th, 2014

Data collection and analysis is public health’s most valuable  renewable resource- which is why we’ve made data analysis such a high priority.  Yesterday, the Office of the Inspector General for HHS published a document that highlights the fact that disciplined data analyses can identify key factors that result in poor outcomes- giving us the information we need to intervene and improve results. 

Yesterday’s report is entitled Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries, and it examines “adverse events” that occurred in skilled nursing facilities nationwide between 2008 and 2012.  “Adverse events” are basically events related to medication, ongoing resident care, or infections. 

The study found that about 22% (of Medicare beneficiaries) had an “adverse event” while at a skilled nursing facility.  Of course, not all of these were preventable, but the study found that almost 60% of the adverse (and temporary harm) events were preventable. The report attributes much of the preventable harm to substandard treatment, inadequate resident monitoring, or a delay in administering necessary care. 

Part of our core mission as an agency is to protect public health and safety by addressing quality of care issues in our licensed healthcare institutions.  As part of that mission, we license and inspect 147 skilled nursing facilities statewide.  The facilities range in size from as few as 10 to as many as 200 patients. 

Today’s study will be a valuable as a tool for us because it’ll help us focus our inspections and facility surveys on areas where we can have the biggest impact on improving care and outcomes.  Over the coming weeks, our skilled nursing survey team will be diving into the details of the report so we can become more familiar with the areas that we should focus on while we’re in the field- including updating our focused reviews of nursing home practices to identify and reduce adverse events. 

Additionally, the Affordable Care Act requires nursing homes to develop Quality Assurance and Performance Improvement (QAPI) programs to address quality problems and improve facility performance. Our survey teams will be including an assessment of adverse event identification and reduction in our evaluations of Arizona’s skilled nursing facilities QAPI plans with a focus on the elements of care identified in today’s report.

Midwife Practice Collaborative

March 4th, 2014

Our Licensing team promotes and protects public health and safety by addressing quality of care issues.  Last week we hosted a forum for our licensed midwives to learn more about our programs and resources to bring them up to speed on our newest initiatives related to maternal and child health so they’ll have the latest tools in their practice toolkit.  About 50% of our licensed professional midwives attended.  

The Bureau of Special Licensing’s Don Gibson took the lead and coordinated presentations on various topics related to maternal and fetal health.  Vital Records presented on how to file a birth certificate, time-frames, and birth data.  Our Birth Defects Program shared data and resources on the prevalence of various asymptomatic congenital conditions.   Newborn Screening covered the various statutory requirements that all newborn children and families are required to be counseled on, and our Immunization Program, Breastfeeding Program, Nutrition and Physical Activity, and Women’s and Children’s Health shared a host of free resources, 24-hour hotlines, and best practices.  

Claudia Montes presented an updated online reporting form.   Special thanks to the presenters: Bianca Soto, Dianna Contreras, Sondi Aponte, Gidget Carle, Fran Altmaier, Dana Goodloe, Anne Whitmire, Mary Ellen Cunningham, Claudia Montes, and Don Gibson.

Driving Down Cesarean Delivery Rates

March 1st, 2014

There’s widespread agreement within the public health community that the percentage of women who deliver by Cesarean Section these days is too high.  In fact, 1/3 of women in the US have cesarean deliveries these days (up from 9.5% in 1990 and 23% in 2008).

Last week the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine collaborated to produce an Obstetric Care Consensus document entitled  Safe Prevention of the Primary Cesarean Delivery, which provides new research analyses and interpretation to help “…health care providers to understand the short-term and long-term tradeoffs between cesarean and vaginal delivery, as well as the safe and appropriate opportunities to prevent overuse of cesarean delivery, particularly primary cesarean delivery.”  The consensus seems to be that it’s safe to let someone labor longer than had been previously recommended.

When we amended our regulations that govern the practice of licensed professional midwives in AZ, we allowed for the new guidelines that we hoped were coming out.  This long awaited document will provide clinicians and our licensed midwives with evidence-based information they can use to help more of their patients have a successful vaginal delivery.