Attendee Questions:

1. Does a blood sugar, preg test or INR test done upon pt admission need to be initialed by a provider as having been reviewed? Yes, you want the ordering practitioner to acknowledge the results of these lab results prior to starting the case. 2. How do we get a "handbook" that is being referenced? Send me an email at [email protected] , and I will respond with an attached copy of the 2015 Handbook. 3. What documentation is required for credentialing and privileging for ultrasound use for peripheal nerve blocks performed by anesthesia? Step 1) your governing body should approve the addition of this technology to the scope of services provided by your organization, Step 2) your medical staff should identify the qualifications, training and competencies required by applicants seeking ultrasound privileges, Step 3) Add the use of ultrasound to the list of privileges on your Anesthesia Delineation of Privileges form , Step 4) review applicants against the criteria in Step 2 and approve or deny requests for ultrasound privileges according to your organization’s policies. 4. Will the CMS handbook you referenced be available at the June “boot camp”? Yes, the CMS Handbook will be available at the June 12-13, 2015 Achieving Accreditation program in San Diego (our “boot camp”). It is has actually been approved by CMS and is available right now. My apologies for not knowing this at the time of the webinar.

5. For QI studies, what if you don' t know/have a quantitative goal? what if you are doing a study to find out if you have a problem? to find out what a standard is in your community and there is no numerical goal? Many quality/performance improvement activities begin with a suspicion or a “hunch” that perhaps your current state of performance is not where it should or could be. So a pilot study might be indicated; a smaller sampling of information, to determine if a problem really exists. You could use an internal benchmark or external benchmark as your target goal and compare your current performance to that goal. For example: are your supply costs for a certain procedure too high ? You could compare your current costs to your historical costs (internal benchmarking) and/or you could compare your current costs to those of other similar facilities or costs reported in a professional publication (external benchmarking) for comparison. If either or both of these comparisons are unfavorable, you might want to dig deeper to see if your other procedure supply costs are too high. 6. If my survey happens prior to the June CMS release date, will the surveyors use those proposed standards or survey using previous interactions? The new 2015 CMS Handbook will become effective with surveys performed on and after July 1, 2015. CMS deemed-status surveys performed prior to that date will be using the 2014 Handbook. 7. I was told that each study needs to have 2 rounds of data collection. Is this correct? Following the 10 elements in Standard 5. Sub-I C., your first round of data collection would be followed by an analysis of that data to determine source(s), frequency and severity of the problem. If your data indicates that your current performance is below your target goal performance, then you would implement a plan of corrective action(s) to improve your performance, and collect another round of data to re-measure your performance.