Accreditation

Briefings on Accreditation and Quality, May 2017

Briefings on Accreditation and Quality, May 1, 2017

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Editor's Note: Click the PDF button above for a full edition of the May 2017 edition of Briefings on Accreditation and Quality

What you need to know about ILSMs in 2017

The Joint Commission announced it was changing its interim life safety measure (ILSM) evaluation process back in November 2016. From now on, the accreditor stated, when a surveyor identifies a Requirement for Improvement (RFI) level deficiency they’ll confer with the facility to pick the most suitable ILSM to use. The Joint Commission also created a new element of performance (EP) for the LS.01.02.01 standard. EP 15 states that if the hospital’s policy allows for ILSMs not addressed in EPs 2–14 to be used, then they must be documented in the “other” section of the hospital’s Survey-Related Plan for Improvement (SPFI).

Infusion errors, instrument cleaning lead ECRI list of top tech hazards


The ECRI Institute published its annual list of the top 10 health technology hazards for the industry. Readers will note that several of the top hazards in 2017 are the same as those in 2016. To guide readers through the hazards, BOAQ spoke to several experts on each issue (including infusion errors, instrument cleaning, and missed ventilator alarms) and about steps that can be taken to prevent it. We also have a chart listing the possible scorable standards for each hazard.

Q&A AAAHC report highlights top problem areas

Each year, the Accreditation Association for Ambulatory Health Care (AAAHC) Institute creates a Quality Roadmap report highlighting different findings related to improving the accreditation process. In the 2016 report, AAAHC found the three top deficiency categories to be:
•    Privileging, credentialing, and peer review
•    Quality improvement programs
•    Documentation
The following is an edited Q&A with Cheryl Pistone, RN, MA, MBA, AAAHC clinical director of ambulatory operations, about the deficiencies and what facilities can do to improve.


New Sentinel Event Alert focuses on leadership's role in culture of safety


The Joint Commission in March unveiled Sentinel Event Alert (SEA) 57, which stresses the role of leadership in developing and sustaining a culture of safety. It goes on to claim that leadership’s failure in this regard contributes to several adverse events, including wrong site surgery and treatment delays. It’s impossible to completely eliminate human and mechanical error completely, the accreditor writes. But leaders can take a role in mitigating and catching these mistakes before they hurt someone.

 

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