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Accreditation Monthly

Sharon Courage, MPH, RN, Vice President of Hospital Services, and other Joint Commission accreditation and regulatory compliance subject matter experts share their views monthly to help accreditation professionals meet standards and compliance expectations.

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Accreditation Monthly

Issue 12, December 9, 2008

• Proctoring/FPPE (Focused Professional Practice Evaluation)

  In traveling from hospital to hospital, I find that the FPPE process is one that is a challenge to...

Issue 11, November 14, 2008

• 2009 Universal Protocol FAQs . . . finally here

  I’m sure you’ve all been waiting with bated breath for the 2009 Universal Protocol (UP...

Issue 10, October 7, 2008

• Take the Pain Out of Pain Reassessments in Three Steps

  The problem Most hospitals have an 80% intrinsic rate of compliance with their pain reassessment...

Issue 9, September 11, 2008

• Update from Executive Briefings #8: RFI Trends

  Pat Adamski reported the following “Problem Standards” from the results of surveys...

Issue 8, August 12, 2008

• Open Shafts in Mechanical Rooms

  This month’s article was written by Brad Keyes, CHSP, a consultant at The Greeley...

Issue 7, July 8, 2008

• New 2009 National Patient Safety Goals

  On June 17, The Joint Commission announced the new National Patient Safety Goals (NPSG) for 2009...

• New Medical Staff Models & Credentialing Challenges

  Dear Greeley Medical Staff Institute Member: You are processing an application for a candidate...

Issue 6, June 10, 2008

• OR temperature and humidity reading logs

  We have heard that Joint Commission surveyors are requesting to review logs of temperature and...

Issue 5, May 13, 2008

• Pain Reassessments

  This month’s article was written by Bud Pate, REHS, and Lisa Eddy, RN, CPHQ, senior...

Issue 4, April 11, 2008

• Creating a Culture of Safety Takes Time

  The new Joint Commission standard calling on hospitals to create a culture of safety will not take...

Issue 3, March 20, 2008

• Oxygen Cylinder Storage Requirements

  This month's e-newsletter was provided by Brad Keyes, CHSP, safety engineer and consultant for...

Issue 2, February 12, 2008

• Two Reasons to Read Perspectives Carefully

  The January 2008 issue of Joint Commission Perspectives contained two seemingly small...

Issue 1, January 8, 2008

• Breaking Life Safety Code news: Start preparing for 2009

  As you've probably heard, the Joint Commission's (formerly JCAHO) Standards Improvement Initiative...