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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 52, December 30, 2014

• Wisconsin nurse investigated for patient infection death

  A former University of Wisconsin Hospital nurse accused of stealing morphine could also face a...

• Staff Challenge: National Patient Safety Goals

  Medications prepared and used in the OR and other procedural areas must be labeled. The label...

Issue 51, December 23, 2014

• CMS announces list of facilities penalized for HACs

  One in five hospitals are being penalized by the CMS for hospital-acquired conditions.

• Report: U.S. is unprepared for future outbreaks

  A new report found that much of the United States is not prepared for future infectious outbreaks.

• Staff Challenge: Provision of Care

  True or false: A postoperative patient who is receiving pain medication should be educated about...

• Webcast: Conduct OSHA mock inspections to ensure compliance, improve safety

  An upcoming HCPro webcast will help attendees ensure safety compliance in physician offices...

Issue 50, December 16, 2014

• Report: Hospital alarms are top healthcare tech hazard

  A new ECRI Institute report says hospital alarm errors top the list of healthcare technology...

• Report: Superbugs could become a worldwide crisis

  A new British government report warns that antimicrobial-resistant infections could lead to 10...

• Staff Challenge: National Patient Safety Goals

  Fill in the blanks: A hospital ________________ should be performed on a regular basis to determine...

Issue 49, December 9, 2014

• Ohio hospital successfully reduces false alarms

  A Cincinnati hospital formed a task force and substantially reduced the number of false alarms from...

• Dallas ER doc: Mistakes were made in Ebola case

  The emergency room physician who initially misdiagnosed the first Ebola patient on U.S. soil now...

• Staff Challenge: Provision of Care

  True or false: A postoperative patient who is receiving pain medication should be educated about...

Issue 48, December 2, 2014

• AHRQ: U.S. hospitals prevented 1.3 million adverse events since 2010

  U.S. hospitals are making headway in preventing adverse events, with the Agency for Healthcare...

• CDC: ER visits at an all-time high

  Emergency departments are busier than ever, with more than 136 million patient visits in 2011...

• Staff Challenge: National Patient Safety Goals

  True or false: When a patient has been seen in the outpatient clinic for a minor eye infection and...

Issue 47, November 25, 2014

• California hospitals reported 6,200 adverse events since 2010

  Hospitals in California reported more than 6,200 adverse events in the last four fiscal years.

• Joint Commission adds Life Safety Code® surveyor to ASC surveys

  The Joint Commission will add a Life Safety Code® surveyor to the survey team for ambulatory...

• Staff Challenge: National Patient Safety Goals

  What does the statement “Immediately Administered Medication” mean?

• Learn about preventing ED violence in upcoming webinar

  A December 10 webinar from HCPro discusses how to prevent ED violence and design an effective...

Issue 46, November 18, 2014

• 2015 National Patient Safety Goals released

  The full chapter of The Joint Commission’s 2015 National Patient Safety Goals has been...

• Joint Commission: 1,200 hospitals achieved Top Performer status

  The Joint Commission recognized more than 1,200 hospitals in its Top Performers on Key Quality...

• Staff Challenge: Provision of Care

  Fill in the blank: A patient’s learning needs and ability to learn should be assessed...

Issue 45, November 11, 2014

• Study: Handoff improvement program reduces medical errors

  Implementing a handoff improvement program has been found to reduce medical errors in nine...

• Team-based approach successful at reducing alarm fatigue

  A study found that using a team-based approach can help hospitals reduce alarm fatigue.

• Staff Challenge: National Patient Safety Goals

  When should staff and physicians be educated about healthcare-associated infections including...

Issue 44, November 4, 2014

• Leapfrog Group releases latest patient safety ratings

  The Leapfrog Group last week released the fall 2014 update to its Hospital Safety Scores, which...

• Joint Commission clarifies pain management standard

  The Joint Commission revised the language to its pain management standard to encourage healthcare...

• Staff Challenge: National Patient Safety Goals

  Patient/family education on the importance of medication management is a critical component of...

Issue 43, October 28, 2014

• CDC releases new Ebola guidelines for ED workers

  The Centers for Disease Control and Prevention this week released new guidelines for emergency...

• Studies: Collaboration with caregivers can help reduce readmissions

  Two new research studies released this month found that better collaboration with community-based...

• Staff Challenge: Provision of Care

  Fill in the blank: Each patient should have a written plan of care that has ______________ and...

• Nov. 17 webcast provides latest guidance on how hospitals can prepare for Ebola

  A new HCPro webcast will help hospitals prepare a response plan in the event they receive a patient...

Issue 42, October 21, 2014

• Joint Commission makes new patient safety chapter available for download

  The Joint Commission is allowing the public to download its new Patient Safety Systems chapter...

• CDC tightens up PPE guidance for Ebola patient care

  The Centers for Disease Control and Prevention has released updated guidance for healthcare workers...

• Staff Challenge: Medication Management

  Fill in the blank: Orders in which the dose is decreased by a particular amount with each dosing...

Issue 41, October 14, 2014

• CDC vows to change Ebola hospital procedures

  In the wake of a Dallas nurse testing positive for Ebola, the director of the CDC says new...

• Hospitals, unions face off over mandatory flu vaccinations

  Some hospital employees are challenging facility mandated flu vaccinations, highlighted by a...

Issue 40, October 7, 2014

• Study: C. diff infection rate levels off

  A new study found that the rate of C. difficile infections in hospitals nearly doubled from 2001 to...

• Medicare levies record number of 30-day readmission fines

  Hospitals are feeling the heat to reduce readmissions, with 2,610 receiving fines from Medicare for...

• Staff Challenge: Environment of Care and Life Safety

  At least ___% of your fire drills should be unannounced.

Issue 39, September 30, 2014

• Unintended retention of objects after surgery tops most-reported sentinel events

  The Joint Commission reviewed 394 sentinel events during the first half of 2014, according to...

• CMS offers categorical waiver allowing power strip use in hospitals

  The CMS is offering a categorical waiver that permits hospitals to use power strips in patient care...

• Staff Challenge: Provision of Care

  What are the time parameters for completing a history and physical?

Issue 38, September 23, 2014

• President signs executive order to fight antibiotic resistance

  President Barack Obama last week announced a national strategy to prevent the spread of...

• Report: Healthcare worker flu vaccination rate is still lacking

  Flu vaccinations for healthcare workers are lacking, according to a new report published in the...

• Staff Challenge: National Patient Safety Goals

  Hospitals are permitted to define what medication information is necessary to be obtained from the...

Issue 37, September 16, 2014

• Joint Commission to add new patient safety chapter to manual

  The Joint Commission is adding a new patient safety-focused chapter to its accreditation manual and...

• Study: Majority of U.S. hospitals overuse antibiotics

  A study conducted by the Centers for Disease Control and Prevention and Premier Safety Institute...

• Staff Challenge: Provision of Care

  Fill in the blank: When a patient is both in restraints AND secluded, the patient must be...

Issue 36, September 9, 2014

• Safety issues continue to dominate top-cited standards list

  Eight of The Joint Commission’s top 10 standards compliance issues for the first half of 2014...

• CMS to resume releasing hospital-acquired conditions data

  After it stopped public reporting data on hospital-acquired conditions, the CMS now plans to resume...

• Staff Challenge: Environment of Care and Life Safety

  Fire drills are required “one per shift, per quarter” in buildings designated as...

• Webcast examines financial benefits of quality and patient safety

  Upcoming HCPro webcast will describe how to build patient safety and quality programs that measure...

Issue 35, September 2, 2014

• Standards revisions align with CMS changes

  New Joint Commission revisions to hospital standards have been made to align with CMS effort to...

• Los Angeles hospital agrees to pay $700,000 in patient dumping case

  A Glendale, California hospital has agreed to pay $700,000 in civil penalties to settle a lawsuit...

• Staff Challenge: Environment of Care and Life Safety

  The e-SOC is comprised of two basic sections. Name them.

Issue 34, August 26, 2014

• New Sentinel Event Alert warns about tubing misconnections

  A new Sentinel Event Alert from The Joint Commission warns hospitals to take extra measures to...

• NC jury awards patient $1.5 million after sound-alike drug mix-up

  A Durham, North Carolina ophthalmologist and hospital were found negligent by a jury after a drug...

• Staff Challenge: Provision of Care

  Name key elements that should be the basis for the “written” plan of care.

• Give us your feedback and win $50 off any HCPro product!

  Take this HCPro customer survey and get a chance to win $50 off any product in the HCPro...

Issue 33, August 19, 2014

• CDC warns of antibiotic overuse

  The Centers for Disease Control and Prevention is urging hospitals to launch antibiotic stewardship...

• Study: Superbugs are increasing in southeastern U.S. hospitals

  A new study published in Infection Control and Hospital Epidemiology found that superbugs grew at...

• Staff Challenge: National Patient Safety Goals

  An important objective of medication reconciliation is to resolve discrepancies between home...

Issue 32, August 12, 2014

• 2015 IPPS Final Rule focuses on healthcare quality efforts

  The fiscal year 2015 IPPS final rule devotes a substantial amount of its updates to hospital...

• U.S. hospitals prepare for possible Ebola cases

  As the Ebola outbreak intensifies in Africa, U.S. hospitals are bracing for a potential influx of...

• Staff Challenge: Rights, Ethics, and Communication

  Name the two major federal laws that support the use of interpreters.

Issue 31, August 5, 2014

• Tennessee surgical quality collaborative touts successes

  A surgical quality collaborative in Tennessee allowed 10 hospitals to reduce surgical complications...

• Report: Hospitals still need to work on medication reconciliation

  A new study found that hospitals need to improve their medication reconciliation processes.

• Staff Challenge: Provision of Care

  When the hospital prepares food for its patients, it must prepare the food under certain...

Issue 30, July 29, 2014

• California fines hospitals for medical errors

  Eight California hospitals were fined a total of $775,000 by the state for preventable medical...

• Study: Fist bumps are more hygienic than handshakes

  A new study found that fist bumps are a safer alternative to handshakes, with nearly twice as many...

• Staff Challenge: National Patient Safety Goals

  Fill in the blank: Current medications include which of the following? a.   ...

Issue 29, July 22, 2014

• Experts to Senate panel: Patient safety remains a huge concern

  Fifteen years after a major Institute of Medicine report, hospitals have made no progress on...

• High-volume emergency departments have lower mortality rates

  A new study found that patients have a lower likelihood of in-hospital death if admitted through...

• Staff Challenge: Medication management

  Fill in the blank: Medication containers should be labeled whenever a medication is prepared but...

Issue 28, July 15, 2014

• Study: OR briefings can improve teamwork, surgical outcomes

  A new study found that preoperative briefings can lead to improved team communication and safety in...

• SC hospital's water investigated as source of bacterial outbreak

  Officials believe water may have been the source of bacteria that infected 15 patients and may have...

• Staff Challenge: Environment of Care and Life Safety

  For hospitals that use The Joint Commission for deemed status: To ensure the proper functioning of...

• Upcoming webcast provides mock tracer guidance

  An HCPro webcast on August 20 will walk attendees through the mock survey process to help improve...

Issue 27, July 8, 2014

• CMS renews deeming authority for Joint Commission

  The CMS has renewed deeming authority for The Joint Commission for hospital accreditation through...

• HHS awards $840 million in emergency preparedness grants

  The U.S. Department of Health and Human Services has awarded more than $840 million in funding to...

• Staff Challenge: Rights, Ethics, and Communication

  A patient has the right to access his or her clinical information, request a copy of his or her...

Issue 26, July 1, 2014

• Report: Problems with patient safety in military facilities

  A New York Times report found that patient safety is severely lacking in U.S. military hospitals...

• Study: Anesthesia providers have poor hand hygiene compliance rates

  A Dartmouth-Hitchcock Medical Center study found that anesthesia providers often fail to clean...

• Staff Challenge: Environment of Care and Life Safety

  When are hospitals required to implement interim Life Safety Code® measures?

Issue 25, June 24, 2014

• Joint Commission prepublication standards aligning with CMS go into effect next week

  Revised standards from The Joint Commission that align with CMS requirements go into effect on July...

• CMS punishing hospitals with worst rates of HAIs, patient injuries

  The federal government this fall will cut Medicare payments for hospitals that have the worst rates...

• Staff Challenge: Provision of Care

  Fill in the blank: It is essential that the handoff communication process include...

Issue 24, June 17, 2014

• Joint Commission issues Sentinel Event Alert on reuse of vials

  A new Sentinel Event Alert from The Joint Commission addresses the misuse of single-dose/single-use...

• Syracuse hospital passes follow-up inspection after allegations of patient abuse

  A Syracuse hospital passed an April inspection required after it was cited earlier in the year for...

• Clarification

  The American Society for Healthcare Engineering clarified that the CMS has not issued a new...

• Staff Challenge: Environment of Care and Life Safety

  Hospitals should have processes in place that continually monitor for specific types of events...

Issue 23, June 10, 2014

• CMS restricts use of power strips in patient care areas

  The CMS is barring the use of power strips in hospital patient care spaces including operating...

• Dallas hospital uses pharmacists in ED to reduce errors

  A Dallas hospital looks to reduce medication errors by having pharmacists work full-time in its...

• Staff Challenge: Rights, Ethics, and Communication

  Fill in the blank: Patients are to be informed about unanticipated outcomes of care by...

Issue 22, June 3, 2014

• Joint Commission: Complete overdue PFIs by July 1

  The Joint Commission now requires that accredited organizations complete or request extensions for...

• WHO: Looking towards a post-antibiotic era

  A new report from the World Health Organization found that antimicrobial resistance poses a serious...

• Staff Challenge: Provision of Care

  Identify three things that are monitored on a continual basis while a patient is receiving...

Issue 21, May 27, 2014

• Joint Commission postpones implementation of revised diagnostic imaging standards

  The implementation of new and revised diagnostic imaging standards from The Joint Commission has...

• Study: Seven of 10 bronchitis patients are prescribed antibiotics

  A new study found that physicians are overprescribing antibiotics, which researchers say are...

• Staff Challenge: Medication Management

  Who should be notified when a medication has been recalled for safety reasons by the FDA or by the...

Issue 20, May 20, 2014

• HHS: Quality initiatives prevent 15,000 deaths, save $4 billion

  Public-private partnerships led to decrease in patient harm during 2011 and 2012.

• Report: Sepsis connected to shocking number of patient deaths

  A new report found that sepsis is present in as many as one in every two hospitalized patients who...

• Staff Challenge: Provision of Care

  Fill in the blank: The Joint Commission standards that cover sedation and anesthesia apply to all...

Issue 19, May 13, 2014

• CMS rule change eliminates unnecessary requirements

  A new rule from the CMS eliminates regulations seen as excessively burdensome on healthcare...

• CMS launches improved QIO program

  The CMS last week announced changes to its quality improvement organization program that re...

• Staff Challenge: Environment of Care and Life Safety

  Dialysis equipment must be properly maintained. ____________ and _____________ testing must be...

Issue 18, May 6, 2014

• Joint Commission clarifies organ procurement requirements

  The Joint Commission has released a new clarification for organ procurement organizations as part...

• Survey: Most physicians say colleagues order unnecessary tests and procedures

  According to a new survey from the ABIM Foundation, three out of four physicians say their...

• Staff Challenge: National Patient Safety Goals

  What additional steps, besides the use of two patient identifiers, are required when preparing to...

Issue 17, April 29, 2014

• Joint Commission releases 2013 sentinel event stats

  Treatment delays and wrong patient/wrong site/wrong procedure errors were the most frequently...

• California senator calls on hospitals to address medical errors

  Sen. Barbara Boxer (D-Calif.) issued a report last week that found that medical errors cause...

• Staff Challenge: Environment of Care and Life Safety

  What does the Safe Medical Device Act of 1990 require of hospitals?

Issue 16, April 22, 2014

• Study examines patient deaths tied to hospital linens

  Five children died at a New Orleans hospital from a fungus infection believed to have been spread...

• California lawmakers mull workplace violence bill after attacks on nurses

  A California bill has been proposed that would require stricter workplace violence prevention...

• Staff Challenge: Medication Management

  A pharmacist must review all medication orders prior to the medication being dispensed except in...

Issue 15, April 15, 2014

• CMS proposes adoption of 2012 Life Safety Code®

  CMS yesterday announced a proposed rule to adopt an updated edition of the Life Safety Code®...

• AORN outlines ways to improve patient safety and outcomes

  Improvements must be made in handoffs, the use of PCA pumps, and postoperative orders to provide...

• Staff Challenge: Rights, Ethics, and Communication

  Fill in the blank: Hospitals must provide information in an understandable format to patients who...

Issue 14, April 8, 2014

• Syracuse surgeon accused of slapping anesthetized patients

  A surgeon at St. Joseph’s Hospital Health Center in Syracuse, N.Y., is accused of slapping...

• Rhode Island hospital found in violation of infection control policies

  The Rhode Island Department of Health has ordered Rhode Island Hospital to make corrections after...

• Staff Challenge: National Patient Safety Goals

  What are two indications for the use of anticoagulant therapy?

Issue 13, April 1, 2014

• Joint Commission releases top-cited standards of 2013

  Safety issues continue to top The Joint Commission’s annual list of top standards...

• CDC: Hospital-acquired infections are declining, but still dangerous

  A new study found that hospitals are making progress in reducing infection rates, but estimated...

• Staff Challenge: Infection Control

  Hospitals should focus their infection control and prevention activities on the areas that pose...

Issue 12, March 25, 2014

• Study: One in five facilities doesn't provide enough hand sanitizer

    A new study found that one in five U.S. health facilities doesn’t make alcohol-based...

• Webinar to focus on worker fatigue

  A Joint Commission official will discuss hospital worker fatigue and its impact on patient and...

• Staff Challenge: Provision of Care

  Fill in the blank: The scope and content of __________________, _____________, and...

Issue 11, March 18, 2014

• Joint Commission releases prepublication standards for EC chapter

  The Joint Commission has released revised requirements for the Environment of Care chapter.

• Study: Surgical checklists may not lead to better outcomes

  A Canadian study of surgical safety checklists found no significant difference in outcomes after...

• Staff Challenge: Rights, Ethics, and Communication

  What are the various questions you should ask when assessing a patient to determine which...

Issue 10, March 11, 2014

• CDC report encourages antibiotic stewardship to prevent HAIs

  A new CDC report provides guidance for hospitals on proper antibiotic prescribing practices.

• Study: New tool helps hospitals reduce readmissions

  A new tool from the American College of Surgeons can help hospitals predict high-risk cases and...

• Staff Challenge: National Patient Safety Goals

  Why is it inappropriate to use a room number as one of the two patient identifiers?

Issue 9, March 4, 2014

• CMS clarifies two-midnight rule, but hospitals still upset

  The CMS last week issued another clarification of its two midnight rule, but hospitals say the...

• Study: Stethoscopes may spread bacteria

  A new study found that physicians’ stethoscopes have the potential to spread germs from...

• Staff Challenge: Medication Management

  Why is the risk for transcription error higher when medication orders are given verbally over the...

Issue 8, February 25, 2014

• Texas hospital declines award after lawsuits filed over botched surgeries

  A Texas hospital announced it won’t accept the Malcolm Baldrige National Quality Award after...

• Stanford study finds checklist use reduces HAI rate

  A study found that using a computerized safety checklist that pulls information from electronic...

• Staff Challenge: Provision of Care

  True or False: The hospital has to provide its patients with a nutritious, appropriate diet. They...

Issue 7, February 18, 2014

• Joint Commission seeks comments on proposed perinatal care certification requirements

  The proposed requirements of a new Joint Commission perinatal care certification program are up for...

• Kentucky VA hospital reduces MRSA rate through screening

  By instituting a screening program for patients, the Louisville (Ky.) Veterans Affairs Medical...

• Kentucky VA hospital reduces MRSA rate through screening

  By instituting a screening program for patients, the Louisville (Ky.) Veterans Affairs Medical...

• Staff Challenge: Leadership

  For deemed status purposes, which medical services or departments require a physician leader?

Issue 6, February 11, 2014

• CMS delays two-midnight rule enforcement

  After opposition from hospitals and physicians, the CMS has delayed enforcement of its...

• Study: Hospitals need to improve ICU infection control practices

  A new study found that improving infection control protocols in intensive care units would have a...

• Staff Challenge: National Patient Safety Goals

  Name at least three different situations where the use of two patient identifiers is required.

Issue 5, February 4, 2014

• Joint Commission clarifies gas cylinder storage requirements

  The Joint Commission has added new clarifications to storage requirements for medical gas cylinders.

• Report explains clinical alarm NPSG

  The Joint Commission explains how it developed its new National Patient Safety Goal on clinical...

• Staff Challenge: Infection Control

    The hospital has a responsibility for communication information about the prevention and...

Issue 4, January 28, 2014

• ISMP launches new medication safety initiative

  The Institute for Safe Medication Practices has begun a campaign to increase awareness of...

• Eisenberg award winners announced

  The Joint Commission and the National Quality Forum have announced the 2013 recipients of the John...

• Staff Challenge: Rights, Ethics, and Communication

  Fill in the blank: Hospitals are required to provide language and _________________ services.

Issue 3, January 22, 2014

• CMS requests comments on emergency preparedness rule

  The CMS is seeking public comments on a new proposed rule on emergency preparedness.

• Joint Commission MM standards to apply to sample meds

  Starting on July 1, many Joint Commission Medication Management standards will apply to sample...

• Staff Challenge: Provision of Care

  True or False: Many patients who have a cardiopulmonary or respiratory event have signs and...

Issue 2, January 14, 2014

• Hospitals entice patients with iPads, quiet spaces

  Some hospitals are kicking off the new year with plans to improve the patient experience by...

• The trouble with EHRs

  Although electronic health records are known to reduce healthcare costs, concerns about accuracy...

• Staff Challenge: Medication Management

  What is the best-sized packaging for medications that are being used in patient care areas?

Issue 1, January 7, 2014

• Top healthcare buzzwords for 2014, part 1

  Big changes in healthcare mean big changes in the way providers and payers talk. Many terms being...

• Top quality issues for 2014, part I

  The pressure to reduce readmissions and preserve reimbursements will only increase in 2014...

• Staff Challenge: Emergency Management

  When an emergency requires the use of LIPs who are not current members of your medical staff, an...

Issue 51, January 2, 2014

• Seven signs providers are opening up about bad healthcare outcomes

  Hospitals and physicians are increasingly working together to be more forthcoming with patients...

• Seven signs providers are opening up about bad healthcare outcomes

  Hospitals and physicians are increasingly working together to be more forthcoming with patients...

• Three favorite nursing trends in 2013

  Some nursing leadership trends emerged quietly this year, but are nonetheless provocative for how...