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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 52, December 26, 2017

• Joint Commission to Increase Hand Hygiene Focus

  The Joint Commission (TJC) will soon be scrutinizing hand hygiene more closely.

Issue 51, December 19, 2017

• CMS memo defines ligature risk and clarifies expectations

  A new CMS memo creates a definition of a ligature risk, a time frame for correcting them, and...

• Occurrence Reporting: Building a Robust Problem Identification and Resolution Process, Second Edition

  You already captured the data. Now use it to make real improvements in your patient care. With the...

• Analyzing the Hospital Life Safety Survey, Third Edition

  Your facility is explored from top to bottom for life safety compliance when life safety surveyors...

Issue 49, December 12, 2017

• CMS and Joint Commission change hospital eligibility requirements

  Both organizations have changed their expectations on the defintion of a hospital.

Issue 48, December 5, 2017

• Joint Commission: Life Safety revisions for behavioral healthcare

  The Joint Commission has revised its Life Safety standards LS.04.01.20 through LS.04.02.50 for its...

Issue 47, November 28, 2017

• Study: Concurrent surgeries are safe

  A review of more than 2,000 neurosurgical cases published in the Journal of the American Medical...

Issue 46, November 21, 2017

• Joint Commission releases list of 2018 National Patient Safety Goals

  The NPSGs cover eight different accreditation programs: ambulatory, behavioral care, critical...

Issue 45, November 14, 2017

• CMS Emergency Prep rule is now enforceable by surveyors

  CMS’ new Emergency Preparedness rule goes into effect on Wednesday, November 15, which means...

• Webinar: Suicide Prevention in Hospitals: Reduce Risk and Comply With Joint Commission Requirements

  Presented on: Tuesday, November 21, 2017, 1:00-2:30 p.m. EST Speaker: Ernest E. Allen, ARM, CSP...

Issue 44, November 7, 2017

• Joint Commission announces four survey focus areas

  Representatives from The Joint Commission, URAC, DNV-GL, the Healthcare Facilities Accreditation...

Issue 43, October 31, 2017

• Joint Commission releases suicide prevention recommendations

  The Joint Commission has released a special report on suicide prevention in the November edition of...

Issue 42, October 24, 2017

• How to deal with unclear infection prevention guidelines

  A team of physicians from the University of Iowa Hospitals and Clinics has put forward a strategy...

• What books should we write in 2018?

  Hello! It's book season at HCPro (also Halloween/Thanksgiving/sweater season) and we need your...

Issue 41, October 17, 2017

• Focusing on OR fire prevention

  Last week was National Fire Prevention Week, but that doesn’t mean the time to focus on fire...

• Seeking nominees for The Platinum Awards

  The Platinum Awards sets the standard for recognizing professionals and organizations who...

Issue 40, October 10, 2017

• Another delay of CMS hospital star ratings system

  CMS will delay an update to its controversial hospital star rating system for the second time in...

• Webinar: USP : Hazardous Drug Compliance and Safety in 2018

  Presented on: 1:00-2:30 p.m. Eastern, Monday, October 30, 2017 Presented by: Patricia C. Kienle...

Issue 39, October 3, 2017

• Joint Commission: screening for violence

  In the October edition of Perspectives, The Joint Commission reiterated the need to screen patients...

Issue 38, September 26, 2017

• Joint Commission updates EM standards to match CMS

  In response to CMS’ final emergency preparedness rule issued earlier this month, The Joint...

Issue 37, September 19, 2017

• CMS temporarily suspends some Medicare requirements for hurricane-stricken hospitals

  CMS Administrator Seema Verma announced the agency is temporarily suspending certain Medicare...

Issue 36, September 12, 2017

• Joint Commission provides tips for improving handoffs

  This September, The Joint Commission posted an infographic on “high-quality hand-offs.&rdquo...

• What providers can do this National Suicide Prevention Week

  National Suicide Prevention Week is September 10-16, bringing awareness to the 10th leading cause...

Issue 35, September 6, 2017

• Utah hospital changes policy after nurse arrest

  Officials at the Utah hospital where a nurse was arrested in July for refusing to draw blood from...

• George Mills lands gig with Chicago firm as his Joint Commission exit approaches

  Two weeks after The Joint Commission confirmed that its engineering department director would be...

Issue 34, August 29, 2017

• What Exactly Is a "High-Performing" Health System?

  Despite all the time, money, and energy spent on improving healthcare quality and value, there is...

• George Mills is leaving The Joint Commission

  The Joint Commission confirmed Thursday afternoon that a key figure in standards interpretation...

• Joint Commission deletes ORYX standard

  The Joint Commission will delete performance improvement standard PI.02.01.03 and its single...

Issue 33, August 22, 2017

• Joint Commission execs: Most outcome measures are inaccurate

  In a new article in the Annals of Internal Medicine, two Joint Commission executives wrote...

Issue 32, August 15, 2017

• Crucial accreditation deadlines on the horizon for pain management and emergency preparedness

  Time is running out to meet the new emergency management (EM) Conditions of Participation (CoP...

Issue 31, August 8, 2017

• Fire and smoke: CMS clarifies which doors must be inspected annually

  After pushback, federal officials backed away from their claim that smoke barrier doors must be...

• The Joint Commission Mock Tracer Made Simple, 19th Edition

  The newest version of HCPro’s premier survey prep guide breaks down the latest Joint...

Issue 30, August 1, 2017

• Joint Commission revises Medication Management EPs

  The Joint Commission has revised Medication Management elements of performance (EP) for several of...

Issue 29, July 25, 2017

• AAMI takes action on medical cart fires

  Last year, the Food and Drug Administration (FDA) released a report warning that mobile medical...

Issue 28, July 18, 2017

• NQF launches opioid stewardship initiative

  Nearly 2 million people suffer from prescription opioid disorder and the number of opioid...

Issue 27, July 11, 2017

• Options to CMS' proposed transparency rule

  Christina Thielst, FACHE says that CMS can reduce variation and increase transparency for consumers...

Issue 26, July 6, 2017

• Coming soon to an accredited org near you: updated ESC forms

  In a bid to make it easier for healthcare organizations to keep themselves in line with all the...

Issue 25, June 27, 2017

• Maintaining security during a Joint Commission survey

  Facilities often have questions when surveyors come to visit. Some of the most frequently asked...

Issue 24, June 20, 2017

• Joint Commission releases revised pain management standards

  The Joint Commission has released prepublication standards on new and updated pain assessment and...

Issue 23, June 13, 2017

• Joint Commission Updates on HAI-related National Patient Safety Goal on HAIs

  The Joint Commission has revised several of its requirements for National Patient Safety Goal...

• Accredtiation Salary Survey!

  Dear Accreditation Professional, Your feedback is essential to us at HCPro. Please take just a...

Issue 22, June 6, 2017

• CMS issues Legionella reduction memo

  On June 2, CMS issued a new memo to surveyors on the importance of reducing cases of Legionella...

Issue 21, May 30, 2017

• Joint Commission issues another warning about improperly cleaned medical devices

  For the second time in three years, The Joint Commission has released a Quick Safety issue on the...

• The Healthcare Diagnostic Devices Reprocessing Toolkit

  Hundreds of people in U.S. hospitals have been sickened by exposure to deadly bacteria on poorly...

Issue 20, May 23, 2017

• Caucus pushes for telemedicine expansion in Congress

  The U.S. House of Representatives and Senate are considering both the Creating Opportunities Now...

• The Active Shooter Response Toolkit for Healthcare Workers

  Hospitals face many challenges in regard to active shooter risk such as providing care to victims...

Issue 19, May 16, 2017

• Easily preventable ransomware attack hits hospitals worldwide

  As of Monday, May 15, more than 300,000 computers in 150 countries were hit by a ransomware virus...

Issue 18, May 9, 2017

• Joint Commission: Three tips on preventing workplace violence

  In late April, Ann Scott Blouin, RN, PhD, FACHE, executive vice president of The Joint Commission...

Issue 17, April 25, 2017

• Study: Single step reduces readmissions by 25%

  A new study published in the Journal of the American Geriatrics Society has found that integrating...

• Study: ED intervention reduces suicide attempts by 30%

  How much of a role can emergency departments (ED) play in preventing suicide attempts? The...

• Webinar: A Practical Approach to Achieving Patient- and Family-Centered Care

  Monday, May 22, 2017, 1:00-2:30 p.m. Eastern Join expert speakers Janiece Gray, MHA, BSW, CPXP...

Issue 16, April 18, 2017

• Transparency and Termination Notices; CMS proposes changes for Accreditation Orgs.

  On April 14, CMS sent out a memo with big proposals for accreditation. If passed, the proposed rule...

Issue 15, April 11, 2017

• Joint Commission urges providers to prevent medication compounding-related errors

  In a recent blog post, The Joint Commission called on providers to work toward the elimination of...

• @HCProAccred; bringing you the news

  Hi everyone, Yesterday we launched the HCPro Accreditation Twitter account to help you stay...

Issue 14, April 4, 2017

• CMS releases new information on emergency preparedness requirements

  CMS has issued new information on the training and testing requirements for its Emergency...

Issue 13, March 28, 2017

• NQF recommends reduction of quality metrics

  In NQF’s 2017 guidance to the Department of Health and Human Services (HHS), the organization...

Issue 12, March 21, 2017

• AMA: Surprise surveys improve mortality rates

  A new study published in the Journal of the American Medical Association found that patients are...

Issue 11, March 14, 2017

• ECRI: Top patient safety concerns of 2017

  The ECRI Institute has published its 2017 list of top patient safety hazards and concerns. The...

Issue 10, March 7, 2017

• Joint Commission surveyors to focus on suicide, self-harm, and ligature

  The Joint Commission announced that as of March 1, its surveyors will place special focus on...

• HCPro, HealthLeaders Media, and DecisionHealth merge to form the H3.Group

  HCPro, HealthLeaders Media, and DecisionHealth merge to form the H3.Group Together as the...

• TEST CHART

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Issue 9, February 28, 2017

• Changes to post-survey categories

  In addition to other changes, The Joint Commission has eliminated its post-survey category of...

• The CMS Conditions of Participation and Interpretive Guidelines

  Compliance with the Conditions of Participation (CoP) is required to meet Medicare and Medicaid...

Issue 8, February 21, 2017

• Joint Commission to check for FDA powdered glove compliance

  The Joint Commission surveyors will now check to see if hospitals are compliant with the Food and...

Issue 7, February 14, 2017

• Joint Commission clarifies "observer" standards

  The Joint Commission announced an update of its “observer” definition in its...

• Beyond CAHPS: A Guide for Achieving Patient and Family Centered Care

  Today, the CAHPS survey often doesn’t capture the entire picture when it comes to customer...

• Lab Safety: Short- and Long-Term Solutions for Preventing Injuries

  Presented on: Tuesday, April 18, 2017 1:00-2:30 p.m. Eastern Level of Program...

Issue 6, February 7, 2017

• Family-centered ICUs improve outcomes

  To improve medical outcomes in intensive care units, some hospitals are attempting to make units...

Issue 5, January 31, 2017

• Joint Commission urges enforcement of oral care policies

  The Joint Commission is placing increased emphasis on the importance of oral care. In a recent blog...

Issue 4, January 24, 2017

• CMS extends eCQM reporting deadline

  In a new blog post, CMS announced that it was extending its electronic clinical quality measure...

Issue 3, January 17, 2017

• FDA: Hospitals banned from using powdered medical gloves

  The Food and Drug Administration’s (FDA) ban on powdered medical gloves goes into effect...

• Webinar: How Parkland Health & Hospital System Successfully Implemented a Suicide Risk Screening Program

  Date: Tuesday, February 7, 1:00-2:30 p.m. EST Presented by: Kimberly Roaten, PhD...

Issue 2, January 10, 2017

• Feedback sought on Joint Commission Pain Assessment and Management program

  The Joint Commission seeks feedback on the proposed requirements for Pain Assessment and Management...

Issue 1, January 3, 2017

• Report: Financial penalties prove effective against readmissions

  Based on data collected from more than 2,800 hospitals, researchers were able to prove the...