(Donna) Hello, and thank you for joining us
for Check-in with The Joint Commission for Hospital Accreditation.
My name is Donna Rutkowski,
and we're happy to be able to spend some time with you.
Today we're going to let you know what's new and what you need to know
regarding standards updates,
tips regarding the actual survey process, including life safety,
and the most commonly asked questions and RFIs.
You'll also hear some updates
regarding activities in some of the states.
We'll send you both the webinar slides and a recording to you via email
a few days after the webinar
so you can have them for reference and to share with your teams.
Who you'll hear from today
is Project Director Laura Smith,
from our Department of Standards and Survey Methods;
Theresa Hendricksen and James Kendig,
both Field Directors for the Hospital programs;
Associate Director Jelitsa Legarreta, from our Standards Interpretation Group,
and Executive Director Mark Crafton, from our Strategic Alliances area.
With that, I'm going to turn it over to Laura
who will help you learn what to expect regarding standards updates for Hospitals.
Laura?
(Laura) Thank you, Donna.
Next slide, please.
What I'm going to review today
are some changes that are effective August 27th
and some that are effective January 1st.
And I'm going to start with some changes for Critical Access Hospitals
that are effective August 27th.
And these are changes that resulted
from our deeming renewal application with CMS.
And the next two slides, this one and the next one,
I will be highlighting some of those changes.
First, there are two new Elements of Performance
that relate to definitions.
The first is related to rural health network
as defined in the Critical Access Hospital
CoP 485.603.
We have an Element of Performance that addresses this,
and then the specific definition of rural health network
can be found in our glossary.
The second new EP addresses personnel qualifications,
and those qualifications specifically relate to clinical nurse specialist,
nurse practitioner, and physician assistant.
And those are tied to Critical Access Hospital
CoP 485.604.
And again, you can find these definitions in our glossary.
We also have added two new Elements of Performance,
one in the Life Safety Code chapter
that says you must comply with the Life Safety Code
and specifies some additional areas,
including tentative interim amendments.
And then there is a second EP
that is in the Environment of Care chapter
that says you must comply with the Health Care Facilities Code.
These are just two new EPs that say you comply with the codes.
Next slide, please.
Some additional Critical Access Hospital changes
that have resulted from our deeming application
include alternative equipment maintenance.
And this is a way you can maintain equipment
instead of using manufacturer's recommendations.
And per part of our deeming application,
we decided that it would be best
to remove references to AEM and manufacturer's recommendations.
so It's up to your Critical Access Hospitals
to determine how you're going to maintain facility and medical equipment.
But keep in mind that we have added guidance,
which is consistent with CMS's interpretive guidelines,
and that can be found
in your organization's Survey Activity Guides.
The guidance is very specific.
If your organization chooses to use an AEM program,
then you need to be in compliance with that guidance.
Next slide, please.
Okay, here are some other updates for August 27th.
And, as you know, we have been conducting a project
to eliminate requirements that are not related to CoPs
and have limited value.
And we have completed phase two.
And this is both for Hospitals and Critical Access Hospitals.
And for these programs,
several Elements of Performance have been consolidated and or deleted.
And you can find those on our website
under the Standards Pre-publication section.
These are effective, again, August 27, 2023.
Next slide, please.
As I just mentioned a few slides ago, for Critical Access Hospitals
and alternative equipment maintenance,
as well as the EPs related to the Life Safety Code
and Health Care Facilities Code requirements,
we added these so that Hospitals and Critical Access Hospitals
are consistent with their requirements
and this supports the Hospital Conditions of Participation as well.
The same changes that were made for alternative equipment maintenance
and manufacturer's recommendations
will be effective for Hospitals in January of 2024.
As far as these changes,
will be available on the Pre-publications page
of our website for the Standards section,
most likely by the end of August.
You can keep an eye out for those coming up.
Next slide, please.
Some changes for January 1st relate to medication compounding,
and these changes involve several revisions
to the requirements at Standard for Medication Management
05.01.07
and EP 3 at NPSG 03.04.01.
And these changes are intended
to better align with national standards of practice
and the Medicare Conditions of Participation.
I'm reminding you that these are applicable
to both Hospitals and Critical Access Hospitals.
And the same situation exists here,
that the changes will not be in the Standards Pre-publication page
until roughly the end of August.
And the September issue of Perspectives
is where you'll find the announcement for this,
and the hospital ADM changes as well.
Next slide, please.
Here are just some other updates of work in progress
or that was recently out for field review.
Environmental sustainability,
there was a new standard with some EPs
that related to the topic that was out for field review
and based on feedback
from the field review and leadership discussions,
it was decided that
we are not moving forward with requirements
or accreditation requirements related to this topic.
The next action or work that we're doing that was just field reviewed
relates to the Infection Control chapter re-write.
And that field review has concluded
and Joint Commission staff are in the process of analyzing
your feedback and responses.
And a final set of standards
will be ready for implementation in July of 2024,
and you can keep an eye out for Perspectives.
It would be most likely January of 2024 for additional information
on the Infection Control chapter revisions.
Next slide, please.
And finally, just giving you a little update
on certification programs.
The first is a reminder
that the Health Care Equity Certification program launched July 1st,
and if you're interested in that,
you will find more information on our website on how to apply
and some guidance for doing so.
The next three areas
basically consist of revisions and updates.
And that's for our stroke certification programs,
the Advanced Certification in Heart Failure,
and Medication Compounding Certifications.
All those changes are effective January 1st, 2024.
And you can find all of this information
and the changes on our Pre-publications website.
And it is there as we speak.
That is it on my slide.
I am going to turn this over to my colleague, Theresa Hendricksen.
(Theresa) Thanks, Laura. Good afternoon, everyone.
I'm here to talk about survey process,
to just give you an update on what's going on.
Next slide, please.
First and foremost, the PHE is over.
Yay! I hope you're all clapping.
And with that, it means we will no longer survey to the vaccination requirements.
And while the standard is remaining in our current manual,
surveyors have been educated not to evaluate for compliance.
And the database will be updated and be reflected
in the next standards release later this year.
It will go away.
Also, we no longer require surveyors to wear masks
unless your organization requires it.
However, many of our field staff are choosing to still wear masks.
And we just ask that that practice is respected
by your organization and team members.
Thank you in advance for that.
Next slide, please.
I know a lot of you have reached out
to your various contacts at The Joint Commission
about a CMS memo that came out about two weeks ago.
At this time, CMS is currently re-reviewing their memo
regarding avoid dates,
same-day notification of surveys, and the complaint survey process.
They sent an email out to all accrediting organizations last Thursday
and told us that they had received a lot of feedback
from various entities and parties,
so they're re-reviewing that memo.
I don't have anything to share with you at this time,
but please know that as soon as we hear from CMS,
we will be communicating with all our customers
on what that is going to look like.
And lastly,
the Corporate/System Team Leaders will fully return in 2024
and you will be notified in fourth quarter of 2023
on your assignments.
Just remember that if you had someone assigned to you,
they, as a system/corporate team lead,
they can do that assignment for three years.
After three years, they have to roll off from your system
and reassign someone new.
If you have someone now, that's only been doing it for a year,
rest assured they will stay on for two more years.
Next slide, please.
And lastly,
we hear you regarding surveyor consistency.
We've had a voice of the customer focus group
that many of you were able to provide us feedback,
and so right now, internally, we have work groups
that are looking at both scoring consistency
and surveyor behaviors consistency.
Your surveyor evaluations are extremely important to us.
Please take a few minutes to complete that at the end of your triennial surveys.
The surveyors want that feedback as well as our central office.
We want to know how we're doing, you know, from your perspective.
And thank you.
With that, I'm going to turn it over to my colleague, Jim Kendig.
Jim?
(Jim) Thanks, Theresa. I appreciate that update.
Let's speak a little bit about life safety updates here
on this particular slide.
What we continue to see is we have a facility orientation
from 8 am to 9 am on day one.
If you can have somebody with keys available at 8:00 am
to pick up the life safety code surveyor,
they're going to do a facility orientation.
Oftentimes, we ask around 7:47, 7:45,
and things are hectic on day one in the morning.
So we don't always get someone to the team room
to pick up the life safety code surveyor.
If you can kind of pencil that in to make sure on day one
that we get someone to pick up the life safety code surveyor
in the team room at 8 o'clock with keys.
We're going to go take a look at the fire alarm panel,
the electrical panel and breaker that serves the panel.
Look at some gen sets, or look at the fire pump,
whether it's diesel or electric.
And we're going to look at the intern life safety measures policy,
as well as the written fire response plan,
and do a quick orientation to the drawings.
And after that, we're going to go ahead and return to the team room
at about five of 9 and go ahead
and do the opening conference with our team.
Team leader do some introductions
and then we're going to scoot to start the document review.
We also-- I'm on a survey right now,
observing a new hire in the middle of the country.
And this came up again today, accurate life safety drawings.
Make sure your drawings are currently reflective
of your campus and your buildings.
Inspection, testing, and maintenance documentation,
these be organized and readily available, paper or electronic or both.
We don't really mind whether it's a hybrid approach,
but make sure if you have an electronic system
that you have someone that can drive that process.
We typically do 120 to 150 minutes for the document review.
If we get much longer than that,
we'll probably take a timeout and start with the building tour
until we can get somebody there to drive that electronic system.
Either way, paper, electronic,
or a hybrid of both, half and half, whatever,
but we will survey to what you have on site.
Mock survey critical pressure areas, take a look at that.
There's still the S&C memos, now QSO memos from CMS.
S&C memos were issued twice, about a year or two apart
to relative humidity and temperature.
Keep in mind the second S&C memo included ambulatory surgery centers
or ASCs.
And what this says is, if you're less than 30% relative humidity,
you need to check with the manufacturers of your equipment and the suppliers
to make sure that the equipment can operate
and the supplies can be stored
in a less than 30% relative humidity environment.
What we find typically is that the surgical lights and Bovie,
the IFUs or instructions from use from the manufacturer,
require that they be in a relative humidity environment of 30% or more.
Make sure you take a broad look at all your supplies and equipment.
Typically when we train new hires we ask them to look at the Bovie,
IFU, instructions for use, and the surgical lights.
That typically does not allow for you to accept that S&C memo
or the lower relative humidity rate.
We want to make sure that the BBI and the E-app
are kind of reconciled.
If you could take a look at that when your AE calls just to make sure
we have the right numbers in both places.
Routinely, Life Safety Code surveyors will look at the BBI,
whereas our clinical colleagues will look at the E-app.
We have done extensive training with the Life Safety Code surveyors,
upon new hire orientation, as well as annual conference,
as well as webinars,
to make sure that the Life Safety Code surveyors
have more of a familiarity with the E-app
and the information located within that.
Make sure that indeed the E-app and the BBI reconcile.
And the new business rules, as a result of our CMS-deemed application.
A couple years ago, we added freestanding ambulatory surgery centers,
if under the HCO, and freestanding EDs.
We typically add a day for each.
However, if they're in close proximity, it doesn't take long to drive.
Again, distance and time to travel is a consideration.
If you're in Los Angeles, 10 miles takes one hour,
where in your rural Ohio, Pennsylvania, or West Virginia,
10 miles actually takes 10 minutes.
We equate that,
both Tim and I take a look at that when requested
to see if we can do a half day at each location again.
It depends on the distance and the time it takes
to travel that distance.
We do have some wiggle room on that
but, typically, we allocate one day, no one questions that,
as far as distance and time to travel.
For the Hospital, we certainly look at that,
as far as the BBI and any freestanding EDs
or ambulatory surgery centers.
Not ambulatory settings,
ambulatory surgery centers only.
Split surveys coming to a close. We've been in a hiring frenzy.
In fact, last week and this week, I'm out in the field signing off
on new Life Safety Code surveyors.
And we have a bunch of interviews coming up.
We're looking forward to filling the September
new field representative orientation program.
And we have one in October as well.
We've been working hard to remove the split surveys.
Don't forget new requirements for water management under EC.02.05.02,
workplace violence, we put that in the HR,
Leadership, and EC chapters,
and Emergency Management, starting with EM.09.01.01.
Take a look at those new standards
that were issued in January and July of 2022.
I also authored an article on the safety briefing.
It showed up in the November Perspectives,
and the December Environment of Care News.
The safety briefing follows the training we've done with our surveyors.
We've had situational awareness training with our surveyors in February of 2023.
And this is just, again, a continuation of our work
to keep our surveyors safe in the field.
This safety briefing can be as long as 30 seconds
or as long as several minutes.
What we essentially want to know is in the environment, in the community,
is there anything that would impact
or potentially impact the surveyor's safety?
Likewise, is there anything within the organization
that may compromise the surveyors safety?
And of course, you can review the codes that you have,
code blue, code black, plain language, whatever,
but typically the orientation includes,
"For your safety, follow staff instructions
to make sure you are safe."
We don't roam, as you know, we are escorted all time.
In lieu of spending a lot of time going over the codes and expectations
I suspect many of our customers would just want to say,
"Hey, stay with your guy, your handler,
and make sure you follow their instructions to ensure your safety."
That's the Safety Briefing.
Could be as, "Jim, I don't have anything to tell you,
either within the hospital or outside the community.
And by the way, yep,
if you hear an overhead code, just listen to the instructions of the staff,
work could be several minutes long."
"Jim, we are hosting a major sports event in the community,
so you may see some activity around that,"
a college event perhaps, or within the organization,
maybe a new contract was ratified,
or "Jim, there's some sensitivity around COVID,
we lost a couple staff members,"
and I remember being on a survey that the organization did articulate that.
Anything you'd like to tell us to ensure the safety of our survey team
while on site is appreciated.
I think that is it for my slides.
Let me turn it over to my colleague, Jelitsa, from SIG,
to go over her slides.
(Jelitsa) Wonderful. Thanks a lot, Jim.
My name is Jalitza.
I am with the Standards Interpretation Group,
and I am going to talk to you
about the top 10 scored standards and elements of performance.
Next slide, please.
All right. This data was collected from July of 2022
through June of 2023.
At a quick glance, we can see that three of these top 10 RFIs
were in the Infection Control chapter,
three of them are in the National Patient Safety Goal chapter,
one of them pertains to Medication Management,
and you'll see that three of them
are in the Provision of Care, Treatment, and Services chapter.
And we're going to discuss these in a bit more detail.
Next slide, please.
As I provide some examples
for each standard and element of performance,
I would like, if you have any questions,
to please refer to the accreditation manual
for the EP language in its entirety.
But beginning with MM.06.01.01 EP 3.
This standard and element of performance pertains to administration of medications
and specifically following the order for such.
Some of the common RFIs that we see are medications being administered
that were not ordered for the patient.
We see this a lot with pain medications being provided for patients
when it doesn't correlate to their pain level as per the order.
And we also see this quite often with titrations not being administered
at the correct starting dose, at the appropriate time intervals,
or not meeting the clinical endpoint as per the order.
Another commonly scored standard and element of performance
is IC.02.01.01 EP 2.
And so this one relates to standard precautions.
Some of those common RFIs relate to open multiple dose vials
that are found in patient treatment areas,
as well as staff failing to perform hand hygiene
while delivering patient care.
In the Element of Performance language, you'll see that there is a reference
to the website of the Centers for Disease Control and Prevention.
And we do follow those injection safety practices
and standards precautions
and usually do refer to them when writing the RFIs.
Next slide, please.
The next one is in the Provision of Care, Treatment and Services chapter,
and this is PC.03.01.03 EP 1.
And so this one pertains to the pre-anesthesia assessment,
and the RFIs are usually specifically noted
that the anesthesia assessment is either not performed at all
or not performed as required per hospital policy,
by laws, or rules and regulation.
The next one is PC.02.01.11 EP 2,
and this one pertains to resuscitation equipment.
Here we'll see RFIs that speak about crash carts
or emergency cart logs being incomplete
as required per organization policy,
or we will also see expired supplies, missing supplies,
and not checking either defibrillators or other equipment
as per the manufacturer instructions for use.
Next slide, please.
These two standards and element of performance
are specific to the need to reduce the patient's risk for suicide.
NPSG.15.01.01 EP 1,
speaks specifically to the environmental risk assessment
that is either not completed,
or at times we'll see that if it has been completed
and there are some environmental risk identified,
there was little to no evidence that progress had been made
to correct those risks.
The next one at that same standard is EP 4,
and this one speaks specifically
to documenting the patient's overall level of risk for suicide
as well as the plan to mitigate.
And here is where we'll see RFIs
that speak to either the level of suicide risk
not being determined or documented
as well as those mitigation strategies
or plans not being either implemented or documented,
such as one-to-one, etc.
Next slide, please.
Now we are back at the Provision of Care, Treatment, and Services chapter.
This is PC.01.02.01 EP 1,
and this one speaks specifically to assessments,
either not defining the assessment that is required
or a lack of implementation of that defined assessment.
UP.01.03.01
is in the National Patient Safety Goal Chapter,
and this is EP 2.
And this one specifically speaks
to not uniformly following the time out policy.
The RFIs that we see written here at this element of performance
are typically pertaining to various staff members
not paying attention or fully participating
in the time out as required per organizational policy.
Next slide, please.
And these are our biggest contributors
to what may be known as an immediate threat to health or safety,
or those that are commonly scored in the high risk category.
Both of these are in the Infection Control chapter.
IC.02.02.01 EP 1 is specific to cleaning
and performing low-level disinfection
of medical equipment, devices, and supplies,
whereas EP 2 speaks to performing intermediate and high-level disinfection,
as well as sterilization of medical equipment,
devices, and supplies.
For EP 1, we usually see RFIs
that speak to staff not following contact time,
or what's known as wet time,
as specified by the manufacturer's instructions for use.
This will be dependent on the type of wipe
that you may be using to wipe down your supplies and equipment.
And one of the higher risk RFIs usually pertains to those equipment
that are at risk for transmission of blood-borne pathogens,
such as glucometers.
At IC.02.02.01 EP 2,
this is where we're going to see lack of monitoring temperature
of high-level disinfectant solution
as required for the manufacturer's instructions for use,
as well as not meeting
the instrument-required sterilization parameters,
such as pressure and temperature, and time.
Next slide, please.
When we are looking at infection control,
specifically when we're speaking to either cleaning
as well as low level and high level
disinfection as well as sterilization,
we refer to the Infection Control Hierarchy.
This hierarchy can be found in the April 2019 Perspectives article,
but this basically gives an outline
of how it is that we survey for these infection control standards.
We want to take a look to see if there are any rules and regulations
that require that either your organization
follow a specific evidence-based guideline,
as well as look at any Conditions of Participations
that speak specifically to any requirements.
However, usually we see these requirements begin to be defined
in the manufacturer's instructions for use.
When your organization is incorporating new supplies,
devices, or equipment,
it is important to maintain
as well as review their instructions for use
as it pertains to maintenance, cleaning, and the use of that device.
If the manufacturer's instructions for use happens to be silent,
then the organization can defer to any adopted evidence-based guidelines
and national standards.
In the absence of that guidance,
there is the ability to defer to consensus documents,
and then, finally, organizational policy.
Please note organizational policy
cannot supersede manufacturer's instructions for use
or outline a process that does not align with those components
that are higher up on the hierarchy.
Next slide, please.
Overall, some of the questions that we commonly see here in SIG
from our customers
pertain to either new or updated standards,
or any mandates that were provided by CMS, or state rules and regulations.
Particularly, we see this with medical staff,
credentialing and privileging.
The Provision of Care, Treatment and Services chapter,
specifically histories and physicals,
and of course, the Infection Control chapter.
Next slide, please.
And finally, I just wanted to be able to voice
the various resources that we have available
on The Joint Commission website,
you'll find some standards frequently asked questions
that provide some pretty in-depth answers to some of these commonly asked questions.
There's also an online submission form where you can either send an email
to an Associate Director in the Standards Interpretation Group
or request a phone call to discuss your very specific question.
There also are three reports,
pre-publication of standards, as mentioned by my colleague Laura.
And then, of course, your Perspectives articles
which are available in the portal,
are always a wealth of information.
And so with that, I am now going to hand it over
to my colleague, Mark Crafton.
(Mark) Thank you, Jelitsa.
I am going to cover seven topics
that are hot issues right now
in terms of state legislation and regulatory activity.
Some of them are directly related to Joint Commission standards.
Some are just tangentially related.
Some really have nothing to do with Joint Commission standards,
but they're just interesting topics
that I think all of us as healthcare consumers
should want to understand and know
that they are being debated in our state legislatures.
Next slide, please.
The first issue that I want to talk about
is legislation that would align state licensure regulations
with the extended Joint Commission re-credentialing cycle.
Late last year,
The Joint Commission revised
the LD standard that allowed organizations
to do re-credentialing from every two-year cycle
to an every three-year cycle,
with one big caveat that was explained in that standard:
where allowed by state law and regulation.
And that turned out to be a very important asterisk
on that standard.
I think a lot of hospitals
want to move from two years to three years.
In the majority of the states, you can do that,
but what we have found since changing that standard
is that there are about 15 states
that have codified the two-year re-credentialing cycle
in their hospital licensing laws and regulations.
In those 15 states,
there is no current ability
to take advantage of that extended year on re-credentialing.
Since we made that change to every three years,
we know of two states, both Indiana and Maryland,
that went through the legislative process and got the governor to sign new law
into place codifying either an every three-year for everyone,
or use whatever timeframe is used by the accrediting organization
that you choose.
And those two states now are perfectly in alignment
with Joint Commission.
But there are still big states that are out there,
including Massachusetts and New York,
where three years is not an option because of the licensure regulation.
So if you are interested in this topic,
I know your state chapters
of your medical staff services professionals
are looking at campaigns to try to modify
the legislation or regulations.
We're happy to support any of that.
We could provide some of our background information
on why we felt ongoing professional practice evaluation
and focused professional practice evaluation
have made it such that one can go three years
between the formal re-credentialing of licensed practitioners.
The second issue that I just want to mention,
actually the two and three here really go hand in hand,
and they epitomize some of the political divides
that we have in our country that became magnified
during the COVID pandemic.
You might recall Individuals
who were hospitalized with COVID
absolutely wanted to be treated with a medication
that was not FDA-approved for treating COVID.
There was no evidence that it had any efficacy at all
for a treatment toward COVID.
But those individuals were adamant that they get that drug,
but there were no physicians on staff at the hospital that they were in
that would prescribe it.
What we have seen
in the last couple of years is legislation
that would allow patients to bring in, "guest physicians,"
if they could not find an appropriate prescriber on staff at the hospital.
They would find a physician who was like-minded
in the philosophy of using a medication,
and they could bring that individual into the hospital.
I have not seen that legislation pass, but it has been introduced.
But I think it would be somewhat detrimental in terms of--
Hospitals that have formal processes in place
for credentialing and granting membership,
even for temporary or emergency privileges,
there are still protocols that hospitals need to implement
to get CEO or chief of staff approval
for granting emergency privileges.
This seems to run counter
to some of those policies
that are in place in most hospitals.
And really the same thing for this last one.
There were individuals who have lobbied their legislatures
that if they want a drug and want to be able to have it prescribed,
hospitals have to carry that drug.
Ivermectin, for instance, being one that,
even if the Pharmacy and Therapeutics Committee
of the hospital doesn't endorse it,
these bills would compel hospitals to carry that medication.
Again, this is a bit of a political battle of,
does the government run medicine
or do medical personnel?
I think this is kind of at the heart of that.
Next slide, please.
Well, one of the other issues
that we've talked about already today
is workplace violence
and criminalizing threats against healthcare workers.
As we all know, hospitals should be places of healing
and should be safe havens and sanctuaries from violence and intimidation.
But all too often that is not the case.
Too many times we are subject
to physical and verbal abuse as healthcare workers.
I myself, one day in the past, was a medical technologist
and I used to hate working midnights,
because every Friday and Saturday night, at about 2 am in the morning,
the labels would print out to go down to the emergency department
and do a blood draw for an ETOH.
And I can tell you that, at 2 o'clock in the morning,
there's only certain reasons
why people are getting a blood alcohol drawn
in the emergency department.
Usually they've been in a physical altercation,
they've been in a motor vehicle accident,
or they have had an untoward engagement with law enforcement.
Either way, they are unhappy.
I used to just hate going down there to draw those patients
because you could get hit, you could get bit,
you could get spit upon or sworn at.
And I always preferred the foul language over the sharing of body fluids.
That was my preferred way to interact with these patients.
But you know what?
Back in the day, that was just called Friday night
in the emergency department.
We really need to change the mentality and philosophy
of thinking about workplace violence,
so that it's not something that's just part of the job,
something that's tolerated.
That's why you're trained to deal with it.
We know that 44% of nurses
experienced physical violence during the COVID pandemic.
We know that 68% of nurses
experienced verbal abuse during the pandemic.
But we see more and more states now adding laws that address assaults
against healthcare workers.
And at least 32 states now consider
assaults against healthcare workers felonies.
We're looking for the other 18 states to move in that direction as well.
Patient visitation,
again, another kind of a political issue
that became a hot button during the COVID pandemic.
You'll know early in the COVID pandemic that patients died,
and they died without their loved ones at their bedside,
because of the visitation limitations that were put in place
to curb transmission of the coronavirus.
People had to Skype with their loved ones,
people missed the birth of their child
because of these limitations.
And even today, we still hear debates in nursing homes
about whether or not the social isolation
that came from not allowing visitation of loved ones
was greater risk to the elderly than a potential COVID outbreak
in their nursing home.
That is still honestly debated in many circles.
We have seen a bunch of bills that have been introduced
that would force facilities to allow visitation
under some limited circumstances,
even during a public health emergency.
You know, big states have implemented
this law that codifies the right to patient visitation,
even if a health commissioner would declare a public health emergency.
And we see the opposite happen as well in other parts of the country,
where states are introducing bills that does give the governor
and the public health commissioner the authority to restrict visitation,
even in limited circumstances.
The third issue on this slide that I'll talk about is mental health.
And I know this is not a behavioral health care customer group
that I'm speaking to, but I think all of you will appreciate
that when people cannot
or will not engage the mental health system
and they have a mental health crisis,
they end up at the hospital for one reason or another.
I think it's important to talk about mental health
with any of our customer bases.
COVID, of course, was bad for everyone's mental health,
especially our youth.
Some of the latest statistics that I've seen that are really alarming
is that 50% of student-aged children
experienced sadness or loneliness during the COVID pandemic
because of their isolation.
20% of students considered harming themselves during COVID,
and just shy of 9% actually did try to harm themselves
during those long months and years of the COVID pandemic.
And those numbers were much higher for LGBTQ youth.
We know that.
Another fact that I think is really alarming to me
is that more Americans under 50 years of age
die from accidental fentanyl overdose than of any other cause.
Think about that.
Homicide,
suicide,
cancer, heart disease,
motor vehicle accidents,
more people under 50 in the U.S.
die of accidental fentanyl overdoses.
We're seeing legislation that tries to address
these cascading mental health issues that are facing our society.
Certainly improving suicide prevention education
is one.
Setting up mobile crisis intervention services for youth
is another legislation that is gaining traction.
Access to mental health services via Telehealth
and actually paying for that
is another bill that is frequently introduced.
Fourthly, improving access to naloxone,
either co-prescribing it with high-dose opioids
or making that available
in places where overdoses frequently occur,
like on school grounds.
And then finally, decriminalizing fentanyl test strips,
so that people who are going to use illicit drugs
have a way to check to see
if it's potentially contaminated with fentanyl.
And the last one I'm going to mention is just interesting to me
because I have a background in risk management
and medical liability insurance.
We now have 20 states
that have laws on the books that require healthcare providers
to seek a patient's consent
before conducting pelvic or rectal examinations
on sedated patients.
And 15 of those 20 states have just passed that law since 2019.
What this means is that,
you know, before you're doing a procedure
that may include some kind of gynecologic
or pelvic or colorectal examination,
you need to have expressed consent from the patient.
And you have to have a separate consent
if any medical students
or other individuals not part of the care team
are present during the examination.
And I get the fundamental premise,
that people have a right to know who may be observing them
and participating while they're sedated.
But this certainly does, in those states where these laws have passed,
create a layer of complexity for teaching hospitals.
Because I think that just basic consent form
that everybody fills out when you enter a teaching hospital
that says, "I know they teach students and students are going to come by,"
probably is not sufficient in these states
with the bills that we're looking at
in terms of medical students and other individuals.
And why it's difficult is that people in teaching hospitals
tell me time and time again that you never know
when you are going to encounter a tumor
or other type of pathology in a patient,
and then you're going to want to have as many students and residents see that
and palpate that pathology as possible.
Because it's so rare, because it looks so different
than anything that they've seen before.
You want your students to be able to view that
and participate in that examination.
Because if you don't,
you know, six years is going to go by, those students are going to be attendings,
and they will encounter something very similar
and will never have had that chance
that they could have had six years prior when they were medical students.
That's kind of the whole philosophy of teaching hospitals,
is to be able to teach on the fly.
I think it remains to be seen just how this type of legislation
with explicit consent for medical students
is going to work in a lot of our teaching hospitals.
But there certainly is a trend with 15 states implementing this
over the last three or four years.
That's a quick run through of state bills and regulations of interest.
And at this time, I'm going to turn it back
to our moderator, Donna.
(Donna) Thank you, Mark. And thank you, Laura, Theresa, Jim and Jelitsa.
And thank all of you for joining us and listening to us today.
We hope you found it valuable.
Please look for the presentation and the recording
in your email in a day or two, they'll both be in there.
You can certainly share that with your teams.
Thank you for all you do and have a great rest of the day.