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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
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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
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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
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Staff Challenge Question: Provision of Care
The initial assessment should include which of the following assessments:
Issue 48, December 8, 2009
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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MRSA control
When a patient is identified to have MRSA, that patient should be put in ____________ isolation.
Issue 15, April 14, 2009
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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
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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
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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
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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
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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
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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
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Recent Joint Commission announcement
The Joint Commission recently announced that this National Patient Safety Goal would no longer be...
Issue 8, February 24, 2009
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Leadership
All patients, regardless of their ability to pay or their source of payment, should:
Issue 7, February 17, 2009
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Medication Reconciliation
Discussion with the patient prior to discharge should include _____________________.
Issue 6, February 10, 2009
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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
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Multidrug-resistant organisms
The number of multidrug-resistant infections is __________ in the United States.
Issue 4, January 27, 2009
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Patient Falls
A patient falls _______ __________ performed at the time of admission can help identify patients at...
Issue 3, January 20, 2009
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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
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Plan of care
Each patient should have a plan of care that is ____________. individualized to meet the...
Issue 1, January 6, 2009
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Restraint and seclusion
When using restraints, the patient must be ____________. Agreeable to the process  ...