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Briefings on Accreditation and Quality will help you with all of your accreditation and survey preparation needs. Every month, Briefings on Accreditation and Quality 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. Briefings on Accreditation and Quality also offers bonus content, tools, sample policies, and more online.
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Issue 12, December 1, 2008 - VIEW THE FULL ISSUE
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Hospitals undergo process to change accrediting organizations
CMS announced September 26 that it had granted deeming authority to Oslo, Norway–based Det... -
Immediate-threat-to-life situations in 2009
With the introduction of Life Safety Code® (LSC) surveyors to The Joint Commission’s... -
Hospital makes staff preparedness a priority
Early on September 15, The Joint Commission posted on its extranet news that surveyors would be... -
Building a better FPPE program
When The Joint Commission implemented focused professional practice evaluations (FPPE) in January...
Issue 11, November 1, 2008 - VIEW THE FULL ISSUE
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CMS approves DNV to accredit hospitals
CMS has announced the approval of DNV Healthcare, Inc., as a deeming authority for U.S. hospitals... -
Executive Briefings: CAMH, numbering changes top RFIs
After reading this article, you will be able to: Discuss the new numbering system used in... -
Spotlight on pain management
Editor’s note: This feature explores problematic Joint Commission standards with expert... -
Restraints Interpretive Guideline: Questions answered
Editor’s note: The following question and answer session took place during HCPro’s... -
Recommendation to avoid errors with drug samples
The National Coordinating Council for Medication Error Reporting and Prevention is an organization... -
Who is responsible for preanesthesia reevaluation?
After reading this article, you will be able to: Identify pertinent EPs for preanesthesia...
Issue 10, October 1, 2008 - VIEW THE FULL ISSUE
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2009 scoring changes: A look at clarifications, thresholds, and more
The Joint Commission in August announced a new scoring system for its hospital accreditation... -
Leadership chapter changes: Defining top roles, relationships
As of January 1, 2009, a revised Leadership standards chapter takes effect, detailing requirements... -
Know the medication management standards
The Medication Management chapter is set up to reflect the continuum of the process, from... -
A new name for an old problem: Working with pharmaceutical waste
There was an interesting e-mail recently posted on a national patient safety listserv about a... -
CMS survey coordinators: Know your survey
There are several ways that hospitals preparing for CMS surveys can get sidetracked. Let’s... -
Universal Protocol, surgical timeouts, and EPs for 2009
Q. Why is The Joint Commission now saying that, beginning in 2009, surgical timeouts should ideally...
Issue 9, September 1, 2008 - VIEW THE FULL ISSUE
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Most recent Sentinel Event Alert highlights disruptive behavior
Rude behavior, unpleasant language, hostile attitudes, and other bad behaviors not only create an... -
Gwinnett Medical Center creates a three-tiered approach to address medication security questions
Gwinnett Medical Center in Lawrenceville, GA, is preparing to roll out a new, three-tiered approach... -
Hospitals continue to struggle with heparin overdoses
Editor's note: This feature explores problematic Joint Commission standards with expert advice from... -
Travel ticket helps New Jersey facility improve handoffs
Sometimes, it's all about the journey, not the destination. And in hospitals, the journey a patient... -
Understand new rules for reporting restraint deaths
Editor's note: Sue Dill Calloway, RN, MSN, JD, director of hospital risk management at OHIC... -
Alcohol-based hand rinses and impaired populations
Editor's note: Patton is the former Joint Commission executive director of accreditation services...
Issue 8, August 1, 2008 - VIEW THE FULL ISSUE
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2009 NPSGs: A focus on HAIs, infection control
The Joint Commission announced its 2009 National Patient Safety Goals (NPSG) and elements of... -
Universal Protocol: Q&A with Peter B. Angood
Editor's note: BOJ recently conducted an e-mail interview with Peter B. Angood, MD, FRCS(C), FACS... -
Effect of the 2009 NSPGs on medication reconciliation
Editor's note: This feature explores problematic Joint Commission standards with expert advice from... -
Simplicity works: Punch clocks help with date/time compliance
Being open to trial and error is a must at a hospital. Cecile Broussard, RN, MS, quality manager at... -
Update: EMTALA, CMS, and your hospital
Editor's note: Sue Dill Calloway, RN, MSN, JD, director of hospital risk management at OHIC... -
Language adds twist to unannounced survey
Hospitals can prepare for their Joint Commission (formerly JCAHO) surveys through several methods...
Issue 7, July 1, 2008 - VIEW THE FULL ISSUE
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Updated protocols, smart pumps help with Goal #3E anticoagulant compliance
A pending survey led one four-hospital system to take a hard look at its anticoagulation therapy... -
Who should handle moderate sedation preassessments?
Editor's note: Patton, MS, RPh, is the former Joint Commission executive director of accreditation... -
Limiting restraints results in increased safety
As hospitals limit the use of restraints and explore various techniques to keep their patients... -
Working with your data
Editor's note: The following is adapted from the April 17 HCPro audioconference, "Core... -
Survey challenges addressed through firsthand experience
Every year, certain National Patient Safety Goals present additional challenges to facilities... -
Heparin recall brings attention to policies
Editor's note: This feature explores problematic Joint Commission standards with expert advice from... -
Ensure appropriate use of soft restraints, drugs
Editor's note: Sue Dill Calloway, RN, MSN, JD, director of hospital risk management for OHIC...
Issue 6, June 1, 2008 - VIEW THE FULL ISSUE
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Getting the most out of your PPR process
After three years of working through the PPR process for its Joint Commission accreditation... -
Q&A with Kurt Patton
Editor's note: Patton is the former Joint Commission executive director of accreditation services... -
Use telepsychiatry to improve assessments
Telepsychiatry, or assessing the mental health of patients via an electronic connection, sounds... -
PI.3.20: Proactively dealing with high-risk, low-volume procedures to increase safety
Editor's note: This feature explores problematic Joint Commission standards with expert advice from... -
Preparation pays off for hospital survey
Being in constant compliance with regulatory standards is one goal for hospitals everywhere. But... -
Clarifying questions on restraint uses
Editor's note: Sue Dill Calloway, RN, MSN, JD, director of hospital risk management for OHIC...
Issue 5, May 1, 2008 - VIEW THE FULL ISSUE
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Accreditor's application for CMS deeming authority moves forward
DNV Healthcare's bid to become the first new accreditation organization for hospitals in the United... -
Q&A with Kurt Patton
Editor's note: Patton is the former Joint Commission executive director of accreditation services... -
Three surveys in four months
When Susan Carvalho, RN, BSN, took over as director of quality and Joint Commission coordinator at... -
Developing methods for addressing Life Safety CodeĀ® challenges for 2008
Editor's note: This feature explores problematic Joint Commission standards with expert advice from... -
Hospital creates policy to make critical test results stick
Virtually every facility has its own way of managing the reporting of critical test results (CTR... -
Building awareness into the survey prep process
Educating staff members in every department about the National Patient Safety Goals allows for... -
Clearing the air about CMS' H&P changes
Editor's note: Sue Dill Calloway, RN, MSN, JD, director of hospital risk management for OHIC...
Issue 4, April 1, 2008 - VIEW THE FULL ISSUE
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Surveyors praise emergency management plan
During the facility's 2007 Joint Commission survey, Memorial Health University Medical Center... -
IV drugs in the emergency department
Identify how Joint Commission standards address mixing IV medications -
Revamped nursing documentation increases patient care, improves Provision of Care
When Gwinnett Medical Center in Lawrenceville, GA, decided to cut nursing paperwork by 50% to... -
MD hospital avoids hand hygiene RFI, finds areas for improvement
Multiple mock surveys prove to be one of the best ways to prepare staff members and hospital... -
How to find methods to assess continual survey readiness in your facility
Finding a way to evaluate hospitals in preparation for the next unannounced survey can be a... -
Looking to the standards to address flash sterilization
Editor's note: This feature explores problematic Joint Commission standards with expert advice from... -
A look at postanesthesia evaluations as related to CMS guidelines
In a recent CMS Corner, we discussed federal regulations published in the Federal Register that...
Issue 3, March 1, 2008 - VIEW THE FULL ISSUE
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Proposed 2009 NPSGs look at infection control, med rec
The Joint Commission just closed the field review period for its proposed 2009 National Patient... -
Universal Protocol: Clarifying the physician's role
Q&A with Kurt Patton -
Simple advance directive identifier limits confusion
It's amazing how far a piece of red plastic can go toward improving how a facility tracks patient... -
Aligning patients' rights standards with CMS CoPs
Editor's note: This feature explores problematic Joint Commission standards with expert advice from... -
Washington state hospital keeps survey 'uneventful'
Often, simple steps help hospitals perform better on Joint Commission surveys. For Valley General... -
Task force looks into implementation of MS.1.20
The Joint Commission has created a task force and charged it with exploring issues surrounding... -
CMS revises interpretive guidelines in infection control
Editor's note: Sue Dill Calloway, RN, MSN, JD, director of hospital risk management for OHIC...
Issue 2, February 1, 2008 - VIEW THE FULL ISSUE
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All you ever wanted to know about S3 but were afraid to ask
The Joint Commission (formerly JCAHO) released its Strategic Surveillance System (S3) in 2007. It... -
Q&A with Kurt Patton
Editor's note: Patton, MS, RPh, is the former Joint Commission executive director of accreditation... -
Hospital turns to HFAP for alternative accreditation
Amsterdam (NY) Memorial Healthcare is a small rural facility with a 15-bed physical rehab unit, a... -
How to connect medication management and black box labels
Editor's note: This feature explores problematic Joint Commission (formerly JCAHO) standards with... -
Hospital improves medication reconciliation compliance by improving past practices
Mandatory training programs, leadership involvement, and frequent audits helped Northwestern... -
Evaluate your organization's readiness plan
Editor's note: The following is an excerpt from the new Joint Commission Survey Coordinator's... -
Methods to address H&P-related standards
Editor's note: Sue Dill Calloway, RN, MSN, JD, director of hospital risk management for OHIC...
Issue 1, January 1, 2008 - VIEW THE FULL ISSUE
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Involve staff in process to improve critical test results policies
Knowing just what the "critical" part of critical test results is can be an ongoing battle between... -
Q&A with Kurt Patton
Wading through complex expectations of critical test results under NPSG #2C -
NPSG #15A: Crafting a suicide risk assessment policy
Creation of a policy to meet the requirements of National Patient Safety Goal (NPSG) #15A-suicide... -
System's RFI numbers decrease with each survey
From February to June 2007, three hospitals of the Main Line Health system in Pennsylvania... -
Medication storage and security
Editor's note: This feature explores problematic Joint Commission (formerly JCAHO) standards with... -
Updating CMS' required infection control policies
Editor's note: Sue Dill-Calloway, RN, MSN, JD, director of hospital risk management for OHIC... -
Briefings on The Joint Commission 2007 index
Briefings on The Joint Commission 2007 index -
Critical values / Critical test results notification
A sample Critical values / Critical test results notification policy, crafted by Sid Peterson...