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Accreditation Insider

AHAP is a community in which survey coordinators and other accreditation specialists share the latest tested tips, tools, and strategies to implement successful accreditation programs and achieve professional growth. In this e-newsletter, you'll read helpful tips and timely news items related to accreditation and survey-readiness improvement. Plus, train your staff and yourself with our weekly quiz questions included with clickable answers.

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Issue 51, December 29, 2009

• Staff Challenge Question: Performance Improvement

  True or false: It is important for an organization to do more than just collect data. The data...

• From the AHAP Blog: Joint Commission releases interim Staffing Effectiveness standards

  The Joint Commission has released a series of interim requirements to the staffing effectiveness...

Issue 50, December 22, 2009

• Staff Challenge Question: Change in Patient Condition

  True or false: Data have shown that prior to a respiratory or cardiac arrest, many patients exhibit...

• From the AHAP Blog: Joint Commission opens proposed version of MS.01.01.01 (formerly MS.1.20) for comment

  The Joint Commission (TJC) has released a proposed version of MS.01.01.01 (formerly MS.1.20) and it...

Issue 49, December 15, 2009

• Staff Challenge Question: Provision of Care

  The initial assessment should include which of the following assessments:

Issue 48, December 8, 2009

• Staff Challenge Question: Informed Consent

  True or false: Informed consent includes information on the risks and hazards of a particular...

• From the AHAP Blog: CMS approves Joint Commission’s application for deeming authority

  The Joint Commission?s hospital accreditation program has been approved for continued deeming...

Issue 47, December 1, 2009

• Staff Challenge Question: Suicide Risk Assessment

  True or false: A suicide risk assessment identifies patients at risk for suicide and should also...

Issue 46, November 24, 2009

• Staff Challenge Question: Emergency Operations Planning

   “HVA” stands for which of the following:

• From the AHAP Blog: Top cited standard summary

  The Joint Commission has officially announced the most-cited standards for the first half of 2009...

• What’s new with AHAP!

  The latest AHAP benchmarking report has been released and is available to AHAP members now. The...

Issue 45, November 17, 2009

• Staff Challenge Question: Surgical Site Care

  Beginning January 1, 2010, surgical sites not involving implantable devices must be monitored for...

• From the AHAP Blog: Joint Commission announces update to PDA

  The Joint Commission has announced two changes to its Preliminary Denial of Accreditation (PDA...

• What's new with AHAP!

  For anyone who missed the Working Group Call on November 5 about incorporating Lean processes into...

Issue 44, November 10, 2009

• Staff Challenge Question: Patient Rights

  Which of the following is false?

• From the AHAP Blog: Announcing Patient Safety Monitor

  HCPro has launched its newest product: Patient Safety Monitor, an online resource for your patient...

Issue 43, November 3, 2009

• Staff Challenge Question: Medication Reconciliation

  True or false: Hospitals should have a process in place that compares a patient’s current...

• What's new with AHAP!

  Is your facility Lean? Hospitals across the country are making use of the Lean concept to help...

Issue 42, October 27, 2009

• Staff Challenge Question: Emergency Operations

  What does "NIMS” stand for?

• From the AHAP Blog: Survey coordinator week

  An AHAP member submitted a question last week that we thought would be a great discussion started...

Issue 41, October 20, 2009

• Staff Challenge Question: Infection Control

  A patient death or serious disability due to a healthcare-acquired infection should be treated as a...

• From the AHAP Blog: Core measures: First contest entry

  Our first success story comes from Cheri Samuels, BSN, MSEd, RN, CPHQ. Her facility was able to...

Issue 40, October 13, 2009

• Staff Challenge Question: Record of Care

  True or false: Every time a staff member documents in a patient’s medical record, the entry...

• From the AHAP Blog: AHAP Contest: Core Measures

  It’s time for another AHAP giveaway! To enter, all you need to do is share a success story...

Issue 39, October 6, 2009

• Staff Challenge Question: Universal Protocol

  The Universal Protocol™ (UP) only applies to procedures performed in operating room suites.

• From the AHAP Blog: Joint Commission’s 2010 Patient Safety Goals Reduce Requirements

  The Joint Commission promised additional details on the 2010 NPSG changes in the October...

• What's new with AHAP!

  Upcoming working group call. Is your facility Lean? Hospitals across the country are making use of...

Issue 38, September 29, 2009

• Staff Challenge Question: Organ donation

  Which of the following statements are true:

• From the AHAP Blog: Executive Briefings: NPSG info

  AHAP members– we just wanted to share the following list– it's the latest breakdown on...

• What’s new with AHAP!

  Are you interested in starting a local AHAP chapter? AHAP wants to help its members connect at a...

Issue 37, September 22, 2009

• Staff Challenge Question: Look-alike/sound-alike medications

  True or false: The hospital’s list of look-alike/sound-alike medications must include at...

• From the AHAP Blog: Executive Briefings

  Just wanted to share some highlights from the New York Executive Briefings session–possibly...

Issue 36, September 15, 2009

• Staff Challenge Question: Performance improvement

  The Joint Commission expects hospitals to:

• What's new with AHAP!

  Are you interested in starting a local AHAP chapter? AHAP wants to help its members connect at a...

• From the AHAP Blog: Joint Commission launches Center for Transforming Healthcare

  The Joint Commission announced a new effort to address the nation’s biggest issues in terms...

Issue 35, September 8, 2009

• Staff Challenge Question: Emergency preparedness

  Which one of the following not considered one of the phases of emergency preparedness?

• From the AHAP Blog: AHAP at Executive Briefings

  We're always curious how well-attended Executive Briefings is by our members. Did you attend the...

Issue 34, September 1, 2009

• Staff Challenge Question: Patient Falls

  It is important to reassess a patient’s fall potential any time his or her _____ changes.

• From the AHAP Blog: Joint Commission releases Sentinel Event Alert

  The latest Sentinel Event Alert was released by The Joint Commission this morning urging healthcare...

• What's new with AHAP!

  Are you interested in starting a local AHAP chapter? AHAP wants to help its members connect at a...

Issue 33, August 25, 2009

• Staff Challenge question: Verbal read-back

  When performing verbal read-back, which of the following statements is false:

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

• What’s new with AHAP!

  For those AHAP members looking to hone their accreditation specialist skills we want to make you...

Issue 32, August 18, 2009

• Staff Challenge question: Deemed status

  Deemed status requires which of the following services to be lead and/or directed by a physician:

• From the AHAP Blog: Joint Commission response to new follow-up survey questions

  A few weeks back, The Joint Commission announced a new type of follow-up survey–occurring...

• What's new with AHAP!

  For those AHAP members looking to hone their accreditation specialist skills we want to make you...

Issue 31, August 11, 2009

• Staff Challenge question: Medication safety

  True or false: Serious medication errors have occurred when physicians, nurses, or other healthcare...

• From the AHAP Blog: Stroke Certification

  This summer, we’ve really stepped up our coverage of Joint Commission stroke certification. I...

• What’s new with AHAP!

  If you're an AHAP member be sure to check out the latest edition of the AHAPInsider, which contains...

Issue 30, July 28, 2009

• Leadership

  True of false: Clinical leaders and members of the medical staff should have the opportunity to...

• AHAP Staff Challenge’s new look

  The AHAP Staff Challenge is rolling out a new look this week to bring you more information on what...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

• Staff Challenge question: Communication

  Communication is critical during an emergency. Communication strategies should include how to...

• From the AHAP Blog: Life safety deficiencies top 2008 citation list

  Thought this might be of interest–a write-up on Life Safety Code’s rise to the top of...

• What’s new with AHAP!

  We’ve posted both of the most recent working group calls about Joint Commission Stroke...

Issue 29, July 21, 2009

• Discharge planning

  True or false: It is not necessary to involve the patient or family in early discharge planning...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 28, July 14, 2009

• Suicide risk assessment

  One of The Joint Commission’s measures to help patients specifically at risk for suicide...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 27, July 7, 2009

• Critical test results

  True or false: Goal #02.03.01 requires the hospital to define the acceptable time frame between...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 26, June 30, 2009

• Medication labeling

  True or false: Serious medication errors have occurred when physicians, nurses, or other healthcare...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 25, June 23, 2009

• Provision of care

  ________ is a critical step in ensuring that the patient’s plan of care truly meets the...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 24, June 16, 2009

• Restraints

  The hospital determines the policy for monitoring of a patient in restraint; however, the...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 23, June 9, 2009

• Infection control

  Which of the following is not considered a multidrug-resistant organism by The Joint Commission...

• Clarification of last week’s posting

  Attention readers: In last week's AHAP Staff Challenge (6/02/2009) there was a mix up between...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 22, June 2, 2009

• Medication Reconciliation

  True or false: Medication reconciliation does not need to be performed when a patient is being...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 21, May 26, 2009

• Sentinel events

  What is the sentinel event most frequently reported to the Joint Commission as of March 31, 2009?

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 20, May 19, 2009

• Patient identification

  Two patient identifiers should be used before _________.

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 19, May 12, 2009

• Universal Protocol

  True or false: A time out prior to surgery is just as effective with just the nursing staff if the...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 18, May 5, 2009

• Handoff communication

  An effective patient handoff may include information about __________.

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 17, April 28, 2009

• Organ Donation

  True or false: The Joint Commission requires hospitals to have an agreement with an Organ...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 16, April 21, 2009

• MRSA control

  When a patient is identified to have MRSA, that patient should be put in ____________ isolation.

Issue 15, April 14, 2009

• Isolation

  PPE stands for ___________________.?

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 14, April 7, 2009

• Medication Safety

  Anticoagulation therapy has led to many serious adverse events.

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 13, March 31, 2009

• Emergency Preparedness

  Hospitals should have an internal emergency operations plan that allows them to sustain...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 12, March 24, 2009

• Discharge Planning

  When transferring a patient to another facility, which of the following does not need to be...

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 11, March 17, 2009

• Universal Protocol

  Which of the following is a step in conducting a timeout?

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 10, March 10, 2009

• Patient Rights

  Patients have a right to:

• Check out the AHAP blog!

  The AHAP blog brings you more of the accreditation news you need, updated on a daily basis. The...

Issue 9, March 3, 2009

• Recent Joint Commission announcement

  The Joint Commission recently announced that this National Patient Safety Goal would no longer be...

Issue 8, February 24, 2009

• Leadership

  All patients, regardless of their ability to pay or their source of payment, should:

Issue 7, February 17, 2009

• Medication Reconciliation

  Discussion with the patient prior to discharge should include _____________________.

Issue 6, February 10, 2009

• NPSG.02.03.01, critical tests and results

  Goal #02.03.01, concerning critical tests and results, requires the hospital to _______ which tests...

Issue 5, February 3, 2009

• Multidrug-resistant organisms

  The number of multidrug-resistant infections is __________ in the United States.

Issue 4, January 27, 2009

• Patient Falls

  A patient falls _______ __________ performed at the time of admission can help identify patients at...

Issue 3, January 20, 2009

• Do-not-use abbreviations

  True or false: All hospitals must have a list of do-not-use abbreviations. This list should be...

Issue 2, January 13, 2009

• Plan of care

  Each patient should have a plan of care that is ____________.   individualized to meet the...

Issue 1, January 6, 2009

• Restraint and seclusion

  When using restraints, the patient must be ____________.   Agreeable to the process  ...