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 6, June 1, 2018

• Switching AOs: Kettering Health answers why they changed from Joint Commission to HFAP

   Kettering Health Network (KHN) is a non-profit network of eight hospitals, 10 emergency...

• Joint Commission: Sentinel events declined again in 2017

  The Joint Commission recently released its final sentinel event statistics for 2017. The same...

• AORN guidelines on unintended retention of a foreign body focuses on counting and communication

   Patients continue to be stitched closed with surgical sponges, gloves, needles, electrodes...

Issue 5, May 1, 2018 - VIEW THE FULL ISSUE

• Congress wants answers from CMS, AOs on hospital patient safety

   If you thought The Joint Commission and other accrediting organizations (AO) were already...

• Study: Recounting the cost of CAUTIs

   While most say the average cost of treating a CAUTI is $1,000, that figure is likely too low...

• CMS and Joint Commission clarify door-closing devices standards

   Examine all automatic door arrangements in light of the newest clarification on fire doors...

• Q&A: A little more on texting PHI

   Earlier this year there was some confusion over CMS’ texting policies. The agency later...

• Part 2: ECRI's top tech hazards list 2018

  The ECRI Institute published its annual list of the top 10 health technology hazards for the...

• SAMHSA: Patient consent now required for substance abuse records

   Appropriate sharing of records for patients with substance abuse disorders should be easier...

Issue 4, April 1, 2018 - VIEW THE FULL ISSUE

• Joint Commission: Test pregnant women for HIV and syphilis before childbirth

  On July 1, 2018, The Joint Commission will implement three new elements of performance (EP) for...

• Q&A: Dealing with sexual harassment in healthcare

  Ideally, everyone could go to work without having to worry about harassment and reprisal. But since...

• Young and old: Ex-surveyor worries about where CMS applies ligature risk definition

  One of the major concerns former Joint Commission surveyor Ernest Allen has with CMS’ new...

• Part 1: ECRI's top tech hazards list 2018

  The ECRI Institute published its annual list of the top 10 health technology hazards for the...

• Clean hands or RFI: Joint Commission not playing around with hand hygiene

  Thanks to a January rule change, if a Joint Commission surveyor sees anyone who directly cares for...

Issue 3, March 1, 2018 - VIEW THE FULL ISSUE

• When police and physicians clash

  A working relationship with law enforcement is key to the safety, efficacy, and wellbeing of...

• CMS defines ligature risk in new memo

  When it comes to preventing patient suicides, CMS has not been idle. In December 2017, the agency...

• CMS clarifies rules on texting patient info

  CMS confirmed that care team members are allowed to text patient information over a secure...

• Taking a second look at overlapping surgeries

  New studies show overlapping surgery isn’t as risky (or as time saving) as once thought.

Issue 2, February 1, 2018 - VIEW THE FULL ISSUE

• It takes two to tango (or qualify as a hospital)

  The difference between being accredited as a hospital or as an outpatient center can mean a...

• CMS updates State Operations Manual for first time since 2015

  For the first time in two years, the online version of CMS’ State Operations Manual, Appendix...

• Joint Commission updates education, EM requirements

  The latest update to The Joint Commission’s Comprehensive Accreditation Manual for Hospitals...

• Q&A: Patient involvement and representatives

  Involving patients in their care isn’t just polite, it’s a CMS requirement.

• Chain of command: Succession planning must be specific to leadership role, not an individual

  You’re working at a hospital during an emergency (e.g., a hurricane). But the person...

• Six steps to beat computer viruses

  CMS issued a warning to hospitals and other providers to tighten up cybersecurity and issued...

• Using fear to teach cybersecurity

  Hospitals should test staff’s cybersecurity chops by sending them spam emails and seeing who...

Issue 1, January 1, 2018 - VIEW THE FULL ISSUE

• New suicide risk expectations from Joint Commission in aftermath of sentinel events stats

  Review your policies and procedures for treating suicidal patients in general acute inpatient and...

• Not out to pasture: George Mills stays in the game after leaving Joint Commission

  George Mills, MBA, FASHE, CEM, CHFM, CHSP, who had served as director of engineering since The...

• Communication breakdown: Sentinel Event Alert calls out bad patient handoffs

  In September, The Joint Commission published Sentinel Event Alert 58, warning healthcare...

• Hospitals need to test for Legionella

  As we begin 2018, it’s time to crack down on the spread of waterborne pathogens such as...

• BOAQ 2017 Index

  Most would agree 2017 was a long and bizarre year and looking ahead, there’s plenty of news...