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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 1, December 29, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Center for Transforming Healthcare releases new video

  The Joint Commission’s Center for Transforming Healthcare has published a new online video...

• Joint Commission appoints new chief medical officer

  The Joint Commission has announced Ana Pujols-McKee, MD, will take on the role of the accrediting...

Issue 52, December 22, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• 2011 CMS CLASBI reporting requirements announced

  The Joint Commission has issued a notification to its accredited hospitals regarding new reporting...

• Joint Commission announces new lab standards in 2011

  Updated and revised laboratory standards have been announced by the Joint Commission. These changes...

Issue 51, December 17, 2010

• Joint Commission announces revisions to medication reconciliation goal

  Medication reconciliation has received a facelift: revisions to the medication reconciliation...

• Field review for proposed VAP/CAUTI NPSGs

  The Joint Commission has opened 2012 National Patient Safety Goals (NSPG) for ventilator-associated...

Issue 50, December 8, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission updates public information policy

  In a recent announcement on their Web site, The Joint Commission has updated the language of its...

• Joint Commission updates sentinel event statistics

  The Joint Commission has updated its website with its latest sentinel event statistics. As of...

Issue 49, December 1, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission releases new website

  The Joint Commission has launched extensive upgrades to its website in order to improve access to...

• CMS adds patient safety measures to hospital comparison website

  Starting in 2011, the Centers for Medicare & Medicaid Services (CMS) plan to add new standards...

Issue 48, November 24, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• ED directors report inadequate emergency surgery coverage

  The majority of ED directors participating in a survey reported inadequate staff coverage for...

• Joint Commission updates policy on ceasing services

  The Joint Commission has announced a new policy, effective January 1, 2011, for organizations that...

Issue 47, November 19, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission issues suicide risk Sentinel Event Alert

  the Joint Commission’s latest Sentinel Event Alert targets suicide risk in the...

• Joint Commission reduces full survey timeframe from 39 to 36 months

  The Joint Commission will reduce the timeframe for surveys by three months. This new rule will go...

Issue 46, November 12, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission launches library of best practices

  The Joint Commission has launched the much-discussed “Leading Practice Library,” in...

• Joint Commission still accepting comments on heart failure certification proposed requirements

  The Joint Commission issued a reminder this week that it is still collecting opinions from the...

Issue 45, November 5, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission announces diabetes Speak Up campaign

  The Joint Commission announced this week a new brochure, as part of its Speak Up™ campaign...

• Joint Commission hand hygiene project makes progress

  The Joint Commission’s Target Solutions Tool™ (TST) launched in September has made...

Issue 43, October 22, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Hand-off communication solutions revealed by CTH

  The Joint Commission’s Center for Transforming Healthcare (CTH) has announced the second in...

• 2011 accreditation and certification categories

  The Joint Commission announced this week that new accreditation and certification decision...

Issue 42, October 15, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• CMS updates requirements for ordering respiratory services

  In order to comply with changes to CMS Conditions of Participation for hospitals regarding who may...

• Joint Commission manual update expected in late October

  The Joint Commission has announced that there has been a slight delay in the publication of its...

Issue 41, October 8, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission issues reminder of MS.01.01.01 changes

  the Joint Commission published a brief reminder this week that changes to Medical Staff standard...

• Watch for Update 2

  The Joint Commission has stated that "Update 2" to its comprehensive manuals will mail in...

Issue 40, October 1, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission appoints 21 to advisory council

  The Joint Commission announced this week the appointment of 21 new members from across the country...

• Lab standard field review closing date approaches

  The Joint Commission continues to accept comments from the field on new and revised laboratory...

Issue 39, September 24, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Most cited standards updated

  The Joint Commission has provided its most challenging standards list for the first half of 2010...

• NPSG.01.03.01 EP 1 revised

  The Joint Commission has announced that Element of Performance (EP) 1 of National Patient Safety...

Issue 38, September 17, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission launches Targeted Solutions Tool

  The Joint Commission has announced the launch of the Targeted Solutions Tool™ (TST), an...

• Joint Commission seeks feedback on field review for lab standards

  The Joint Commission has posted for public comment new and revised lab standards for 2011. The...

Issue 37, September 10, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission proposes new and revised lab standards for 2011

  The Joint Commission has posted new and revised laboratory services standards for 2011 for field...

• Joint Commission set to launch primary care home option

  The Joint Commission intents to expand its ambulatory health care organization accreditation...

Issue 36, September 6, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission reminder: How to comment on standards

  The Joint Commission issued a brief reminder to organizations on how to provide feedback and...

• Joint Commission appoints new Director of Business Excellence

  The Joint Commission has announced the appointment of Alex Vandiver, MBB, as director of Business...

Issue 35, August 30, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• PC.02.01.05 revisions released

  PC.02.01.05, element of performance (EP) 2, has been updated in order to meet requirements...

• Center for Transforming Healthcare hand hygiene compliance project

  The Joint Commission Center for Transforming Healthcare has announced it will release a tool...

Issue 34, August 23, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission releases latest list of most challenging requirements

  The Joint Commission announced this week its most challenging requirements list for the first half...

• Joint Commission updates Sentinel Event statistics

  The Joint Commission released this week its most recent figures for sentinel event reporting...

Issue 33, August 16, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Teen dies in restraints at Missouri hospital

  A 16-year-old girl suffocated while in restraints at SSM DePaul Health Center in Bridgeton, MO...

• Joint Commission seeks feedback

  The Joint Commission seeks feedback on revisions to the 2010 version of Universal Protocol &trade...

Issue 32, August 9, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission releases new free monograph

  The Joint Commission has released its most recent free downloadable monograph. This document...

• Medication Reconciliation update

  The Joint Commission announced this week the results of a July 27 discussion of the results of its...

Issue 31, August 2, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Interim Staffing Effectiveness standards to receive field review

  The Joint Commission has announced that it will undertake a follow-up field review for two proposed...

• ’Speak Up’ campaign targets patient falls

  In late July, The Joint Commission released an update to its popular “Speak Up&rdquo...

Issue 30, July 26, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• HHS announces final rule on meaningful use

  The Department of Health and Human Services (HHS) announced its Final Rule on Meaningful Use...

• Healthcare systems with more than one hospital can opt for concurrent survey

  Those healthcare systems with more than one hospital or other accredited body organized as a single...

Issue 29, July 19, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission focuses on safe injection practices

  All hospitals receiving Joint Commission accreditation will now have to pay special attention to...

• New survey reveals catheter-related bloodstream infections are still an issue

  A recent survey conducted by the Association for Professionals in Infection Control and...

Issue 28, July 12, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Berwick appointed to head CMS

  President Barrack Obama has appointed Donald Berwick, MD, president and co-founder of the Institute...

• Joint Commission looks to refine, improve tracer methodology

  The Joint Commission is looking to refine and improve its tracer methodology, according to an...

Issue 27, July 5, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission discusses field review results

  The Joint Commission announced recently that through the field review process it became apparent...

• Joint Commission sends alert of EPINEPHrine pre-filled syringe shortage

  The American Society of Health-System Pharmacists and the Institute for Safe Medication Practices...

Issue 26, June 28, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission International announces change in leadership

  The Joint Commission has announced that its long-time president and chief executive of Joint...

• National Patient Safety Goals Element of Performance revisions

  The Joint Commission announced revisions to four Elements of Performance within the National...

Issue 25, June 21, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• New MRSA study seeks updates on trends in infection control

  The Association for Professionals in Infection Control and Epidemiology (APIC) conducted the first...

• Over 3,000 patients receive notification about possible endoscopic equipment contamination

  Palomar Pomerado Health System (PPHS), a public hospital based in Escondido and Poway in CA, has...

Issue 24, June 14, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission pushes back telemedicine requirements until March 2011

  The Joint Commission's plan to implement CMS telemedicine standards for hospitals, both acute and...

• Many physicians and hospitals believe electronic medical record goals are unrealistic

  Feedback from some of the nation’s most advanced hospitals indicates that many facilities...

Issue 23, June 7, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission releases its latest sentinel event alert

  The Joint Commission has released its latest Sentinel Event Alert, this time on preventing violence...

• Medication error costs infant her life

  Alicia Coleman was born three months premature and relatively healthy. However, 12 days after her...

Issue 22, May 31, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• CMS proposes two hospital-acquired infection measures

  The Centers for Medicare & Medicaid Services (CMS) has published a notice of proposed changes...

• ASHP comments on proposed revisions to medication reconciliation

  The American Society of Health-System Pharmacists (ASHP) is happy with the proposed revisions made...

Issue 21, May 24, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission releases updated list of Measure of Success requirements

  The Joint Commission has followed up its announcement regarding deletion of Measures of Success for...

• Doctors, nurses defend allegations of substandard care

  Doctors and nurses of Olive View-UCLA Medical Center in Sylmar, CA, gathered outside on May 19 to...

Issue 20, May 17, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission suspends 'automatic' sentinel event adverse decision

  The Joint Commission has suspended the policy that triggers an "automatic" adverse...

• The Joint Commission releases most challenging requirements of 2009

  The Joint Commission has published a list of the most challenging requirements identified in 2009...

Issue 19, May 10, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission updates sentinel events statistics

  The Joint Commission has updated its sentinel events statistics, according to an official statement...

• Joint Commission clarifies IM standards

  The Joint Commission has announced a clarification on Information Management standard IM.02.02.01...

Issue 18, May 3, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission removes Measure of Success requirements

  Effective immediately, The Joint Commission has announced that the Measure of Success requirements...

• AHAP conference in Las Vegas is days away

  The Association for Healthcare Accreditation Professionals (AHAP) will hold its annual conference...

Issue 17, April 26, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission reinstates anti-discrimination requirements to Leadership standards

  The Joint Commission has announced it will reinstate an anti-discrimination requirement which had...

• AHAP continues contest for free registration to conference in Las Vegas

  The Association for Healthcare Accreditation Professionals (AHAP) will hold a drawing for seats to...

Issue 16, April 19, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Nurses Week gains coverage from The Joint Commission through Facebook discussion

  The Joint Commission plans to recognize nurses in a variety of activities leading up to Nurses Week...

Issue 15, April 12, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Four percent of healthcare workers MRSA-positive

  A study conducted by Carlos Guerra, MD, from the Brody School of Medicine at East Carolina...

Issue 14, April 5, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission seeks input on suggested revisions to NPSG on medication reconciliation

  The Joint Commission is inviting healthcare organizations to comment on the suggested revisions to...

Issue 13, March 29, 2010

• Study shows C-diff infections may be on the rise

  The infections caused by the superbug, Clostridium difficile, better known as C-diff, often...

Issue 12, March 22, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Revised medical staff bylaws receive approval from Joint Commission

  The Joint Commission has approved the revised medical staff bylaws standard MS.01.01.01, according...

• Joint Commission releases findings from 2009 annual report

  The Joint Commission released its fourth annual report, stating accredited hospitals continue to...

Issue 11, March 15, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Two National Patient Safety Goals receive minor changes

  The Joint Commission has made minor changes to two National Patient Safety Goals (NPSG), according...

• Breast Cancer quality measures next on the Joint Commission’s list

  The Joint Commission Division of Quality and Research is now focusing on developing quality...

Issue 10, March 8, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• AHCJ requests better reporting from The Joint Commission’s Web site

  The Association of Health Care Journalists (AHCJ) recently wrote a letter to the Joint Commission's...

• AHAP continues contest, offers free registration to conference in Las Vegas

  The Association for Healthcare Accreditation Professionals (AHAP) will hold a series of drawings...

Issue 9, March 1, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission introduces new survey terminology

  At recent site visits, the Joint Commission has been using the term "observed but corrected...

• Florida hospital improves revenue with disease education program

  After discovering a significant portion of the patients at Parrish Medical Center in Boca Raton...

Issue 8, February 22, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• National database missing disciplined healthcare workers

  After more than 20 years, the federal government will finally allow healthcare facilities to access...

• AHAP continues contest, offers free registration to conference in Las Vegas

  The Association for Healthcare Accreditation Professionals (AHAP) will hold a drawing for three...

Issue 7, February 15, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission postpones field review of revised Medication Reconciliation

  The Joint Commission will wait to release the National Patient Safety Goal on medication...

• Association begins contest for free registration to conference in Las Vegas

  The Association for Healthcare Accreditation Professionals (AHAP) will hold a drawing for three...

Issue 6, February 8, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission extends its accreditation to advanced diagnostic imaging

  The Centers for Medicare & Medicaid Services (CMS) has designated The Joint Commission for...

• FDA extends time to replace Steris sterilizing system

  Those healthcare facilities using the Steris© sterilizing system will now have an 18-month...

Issue 5, February 1, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• The Joint Commission releases alert about preventing maternal death

  The Joint Commission issued its latest Sentinel Event alert focusing on preventing maternal death...

• Thirteen CA hospitals receive fines due to medical errors

  The California Department of Public Health (CDPH) has fined 13 California hospitals for medical...

Issue 4, January 25, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• CO surgery technician exposes thousands of patients to Hepatitis C

  Between two Colorado hospitals, 6,000 patients have been exposed to Hepatitis C due to a surgery...

• Study shows variations in MRSA superbug

  British scientists believe that the superbug methicillin-resistant Staphylococcus aureus (MRSA) can...

Issue 3, January 18, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission releases new survey development process

  Relief will come to those facilities waiting for their unannounced survey from The Joint...

• Patient Care Quality shows improvement over a seven-year period

  The fourth annual report released by The Joint Commission shows there has been a steady increase in...

Issue 2, January 11, 2010

• Maine law requires hospitals to test for MRSA in high-risk patients

  After the death of an 83-year-old man last year who contracted Methicillin-resistant Staphylococcus...

• Joint Commission opens field review of modifications of MS.01.01.01

  The Joint Commission Board of Commissioners has approved the distribution of the proposed...

Issue 1, January 4, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Joint Commission approves field review of MS.01.01.01 (formerly MS.1.20)

  After receiving negative feedback from hospitals and physicians about MS.01.01.01 and then allowing...

• Targeting trouble areas with Six Sigma tactics shows major results

  Let's throw a pair of numbers out there: 26% and 3%. Those are the percentages for emergency...

Issue 44, October 29, 2010

• Greeley Reflections

  Each week, a senior consultant from The Greeley Company's Center for Healthcare Accreditation will...

• Center for Transforming Healthcare announces leadership council

  The Joint Commission’s Center for Transforming Healthcare has announced the makeup of its new...

• Clarification of informed consent standards

  The Joint Commission has added a clarification to stanadrd RC.o2.01.01, EP 4, under the Record of...