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Accreditation

A leading source of information and education for accreditation professionals, the accreditation department assists hospitals with achieving Joint Commission (formerly JCAHO) accreditation and compliance with CMS' Conditions of Participation, while also ensuring a higher level of care.

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Top Stories

  • Greeley Reflections

    Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. To learn more visit The Center for Healthcare Accreditation.

    Laure Dudley

    Laure Dudley
    Senior Consultant

    Medication Management and pharmacist first-dose review

    Part 7 of 7

    Performance review and improvement

    A good way to test your process is by incorporating ongoing tracers, along with retrospective record review, for each of your medication administration sites to identify issues or vulnerabilities related to the first review of medication orders.

  • Greeley Reflections

    Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. To learn more visit The Center for Healthcare Accreditation.

    Laure Dudley

    Laure Dudley
    Senior Consultant

    Medication Management and pharmacist first-dose review

    Part 6 of 7

    Provide 24/7 accountability

    Even when a pharmacy is not open 24/7 a “qualified” individual must perform a review prior to dispensing and, even then, a pharmacist must be on-call so that expertise is available. A retrospective review of orders must then be completed as soon as a pharmacist is available. There is also the expectation that any discrepancies be resolved prior to dispensing the medications.

  • Greeley Reflections

    Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. To learn more visit The Center for Healthcare Accreditation.

    Laure Dudley

    Laure Dudley
    Senior Consultant

    Medication Management and pharmacist first-dose review

    Part 5 of 7

    Evaluate care sites

    There are care delivery areas in which medications are not typically needed urgently or are not LIP-controlled environments where it doesn’t make sense to bypass the pharmacist review requirement in the first place.

  • Greeley Reflections

    Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. To learn more visit The Center for Healthcare Accreditation.

    Laure Dudley

    Laure Dudley
    Senior Consultant

    Medication Management and pharmacist first-dose review

    Part 4 of 7

    Meeting the requirements continued

    Pharmacist Access to Patient Information

    In order to provide the best recommendations, pharmacists need ongoing access to patient information. Pharmacist review is only as encompassing as the availability of patient-specific information.

  • Greeley Reflections

    Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. To learn more visit The Center for Healthcare Accreditation.

    Laure Dudley

    Laure Dudley
    Senior Consultant

    Medication Management and pharmacist first-dose review

    Part 3 of 7

    Meeting the requirements

    Your goal should be to develop processes that do incorporate pharmacy review of all medications prior to administration except in an emergency situation, physician controlled area, or where established, approved guidelines exist.

  • Greeley Reflections

    Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. To learn more visit The Center for Healthcare Accreditation.

    Laure Dudley

    Laure Dudley
    Senior Consultant

    Medication Management and pharmacist first-dose review

    Part 2 of 7

    The Hospital Requirements

    In the standards for medication management, The Joint Commission requires that prior to dispensing, a pharmacist reviews all newly ordered medications except in areas controlled by a Licensed Independent Practitioner (LIP) (e.g. Emergency Department) or in an urgent situation in which a delay would adversely affect the patient. It also requires that medications be dispensed in accordance with professional standards of practice.

Accreditation Blogs

From the Center for Healthcare Accreditation Website, a blog capturing the latest from our consultants on healthcare accreditation.
Read Center Reflections

Healthcare accreditation professionals hear from AHAP (Association) advisors and other accreditation experts about challenges and solutions.
Read AHAP Blog

Spotlight

  • The CMS Joint Commission Crosswalk 2010 Edition

    The CMS Joint Commission Crosswalk 2010 Edition

    In a practical, side-by-side table format, the book walks you through each of the CMS Conditions of Participation (CoP) and relates them to corresponding Joint Commission standards and elements of performance for 2010.

    Purchase this book from our HCMarketplace.