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Accreditation Insider

AHAP is a community in which survey coordinators and other accreditation specialists share the latest tested tips, tools, and strategies to implement successful accreditation programs and achieve professional growth. In this e-newsletter, you'll read helpful tips and timely news items related to accreditation and survey-readiness improvement. Plus, train your staff and yourself with our weekly quiz questions included with clickable answers.

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Issue 14, April 5, 2011

• AHAP Staff Challenge: Communication

  True or false: Critical values may indicate a serious medical situation that must be treated...

• From the AHAP Blog: Joint Commission to release update to manual in April

  The Joint Commission announced this week that its annual “Update 1″ to its...

• Take our salary survey!

  Every year we host an anonymous salary survey for our members as a way to help gauge how the...

Issue 5, March 15, 2011

• AHAP Staff Challenge: Universal protocol

  True or false: Pre-procedure verification is an ongoing process where information is gathered...

Issue 5, February 8, 2011

• AHAP Staff Challenge: Evidence of standards compliance

  The time frame for corrective action is which of the following:

• From the AHAP Blog: BMJ reports on patient care and falls

  In a January report, the British Medical Journal (BMJ) found that patients who fall out of bed...

Issue 52, December 27, 2011

• AHAP Staff Challenge: Emergency Management

  True or False: Power failures, loss of water or utilities, floods, and tornados are all examples...

• From the AHAP Blog: Joint Commission releases easy-to-read 2012 NPSGs

  Earlier this week The Joint Commission released the National Patient Safety Goals (NPSGs) for 2012...

• What’s new with AHAP!

  Download the latest benchmarking report!

Issue 51, December 20, 2011

• AHAP Staff Challenge: Record of care

  Which of the following would be considered a medical record history?

• From the AHAP Blog: Texting while rounding?

  One of AHAP’s sister blogs, the Patient Safety Monitor Blog, has a fantastic post by writer...

• What’s new with AHAP!

  Download the latest benchmarking report!

Issue 50, December 13, 2011

• AHAP Staff Challenge: National Patient Safety Goals

  True or False: When using a two person verification process prior to starting a blood transfusion...

• From the AHAP Blog: Joint Commission releases new information on flu vaccine standard

  The Joint Commission has released new information on IC.02.04.01, the Infection Control standard...

• What’s new with AHAP!

  Briefings on The Joint Commission, AHAP’s sister newsletter, would like to announce that...

Issue 49, December 6, 2011

• AHAP Staff Challenge: Leadership

  True or False: The hospital’s scope of service must be approved by the governing board.

• From the AHAP Blog: Joint Commission seeks comments on NPSG addressing overuse of treatments

  The Joint Commission is proposing a new National Patient Safety Goal (NPSG) addressing growing...

• What’s new with AHAP!

  AHAP Members: The association is once again working with its sister newsletter, Briefings on The...

Issue 48, November 29, 2011

• AHAP Staff Challenge: Infection control

  True or False: Good infection control practices can have a major, positive impact on patient safety...

• From the AHAP Blog: Effective date announced for patient-centered communication standards

  The Joint Commission has announced that the previously approved patient-centered communication...

• What’s new with AHAP!

  The latest quarterly networking call is available for download.

Issue 47, November 22, 2011

• AHAP Staff Challenge: Environment of Care and Life Safety

  True or False: Hospitals have the option to incorporate all the environment of care (EC) areas...

• From the AHAP Blog: Texting verbal orders FAQ published

  The Joint Commission has published an FAQ addressing texting orders on its Frequently Asked...

• What’s new with AHAP!

  Take our latest poll!

Issue 46, November 15, 2011

• AHAP Staff Challenge: Rights, ethics, and communication

  True or False: Communication is one of the key cornerstones of patient safety and quality care.

• From the AHAP Blog: Joint Commission changes term "disruptive behavior" in the standards

  The Joint Commission has altered the term “disruptive behavior” in the...

• What’s new with AHAP!

  Last chance to take out latest benchmarking survey and join our networking call!

Issue 45, November 8, 2011

• AHAP Staff Challenge: Provision of care

  True or False: It is not necessary for community hospitals to have processes in place for...

• From the AHAP Blog: Joint Commission and SGS team up for accreditation/ ISO program

  The Joint Commission announced this week that it will work with SGS, a leading verification...

• What’s new with AHAP!

  Take our latest benchmarking survey!

Issue 44, November 1, 2011

• AHAP Staff Challenge: Medication management

  True or False: A hospital may use some discretion when developing its list of...

• From the AHAP Blog: New FAQ posted on storing laryngoscope blades

  The Joint Commission has posted its latest Frequently Asked Question (FAQ) information, discussing...

• What’s new with AHAP!

  Last chance to join us on the podium!

Issue 43, October 25, 2011

• AHAP Staff Challenge: Emergency Management

  True or False: When developing your Emergency Operations Plan, you should seek input from medical...

• From the AHAP Blog: Joint Commission Critical Access Hospital Accreditation program receives CMS recognition

  The Centers for Medicare and Medicaid Services (CMS) have granted deeming authority to The Joint...

• What’s new with AHAP!

  AHAP is currently seeking speakers to present at the 2012 AHAP Sixth Annual Conference to be held...

Issue 42, October 18, 2011

• AHAP Staff Challenge: Medication safety

  True or False: Heparin should be administered continuously, via a programmable pump, intravenously...

• From the AHAP Blog: First Disease-Specific Care certifications for nursing homes issued by Joint Commission

  The Joint Commission has announced that to Illinois nursing homes have become the first facilities...

• What’s new with AHAP!

  Upcoming working group call

Issue 41, October 11, 2011

• AHAP Staff Challenge: Communication

  True or False: Hospitals must define critical test/ procedure values/results.

• From the AHAP Blog: Cappiello named COO of Healthcare Facilities Accreditation Program

  We’d like to report some exciting news: former Joint Commission vice president and long-time...

• What’s new with AHAP!

  Join us on the podium at the 2012 AHAP Conference

Issue 40, October 4, 2011

• AHAP Staff Challenge: Universal protocol

  True or False: The Universal Protocol applies to both surgical and non-surgical invasive...

• From the AHAP Blog: Joint Commission releases R3 report looking at CAUTI

  The Joint Commission has just released a new R3 report examining the 2012 National Patient Safety...

• What’s new with AHAP!

  Save the date for our next quarterly networking call!

Issue 39, September 27, 2011

• AHAP Staff Challenge: Risk assessment

  Complete this sentence: On an inpatient psychiatric unit, staffed 24 hours a day, seven days a...

• From the AHAP Blog: ISMP updates confusing drug name list

  The Institute for Safe Medical Practices (ISMP) recently updated its “List of Confused Drug...

• What’s new with AHAP!

  Join us on the podium at the 2012 AHAP Conference

Issue 38, September 20, 2011

• AHAP Staff Challenge: Restraint and seclusion

  When it is necessary to use restraint or seclusion to protect the physical safety of the patient...

• From the AHAP Blog: AHA releases report looking at readmissions

  The American Hospital Association’s (AHA) TrendWatch has released a recent report looking at...

• What’s new with AHAP!

  Save the date for the 6th annual AHAP Conference, May 10-11, 2012 in Orlando, FL! The 6th Annual...

Issue 37, September 13, 2011

• AHAP Staff Challenge: Evidence of standards compliance

  “C” EPs require a compliance level of _____________.

• From the AHAP Blog: HHS encourages equal visitation and representation rights

  The Department of Health and Human Services (HHS) issued a press release this week to give added...

• What’s new with AHAP!

  Meet our latest member of the month!

Issue 36, September 6, 2011

• From the AHAP Blog: Drug shortages and the gray market?

  Are hard economic times and a lack of key drugs leading to more drugs being sold through the...

• AHAP Staff Challenge: Infection control

  The Joint Commission says hospitals may follow the hand hygiene guidelines of the______________ or...

• What’s new with AHAP!

  If you haven’t entered out Joint Commission Chapter Compliance contest, there is still time!

Issue 35, August 30, 2011

• AHAP Staff Challenge: Environment of care

  Complete this sentence: The hospital should conduct fire drills in patient care areas once...

• From the AHAP Blog: Latest Sentinel Event Alert: Radiation risks of diagnostic imaging

  The Joint Commission released its latest Sentinel Event Alert this morning highlighting the need...

• What’s new with AHAP!

  Enter our newest contest!

Issue 34, August 23, 2011

• AHAP Staff Challenge: Provision of care

  The Joint Commission requires a history and physical to be completed on all inpatients. The...

• From the AHAP Blog: Joint Commission posts "Sudden Cardiac Arrest Initiatives" publication

  The Joint Commission unveiled this week a free PDF publication entitled “Sudden Cardiac...

• What’s new with AHAP!

  Your colleagues love to hear from you!

Issue 33, August 16, 2011

• AHAP Staff Challenge: Patient identification

  True or False: One of the frequently occurring patient errors has to do with caregivers selecting...

• From the AHAP Blog: In Ireland, law would require admission of medical mistakes

  In an effort to ensure more reporting of adverse events, Minister for Health James Reilly is...

• What’s new with AHAP!

  AHAP is starting to gear up some discussion selecting speakers for the 2012 AHAP conference, and...

Issue 32, August 9, 2011

• AHAP Staff Challenge: Medication Safety

  True or False: The International Normalized Ratio (INR) is used to measure the patient’s...

• From the AHAP Blog: Telemedicine pre-pub standards available

  The Joint Commission has published its prepublication standards for telemedicine (LD.04.03.09 and...

• What’s new with AHAP!

  AHAP is starting to gear up some discussion selecting speakers for the 2012 AHAP conference, and...

Issue 30, July 26, 2011

• AHAP Staff Challenge: Performance improvement

  When core measures data are out of compliance for _____________ or more consecutive quarters, you...

• AHAP Staff Challenge: Record of care

  The quarterly delinquent medical record rate cannot exceed _____________.

• From the AHAP Blog: Joint Commission seeks panel experts for critical access hospital project

  The Joint Commission is seeking panel members for its new project to assess and implement...

• From the AHAP Blog: Joint Commission recommends a look at sterilization and high-level disinfection

  In a recent announcement, The Joint Commission has urged hospitals and other accredited...

• What’s new with AHAP!

  The latest benchmarking report—with complete results and an executive summary— has...

• What’s new with AHAP!

  The latest AHAP working group call on tracers was a great success! Thank you to all who joined in...

Issue 29, July 19, 2011

• AHAP Staff Challenge: Environment of Care

  Needle boxes should be removed when they are _____________.

• From the AHAP Blog: Can videos curb infection rates?

  Our colleagues over at the Patient Safety Monitor blog found an interesting project this week...

• What’s new with AHAP!

  New Survey

Issue 28, July 12, 2011

• AHAP Staff Challenge: Infection control

  True or false: Surgical hand and forearm scrubs should follow manufacturer instructions but are...

• From the AHAP Blog: Does July actually bring higher mortality rates?

  Because a new class of medical school graduates begins their residencies in July, the month has a...

• What’s new with AHAP!

  Our next working group call will take place on Wednesday, July 27th at 3 pm EST (2 pm Central...

Issue 27, July 5, 2011

• AHAP Staff Challenge: Medication Safety

  True or False: Baseline coagulation status should be determined before starting anticoagulation...

• From the AHAP Blog: Wall Street Journal: The road to fewer readmissions

  One in every ten dollars spent on healthcare goes toward preventable readmissions, according to a...

• What’s new with AHAP!

  Upcoming working group call

Issue 26, June 28, 2011

• AHAP Staff Challenge: Restraint and seclusion

  True or False: It is permissible to use standing orders or PRN orders for the initiation of...

• From the AHAP blog: Is preventing wrong-site surgery rocket science?

  AHAP members, I’d like to share with you a post first published over on our sister blog, the...

• What’s new with AHAP!

  We'll be closing our latest benchmarking survey shortly hope that you'll participate! This...

Issue 25, June 21, 2011

• AHAP Staff Challenge: Restraint and seclusion

  Would a patient death while in restraint or seclusion be considered a sentinel event?

• From the AHAP Blog: AAAASF receives deeming authority through CMS

  Earlier this week, The Centers for Medicare & Medicaid Services (CMS) announced the approval...

• What’s new with AHAP!

  AHAP will be launching a survey this week on tracers, which will help inform our July working...

Issue 24, June 14, 2011

• Website hosts combined efforts between Joint Commission, leading lab organizations

  Lab AdvantageTM has launched a new web site to help highlight the concerted efforts of The Joint...

• What’s new with AHAP!

  We are currently looking for ideas or potential speakers for our next working group call. Have a...

Issue 23, June 14, 2011

• AHAP Staff Challenge: Infection control

  True or false: Femoral veins are the preferred sites for the insertion of central venous catheters...

• From the AHAP Blog: CMS posts diagnostic imaging FAQs

  The Centers for Medicare and Medicaid Services (CMS) have released a set of ten Frequently Asked...

• What’s new with AHAP!

  AHAP is currently looking for topic suggestions for its upcoming benchmarking survey. If there are...

Issue 22, May 31, 2011

• AHAP Staff Challenge: Evidence of standards compliance

  True or false: When providing data for an MOS, four monthly data points are required.

• From the AHAP Blog: ANA praises Joint Commission standards for nurse-led medical homes

  The American Nurses Association (ANA) issued a press release applauding The Joint Commission for...

• What’s new with AHAP!

  AHAP is currently looking for topic suggestions for its upcoming benchmarking survey. If there are...

Issue 21, May 24, 2011

• AHAP Staff Challenge: Communication

  True or false: We need to define what are critical values, as well as the time frames for...

• From the AHAP Blog: New NPSG announced

  They Joint Commission has approved a new National Patient Safety Goal (NPSG) set to go into effect...

• What’s new with AHAP!

  AHAP is currently looking for topic suggestions for its upcoming benchmarking survey. If there are...

Issue 20, May 17, 2011

• AHAP Staff Challenge: Infection control

  True or false: Hands should be washed or decontaminated with hand gel after every contact with a...

• From the AHAP Blog: Joint Commission calls CMS revised telemedicine standards a "positive step"

  The Joint Commission has released an official statement reacting to revisions by the Centers for...

• What’s new with AHAP!

  The 2011 Salary Survey Report has been uploaded and is available for viewing on the AHAP website...

Issue 19, May 10, 2011

• AHAP Staff Challenge: Universal protocol

  The Joint Commission requires which of the following?

• From the AHAP Blog: CMS posts telemedicine final rule in Federal Register

  The Centers for Medicare and Medicaid Services (CMS) have released a much-anticipated final rule...

• What’s new with AHAP!

  The 2011 Salary Survey Report has been uploaded and is available for viewing on the AHAP website...

Issue 18, May 3, 2011

• AHAP Staff Challenge: Evidence of standards compliance

  True or false: "A" EPs without an MOS require at least four months of monitoring.

• From the AHAP Blog: Research shows simple post-surgical step reduces infections

  According to the latest edition of the Archive of Surgery, a basic bedside technique of gently...

• What’s new with AHAP!

  The recording of last week’s working group call on Environment of Care has been uploaded and...

Issue 17, April 26, 2011

• AHAP Staff Challenge: Infection control

  True or false: Hands should be cleaned after taking a patient's pulse, moving the patient up in...

• From the AHAP Blog: Joint Commission and FDA target alarm fatigue

  The Joint Commission recently told The Boston Globe that it would work with the Food and Drug...

• What’s new with AHAP!

  AHAP conference There’s only 10 days left until the fifth annual AHAP conference! Head over...

Issue 16, April 18, 2011

• AHAP Staff Challenge: Fire alarm testing

  True or false: It is a requirement that hospitals test their fire alarm audible and visual systems...

• HCPro offers Patient Safety Monitor demo

  HCPro will be hosting a complimentary live demo of Patient Safety Monitor on April 26! Patient...

• What’s new with AHAP!

  Hello, AHAP Members, We are proud to announce our second winner of our annual AHAP Conference...

Issue 15, April 12, 2011

• AHAP Staff Challenge: Restraint and seclusion

  True or false: It is permissable to use standing orders or PRN orders for the initiation of...

• From the AHAP Blog: Animated short reminds people to "Speak Up"

  The Joint Commission’s Speak Up ™ campaign has launched the second in a series of...

• What’s new with AHAP!

  Take our salary survey!

Issue 14, April 5, 2011

• What’s new with AHAP!

  Don’t miss out on the opportunity to network with other accreditation professionals from...

Issue 13, March 29, 2011

• AHAP Staff Challenge: Infection control

  True or false: When using an alcohol-based hand gel, the gel should be placed in the palm of the...

• From the AHAP Blog: AHAP conference announces 2011 agenda

  The formal agenda for this year’s Association for Healthcare Accreditation Professionals...

• What’s new with AHAP!

  Benchmarking Report Roundup

Issue 12, March 22, 2011

• AHAP Staff Challenge: Evidence of standards compliance

  True or false: When providing data for an MOS, four monthly data points are required.

• From the AHAP Blog: Joint Commission releases new BoosterPak

  The Joint Commission has posted the latest in a series of BoosterPaks ™ to assist hospitals...

• What’s new with AHAP!

  The AHAP team selected at random our first winner for our AHAP Conference giveaway. We received a...

Issue 11, March 15, 2011

• From the AHAP Blog: CDC report targets CLABSI

  The Centers for Disease Control and Prevention (CDC) have issued a media advisory stating that...

• What’s new with AHAP!

  AHAP Conference Contest

Issue 10, March 8, 2011

• AHAP Staff Challenge: Evidence of standards compliance

  True or false: "A" EPs without an MOS require at least four months of monitoring.

• From the AHAP Blog: Patient Safety Awareness Week

  Patient Safety Awareness Week is coming up and the National Patient Safety Foundation (NPSF) is...

• What’s new with AHAP!

  AHAP Conference Contest winner!

Issue 9, March 1, 2011

• AHAP Staff Challenge: Communication

  True or false: Hospitals must establish time frames for the reporting of critical results AND they...

• From the AHAP blog: Hospitals failing on communication compliance

  Two former language-expert hospital administrators in conjunction with Language Line Services have...

• What’s new with AHAP!

  We’ll be announcing the first of two winners in our AHAP Conference giveaway today, so keep...

Issue 8, February 22, 2011

• AHAP Staff Challenge: Restraint and seclusion

  True or false: CMS exempts hospitals that use The Joint Commission for deemed status from having...

• From the AHAP Blog: A "sweet" entry to the AHAP conference contest

  Member Anne Radtke, accreditation manager with the Ministry St. Michael’s Hospital/Ministry...

• What’s new with AHAP!

  Missed the last working group call?

Issue 7, February 15, 2011

• AHAP Staff Challenge: Universal protocol

  Members of the healthcare team should be ____________ involved in the timeout.

• From the AHAP Blog: Sentinel event statistics updated; Joint Commission improves format

  The Joint Commission has updated its sentinel event statistics webpage with the latest statistics...

• What’s new with AHAP!

  We are once again gearing up for our annual AHAP Conference, which will take place May 12-13 at...

Issue 6, February 8, 2011

• What’s new with AHAP!

  We are once again gearing up for our annual AHAP Conference, which will take place May 12-13 at...

Issue 5, February 1, 2011

• AHAP Staff Challenge: Infection control

  When hands are contaminated or visibly dirty, select which of the following statements is true:

• From the AHAP Blog: Joint Commission proposes performance expectations for ORYX measures

  The Joint Commission has opened for field review a proposed requirement intended to establish...

• What’s new with AHAP!

  We’re taking suggestions for the next working group call and looking for members interested...

Issue 4, January 25, 2011

• AHAP Staff Challenge: Record of Care

  The patient's medical record should contain information needed to:

• From the AHAP Blog: CMS proposes new rule: Perform well, be rewarded

  The Centers for Medicare & Medicaid Services (CMS) has announced a new rule for hospital...

• What’s new with AHAP!

  AHAP’s next working group call is TODAY, January 25th at 3 pm EST (2 pm Central, Noon...

Issue 3, January 18, 2011

• From the AHAP Blog: New standards changes towards CMS compliance

  As part of the organization’s ongoing process to comply with CMS Conditions of Participation...

• What’s new with AHAP!

  The new benchmarking report has been added to the AHAP website, and is now available for download.

Issue 2, January 11, 2011

• AHAP Staff Challenge: Suicide Risk Assessment

  True or false: Patient and family education is a critical component when discharging a patient who...

• From the AHAP Blog: NPSG field review still open for comment

  The Joint Commission continues to request comments on its proposed National Patient Safety Goals...

• What’s new with AHAP!

  AHAP’s next working group call will take place on January 25th at 3 pm EST (2 pm Central...

Issue 1, January 4, 2011

• AHAP Staff Challenge: Medication Safety

  True or false: Medication containers should be labeled when performing procedures outside of the...

• From the AHAP Blog: Center for transforming healthcare releases new video

  The Joint Commission’s Center for Transforming Healthcare has published a new online video...

• What’s new with AHAP!

  Keep an eye out for the downloadable version of the Survey Coordinator’s Handbook, 12th...