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.

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Briefings on The Joint Commission

Issue 12, December 1, 2009 - VIEW THE FULL ISSUE

• Hand hygiene rates improved through variety of reinforcement styles

  It takes more than one method to bring a hospital’s hand hygiene compliance rate up over 90...

• Facility cuts timelines, develops a standardized pain tool

  There are various ways pain can be measured by hospital staff members, depending on the...

• NPSGs in 2010: A look at the retained goals

  There are significant changes in the NPSG, many of which are refreshing. The intent in making these...

• Gray matters: Red alert

  I will freely admit that things are a little calmer this year on the survey front, at least in...

Issue 11, November 1, 2009 - VIEW THE FULL ISSUE

• Joint Commission looks at culture, improvements

  The Joint Commission has made significant steps to improve its performance and culture in 2009, the...

• Joint Commission’s role in internal quality data

  In a world where a consumer can collect encyclopedic knowledge on a car or home electronics...

• Taking a quick look at the 2009 NPSGs

  So far, so good. The release of the 2010 National Patient Safety Goals (NPSG) rolled back some of...

• How to track CMS changes and announcements

  Ever feel like navigating the world of CMS changes is an uphill battle? You are not alone. Survey...

• Joint Commission stroke certification update

  Q: Are there additional factors to monitor outside of the required stroke center measures?

Issue 10, October 1, 2009 - VIEW THE FULL ISSUE

• When multiple disease- specific care surveys arrive

  On the upside, disease-specific care (DSC) certification surveys provide a little more notice for...

• The many variations of CHF discharge instructions

  When patients come into the hospital with an illness or health problem, staff members must do all...

• Prudence or wisdom? Can your policies pass muster?

  Editor’s note: WendySue Woods, RN, MHSA, CSHA, is a senior consultant at The Greeley Company...

• The value of root cause analysis

  Latino regularly blogs on the topic at www.reliability.com/industry/training/rca_blog.html. He can...

• A look at dietetic/food service standards and CoPs

  Editor’s note: This feature explores problematic Joint Commission standards with expert...

Issue 9, September 1, 2009 - VIEW THE FULL ISSUE

• MS.01.01.01: A step forward or a return to older methods?

  The standard formerly known as MS.1.20 is on the move again. The Joint Commission opened up the...

• New accreditation decision: What will this mean for your facility in 2010 surveys?

  The Joint Commission has announced it will adopt a new accreditation decision for 2010. This...

• Surveys focus on steam sterilization

  In July, The Joint Commission announced a focus on the interpretation of standards and survey...

• Joint Commission updates position on steam sterilization

  After working with multiple professional and trade organizations on the common and proper use of...

• Best practice: Avoiding near misses with look-alike/soundalike drugs

  In 2008, Linda Severson, RN, of Cherokee Mental Health Institute (CMHI), Cherokee, IA, was called...

• Maintain survey readiness: A primer

  Once your survey is completed, your work has just begun. You must keep the momentum going and stay...

Issue 8, August 1, 2009 - VIEW THE FULL ISSUE

• Trio of steps for survey prep

  After reading this article, you will be able to: Describe the J-Day Blitz List concept...

• Medication error prevention: Defeating work-arounds

  After reading this article, you will be able to: Identify common medication errors Explain...

• Critical test? Critical value? Critical result—yes!

  After reading this article, you will be able to: Discuss recent changes to National Patient...

• Standards update: Answering your questions on restraints and more

  Restraint remains one of the most challenging issues in hospital accreditation today. To that end...

• Flu pandemic preparation: What does your facility need to know?

  Editor’s note: This feature explores problematic Joint Commission standards with expert...

Issue 7, July 1, 2009 - VIEW THE FULL ISSUE

• Documentation control highlights ISO certification

  When the concept of introducing ISO 9001 to the hospital setting first arose, hospital leaders...

• Greeley survey solutions: Time to start working on restraint

  Before tracers, restraint was one of the most frequently cited RFIs (formerly known as "Type 1...

• Unannounced survey monitor: Hospital lives and learns through mistakes

  In January 2006, Rehabilitation Hospital of the Cape and Islands (RHCI) in East Sandwich, MA, had...

• Standard of the month: Making tracers work for you

  Tracer methodology, used by The Joint Commission since 2004, has increased the focus on the patient...

• Survey prep: Identify the most frustrating standards

  According to an old Chinese proverb, it is better to sweat more during peace and bleed less during...

Issue 6, June 1, 2009 - VIEW THE FULL ISSUE

• Putting a stop to ventilator-associated pneumonia

  For a long time, ventilator-associated pneumonia (VAP) had been viewed as an unavoidable evil...

• Sight gags abound in patient safety "room of horrors"

  Propped up on a pillow, wearing a baseball hat and a pink cast on his ankle, the patient is...

• Joint Commission standards update: Deemed status application revisions for 2009

  In our April column, we took a look at the changes released earlier this year by The Joint...

• Two-day survey turns into nine-hour success

  Brattleboro (VT) Retreat, a freestanding psychiatric hospital, was expecting its most recent...

• The board?s role in conflict-of-interest situations

  What is conflict of interest and why is it important? Isn’t it just a concern of the board...

Issue 5, May 1, 2009 - VIEW THE FULL ISSUE

• New York hospital aims to eliminate MRSA cases

  When Rochester (NY) General Health System determined to cut down on methicillin-resistant...

• Greeley Survey Solutions: Tips to meeting infection control milestones

  In 2009, three infection control goals were added to the National Patient Safety Goals list...

• Q&A with MARSHA BARNDEN: Answers to your questions about infection control issues

  I am looking for policies and procedures on insertion of central lines at the bedside, especially...

Issue 4, April 1, 2009 - VIEW THE FULL ISSUE

• Washington hospital moves to DNV accreditation

  For one Washington hospital, making the move from Joint Commission accreditation to DNV Healthcare...

• Validation surveys: Tips for maintaining readiness

  Reports from the field indicate that validation surveys by state surveyors on behalf of CMS are...

• Weighing accreditation options

  Reports from the field indicate that validation surveys by state surveyors on behalf of CMS are...

• Life safety success highlights survey

  It has been a little more than six months since Det Norske Veritas (DNV) was awarded hospital...

• Establish compliance with new and revised 2009 standards

  Community Memorial Hospital (CMH) in Hicksville, OH, was expecting The Joint Commission sometime in...

• CMS and physician supervision: Off-site physicians

  CMS has clarified its ruling on the physician supervision of on-campus hospital outpatient...

Issue 3, March 1, 2009 - VIEW THE FULL ISSUE

• Cameras help rural sites meet med management compliance needs

  Medication management compliance is difficult enough, but when you are trying to comply while...

• Kentucky collaborative targets MRSA

  Infection prevention and control issues continue to weigh heavily on hospitals. National Patient...

• Hospital offers helping HAND

  In 2005, Pam Stodghill, MS, RN, director of performance improvement and risk management at Shriners...

• Ensuring safe medication storage tactics in the ED

  Q. This question came up today in our medication management committee from one of the emergency...

• Infection control and prevention in 2009 is front page news

  The past 12 months have been incredibly busy with regard to infection control issues. Take a look...

Issue 2, February 1, 2009 - VIEW THE FULL ISSUE

• Mock surveys make a difference in staff education

  After reading this article, you will be able to: Describe methods for setting up a tracer program...

• Florida hospital system weathers survey surprises

  After reading this article, you will be able to: Describe unexpected changes encountered during...

• A look at Joint Commission scoring 101

  After reading this article, you will be able to: Identify key changes to 2009 elements of...

• Fall assessment policy raises the bar

  Bellin’s upgraded fall assessment for home care receives praise from The Joint Commission

• Clarifying processes for patient identifiers

  Q. Our cardiopulmonary staff members have a short period of time to perform EKGs on patients coming...

Issue 1, January 1, 2009 - VIEW THE FULL ISSUE

• Universal Protocol FAQs offer clarity for compliance

  After reading this article, you will be able to: Discuss the most recent Universal...

• Understand the guiding principles of behavioral restraint

  After reading this article, you will be able to: Describe CMS requirements for restraint and...

• Joint Commission survey brings positive insight to hospital’s policies and procedures

  When Joint Commission surveyors came to St. Luke’s Hospital in Chesterfield, MO, the morning...

• Trio of changes in October 2008 clarifications

  After reading this article, you will be able to: Discuss clarifications to standing orders...

• LD.03.01.01: Leadership evaluation of culture of safety

  Q. The new leadership standard LD.03.01.01 says leaders regularly evaluate the culture of safety...

• Briefings on The Joint Commission 2008 index

  Accreditation alternatives Accreditor’s application for CMS deeming authority moves forward...