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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 44, October 23, 2018

• Checklist: Re-opening after a disaster

  On October 10, Hurricane Michael made landfall in Florida, forcing two Florida hospitals to...

Issue 43, October 16, 2018

• Revisions deeming EPs

   Starting January 1, five revisions to The Joint Commission’s Elements of Performance...

Issue 42, October 9, 2018

• Increased oversight means more pressure on AOs

  Expect CMS to continue to put pressure on The Joint Commission and other accrediting organizations...

Issue 41, October 2, 2018

• Last Flu Season Led to 80,000 Deaths

  Federal public health officials are urging everyone six months and older to get vaccinated against...

• Accreditation Book Survey 2019

   We're working on books for 2019 and like to hear from you. Please take this short survey and...

Issue 40, September 25, 2018

• Hospitals Can Improve Their Infection Prevention Strategies, Study Finds

   A new review of 144 studies found that healthcare-associated infections (HAI) can be reduced...

Issue 39, September 18, 2018

• Executive Briefings: Joint Commission Surveyor Focus Remains on EC, LSC, Ligature Risks

  Top takeaways from The Joint Commission’s (TJC) annual Hospital Executive Briefings held...

• Webinar: Are You Ready? Targeting Hot Spots in Hospital Compliance

  Wednesday, September 26, 2018 1:00 – 4:00 pm Eastern In this three-hour virtual workshop...

Issue 38, September 11, 2018

• Joint Commission Revises Scoring for IC Standard

  The Joint Commission (TJC) this week announced scoring changes for its IC.02.02.01 standard, which...

Issue 37, September 4, 2018

• Joint Commission clarifies how some devices will be evaluated for infection control on survey

  The Joint Commission (TJC) doesn’t require medical instruments that touch mucous membranes to...

Issue 36, August 28, 2018

• FDA warning on surgical fires

   This summer, FDA issued an alert reminding healthcare professionals and facility staff of...

• The CMS Compliance Crosswalk, 2018 Edition

   This book shows you how to comply with each Condition of Participation (CoP) set forth by CMS...

Issue 35, August 21, 2018

• HFAP ligature standard remain same after newest CMS memo

  HFAP updated 13 of its ligature standards to align CMS this spring (see story below.) Since then...

Issue 34, August 14, 2018

• Be ready for surveyor focus on dialysis

   Surveyors from CMS and The Joint Commission are taking an interest in dialysis compliance...

Issue 33, August 7, 2018

• New CMS guidance on ligature risk says Joint Commission recommendations set the bar

   Expect CMS surveyors to be referring to recommendations set out by The Joint Commission last...

• Accreditation 101: A Toolkit for Accreditation Professionals

   Accreditation 101: A Toolkit for Accreditation Professionals provides a road map to the new...

Issue 32, July 31, 2018

• Survey: 36% of facilities struggle to meet TJC MRI standards

  A new survey found that 36% of medical resonance imaging (MRI) providers do not comply with The...

Issue 31, July 24, 2018

• ECRI resuscitates healthcare clearinghouse data

  The ECRI Institute will step in to provide critical healthcare data that otherwise became...

Issue 30, July 17, 2018

• CMS Revises Memo on Requirements to Reduce Risk of Legionella Infection

   Be prepared for renewed interest in your water management program and especially how it is...

• Infection-Free Vaccination: Safely Storing, Handling, Injecting, and Infusing Medications

  During this 90-minute webinar, expert speaker Terri Rebmann, PhD, RN, CIC, FAPIC, will explain how...

Issue 28, July 10, 2018

• Study: CMS Penalties for Hospital-Acquired Conditions Have Little Impact

   A study published in Infection Control & Hospital Epidemiology found that hospitals may...

Issue 27, July 3, 2018

• Catheters Pose More Risks Than Just CAUTIs

   UTIs are five times less common than non-infectious problems caused by indwelling urinary...

• Accreditation Focus Group

   This July we’re going to be running two Accreditation and Quality focus groups. The...

Issue 25, June 26, 2018

• Human Trafficking and Healthcare

   This June, The Joint Commission released Quick Safety Issue 42 on identifying human...

Issue 24, June 19, 2018

• CMS Delays Hospital Star Ratings Update, Again

   Citing “stakeholder concerns,” the Centers for Medicare & Medicaid Services...

Issue 23, June 12, 2018

• AHRQ Data Shows Drop in Hospital-Acquired Conditions

   A new report from the Agency for Healthcare Research and Quality (AHRQ) found that...

Issue 22, June 5, 2018

• Dead Woman Found in Stairway of SF Hospital Building

  In an incident eerily reminiscent of one that occurred five years ago, a woman was found dead last...

• Occurrence Reporting: How to Report, Identify, and Resolve Problems

  In this webinar, performance improvement expert Kenneth R. Rohde provides practical techniques and...

Issue 21, May 22, 2018

• AORN Expects to Revise its Guideline for OR Headwear

  For the coverage of ears, AORN is “probably going to come out in our new guideline and say...

• Report: Medication Errors Led to Patient Death at Boston Children?s Hospital

  Boston Children’s Hospital was threatened with termination from Medicare last year after...

Issue 20, May 15, 2018

• National Guidelines, Quality Measures Clearinghouses Shutting Down

   If you or anyone at your hospital use the National Guidelines Clearinghouse or National...

Issue 19, May 8, 2018

• New NFPA Standard Focuses on Responding to Active-Shooter Incidents

  Early this year, the NFPA promised to fast-track a new standard to help first responders...

Issue 18, May 1, 2018

• Study: Improvement in Errors, Accidents, Infections

   The Leapfrog Group this week released its spring 2018 Hospital Safety Grades, which found...

Issue 17, April 24, 2018

• Study Questions Effectiveness of Performance Measures

   The study’s researchers recommend that organizations should stop using performance...

• Seeking comment on suicide prevention book

  We're trying to get a potential Suicide Prevention in Hospitals book approved and need your help...

• Patient Safety Strategies: Building a Fall Prevention Toolkit

  During this three-hour virtual workshop, Carole Eldridge, DNP, RN, CNE, NEA-BC, and Virginia Hall...

Issue 16, April 17, 2018

• Joint Commission Urges Hospitals to Protect Workers from Abuse

  The Joint Commission is the latest healthcare heavy-hitter to call for better protection of...

Issue 15, April 10, 2018

• HFAP to keep name going forward

  HFAP will be keeping its name. The accreditor had originally planned to take the name of the...

Issue 14, April 3, 2018

• Study: Link between infection control and antibiotic stewardship

   Healthcare facilities must ensure that infection prevention and control (IPC) and antibiotic...

Issue 13, March 27, 2018

• The Joint Commission: Comments open on proposed suicide risk NPSG through May 7

  Wishing you could weigh in on The Joint Commission’s expectations about suicide risk? You...

Issue 12, March 20, 2018

• Lawmakers want more AO oversight

  In a letter to CMS Administrator Seema Verma, the committee is asking for what could be reams of...

Issue 11, March 13, 2018

• 3 Ways to Knock C. diff Rates Down to Zero

  For Necia Kimber, RN, CIC, MHA, infection control practitioner at Stillwater (Oklahoma) Medical...

Issue 10, March 6, 2018

• Joint Commission releases 2017 sentinel event stats

  Unintended retention of a foreign body, patient falls, and wrong-site surgery top The Joint...

Issue 9, February 27, 2018

• Report: Six opportunities to improve patient safety

  Over the next four years, $383.7 billion will be spent on adverse patient safety events in the...

• Webinar: How Vanderbilt University Medical Center Established a Hand Hygiene Program

  Presented on: March 22, 2018, 1:00-2:30 p.m. EST Presented by: Thomas R. Talbot, MD, MPH Level of...

Issue 8, February 20, 2018

• Involving patients and representatives in care decisions

  Involving patients in their care isn’t just polite, it’s a CMS requirement.

Issue 7, February 13, 2018

• Like CMS, you should pay attention to sexual harassment

  With all the recent focus on sexual harassment in the workplace, healthcare organizations...

Issue 6, February 6, 2018

• Joint Commission updates LS, EC chapters

  Three revisions to The Joint Commission’s Life Safety and Environment of Care chapters will...

• Webinar: Occurrence Reporting: How to Report, Identify, and Resolve Problems

  Presented on: February 27, 2018, 1:00-2:30 p.m. EST Speaker: Kenneth R. Rohde Program Level...

Issue 5, January 30, 2018

• CMS Inpatient-Only List: Preparing for Critical Changes in 2018

  Each year CMS revises its inpatient-only list of approximately 1,700 procedures. The most notable...

Issue 4, January 23, 2018

• Surgeon sued for double booking surgery

  There’s a reason why the American College of Surgeons (ACS) recommends asking patients if...

Issue 3, January 16, 2018

• Joint Commission to roll out new maternal care and infectious disease requirements

  The accreditor made the announcement in the latest R3 Report, with the aim of protecting both the...

• High Reliability and Safety in Healthcare Workshop

  Gain the tools and guidance to create a culture of high reliability and safety within your...

Issue 2, January 9, 2018

• Prepping for winter storms

  With the biting cold and heavy snow that struck the East Coast this month, and with more on the way...

• The CMS Conditions of Participation and Interpretive, 2018 Edition

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

Issue 1, January 2, 2018

• CMS: Providers can text, just not medical orders

  CMS is clearing up recent confusion on what medical providers can text each other. The agency...