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Accreditation Insider Patient Safety Monitor Insider
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 48, December 7, 2010
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Suicide Risk Assessment
On an inpatient psychiatric unit, staffed 24 hours a day, seven days a week, _________ is one of... -
Joint Commission updates sentinel event statistics
The Joint Commission has updated its website with its latest sentinel event statistics.
Issue 47, November 29, 2010
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AHAP Staff Challenge: Fire alarms
True or false: It is a requirement that hospitals test their fire alarm audible and visual systems... -
From the AHAP Blog: CMS adds patient safety measures to hospital comparison website
Starting in 2011, the Centers for Medicare & Medicaid Services (CMS) plan to add new standards... -
What’s new with AHAP!
Save the date!
Issue 46, November 23, 2010
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AHAP Staff Challenge: Record of care
True or false: HIPAA is the law that protects patient privacy. -
From the AHAP Blog: Joint Commission reduces full survey timeframe from 39 to 36 months
The Joint Commission will reduce the timeframe for surveys by three months. This new rule will go... -
What’s new with AHAP!
Save the date!
Issue 51, December 28, 2010
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AHAP Staff Challenge: Record of Care
True or false: Patient allergies must be documented in the patient's medical record. -
From the AHAP Blog: Joint Commission launches new lab standards for 2011
Updated and revised laboratory standards have been announced by the Joint Commission, to go into... -
What’s new with AHAP!
Keep an eye out for the latest AHAP Insider in your email inboxes—the latest updates on AHAP...
Issue 50, December 21, 2010
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AHAP Staff Challenge: Environment of Care
True or false: It is safe to store non-sterile patient care equipment under sinks. -
From the AHAP Blog: Field review for proposed VAP/CAUTI NPSGs
The Joint Commission has opened 2012 National Patient Safety Goals (NSPG) for... -
What’s new with AHAP!
We’ve launched our latest benchmarking survey, and this time we’re looking into Medical...
Issue 49, December 14, 2010
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AHAP Staff Challenge: Patient Identification
True or false: One of the frequently occuring errors has to do with caregivers selecting either... -
Joint Commissions announces revision to medication reconciliation goal
Medication reconciliation has received a facelift: revisions to the medication reconciliation... -
What’s new with AHAP!
Take our latest benchmarking survey!
Issue 48, December 7, 2010
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What’s new with AHAP!
Save the date!
Issue 45, November 16, 2010
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AHAP Staff Challenge: Environment of Care
True or false: In the event of a fire, windows and doors are to be shut. -
From the AHAP Blog: Joint Commission launches library of best practices
The Joint Commission has launched the much-discussed “Leading Practice Library,” in... -
What's new with AHAP!
Save the date!
Issue 44, November 9, 2010
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Medication safety
True or false: It is important to educate caregivers on the risks of coagulation therapy... -
Joint Commission's Target Solutions Tool makes headway
The Joint Commission’s Target Solutions Tool™ (TST) launched in September has made... -
What’s new with AHAP!
Don’t forget that the latest edition of the Survey Coordinator’s Handbook will be...
Issue 43, November 2, 2010
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Performance Improvement
True or false: It is important to evaluate the effectiveness of your improvement actions to know... -
Clarification of informed consent standards
The Joint Commission has added a clarification to standard RC.02.01.01, EP 4, under the Record of... -
What's new with AHAP!
Thanks to all who participated in the last Working Group Call.
Issue 42, October 26, 2010
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Environment of care
True or false: The safety officer has the authority to take immediate action if he/she feels that... -
Hand-off communication solutions revealed by CTH
The Joint Commission’s Center for Transforming Healthcare (CTH) has announced the second in... -
What’s new with AHAP!
Thanks to all who participated in last week’s Working Group Call.
Issue 41, October 19, 2010
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Patient identification
True or false: When preparing to administer blood or blood products, it is important to use a... -
CMS updates requirements for ordering respiratory services
In order to comply with changes to CMS Conditions of Participation for hospitals regarding who may... -
What's new with AHAP!
Join us for our next AHAP working group call!
Issue 40, October 12, 2010
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Medication safety
True or false: Medication containers should be labeled when performing procedures outside of t he... -
Watch for Update 2
The Joint Commission has stated that “Update 2″ to its comprehensive manuals will mail... -
What's new with AHAP!
Join us for our next AHAP working group call!
Issue 39, September 28, 2010
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AHAP Staff Challenge: Performance Improvement
True or false: It is not necessary to use statistical tools (graphs, charts, sampling methods... -
What’s new with AHAP!
AHAP is happy to announce that its next Working Group Call will take place on Thursday, October 21... -
Provision of care
True or false: Nutrition and hydration status should be part of the initial inpatient assessment. -
From the AHAP Blog: Executive Briefings
Hello, AHAP members. The organization had a representative in the audience at the New York... -
Lab standard field review closing date approaches
The Joint Commission continues to accept comments from the field on new and revised laboratory... -
What's new with AHAP!
Join us for our next AHAP working group call!
Issue 38, September 21, 2010
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Environment of care
True or false: It is a requirement that hospitals test their fire alarm audible and visual systems... -
Joint Commission launches Targeted Solutions Tool
The Joint Commission has announced the launch of the Targeted Solutions Tool™ (TST), an... -
What's new with AHAP!
Keep an eye on the AHAP blog for a summary of what we learned at Executive Briefings last week!
Issue 37, September 14, 2010
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Record of care
True or false: Verbal orders must be signed within 48 hours. -
Joint Commission set to launch primary care home option
The Joint Commission intents to expand its ambulatory health care organization accreditation... -
What's new with AHAP!
AHAP on Facebook
Issue 36, September 7, 2010
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AHAP Staff Challenge: Patient identification
True or false: It is not necessary to use two patient identifiers when you are administering... -
From the AHAP Blog: Joint Commission reminder: How to comment on standards
The Joint Commission issued a brief reminder to organizations on how to provide feedback and... -
What's new with AHAP!
AHAP on Facebook
Issue 35, August 31, 2010
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AHAP Staff Challenge: Medication safety
True or false: Baseline coagulation status should be determined before starting anticoagulation... -
From the AHAP Blog: Center for Transforming Healthcare hand hygiene compliance project
The Joint Commission Center for Transforming Healthcare has announced it will release a tool... -
What's new with AHAP!
Fall Working Group call We are currently looking for ideas or potential speakers for our fall...
Issue 34, August 24, 2010
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Staff Challenge of the Week: Environment of care
True or false: Hospitals should perform a risk assessment to determine what areas of the hospital... -
From the AHAP Blog: Joint Commission releases latest list of most challenging requirements
The Joint Commission announced this week its most challenging requirements list for the first half... -
What’s new with AHAP
Thank you to all members who participated in our benchmark survey on restraints use. Results will...
Issue 33, August 16, 2010
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Staff Challenge of the Week: Suicide risk assessment
True or false: Patient and family education is a critical component when discharging a patient who... -
From the AHAP Blog: Universal Protocol feedback
The Joint Commission seeks feedback on revisions to the 2010 version of Universal Protocol... -
What’s new with AHAP!
AHAP would like to remind any members who would like to participate in our upcoming benchmarking...
Issue 32, August 10, 2010
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Staff Challenge Question: Suicide Risk Assessment
True or false: Psychiatric hospitals and acute hospitals that treat patients for behavioral or... -
From the AHAP Blog: Accreditation Positions Open in Your Area
One of the AHAP members asked us to circulate an opening at their facility for a Joint Commission... -
What’s new with AHAP!
Looking for an accreditation specialist?
Issue 31, August 3, 2010
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Staff Challenge Question: Universal Protocol
True or false: Informed consent includes information on the risks and hazards of a particular... -
From the AHAP Blog: HHS Announces Final Rule on Meaningful Use
The Department of Health and Human Services (HHS) announced yesterday its Final Rule on Meaningful... -
What’s new with AHAP!
Looking for an accreditation specialist?
Issue 30, July 27, 2010
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Staff Challenge Question: Patient Involvement in Care
True or false: Open communication between care givers, patients, and families, as appropriate, is... -
From the AHAP Blog: AHAP on Facebook
AHAP has started its own group on Facebook. Please stop by and feel free to join! -
What’s new with AHAP!
Looking for an accreditation specialist?
Issue 29, July 20, 2010
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Staff Challenge Question: Basic Emergency Operations
True or false: Emergencies cause a sudden, unexpected effect on an organization’s ability to... -
From the AHAP Blog: Berwick appointed to head CMS
President Barack Obama has appointed Donald Berwick, MD, president and co-founder of the Institute... -
What’s new with AHAP!
We would like to thank everyone who participated in the most recent working group call on going...
Issue 28, July 13, 2010
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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: Tracer methodology in the news
The Joint Commission is looking to refine and improve its tracer methodology, according to an... -
What’s new with AHAP!
We would like to thank everyone who participated in last week’s successful working group call...
Issue 27, July 6, 2010
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Staff Challenge Question: Performance Improvement
True or false: There are many processes that can be measured, and there are often more improvement... -
From the AHAP Blog: 2010 Education and training chart
Subscribers to Briefings on The Joint Commission (BOJ), found in the July issue an article by... -
What’s new with AHAP: Working Group Call
Just a reminder to AHAP members, the next working group call will take place on Thursday July 8th...
Issue 26, June 29, 2010
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Staff Challenge Question: Emergency Operations
True or false: NIMS training is required of hospitals receiving certain federal funds to help the... -
From the AHAP Blog: National Patient Safety Goals Element of Performance revisions
The Joint Commission announced today revisions to four Elements of Performance within the National... -
What's new with AHAP!
The AHAP blog has been following a number of standards news and updates stories—be sure to...
Issue 25, June 22, 2010
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Staff Challenge Question: Infection Control
Hair removal at the surgical site, prior to surgery, should be done by: -
Check out the AHAP blog!
The AHAP blog brings you more of the accreditation news you need, updated on a regular basis. The... -
What's new with AHAP!
Do you want to learn how to effectively respond to CMS letters, reports, and adverse actions by...
Issue 24, June 15, 2010
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Staff Challenge Question: Patient Rights
True or false: It is important to ensure that we provide information to our patients in a manner in... -
From the AHAP Blog: Joint Commission pushes back implementation date for telemedicine standards
The Joint Commission’s plan to implement CMS telemedicine standards for hospitals, both acute...
Issue 23, June 8, 2010
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Staff Challenge Question: Change in patient condition
True or false: It is important to train staff members to be able to recognize early warning signs... -
From the AHAP Blog: Sentinel Event Alert: Preventing workplace violence
The Joint Commission has released its latest Sentinel Event Alert, this time on preventing violence...
Issue 22, June 1, 2010
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Staff Challenge Question: Organ Donation
True or false: More people are receiving organ/tissue transplants each year, and those individuals... -
From the AHAP Blog: CMS proposes two hospital-acquired infection measures
The Centers for Medicare & Medicaid Services (CMS) has published a notice of proposed changes... -
What's new with AHAP!
Attention AHAP Members: Make sure to keep an eye out on the home page and the AHAP blog over the...
Issue 21, May 25, 2010
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Staff Challenge Question: Patient falls
True or false: It is important for patients and families to understand the individual...
Issue 20, May 18, 2010
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Staff Challenge Question: Restraint and seclusion
True or false: Staff members must receive training on the use and management of restraint and... -
From the AHAP Blog: 2009 top cited standards announced
The Joint Commission has released its list of the most cited standards for 2009. Unsurprisingly...
Issue 19, May 11, 2010
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Staff Challenge Question: Critical test results
True or false: Hospitals not only need to monitor time frames for reporting critical test results... -
Joint Commission updates sentinel events statistics
The Joint Commission has updated its sentinel events statistics, according to an official statement... -
What's new with AHAP!
We wanted to thank more than 70 AHAP members who were able to attend this year’s AHAP...
Issue 18, May 4, 2010
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Staff Challenge Question: Provision of Care
True or false: An admission history and physical completed within 30 days prior to admission must... -
From the AHAP Blog: Open Position for Hire
Every so often, AHAP receives a request to help get the word out about an open position that might...
Issue 17, April 27, 2010
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Staff Challenge Question: Patient Involvement in Care
True or false: It is important to educate patients and families on ways to prevent infection and... -
From the AHAP Blog: Joint Commission clarifies IM standard
The Joint Commission recently announced a clarification on Information Management standard... -
What's new with AHAP!
Attention accreditation professionals: the AHAP Conference is next week! You can still register for...
Issue 16, April 20, 2010
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Staff Challenge Question: Staff Training
True or false: Staff members, other than physicians, who administer blood or IV medications must... -
From the AHAP Blog: Joint Commission reinstates anti-discrimination requirements to Leadership standards
The Joint Commission has announced it will reinstate an anti-discrimination requirement which had...
Issue 15, April 13, 2010
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Staff Challenge Question: Medication Safety
Which is true for patients being started on warfarin? -
From the AHAP Blog: April contest winner announced
We’d like to announce this month’s blog contest winner of a free registration to the...
Issue 14, April 6, 2010
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Staff Challenge Question: Handoff communication
The content of an effective handoff communication should include __________. -
From the AHAP Blog: Joint Commission announces field review for med rec
The Joint Commission has announced the field review of its revised medication reconciliation... -
What’s new with AHAP!
The April winner for the AHAP Conference’s free registration has been picked. Heather Forbes...
Issue 13, March 30, 2010
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Staff Challenge Question: Performance Improvement
True or false: There are many processes that can be measured and often more improvement... -
From the AHAP Blog: Contest entry: Monitoring Report
The AHAP Blog is running a contest for a drawing to win a free seat to its annual conference in Las...
Issue 12, March 23, 2010
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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: MS.01.01.01: Revisions to troublesome standard receive approval
Revisions to Medical Staff standard MS.01.01.01 have received approval from The Joint Commission...
Issue 11, March 16, 2010
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Staff Challenge Question: Suicide risk assessment
True or false: When we identify that a patient is a potential suicide risk, it is important to... -
From the AHAP Blog: The Joint Commission releases small changes to NPSG
The Joint Commission recently identified a few small tweaks to a pair of NPSGs and released the... -
What’s new with AHAP!
For anyone who missed it, AHAP recently released its annual salary survey. Members can download the...
Issue 10, March 9, 2010
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Staff Challenge Question: Communication
True or false: If data collection shows that handoff communication results are not falling within... -
From the AHAP Blog: AHAP Conference Contest: Continual Readiness Plan
The AHAP Blog is running a contest for a drawing to win a free seat to its annual conference in Las...
Issue 9, March 2, 2010
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Staff Challenge Question: Universal Protocol
True or false: An important part of the preop verification process that occurs in the preprocedure... -
From the AHAP Blog: AHAP Conference Contest: Timing and dating
The AHAP Blog is running a contest for a drawing to win a free seat to its annual conference in Las... -
What’s new with AHAP!
We’re happy to announce the first winner of the AHAP Conference contest. The winner receives...
Issue 8, February 23, 2010
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Staff Challenge Question: Patient Rights
True or false: Informed consent includes information on the risks and hazards of a particular... -
From the AHAP Blog: AHAP Conference Contest: Unannounced survey
Our latest contest entry comes from Linda M. Glaeser, RN, MS, manager of healthcare accreditation... -
What's new with AHAP!
In case you missed the February 11th working group call on flash sterilization requirements, the...
Issue 7, February 16, 2010
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Staff Challenge Question: Medication Safety
True or false: When unlabeled medications are found, it is safe to use them if you can compare the... -
From the AHAP Blog: The first entry from the AHAP Conference Contest
The Quality Department of Regional Medical Center of San Jose in San Jose, CA, sent in the...
Issue 6, February 9, 2010
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Staff Challenge Question: Infection Control
True or false: When wearing gloves, it is acceptable to use hand gel to clean the gloves between... -
From the AHAP Blog: Enter to win a free registration to the 2010 AHAP Conference
Each month, we will give away one free registration to the upcoming AHAP Conference in Las Vegas on... -
What’s new with AHAP!
Just a reminder to the AHAP members, the next working group call will take place this week on...
Issue 5, February 2, 2010
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Staff Challenge Question: Record of Care
Which of the following patient-specific pieces of information are required to be documented in the... -
From the AHAP Blog: Joint Commission issues new Sentinel Event Alert
The Joint Commission announced its latest Sentinel Event Alert, Preventing Maternal Death. This... -
What's new with AHAP!
Just a reminder to the AHAP members, the next working group call will take place on Thursday...
Issue 4, January 26, 2010
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Staff Challenge Question: Patient Falls
True or false: One of the first steps in a falls reduction program is an accurate assessment of... -
From the AHAP Blog: Hospital says it will not hire smokers
Many hospitals have some sort of program to help curb smoking–whether it’s a smoking... -
What’s new with AHAP!
Members: Once again, the association will hold a contest for a free seat at the AHAP Conference in...
Issue 3, January 19, 2010
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Staff Challenge Question: Emergency Operations
What does "NIMS” stand for? -
From the AHAP Blog: Joint Commission releases annual report, sees improvements to patient care quality
According to The Joint Commission’s annual report, the US has seen a steady improvement over... -
What’s new with AHAP!
Just a reminder to the AHAP members, the latest issue of AHAP Insider went out last week.
Issue 2, January 12, 2010
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Staff Challenge Question: Organ donation
True or false: All hospitals must have a written agreement with a transplant/organ procurement... -
What's new with AHAP!
The annual survey coordinator salary survey is now available. The survey looks at hospital size...
Issue 1, January 5, 2010
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Staff Challenge Question: Communication
True or false: Hospitals must monitor the timeliness of reporting routine critical test results and... -
From the AHAP Blog: Thoughts on staffing effectiveness changes?
Now that the public has had a few days to review the interim staffing effectiveness standards for... -
What's new with AHAP!
Stay tuned for the AHAP annual survey coordinator salary survey, which will be published by January...
