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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 49, December 18, 2006

• JCAHO plans to change its name in January

  Beginning in January, the JCAHO plans to change its name to simply, "The Joint Commission." A...

• IHI calls for reductions in 5 Million Lives Campaign

  Healthcare professionals last week vowed to meet the challenge of the Institute for Healthcare...

• What happens after your Joint Commission survey?

  The JCAHO has posted to its Web site a resource that answers the question: What happens after your...

• AHA supports Joint Commission's data plan

  More than a year ago, the American Hospital Association (AHA) criticized the Joint Commission's...

Issue 48, December 11, 2006

• JCAHO seeks comment on proposed 2008 National Patient Safety Goals

  The JCAHO invites you to comment on its list of proposed 2008 National Patient Safety Goals and...

• All hospital survey teams to include LSC surveyor in 2008

  Beginning with surveys in 2008, all JCAHO survey teams will include a surveyor trained in the Life...

• JCAHO: Goals FAQ doc release 'early next year'

  The JCAHO says its highly anticipated answers to frequently asked questions about the 2007 National...

• CMS deems JCAHO an accreditor for durable medical equipment

  The Centers for Medicare & Medicaid Services (CMS) on November 29 granted the JCAHO deeming...

Issue 47, December 5, 2006

• PFP reports available for all JCAHO survey types in 2007

  To provide accredited organizations with more information more frequently, the JCAHO plans to begin...

• NY may eliminate thousands of hospital beds

  Getting a lot of attention last week was a New York commission's recommendations to close nine...

• H&Ps, verbal orders among CMS reg revisions for hospitals

  The Centers for Medicare & Medicaid Services (CMS) published a final rule on November 27, 2006...

• Hospital blog reports JCAHO imposters

  William W. Backus Hospital in Norwich, CT, reports in its blog that the Connecticut Hospital...

Issue 46, November 27, 2006

• Magazine reports JCAHO income, executive salaries

  According to the article in Modern Healthcare, which can only be accessed by paying subscribers...

• Magazine reports JCAHO income, executive salaries

  According to the article in Modern Healthcare, which can only be accessed by paying subscribers...

• Studies suggest hospitals can do more to prevent infections

  Infections acquired in hospitals, which take a heavy toll on patients, arise mainly from poor...

• Premier Inc. wins Malcolm Baldrige National Quality Award

  Each year, the Commerce Department recognizes up to three organizations in each of the following...

• The holidays can be a time to talk about end-of-life care

  Dr. Mary Dunn of Vassar Brothers Hospital in Poughkeepsie says no one likes to bring up difficult...

Issue 45, November 20, 2006

• JCAHO says Goals FAQs coming soon

  The JCAHO plans to release answers to frequenty asked questions (FAQ) about the National Patient...

• Case study released on meeting USP 797 requirements

  A case study that summarizes the process used by Swedish Medical Center in Seattle, WA, to comply...

• One hospital designs a hand-offs process based on race-car pit teams

  After surgeons completed a six-hour operation to fix a hole in a boy's heart, a doctor supervised...

• First-of-its kind collaborative addresses IV medication use

  The San Diego Medication Safety Task Force has created a collaborative for safer use of IV...

Issue 41, October 23, 2006

• JCAHO seeks participants for inpatient psychiatric measure test

  The JCAHO posted to its Web site last week information about how to participate in its...

• CDC releases report, guidelines on 'super bugs'

  The Centers for Disease Control and Prevention (CDC) is urging hospitals to manage "super bugs...

• Embattled King/Drew may close

  Facing the loss of $200 million in federal funds and a possible shutdown of Martin Luther King...

• Medical tourism heats up

  More than 500,000 U.S. residents in 2005 traveled abroad for medical or dental treatment, according...

Issue 40, October 16, 2006

• Time is running out to submit comment on MS.1.20

  JCAHO-accredited organizations have until October 27 to submit feedback about the proposed...

• Article: Fixing America’s hospitals

  No institution is doing everything right, according to Newsweek magazine, but it claims to have...

• Study looks at physician communication of new meds to patients

  Physicians could do a better job communicating medication use when they prescribe new drugs to...

• Five steps to get on the pandemic preparedness path

  With three influenza pandemics occurring within the past 100 years, some emergency planners say it...

Issue 39, October 9, 2006

• Disruptive behavior, anticoagulants on JCAHO’s list of possible 2008 National Pa

  Seven topics will likely be presented to the field for a review as the JCAHO begins narrowing its...

• JCAHO standards manuals enter extensive revision for big changes in 2009

  The JCAHO announced in its October edition of Perspectives, which all accredited organizations...

• TV series examines healthcare quality

  The quality of healthcare is explored in a four-part PBS series that began October 5 called...

• Los Angeles hospital fails CMS inspection, loses funding

  Martin Luther King Jr./Charles R. Drew Medical Center in Los Angeles learned September 22 that it...

Issue 38, October 2, 2006

• JCAHO extends eSOC compliance date

  The JCAHO is giving organizations six additional months to move from paper-based management of...

• Hospital standards manual update hits mailboxes

  The JCAHO’s second of two planned updates to its standards manuals for 2006 were hitting...

• Government takes notice of ED overcrowding

  Emergency rooms at many hospitals are routinely stretched to the breaking point, raising concerns...

• HCPro unveils Association for Healthcare Accreditation Professionals

  The Association for Healthcare Accreditation Professionals (AHAP), a new community for specialists...

Issue 37, September 25, 2006

• Indiana hospital takes steps to prevent future med errors in preemies

  Methodist Hospital in Indiana took steps last week to prevent overdoses of an anti-clotting drug...

• JCAHO accredits a retail healthcare provider

  The JCAHO recently awarded accreditation to MinuteClinic, a retail healthcare company owned by CVS...

• JCAHO and NQF announce 2006 Eisenberg winners

  JCAHO and The National Quality Forum (NQF) announced last week the 2006 recipients of the annual...

• New IOM report supports P4P for Medicare

  An Institute of Medicine (IOM) report released last week supports pay-for-performance (P4P).

Issue 36, September 18, 2006

• Article suggests industry associations looking next at JCAHO’s leadership standa

  The initial response to proposed changes to the JCAHO’s medical staff bylaw standard...

• Medical tourism getting noticed by employers

  Several companies have sprung up to facilitate employer-sponsored medical tourism, according to a...

• Senate examines hospital charity care

  The Washington Post reports that Senate investigators have found nonprofit hospitals routinely...

• Hospital v. union, and nurses taking sides

  Recent events at a medical center in Nebraska have rekindled a union issue.

Issue 35, September 11, 2006

• New Sentinel Event Alert focuses on emergency power failures

  The JCAHO last week issued a new Sentinel Event Alert encouraging hospitals to conduct risk...

• JCAHO posts FAQs about access to case-identifiable data

  The JCAHO answers questions about its potential access to case-identifiable data in a new FAQ...

• Med rec gems found on a JCAHO Web site

  Several Accreditation Connection readers and field consultants point out that the JCAHO provides...

• JCAHO seeks help with hand-hygiene compliance

  The JCAHO is partnering with infection control leadership organizations to identify the best...

Issue 34, September 4, 2006

• MS.1.20 back up for field review

  The JCAHO invites the field to comment on the latest revision of its hotly debated medical staff...

• JCAHO releases more standards questionnaires

  The JCAHO seeks field comment about its standards chapters in seven questionnaires it has posted to...

• Extreme makeover for an old, crowded ED

  At a Connecticut hospital, doctors, nurses, crisis workers, and patients have made do in a cramped...

• Opinion: Perfection is expected, but is it realistic?

  Robert M. Wachter, M.D., associate chairman of medicine at the University of California, San...

Issue 33, August 28, 2006

• JCAHO posts updated public information policy

  The JCAHO has modified its public information policy to address: requests from state licensing...

• Study: Magazine ’best’ list left off many

  A new JCAHO study finds that many hospitals were left off a national magazine’s list of best...

• How device maker and physician clients relationships could affect hospitals

  Hospitals could soon find themselves facing legal heat stemming from schemes in which they may have...

• Article explores a healthy, profitable hospital

  Click here to read how steady growth, controlled costs, and investments helped one hospital become...

Issue 32, August 21, 2006

• JCAHO revises look-alike/sound-alike list

  The JCAHO has updated its look-alike/sound-alike drug list for the first time in several years.

• Going digital in the OR

  A Florida hospital is joining other community hospitals in upgrading its operating room suites with...

• Article explores healthcare quality Web sites

  Healthcare quality Web sites, such as the JCAHO’s Quality Check are examined in an August 16...

Issue 31, August 14, 2006

• JCAHO posts new FAQ on LIP health screening

  The JCAHO posted a new FAQ on August 2 answering the question: "Are non-employed physicians and...

• GAO issues report on disaster preparedness

  The United States Government Accountability Office (GAO) has released a report on disaster...

• CMS announcement round-up

  In case you missed it, the Centers for Medicare & Medicaid Services on August 8 made two important...

Issue 30, August 7, 2006

• JCAHO to launch free data tracking system in ’07

  The JCAHO is set to launch a free organizational dashboard system called Strategic Surveillance...

• JCAHO seeks psych hospitals to test measures

  Psychiatric hospitals are being sought by the JCAHO to test five performance measures that address...

• CMS takes first steps toward cost and severity payment changes in final rule

  CMS last week announced plans for sweeping reforms to the Inpatient Prospective Payment System...

• What hospitals and health systems made the 2006 ’most wired’ list?

  Hospitals & Health Networks Most Wired Magazine, a publication of the American Hospital...

Issue 29, July 31, 2006

• JCAHO: Tell us what you think about IM, HR, PI standards

  The JCAHO last week posted to its Web site questionnaires for three of its hospital program...

• Doctors call on JCAHO to mandate improvements in the ED

  Leading experts in emergency department (ED) care are calling on the JCAHO to mandate an end to ED...

• What’s going on with the Patient Safety and Quality Improvement Act?

  Modern Healthcare points out that it’s been a year since President Bush signed into law the...

• An in-depth look at OR inventory issues

  An in-depth piece in the August 1 edition of SurgiCenter explores operating room inventory issues...

Issue 28, July 24, 2006

• IOM issues new report on medication errors, makes recommendations

  Medication errors are among the most common medical errors, harming at least 1.5 million people...

• JCAHO works with American Diabetes Association to offer certification

  The JCAHO announced July 20 that it is collaborating with the American Diabetes Association (ADA...

• Study: ED use varies in U.S. more than thought

  Emergency department (ED) use in 12 nationally representative communities varied considerably from...

• ISMP, FDA take on abbreviation errors in campaign, offer resources

  The Institute for Safe Medication Practices (ISMP) and the U.S. Food and Drug Administration (FDA...

Issue 27, July 17, 2006

• Berwick, O'Leary, among contributors of new board quality study

  A new study from The Governance Institute finds that when a hospital's board is involved in quality...

• Magazine publishes annual ’best hospitals’ report

  U.S. News & World Report is out with its annual edition of its Best Hospitals report.

• New lab APR meets CMS requirement

  The JCAHO recently approved a new Accreditation Participation Requirement (APR) for the laboratory...

• JCAHO seeks performance measures for osteoporosis monograph

  The JCAHO seeks input in its plans to develop a set of performance measures designed to effect...

Issue 26, July 10, 2006

• Article: JCAHO, not outside groups, will choose next president

  The naming of a successor to JCAHO President Dennis O’Leary won’t be as simple as it...

• Group backs verbal order read-back safety goal

  A Patient Safety Advisory article suggests patients are at greater risk of medication errors when...

• JCAHO president, other leaders, back health courts

  Common Good, a bipartisan legal reform coalition, announced last week that six leaders in patient...

• Child's death in restraints refuels debate

  A story about a 12-year-old who died in restraints at a Minnesota treatment center in May is...

Issue 25, July 3, 2006

• GAO report criticizes laboratory quality oversight

  The Government Accountability Office (GAO) in June released a 99-page report that suggested...

• Pre-publication standards posted for HR, MS

  The JCAHO has posted to its Web site pre-publication standards for all its accreditation programs.

• JCAHO posts revised FAQ on credentialing LIPs

  The JCAHO on June 23 published a revised FAQ for credentialing non-medical staff licensed...

Issue 24, June 26, 2006

• Alternative accreditor's deemed status is delayed

  TÜV Healthcare Specialists (TÜVHS) has been notified by the Centers for Medicare Services (CMS...

• ANA lawsuit tackles HHS, JCAHO nurse staffing requirements

  The American Nurses Association (ANA) and two of its state affiliates filed a lawsuit in U.S...

• IOM publishes three reports on emergency care

  The Institute of Medicine (IOM) announced this month that it has published three reports from a...

• JCAHO posts revised FAQ on H&Ps for surgery

  The JCAHO on June 16 published a revised FAQ for history and physical (H&P) examinations for...

Issue 23, June 19, 2006

• JCAHO releases ’07 Goals, tweaks scoring

  The JCAHO last Monday officially announced the 2007 National Patient Safety Goals in a press...

• IHI campaign exceeds goal for saving lives

  The more than 3,000 U.S. hospitals participating in the Institute for Healthcare Improvement's...

• JCAHO publishes study on disaster preparedne

  The JCAHO recently published a study with some key findings and recommendations about disaster...

• New IC standard addresses staff influenza vaccinations

  The JCAHO announced last week approval of an infection control (IC) standard that requires...

Issue 22, June 12, 2006

• 2007 Goals are coming

  Expect the JCAHO to release its annual list of National Patient Safety Goals this week.

• JCAHO president: P4P environment ’heating up’

  Interest in pay-for-performance (P4P) is intensifying, if the number of listeners calling in to a...

• Med rec, med error efforts in Mass in the spotlight

  The May issue of Health Executive features a story about the Massachusetts Coalition for the...

• Expanding hospitals for expanding waistlines?

  An interesting article in China Daily that reports some U.S. hospitals are making physical changes...

Issue 21, June 5, 2006

• An alternative accreditor awaits approval

  Later this month it is expected that TÜV Healthcare Specialists (TÜVHS) will hear back from the...

• JCAHO board member: Hospitals have to compete for patients

  Two Cleveland-area hospitals are expanding, and although both deny they are eyeing the competition...

• Indiana is second state to require mistake reporting

  Indiana hospitals must now report serious medical mistakes, becoming the second state behind...

• Start of hurricane season is an emergency management planning reminder

  An article in The New York Times provides some interesting insight into how states are preparing...

Issue 20, May 29, 2006

• JCAHO response to Congressional investigation

  The Joint Commission on Accreditation of Healthcare Organizations welcomes a review by Congress...

Issue 18, May 15, 2006

• Modifying the rapid response team concept for a small facility

  When patients' conditions change so that the hospital can no longer care for them, it must transfer...

• When to start planning for flu season

  Flu season usually begins in October, but it isn't too early now to begin planning for it by...

Issue 17, May 8, 2006

• One way to conduct the annual risk assessment for IC.2.10

  Infection risks vary by hospital due to factors such as patient populations, surrounding...

• Define which test results are critical and how soon you must receive the result

  Ambulatory surgery centers (ASCs) must comply with National Patient Safety Goal 2c which requires...

Issue 16, May 1, 2006

• Try using songs to teach handwashing

  Upper Shore Community Mental Health Center in Chestertown, MD, looked to nursery rhymes to remind...

• Incorporate safety themes in patient falls prevention

  University of Utah Health Care in Salt Lake City uses an approach that illustrates how safety folks...

Issue 15, April 24, 2006

• Hospitals should coordinate meaning of wristband colors regionwide

  Hospitals should coordinate meaning of wristband colors regionwide

• Tips for the new policy required under MM.2.20

  Tips for the new policy required under MM.2.20

Issue 14, April 17, 2006

• The signs in your facility that should be continuously updated

  The signs in your facility that should be continuously updated

• New element of performance for MM.2.20 requires a policy

  New element of performance for MM.2.20 requires a policy

Issue 13, April 7, 2006

• Tip for medication labeling in a sterile environment

  Tip for medication labeling in a sterile environment

Issue 12, March 31, 2006

• JCAHO expands number of RFIs hospitals may receive during survey

  JCAHO expands number of RFIs hospitals may receive during survey

• Tip for tackling competency assessment

  Tip for tackling competency assessment

• What are some tips for addressing the problem of unapproved abbreviations?

  What are some tips for addressing the problem of unapproved abbreviations?

Issue 10, March 20, 2006

• Tips for averting drug diversion

  Tips for averting drug diversion

Issue 9, March 10, 2006

• Create patient safety awareness with 'room of horrors'

  Create patient safety awareness with 'room of horrors'

• What is the status of the JCAHO bar coding requirement?

  What is the status of the JCAHO bar coding requirement?

Issue 8, March 3, 2006

• JCAHO develops international patient safety goals

  JCAHO develops international patient safety goals

• Small West Texas hospital rates higher than average

  Small West Texas hospital rates higher than average

• Use an algorithm for RRT calls

  Use an algorithm for RRT calls

• Is medication reconciliation required between the nursing floor and surgery?

  Is medication reconciliation required for patients going from the nursing floor to surgery?

• Is medication reconciliation required between the nursing floor and surgery?

  Is medication reconciliation required for patients going from the nursing floor to surgery?

• Is medication reconciliation required between the nursing floor and surgery?

  Is medication reconciliation required for patients going from the nursing floor to surgery?

Issue 6, February 20, 2006

• Patients in police custody policy and procedure

  Patients in police custody policy and procedure

• Hand-off tips

  Hand-off tips

• Does medication reconciliation apply to outpatient areas?

  Does medication reconciliation apply to outpatient areas?

• Can you hire a former employee to do inpatient audits?

  Can you hire a former employee to do inpatient audits?

Issue 5, February 13, 2006

• Tell staff: National Patient Safety Goals are more than

  Tell staff: National Patient Safety Goals are more than "just a requirement"

• Does the medication reconciliation Goal apply to outpatient areas?

  Does the medication reconciliation Goal apply to outpatient areas?

Issue 4, February 6, 2006

• Sample policy and procedure for vendors in the operating room

  Sample policy and procedure for vendors in the operating room

• How do you measure the success of SBAR?

  How do you measure the success of SBAR?

Issue 3, January 23, 2006

• Comment period open on JCAHO's revised anesthesia standard

  The JCAHO is accepting comment on its proposed revisions to a standard for plan of care for...

• JCAHO seeks comments on venous thromboembolism quality measures

  The JCAHO seeks public comment on a set of standardized performance measures for prevention and...

• Questions to ask staff about medication labeling and patient hand-offs

  Questions to ask staff about medication labeling and patient hand-offs

• Tips on how to reach out to community emergency coordinators for drills.

  Tips on how to reach out to community emergency coordinators for drills.

• How to track down safety deficiencies in anticipation of an unannounced survey

  How to track down safety deficiencies in anticipation of an unannounced survey

• Does the Universal Protocol apply everywhere in the hospital?

  Does the Universal Protocol apply everywhere in the hospital?

Issue 2, January 20, 2006

• Bill would increase CA hospital inspections

  A California lawmaker plans to introduce legislation this week that would increase state hospital...

• Should friends and family accompany patients beyond the ED waiting room?

  Should friends and family accompany patients beyond the ED waiting room?

• What can be expected during the emergency management meetiing with surveyors?

  What can be expected during the emergency management meetiing with surveyors?

Issue 1, January 9, 2006

• Questions to ask during daily briefings with surveyors

  Questions to ask during daily briefings with surveyors

• The importance of handwashing technique

  The importance of handwashing technique

Issue 3, March 2, 2006

• Ensure all healthcare professionals have the necessary skills to deliver the org

  Standard A in Chapter 4: Quality of Care Provided of the AAAHC Accreditation Handbook for...

Issue 1, January 5, 2006

• AAAHC announces 2006 Achieving Accreditation seminar dates

  The AAAHC will organize four Achieving Accreditation educational seminars in 2006. Selecting easily...