Accreditation Newsletters

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

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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 Code® 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

• 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

• 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

• 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

• 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...