Quality & Patient Safety Newsletters

Briefings on Infection Control Briefings on The Joint Commission Patient Safety Monitor

Briefings on The Joint Commission will help you with all of your accreditation and survey preparation needs. Every month, BOJ takes a look at problematic standards, identifies best practices, and clarifies the latest updates and changes from The Joint Commission, CMS, and other regulatory and accreditation organizations. BOJ also offers bonus content, tools, sample policies, and more online.

Subscribe »

2012 | 2011 | 2010 | 2009 | 2008 | 2007 | 2006 | 2005 | 2004 | 2003 | 2002 | 2001

Briefings on The Joint Commission

Issue 12, December 1, 2007 - VIEW THE FULL ISSUE

• C-suite takes active role in survey process

  During compliance group meetings at Altru Health System in Grand Forks, ND, you will encounter an...

• IA hospital weathers visit from CMS surveyors

  University of Iowa Hospitals and Clinics' (UIHC) staff members are accustomed to Joint Commission...

• Is there an ideal medication reconciliation form?

  Editor's note: Patton is former Joint Commission executive director of accreditation services and...

• BOJ survey looks at readers' RFI concerns

  BOJ recently invited its readers to discuss RFIs received during their most recent Joint Commission...

• Looking back at 2007's standards of the Month

  Editor's note: This feature explores problematic Joint Commission standards with expert advice from...

• Help staff defeat the 'Joint Commission jitters'

  Even the best-trained staff members can find themselves a bundle of nervous energy on the day of a...

• Changes to EMTALA, physician ownership disclosure

  The 2008 hospital inpatient prospective payment system (IPPS) rules included a section related to...

Issue 11, November 1, 2007 - VIEW THE FULL ISSUE

• The evolution of mock survey tracers

  For facilities that had their most recent announced Joint Commission (formerly JCAHO) survey in...

• Q&A with Kurt Patton

  Editor's note: Patton is former Joint Commission executive director of accreditation services and...

• Highlights and hot topics from Executive Briefings

  Although this year's Executive Briefings provided audiences with a chance to interact with Joint...

• Patients' plan of care helps comply with PC.4.10

  Editor's note: This feature explores problematic Joint Commission standards with expert advice from...

• Tracers, Universal Protocol focus in survey

  Patient tracers have become a primary tool for surveyors during unannounced surveys, making the use...

• Q&A with Mark R. Chassin, MD

  In August, The Joint Commission (formerly JCAHO) announced its choice of successor as president of...

• CMS to stop paying for eight adverse events

  Editor's note: Sue Dill-Calloway, RN, MSN, JD, director of hospital risk management for OHIC...

Issue 10, October 1, 2007 - VIEW THE FULL ISSUE

• Publicly released survey results increase transparency

  Beth Israel Deaconess Medical Center (BIDMC) in Boston recently did what has been considered...

• Q&A with Kurt Patton

  Q: We anticipate opening a new bariatric surgery center in a few months, and we realize that...

• Set schedule, adequate documentation vital to compliance with fire safety standard

  Editor's note: This feature explores problematic Joint Commission (formerly JCAHO) standards with...

• Hand hygiene guidelines expanded to include World Health Organization standards

  The Joint Commission (formerly JCAHO) has expanded its requirement for hand hygiene by allowing...

• Hospital continues to focus on medication management

  Bon Secours St. Francis Hospital in Charleston, SC, had an unannounced three-day survey in...

• MM.4.10: Wading through medication management confusion

  MM.4.10: Wading through medication management confusion

• VA crafts policy to address anticoagulation NPSG

  The 2008 National Patient Safety Goals (NPSG) has targeted anticoagulation therapy as an area of...

Issue 9, September 1, 2007 - VIEW THE FULL ISSUE

• Surgical site marking: Standardization key in preventing errors

  Approximately five years ago, the healthcare industry began experiencing an increase in reporting...

• Q&A with Kurt Patton

  Q: The Joint Commission has many standards, safety goals, and policy requirements that involve...

• Collaboration, staying current with policies important in complying with PC.2.120

  Editor's note: This feature explores problematic Joint Commission standards with expert advice from...

• Standard MS.1.20 revisions approved

  Change is in the air: The Joint Commission recently announced that its Board of Commissioners has...

• California hospital relies on training, preparedness for a successful unannounced survey

  On a Monday morning in June, a staff member at Loma Linda (CA) University Medical Center (LLUMC...

• Revised standards designed to align with CMS

  The Joint Commission recently announced revisions to four accreditation standards that hospitals...

Issue 8, August 1, 2007 - VIEW THE FULL ISSUE

• New NSPGs include anticoag therapy, responding to unexpected deterioration

  For the first time, hospitals will have a full year to phase in the requirements, with full...

• Q&A with Kurt Patton

  Q: How can you avoid an immediate threat decision? I heard someone at a conference mention that...

• Patient safety, med management, and communication comprised recent survey

  During Northwestern Memorial Hospital's five-day unannounced survey this past spring, surveyors...

• Nursing assessment, care planning, and education are crucial to care improvement

  Your hospital's nursing assessment, care planning, and education should be coordinated to tell the...

• Prohibiting 'do not use' abbreviations on all documentation is the safest way

  Editor's note: Each month, BOJ will analyze a National Patient Safety Goal (NPSG) FAQ with expert...

• Having a centralized policy management system is essential to LD.3.90 compliance

  Editor's note: This feature explores problematic Joint Commission standards with expert advice from...

• Creating a compliant informed consent form

  Editor's note: Sue Dill-Calloway, RN, MSN, JD, director of hospital risk management for OHIC...

Issue 7, July 1, 2007 - VIEW THE FULL ISSUE

• Take a time-out to look at your Universal Protocol plan

  During a March press conference to discuss the report Improving America's Hospitals: A Report on...

• Q&A with Kurt Patton

  Should surveyors be hitting organizations with multiple RFIs for the same problem?

• Labeling meds an issue outside the operating room

  Editor's note: Each month, BOJ will analyze a National Patient Safety Goal (NPSG) FAQ with expert...

• PC.8.10 compliance depends on having a well designed policy

  Editor's note: This feature explores problematic Joint Commission standards with expert advice from...

• 12 simple steps to Joint Commission survey success

  Constant readiness for a Joint Commission survey may never be easy or perfected, but there are...

• New informed consent guidelines address surgery

  Editor's note: Sue Dill-Calloway, RN, MSN, JD, director of hospital risk management for OHIC...

Issue 6, June 1, 2007 - VIEW THE FULL ISSUE

• Joint Commission rescinds interim action to MM.4.10

  Hospitals still trying to comply with prospective pharmacist reviews After reading this article...

• Handwashing reminders impressed surveyors

  After reading this article, you will be able to: 1. -List an item surveyors check during timeout...

• Physician involvement key to med reconciliation success

  After reading this article, you will be able to: 1. Provide a reason why nurses shouldn't be the...

• New guidelines improve informed decision information

  Editor's note: Sue Dill-Calloway, RN, MSN, JD,director of hospital risk management for OHIC...

Issue 5, May 1, 2007 - VIEW THE FULL ISSUE

• The Joint Commission says hospitals are improving

  In a report that looked at data collected from 2002 to 2005, The Joint Commission found that...

• Q&A with Kurt Patton

  Editor's note: Kurt Patton, MS, RPh, is former Joint Commission executive director of accreditation...

• Solid policy, authenticating medical records are factors in challenge of IM.6.10

  Editor's note: This feature explores problematic Joint Commission standards with expert advice from...

• One year later, hospital is still busy gathering data

  Editor's note: Unannounced Survey Monitor normally reviews a hospital that recently had its survey...

• Hospitals must be clear about using patient identifiers

  Editor's note: Each month, BOJ will analyze a National Patient Safety Goal (NPSG) FAQ with expert...

• Assessing medication management risks essential to drug safety of hospital

  Because it's the final medication management (MM) standard and surveyors don't commonly cite...

Issue 4, April 1, 2007 - VIEW THE FULL ISSUE

• NPSG #2 tops 2006 list of compliance issues

  The Joint Commission published its list of top standards compliance issues from January-July 2006...

• Q&A with Kurt Patton

  Are rounds enough to justify an opportunity for face-to-face questions on handoffs?

• Defining values and tests crucial to CTR standard

  What's one of the most common reasons that hospitals cannot adhere to National Patient Safety Goal...

• Standard of the month-EC.1.10

  Editor's note: This feature explores problematic Joint Commission standards with expert advice from...

• Fine-tune your handoff communication processes

  Editor's note: Each month, BOJ will analyze a National Patient Safety Goal (NPSG) frequently asked...

• Hospital's preparedness allowed surveyors to put staff at ease during process

  Although The Joint Commission surveyors showed up unannounced at Broadlawns Medical Center in Des...

• Answers to your FAQs on the CoP

  Editor's note: Sue Dill-Calloway, RN, MSN, JD, director of hospital risk management for OHIC...

Issue 3, March 1, 2007 - VIEW THE FULL ISSUE

• GAO report finds that Joint Commission/JCR firewall okay

  A U.S. Government Accountability Office (GAO) report finds no fault with the separation between The...

• Q&A with Kurt Patton

  What time frame should we use for testing inaccessible fire and smoke dampers?

• The Joint Commission releases 147 FAQs for 2007 National Patient Safety Goals

  On February 1, The Joint Commission released new FAQs addressing the 2007 NPSGs, and there are 147...

• Compliance with MM.3.20 comes down to following hospital policy for med orders

  Editor's note: This article explores problematic Joint Commission standards with expert advice from...

• Two surveys show consistency in The Joint Commission's survey process

  Most survey coordinators who went through survey in 2006 under The Joint Commission's new...

• New rule for hospital discharges takes effect July 1

  Rule sets forth requirements for notifying Medicare beneficiaries CMS has made changes to its...

Issue 2, February 1, 2007 - VIEW THE FULL ISSUE

• JCAHO changes its name to The Joint Commission

  On January 7, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) became...

• Q&A with Kurt Patton: Who should perform med rec at transfer?

  Editor's note: Kurt Patton, MS, RPh, is former Joint Commission executive director of accreditation...

• Meeting EC 5.20 more challenging in 2007

  Editor's note: This feature explores problematic Joint Commission standards with expert advice from...

• Surveyor's mastery of tracer methodology shows during lab survey

  The biggest difference between LifeCare Hospitals of San Antonio's lab survey in 2003 and its...

• Dealing with physician-to- physician hand-offs

  Editor's note: The following story first appeared in the January Quality Improvement Report...

• Keeping up with the growing list of EC demands

  Editor's note: The following excerpt is taken from The JCAHO Survey Coordinator's Handbook, Eighth...

• New rule means restraint and seclusion policy update

  Hospitals that accept Medicare or Medicaid patients must follow new regulations for patient rights...

Issue 1, January 1, 2007 - VIEW THE FULL ISSUE

• 2007 predictions and issues to lose sleep over

  BOJ asked a long-time surveyor, who asked to remain anonymous, to look into a crystal ball and...

• Q&A with Kurt Patton: Don't complain to JCAHO--good advice?

  Editor's note: Kurt Patton, MS, RPh, is a former JCAHO executive director of accreditation services...

• Field notebooks from the JCAHO's 2006 Hospital Executive Briefings sessions

  The following are highlights from notes taken by BOJ advisors and other field professionals who...

• JCAHO collects field comment on proposed 2008 National Patient Safety Goals

  Anticoagulants, fatigue, sleep apnea, and other topics up for review The JCAHO invites you to...

• Standard of the month: MM.2.20

  Editor's note: This feature explores problematic JCAHO standards with expert advice from two BOJ...

• BOJ 2006 index

  BOJ 2006 index

• Four changes to CMS regs take effect this month

  New rule addresses H&Ps, verbal orders, drug security, and postanesthesia assessment The Center...

Issue 5, May 1, 2007

• CoP hot topics: Restraint reporting questions remain

  Editor's note: Sue Dill-Calloway, RN, MSN, JD, director of hospital risk management for OHIC...