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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 47, December 16, 2005

• Follow medication procedures to control contrast media

  The materials management department at Tennessee Christian Medical Center in Madison purchases...

• Hospitals reevaluating emergency plan in the wake of Katrina

  A survey conducted by VHA, Inc., a national healthcare alliance based in Irving, TX, shows that...

Issue 46, December 12, 2005

• Questions to think about as your hospital prepares for an influenza outbreak

  Questions to think about as your hospital prepares for an influenza outbreak

• Are isolators acceptable alternatives for USP 797 compliance?

  Are isolators acceptable alternatives for USP 797 compliance?

Issue 45, November 28, 2005

• Sample policy for credentialing physicians in the event of disaster

  Sample policy for credentialing physicians in the event of disaster

• Seven tips for effective laboratory compliance training

  Seven tips for effective laboratory compliance training

• Should we still consider medications when assessing a patient's fall risk?

  Should we still consider medications when assessing a patient's fall risk?

• Educating staff about prohibited abbreviations

  Educating staff about prohibited abbreviations

Issue 44, November 21, 2005

• Building a culture of support

  Building a culture of support

• What to look for in a bar-code system

  What to look for in a bar-code system

Issue 42, November 7, 2005

• How can we improve compliance with the JCAHO’s prohibited abbreviations list?

  How can we improve compliance with the JCAHO’s prohibited abbreviations list?

• How will the JCAHO survey our disaster plan in 2006?

  How will the JCAHO survey our disaster plan in 2006?

Issue 41, October 31, 2005

• Sample checklist for complying with RI.2.10, respecting the rights of patients.

  Sample checklist for complying with RI.2.10, respecting the rights of patients.

• How does the new survey process involve my lab?

  How does the new survey process involve my lab?

Issue 40, October 24, 2005

• How hospitals can ccntrol a patient’s home medications

  How hospitals can ccntrol a patient’s home medications

• What's required of an organization for patient falls assessment and prevention?

  What's required of an organization for patient falls assessment and prevention?

Issue 39, October 17, 2005

• Tips for successful med reconciliation training

  Tips for successful med reconciliation training

Issue 37, October 10, 2005

• How to prepare for an EC tracer

  How to prepare for an EC tracer

• How do we plan for a possible bar coding requirement?

  How do we plan for a possible bar coding requirement?

Issue 36, September 30, 2005

• JCAHO assembles 39-member panel on technology

  The Joint Commission has established the Healthcare Information Technology Advisory Panel. The...

• Sample questions for an infection control mock tracer

  Sample questions for an infection control mock tracer

• How will the JCAHO review emergency disaster plans in 2006?

  How will the JCAHO review emergency disaster plans in 2006?

Issue 35, September 26, 2005

• JCAHO offers field review on proposed changes to leadership chapter

  After completing a comprehensive review of the leadership standards for all healthcare settings...

• Updated sentinel event statistics released

  The JCAHO updated and released its sentinel event statistics. The most recent data includes...

Issue 34, September 19, 2005

• Educating staff about new drugs

  Educating staff about new drugs

• Sample policy for credentialing physicians in the events of a disaster

  Sample policy for credentialing physicians in the events of a disaster

• Changing staff behavior to implement a National Patient Safety Goal

  Changing staff behavior to implement a National Patient Safety Goal

• Critical test results read-back rules

  Critical test results read-back rules

Issue 33, September 12, 2005

• Ongoing compliance with USP 797

  Ongoing compliance with USP 797

• Whis is best: triage or complete screening for patients who present to the ED?

  Whis is best: triage or complete screening for patients who present to the ED?

Issue 32, September 5, 2005

• Safety culture, rapid response considered; standards changes announced

  Among the topics the Sentinel Event Advisory Group will consider when it meets September 12 include...

• Universal medication form puts patient safety in hands of patients

  Universal medication form puts patient safety in hands of patients

• Universal medication form puts patient safety in hands of patients

  Universal medication form puts patient safety in hands of patients

• When to obtain informed consent, and the difference between it and surgical.

  When to obtain informed consent, and the difference between it and surgical.

Issue 31, August 29, 2005

• "100,000 Lives Campaign" strategy for reducing healthcare-acquired infections

  Over a five-year period, the average ventilator-assisted pneumonia (VAP) rate at the Saint Barnabas...

• Where begin to comply with the handoff communication patient safety goal

  Where begin to comply with the handoff communication patient safety goal

Issue 30, August 22, 2005

• JCAHO and World Health Organization announce initiative to reduce medical errors

  JCAHO and World Health Organization announce initiative to reduce medical errors

• Tip of the Week: Educate staff about unapproved abbreviations

  Tip of the Week: Educate staff about unapproved abbreviations

• Ask the Expert: Can PPR audits be used for survey?

  Ask the Expert: Can PPR audits be used for survey?

Issue 29, August 15, 2005

• Tip of the Week: Monitoring the patient’s first dose

  Tip of the Week: Monitoring the patient’s first dose

• Ask the Expert: continuous loop recording of pediatric rooms

  Ask the Expert: continuous loop recording of pediatric rooms

• Write off illegibility problems with ’STAR’

  Write off illegibility problems with ’STAR’

Issue 28, August 1, 2005

• Tip of the Week: Medical Staff bylaws

  Your medical staff (MS) bylaws and policies/procedures should outline the processes necessary to...

• Design a safety retreat agenda

  Design a day-long safety retreat to motivate and educate staff about safety compliance issues in...

• Ask the Expert: Comply with MM.4.80

  How can we comply with MM.4.80, which requires a procedure to manage medications sent back to the...

• What does the JCAHO require as part of the medication reconciliation process?

  What does the JCAHO require as part of the medication reconciliation process?

Issue 27, July 25, 2005

• JCAHO seeks comment on measures for staffing certification

  The JCAHO is seeking comment on an initial set of four performance measures to be used in its...

• Data reporting improves performance, studies show

  A report in the San Francisco Chronicle contends that initiatives that require hospitals to report...

• Tip of the week: scavenger hunt for safety equipment

  Use a scavenger hunt to help familiarize your staff with the locations of critical safety equipment.

• Ask the Expert: pharmacy discretion when filling orders

  When will the JCAHO make an announcement that pharmacists will be allowed to use discretion when...

Issue 26, July 18, 2005

• JCAHO issues Sentinel Event Alert on chemo drug

  The JCAHO issued a Sentinel Event Alert Thursday, July 14 regarding mix-ups in delivering the...

• Medication mix-up sparks investigation

  This week's report of a medication mix-up at a CVS pharmacy in Massachusetts led to several new...

Issue 25, July 11, 2005

• New FAQ out on Broselow tape and the Rule of 6

  The JCAHO recently posted an FAQ on its Web site regarding Broselow tape and the Rule of 6.

• JCAHO gives four hospitals preliminary denial of accreditation

  Four of five hospitals in the Lovelace Sandia Health System in Albuquerque, NM received preliminary...

• Tip of the Week: Eight tips for developing your IC plan

  With so much to cover in an infection control (IC) plan, figuring out where to get started and what...

• Ask the Expert: Four ways to include security in disaster planning

  Disaster planning is tough enough; how can you be expected to work security into your planning as...

Issue 24, July 4, 2005

• Flaw found in JCR software

  A defect was found in Joint Commission Resources Inc. software that hospitals use to assist them in...

• JCAHO announces implementation expectations for '06 Goals

  The JCAHO has posted implementation expectations for the 2006 National Patient Safety Goals on its...

• Tip of the Week: Three tips for collecting data

  Collecting data isn't enough; the JCAHO expects you to do something with it.

• Flaw found in JCR software

  A defect was found in Joint Commission Resources Inc. software that hospitals use to assist them in...

• Ask the Expert: Three tips to comply with MM standards

  With three medication management standards topping the charts of the most commonly cited standards...

Issue 23, June 27, 2005

• Organizations don't need to add to "do-not-use" list

  The JCAHO lifted the requirement in National Patient Safety Goal 2b that hospitals must add three...

• JCAHO president encourages systems approach to healthcare

  JCAHO President Dennis S. O'Leary, MD, testified to congressional leaders on June 9 that healthcare...

• Tip of the Week: Three cost-effective ways to improve quality

  Missi Halvorsen, RN, BSN, the Jacksonville, FL-based Baptist Medical Center's senior JCAHO and...

• Ask the Expert: When going electronic, beware of unforeseen issues

  Although switching to CPOE is supposed to help organizations decrease errors caused by illegible...

Issue 22, June 20, 2005

• JCAHO makes efforts to avoid needlestick injuries

  Nearly 80% of 400 surveyed nurses caring for patients with diabetes reported at least one...

• JCAHO urges proactive stance toward aging population

  As the Baby Boomer generation begins turning 60 years old next year, healthcare organizations face...

• Tip of the Week: Keep your hospital safe and maintain a hospitable environment

  Preplanning and recognizing risks can curtail the need for designing a fortress instead of a...

• Ask the Expert: Do your pharmacists understand age-related drug needs?

  Pharmacists must understand age-specific needs since drug metabolism changes as people grow older...

Issue 21, June 13, 2005

• JCAHO seeks input on disaster privilege standards

  The JCAHO is conducting an online field review through July 12 on two draft human resource (HR...

• Small hospital weighs renovating, rebuilding

  Doctors and administrators at a 25-bed hospital in West Virginia are debating whether or not to...

• Tip of the Week: Four tips for guarding paper records

  Although some hospitals have already gone electronic, there are still plenty of organizations that...

• Ask the Expert: Five tips to create a safer environment during construction

  Because construction projects at your hospital can add a confusing and dangerous element to your...

• JCAHO releases a slew of new FAQs

  If you caught spring fever, you may have missed one of the 26 new, revised, or updated hospital...

Issue 20, June 6, 2005

• JCAHO releases 2006 National Patient Safety Goals

  The JCAHO released two new National Patient Safety Goals for 2006 on May 31.

• Tool helps hospitals meet EC.1.30 EP 5

  The U.S. Department of Health and Human Services (DHHS) released a new clinical tool to help...

• Tip of the Week: Improve your hospitalist program with improved communication

  Communication is the single most important component of a successful hospitalist program. Typically...

• Ask the Expert: How can you ensure communication of critical test results?

  Because physicians are so difficult to reach, how can you ensure that critical test results are...

• Protect against imposter surveyors

  Recent mainstream media news stories and a bulletin from the U.S. Department of Homeland Security...

Issue 19, May 30, 2005

• Hospital receives preliminary denial of accreditation

  The JCAHO found more than 23 standards violations during a survey of Good Samaritan Hospital in...

• Study shows 98,000 die due to medical mishaps

  The Journal of the American Medical Association released a study May 18 that said almost 100,000...

• Good lighting at your hospital may be more important than you think.

  "Lighting is important in many different ways beyond letting people see well," says Helen Diemer...

• Ask the Expert: How can you get everyone in your hospital involved with IC?

  "Having a standing committee makes infection control (IC) a priority," says Tammy Lundstrom, MD...

• Preanesthesia assessment tool impresses surveyors

  One hospital's preanesthesia assessment tool impressed JCAHO surveyors so much that they didn't...

Issue 18, May 23, 2005

• California hospital workers approve strike

  About 3,500 healthcare employees voted to strike against six Sutter Health Hospitals in the San...

• Hospital works its way up to conditional accreditation

  If Flagstaff Medical Center in Arizona improves eight areas cited by the JCAHO, its conditional...

• Tip of the Week: Make medication reconciliation easy

  The Reconciling Medications Collaborative, sponsored by the Massachusetts Coalition for the...

• Ask the Expert: How can you ensure safety in the OR?

  Patricia Gilroy, MSN, MBA, the clinical patient safety coordinator at the Alfred I. duPont Hospital...

• Survey monitor: EC veteran sees potential in life safety surveyors

  Hospitals encountering the new Life Safety Code® (LSC) engineering surveyors for the first time are...

Issue 17, May 16, 2005

• Hospital works to regain accreditation

  Hospital officials from Berkeley, CA, met May 5 to discuss how to keep their facility from losing...

• Hospital undergoes survey while being questioned on financial practices

  Earlier this month, JCAHO surveyors visited The University of Medicine and Dentistry in Newark, NJ...

• Tip of the Week: Use baseline studies to gauge your culture of safety

  The International Atomic Energy Agency defines a safety culture as an assembly of characteristics...

• Ask the Expert: How can you help prevent worker fatigue?

  "Fatigue is one of the most serious threats to patient safety," says Kirsty Kerin, PhD, a...

• Eight tips for advance directives

  The death of Terri Schiavo in Florida on March 31 renewed the debate about end-of-life decisions...

Issue 16, May 9, 2005

• JCAHO delays MS requirement until 2007

  Medical staff services professionals (MSPs) can breathe a huge sigh of relief. The JCAHO announced...

• Imposter surveyors strike two Indiana hospitals

  On the same day that an Indianapolis hospital reported suspicious people trying to enter its...

• Tip of the Week: Three tips to reduce blood transfusion errors

  Twenty patients in the United States died in 2004 when staff mislabeled blood tubes or failed to...

• Ask the Expert: Staff intimidation and verbal abuse can trigger errors

  How can you prevent medication errors when abusive and intimidating behavior is so widespread and...

• Eight tips for advance directives

  The death of Terri Schiavo in Florida on March 31 renewed the debate about end-of-life decisions...

Issue 15, May 2, 2005

• Organization pleads case for accreditation

  An Indiana healthcare system argued for accreditation on April 21 to a JCAHO committee that gave...

• Hospital reports sentinel event after safety publicly questioned

  Virginia Mason Medical Center in Washington reported a sentinel event to state regulators recently...

• IC and decontamination preparation go hand in hand

  Infection control (IC) professionals can play a critical role in helping develop a decontamination...

Issue 14, April 25, 2005

• Hospital renovation project receives JCAHO praise

  Aspen Valley Hospital in Colorado earned accolades last week from the JCAHO for its renovation and...

• JCAHO opens patient safety center

  The JCAHO this month launched the International Center for Patient Safety. The new branch of the...

• JCAHO stroke center certification meets emerging standard

  A patient in her 50s experiences an acute stroke while recovering from surgery. Because her...

Issue 13, April 18, 2005

• Scorecard helps patients choose hospitals

  Patients can now visit a Web site developed by the Centers for Medicare & Medicaid Services (CMS...

• Hospital appeals JCAHO survey, gets accreditation

  Kaleida Health in Buffalo, NY, earned full JCAHO accreditation status after objecting to survey...

• Six steps for submitting a clarification to JCAHO

  Hospitals continue to struggle with writing clarifications of how they comply with a standard...

Issue 12, April 11, 2005

• JCAHO releases new standards FAQs

  The JCAHO on April 1 posted answers to frequently asked questions about several new, revised, and...

Issue 8, March 7, 2005

• Hospitals get new JCAHO requirements, revised patient safety goal

  Find out which JCAHO requirements are new, revised, corrected, or changed.

Issue 7, February 28, 2005

• Take note: Several important changes in February CAMH update

  A new accreditation participation requirement (APR) and several standards, elements of performance...

Issue 6, February 21, 2005

• JCAHO reports on annual surveyor conference

  Much has been written about the JCAHO's annual surveyor conference that took place January 3-9...

Issue 5, February 14, 2005

• JCAHO takes action to promote adverse event reporting

  The JCAHO on February 10 announced a call to action for medical liability reform, saying a system...

Issue 4, February 4, 2005

• JCAHO seeks input on abbreviations

  The JCAHO invites healthcare organizations to complete an online survey about medical abbreviations...

• Hospital stripped of JCAHO accreditation

  A California hospital is making national headlines with the loss of its JCAHO accreditation. The...

Issue 3, January 28, 2005

• JCAHO encourages patients to "Speak Up"

  The JCAHO launched a nationwide campaign on January 27 designed to empower patients to take a...

• JCAHO releases proposed 2006 National Patient Safety Goals

  The JCAHO on January 28 released its proposed 2006 National Patient Safety Goals and requirements...

• A Q&A with JCAHO president Dennis O'Leary

  What does JCAHO president Dennis O'Leary, M.D., think are the most significant obstacles to...

Issue 2, January 20, 2005

• Hospital adapts practices to meet pediatric needs

  Obtaining a perfect survey score is not an easy feat. But with extensive preparation and a staff...

• Peer review--it's not just for doctors anymore

  Not unlike the peer review processes for physicians, peer review for nurses is prone to manmade...

Issue 1, January 6, 2005

• A surprise CMS visit puts patient safety in the spotlight

  Patient safety dominated a surprise Centers for Medicare & Medicaid Services (CMS) survey recently...

• Untangle the scoring process for JCAHO standards

  While assisting the JCAHO with the development of its new Shared Vision-New Pathways, the JCAHO's...

• Learn why respiratory infections such as SARS are so difficult to combat

  Outbreaks of Severe Acute Respiratory Syndrome (SARS) in 2003 provided a dramatic look at the...

• Take the lead in PCA safety: How pharmacists can improve patient outcomes

  Patient-controlled analgesia (PCA) can be an effective way to treat a patient's pain, but be aware...

• Tip of the week

  During an HCPro audioconference about operating room fires, Jan Ehrenworth, professor of...

• Define what

  Define what "critical test result" means in your organization to help comply with the JCAHO's...

• Ask the Expert

  What should we know about reviewing medication orders for ED boarders?

• Effectiveness of clinical alarms

  Why can't I find improving the effectiveness of clinical alarms in the list of National Patient...

Issue 8, August 9, 2005 - VIEW THE FULL ISSUE