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Accreditation Connection

This e-mail newsletter delivers the latest weekly accreditation news, analysis, and advice for any healthcare professional involved in CMS (formerly HCFA), JCAHO, or other survey preparation-in any setting.

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Accreditation Connection

Issue 52, December 28, 2004

• How to ban artificial nails in your hospital

  As part of a new dress code policy, Greenville (SC) Hospital System banned the wearing of...

• Learn three common pitfalls with preprinted order forms

  Between September 1998 and August 2003, the U.S. Pharmacopeia (USP) MEDMARX error-reporting...

Issue 51, December 22, 2004

• Create an effective policy to comply with standard IC.6.10

  Standard IC.6.10 is a major addition to the 2005 JCAHO standards. It is part of emergency...

• How to comply with standard LD.2.50

  Surveyors now expect leaders to use information from the past and present to build a fiscal map to...

Issue 50, December 17, 2004

• Do you know what the JCAHO expects from pain assessments?

  xpect JCAHO surveyors to take a closer look at how and when your caregivers assess pain. The...

• Learn a colorful way to separate medications

  Pharmacy technicians at Tennessee Christian Medical Center in Madison, TN, used to traverse the...

Issue 49, December 10, 2004

• Get survey ready for standard LD.2.20

  The standard LD.2.20 requires that an organization maintain effective leadership in every...

• What you need to know about managing sample drugs

  Pharmaceutical sales representatives are infamous for arriving at your hospital with all sorts of...

Issue 48, December 2, 2004 - VIEW THE FULL ISSUE

• Six steps to making a decision about your PPR

  If you don't know where to begin when weighing the Periodic Performance Review (PPR) options...

Issue 47, November 23, 2004

• Arm your staff with surveyor slang to prepare them for survey

  At Northwestern Memorial Hospital, Cynthia Barnard, MBA, MSJS, CPHQ, director of quality...

• Learn why it may be a good time to revisit your infection control policy

  With the JCAHO's recent emphasis on infection control, now is a good time to revisit your policy...

Issue 46, November 19, 2004

• What does the JCAHO expect with its new scoring guidelines?

  Do you have a perfect staff (no one makes mistakes and they never will)? If you answer "yes," then...

• How to prevent problems with your postoperative information

  Arm your patients with explicit information on what they should do after surgery. "There...

Issue 45, November 12, 2004

• Learn more about hand-gel regulations

  An amendment to the 2000 and 2003 editions of the Life Safety Code says healthcare facilities under...

• How to become a 'virtual' pharmacy with technology

  When JCAHO surveyors inspected Hendry Regional Medical Center in Clewiston, FL, in January, they...

Issue 44, November 5, 2004

• Learn how hand gel container placement can lead to a flash fire

  Two amendment provisions specifically deal with the placement of hand gel containers. Both only...

• Get some good advice on complying with patient identification

  In 2005, the JCAHO wants your staff to use at least two patient identifiers not only when...

Issue 43, October 29, 2004

• Arm your staff with good infection control habits

  Proper infection control (IC) practices by staff will solidify a healthful environment for...

• Learn why isolation cabinets may be better than isolation carts

  Some hospitals are solving a fire safety dilemma by using isolation cabinets instead of bulky...

Issue 42, October 22, 2004

• Learn how an imperfection can lead to conditional accreditation

  The JCAHO scoring guidelines are strict and in many cases rely on surveyor interpretation of...

• How to prevent postoperative infections

  Without thorough infection control (IC) routines, patients could suffer moderate to severe...

Issue 41, October 14, 2004

• How will you obtain your patient’s complete list of current medications?

  According to the 2005 National Patient Safety Goals, your hospital must develop a process for...

• Learn why pain management is still a pain point

  A general fear exists among providers and patients that legitimate narcotics use may cause...

Issue 40, October 8, 2004

• See why fire drill critiques draw interest

  This survey occurred May 19-21 at Santa Rosa Medical Center, a 129-bed, acute care community...

• Learn how to become a ’virtual’ pharmacy with technology

  When JCAHO surveyors inspected Hendry Regional Medical Center in Clewiston, FL, in January, they...

Issue 39, October 1, 2004

• Tackle the JCAHO’s infection control standards with a group approach

  Create a committee to comply with the JCAHO’s proposed infection control standards, which...

Issue 38, September 24, 2004

• Learn how to comply with National Patient Safety Goal #8a

  Now that the new goals are finally out, we asked accreditation and patient safety experts to share...

• Check out what interested surveyors during one hospital’s safety building tour

  Surveyors who visited Santa Rosa Medical Center in Milton, FL, between May 19-21, went through the...

Issue 37, September 17, 2004

• Is there a good way to disagree with a surveyor’s finding?

  If you disagree with a surveyor’s finding, call the JCAHO immediately to contest it, advises...

• Learn how to stay compliant with improving the safety of medication use

  The requirement for Goal #c is established to improve the safety of medication use. The JCAHO...

Issue 36, September 10, 2004

• Arm yourself with nine survey readiness secrets

  How did Anaheim (CA) Memorial Medical Center stay survey-ready day after day in preparation for...

• Learn how to stay compliant with the new requirement for reporting test results

  We know that many of you are still grappling with the new National Patient Safety Goals, so we...

Issue 35, September 3, 2004

• How to comply with the National Patient Safety Goal on the use of patient IDs

  The JCAHO has clarified a 2004 goal that will continue in 2005. According to the JCAHO...

• Could your hospital be sued because of unsanitary conditions?

  Bacteria concerns have fueled lawsuits at Jewish Hospital in Louisville, KY. The hospital will meet...

Issue 34, August 27, 2004

• Check out handy tips to keep staff and patients aware of your renovations

  No hospital wants its renovation or upgrade project endangering the health and safety of employees...

• Learn how supermarket-style bar codes can improve patient safety

  One of the JCAHO's National Patient Safety Goals requires you to improve the accuracy of patient...

Issue 33, August 20, 2004

• Learn how to win over the JCAHO with complete and neat records

  Pharmacy staff at Northwestern Memorial Hospital in Chicago learned during their April survey that...

• Check out four quick ways to help staff comply with PC.13.20

  Educate medical staff on the definitions of moderate and deep sedation. Be sure your entire...

Issue 32, August 13, 2004

• Learn what one hospital is doing to comply with the abbreviations goal

  Stumped on how to get physicians to stop using prohibited abbreviations? Try slapping them below...

• Hear what surveyors look for in hospital clean rooms

  JCAHO surveyors are looking at hospital clean rooms during surveys, and one of their questions...

Issue 31, August 6, 2004

• Learn why hospitals call on safety coaches for compliance plans

  Consider appointing patient-safety coaches on every unit to help staff comply with your...

• Arm your pharmacy staff with six surveyor questions

  Check out the following six questions that surveyors asked pharmacy staff at Henderson (TX...

Issue 30, July 30, 2004

• One way to turn the Patient Safety Goals into fun games

  Atlantic City Medical Center in Pomona, NJ, pulled out all the stops during its patient safety fair...

• How to eliminate dangerous abbreviations

  Hospitals in the Madison (WI) Patient Safety Collaborative share seven of their most successful...

Issue 29, July 23, 2004 - VIEW THE FULL ISSUE - VIEW THE FULL ISSUE

Issue 28, July 9, 2004

• A few low-tech ways to improve quality

  Documentation came under the microscope during two recent surveys by the JCAHO. At one hospital...

• Check out the 2005 National Patient Safety Goals

  The Joint Commission on Accreditation of Healthcare Organization's (JCAHO) Board of Commissioners...

• Verbal orders and proper equipment were the focus of two recent surveys

  Documentation came under the microscope during two recent surveys by the JCAHO. At one hospital...

• Learn how one hospital improved blood-transfusion safety

  Blood-transfusion errors are among the top 10 sentinel events that have occurred at accredited...

Issue 26, July 2, 2004

• Supermarket-style bar codes could improve patient safety

  The JCAHO's National Patient Safety Goal #1 requires you to improve the accuracy of patient...

Issue 25, June 25, 2004

• How one hospital fosters team training

  Departments can no longer function independently of each other now that the JCAHO expects hospitals...

• The JCAHO expects consistent answers from your staff during survey

  One nurse surveyor toured Shriners Hospital for Children over a three-day period in February, and...

Issue 24, June 18, 2004

• Understanding the JCAHO's clarification to the new scoring guidelines

  The JCAHO's February update to the Comprehensive Accreditation Manual for Hospitals contains...

• How one hospital guards against wrong-site surgical errors

  The policy to protect against wrong-site surgical errors at CGH Medical Center in Sterling, IL...

Issue 23, June 11, 2004

• Lessons learned from one hospital's disaster plan

  On Thursday, February 12, an anhydrous ammonia leak from a 3/4 in x 2 in pipe was discovered at a...

• Why some hospitals are leaving the JCAHO, and where they're going

  Pressure to contain costs is one challenge that compels some hospitals to consider less expensive...

Issue 21, June 1, 2004

• A Texas hospital is scrutinized for its unacceptable drug abbreviations

  Up until November, when the JCAHO issued its minimum list of nine dangerous abbreviations...

• What do surveyors want to see in your EC plans?

  Complying with the JCAHO's 2004 Environment of Care (EC) standards means more than conducting...

• Your state can answer your telemedicine questions

  Telemedicine, for all of its advantages, removes some of a hospital's direct control over the care...

• How to foster team training

  Departments can no longer function independently of each other now that the JCAHO expects...

Issue 20, May 21, 2004

• Alert: JCAHO surveyors are finding unapproved abbreviations

  Don't forget to check patient medical records for the JCAHO's unapproved abbreviations when you...

Issue 19, May 17, 2004

• Check out what JCAHo surveyors focused on during an ambulatory survey

  Memorial Same Day Surgery Center was one of the first ambulatory centers surveyed under the...

• New AOA infection control standards

  The American Osteopathic Association (AOA) is revamping its infection control (IC) standards

Issue 18, May 10, 2004

• Patient tracers involve environment-of-care standards

  One of the new survey tools used by the JCAHO is the tracer method in which a surveyor follows a...

• Gear up for the JCAHO's proposed patient fall goal

  Take a hard look at patients' risk for falling and get ready to create a comprehensive...

Issue 17, May 3, 2004

• See what standards caught an OSHA inspector's attention

  In June 2003, an inspector from the Occupational Safety and Health Administration (OSHA) showed up...

• Ask medical leaders to attend JCAHO prep meetings

  Expect surveyors to ask physicians about patient safety, restraint use, pain management...

Issue 16, April 26, 2004

• Ammonia leak tests hospital's disaster plans

  On Thursday, February 12, an anhydrous ammonia leak was discovered at a pork-processing plant with...

• Mark surgical sites consistently

  Although organizations have until July 1 to comply with the JCAHO’s Universal Protocol for...

Issue 15, April 19, 2004

• Medication security was a recent JCAHO survey focus

  One east Texas hospital changed how it monitors narcotics after its JCAHO survey in January.

• Don't forget to train temporary workers

  A hospital that uses temporary workers from a staffing agency must still offer safety-related...

Issue 14, April 12, 2004

• Eliminating dangerous abbreviations is a long-term project

  Telling physicians what to do is never easy. Getting them to stop using abbreviations they've been...

• Know how to handle high-security and prisoner patients

  Chances are, your hospital deals with high-security and prisoner patients regularly.

Issue 13, April 5, 2004

• Smart IV pumps reduce medication errors

  A patient is supposed to receive 5.1 mcg/kg/minute of dopamine through an intravenous (IV) feed...

• Use patient safety coaches to boost compliance

  Consider appointing patient-safety coaches on every unit to help staff comply with your...

Issue 12, March 29, 2004

• Using e-prescribing systems can reduce errors

  Illegible handwriting on prescriptions can lead to patients receiving the wrong medication or the...

• A tip on how to best destroy IV labels

  If your hospital is struggling to develop a way to properly dispose of intravenous (IV) bag labels...

Issue 11, March 22, 2004

• Don't get in a sticky situation with bloodborne pathogens

  Ambulatory center staff are often exposed to hazardous materials and situations that have the...

• Learn how to move patients more quickly through your ED

  The emergency department (ED) throughput subprocess begins when the patient arrives at the ED for a...

Issue 10, March 15, 2004

• JCAHO surveyors focused on verbal orders, equipment

  Documentation was a key focus of two recent surveys by the JCAHO.

• Surveillance is crucial to LTC infection control

  IC activities performed in long-term care (LTC) facilities differ from those in hospitals, but both...

Issue 9, March 8, 2004

• Prep staff on drug recalls before your next JCAHO survey

  Drug recalls may be a topic of conversation during your next Joint Commission on Accreditation of...

• Know how HIPAA applies when employees become patients

  "As we began staff training for the Health Insurance Portability and Accountability Act of 1996...

Issue 8, March 1, 2004

• Learn how one facility reduced bed turnaround time by 76%

  At this time last year, hospitals within San Antonio's University Health System (UHS) took an...

• Infant abduction training should be done regularly

  The first hospital infant abduction in the country in 22 months happened on Christmas Eve at the...

Issue 7, February 23, 2004

• Beat fatigue and improve patient safety

  Whether brought on by mandatory overtime, voluntary extra hours, or a desire for flexible...

• Mold becomes a high priority for hospitals

  Mold presents a difficult and expensive dilemma for hospitals. Not only does it cause structural...

Issue 6, February 6, 2004

• Take extra precautions with elderly patients' medications

  Fifty-five percent of fatal hospital medication errors in 2002 involved elderly patients, according...

Issue 5, February 2, 2004

• Master The JCAHO's New IM Standards

  In its revised information management (IM) standards for 2004, the JCAHO encourages facilities to...

Issue 4, January 26, 2004

• Use These Tips To Plan For Disaster Recovery

  By now, the cornerstones of your emergency management plans have a familiar ring-mitigation...

Issue 3, January 19, 2004

• Plan for long-term capacity challenges during outbreaks

  Plan for long-term capacity challenges during outbreaks

• Know how to handle drug shortages

  Know how to handle drug shortages

Issue 26, July 2, 2004

• How one hospital guards against the Universal Protocol

  The policy to protect against wrong-site surgical errors at CGH Medical Center in Sterling, IL...

Issue 11, September 2, 2004

• The AAAHC announces accreditation guidebook for managed care organizations

  The Accreditation Association just released its 2004 Accreditation Guidebook for Managed Care...

Issue 1, June 18, 2004

• There’s nothing better than advice from those who have been through the survey

  There’s nothing better than advice from those who have been through the survey experience...

• Where can we find benchmark data on how often staff wash hands?

  Where can we find benchmark data for observation rates on how often hospital staff use...

• I understand that the JCAHO wants the patient’s vital signs listed on the H&P

  I understand that the JCAHO wants the patient’s vital signs listed on the history and...

• Learn how to tackle problematic standard (IM.6.30)

  Learn how to tackle problematic standardard (IM.6.30), and ensure your complete medical records are...

• Does the manager need to be evaluated annually for age-specific competency?

  We have a manager who assesses age-specific competency of staff. Does the manager need to be...

• How to address JCAHO standard RI.2.60

  How to address JCAHO standard RI.2.60

• Pay attention to alarms and life safety equipment

  Many hospitals are good at checking the batteries in the ventilators, but forget the other...