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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 28, 2015

• Safe rooms for suicidal patients

  An environment where suicide risk reduction strategies have been implemented can delay spontaneous...

• Report: Olympus knew about duodenoscope infection risks for three years

  A new Los Angeles Times report alleges that device maker Olympus Corp. knew about the risk of...

• Hospital cooperation drops patient harm in half

  The Florida Hospital Association (FHA) recently reported on the success of the largest hospital...

• Doctors, patients, and email

  How much of an impact does email have on patient health? According to a new Kaiser Permanente...

Issue 51, December 21, 2015

• Culture of Safety and Just Culture

  The ability of a hospital or health system to deliver quality clinical, financial, and operational...

• Opioid over-prescription not limited to a few physicians

  Prescription opioid sales have increased 300% since 1999 according to the Centers for Disease...

• Mortality rankings improve when DNR patients are factored out

  A study published in The Journal of the American Medical Association found that do-not-resuscitate...

• Physicians more burned out than ever

  A study published in the Mayo Clinic Proceedings shows a rise in burnout rates and dissatisfaction...

Issue 50, December 14, 2015

• Impact of Leadership on Today's Healthcare Environment

  With a nationally and federally driven emphasis on transparency, public reporting of key...

• New superbug shares its antibiotic resistance with other bacteria

  More cases of a dangerous strain of Carbapenem-resistant Enterobacteriaceae (CRE) have been...

• The steps that ERs aren't taking to reduce crowding

  A study published in Health Affairs found that emergency rooms (ER) haven’t been taking steps...

• Nearly 800 hospitals penalized by Medicare for not meeting safety standards

  Medicare is lowering all its payments to 758 hospitals by 1% over the course of the federal fiscal...

Issue 49, December 8, 2015

• What do checklists bring to healthcare?

  A checklist is a staple in any high-reliability industry. Checklists support human memory and serve...

• CDI increases mortality in patients five-fold

  A study published in The Journal of the American Medical Association found heightened morbidity and...

• Hospital acquired conditions rates level off; areas still in need of improvement

  The Department of Health & Human Services released a study showing that the rate Hospital...

• ICUs not as clean as they appear

  A recent study published in The American Journal of Infection Control found that while most areas...

Issue 48, December 1, 2015

• Developing situational awareness

  In healthcare, situational awareness (SA) is defined as the perception of the elements within a...

• FDA warns intravascular device coatings can peel during surgery

  FDA recently issued a safety communication on intravascular medical devices (IMD), stating that...

• Makers of duodenoscope and reprocessor face wrongful death lawsuit

  A wrongful death lawsuit was filed last month against the makers of a duodenoscope and reprocessor...

Issue 47, November 24, 2015

• Keeping an eye on Congress in 2016

  As CMS works to get its legislative agenda back on track, there are several key issues that The...

• Joint Commission puts Acute Stroke Ready Hospital performance measures up for public comment

  The Joint Commission seeks comments on its proposed of Acute Stroke Ready Hospital (ASRH...

• Study: Acute Care for the Elderly units benefit seniors

  A new study published in the Journal of the American Geriatrics Society found that Acute Care of...

• Joint Commission puts antimicrobial stewardship standard up for field review

  The Joint Commission seeks comments from healthcare facilities about a proposed standard that would...

Issue 46, November 16, 2015

• Safety alert: Bacterial infections associated with heater-cooler devices

  Last month, the FDA and Centers for Disease Control and Prevention released a safety communication...

• Joint Commission: Procedure errors, retention of foreign body, suicide top sentinel event list

  Through the third quarter of 2015, the top sentinel events reported to The Joint Commission were...

• Study: Hospitalization and discharge procedures send patients back to hospital

  Even when patients are being cared for, the stress of being in hospitalized can put their health in...

• Joint Commission opens up stroke-ready certification to off-site hospital-owned EDs

  As of October 1, hospital-owned off-site emergency departments (ED) are eligible for The Joint...

Issue 45, November 10, 2015

• Setting up a tracer training program

  Here we will focus specifically on tracer training and implementation: the "who,"...

• CMS revises guidance for pharmaceutical services and compounding medications

  The CMS last week released revised hospital guidance for pharmaceutical services and expanded...

• We need your feedback

  What are your biggest job challenges and priorities? Give us your feedback as we prepare...

Issue 44, November 3, 2015

• The first 100 days: Making the transition into the world of accreditation

  In this guest column, Heather Forbes, clinical education program coordinator for Maine Medical...

• CMS proposal would give patients a say in discharge process

  A proposed rule from CMS would provide greater weight to patient preference during the hospital...

• Leapfrog finds slow improvements in patient safety

  The latest release of the Leapfrog Group’s Hospital Safety Scores finds slow patient safety...

• December webcast to highlight survey hot spots for 2016

  What are the CMS and Joint Commission hot spots for 2016? Join Bud Pate, REHS, and Lisa Eddy, RN...

Issue 43, October 27, 2015

• FDA issues safety alert on bronchoscopes

  The FDA issued a safety alert in September about infections associated with reprocessed flexible...

• Study: Medication errors occur in half of surgeries

  A new study found that medication errors occurred during nearly half of the surgeries examined.

• CMS to reward 1,800 hospitals through VBP program in 2016

  The federal government’s value-based purchasing program will award bonuses to 1,800 hospitals...

Issue 42, October 20, 2015

• How many policies should the medical staff approve?

  With an increasing number of regulations, National Patient Safety Goals, Sentinel Event Alerts, and...

• AAAHC acquires HFAP to offer hospital accreditation program

  The Accreditation Association for Ambulatory Health Care last week announced it has acquired the...

• Experts: U.S. still at risk for infectious disease outbreak

  Experts say heightened vigilance and additional funding will be keys to preparing for the next...

Issue 41, October 13, 2015

• Use gratitude to strengthen your organization

  Gratitude is one of the most powerful forces that move an organization forward. It requires little...

• Study: Infections lead to increased fall risk

  New research shows that infections can be an underlying cause of patient falls.

• Hospital workers still at risk of infection despite gloves and gowns

  A new study found that even with protection from gowns and gloves, hospital workers have a nearly...

• Webcast focuses on hazardous waste disposal in healthcare

  Complicated rules surround hazardous waste disposal and healthcare facilities want to reduce volume...

Issue 40, October 6, 2015

• How burnout can affect your healthcare organization

  Burnout drains organizations of their mission and leads to costly and sometimes lethal...

• Joint Commission approves 2016 accreditation decision rules

  The Joint Commission recently approved the 2016 accreditation and certification decision rules for...

• GAO: Quality hasn't improved in three years under VBP program

  A new Government Accountability Office report examining the first three years of Hospital...

Issue 39, September 29, 2015

• Putting together an alarm management plan

  The topic of alarm hazards has crowned ECRI's top 10 list of health technology hazards for the last...

• New Sentinel Event Alert focuses on patient falls prevention

  A new Sentinel Event Alert (SEA) issued by The Joint Commission this week urges healthcare...

• Boston hospital to pay $2.3 million settlement over stolen drugs

  Massachusetts General Hospital agreed to pay $2.3 million as part of a settlement over allegations...

Issue 38, September 22, 2015

• Infection control is an area of increased concern in 2015

  When The Joint Commission released its list of the five most-cited standards for the first half of...

• FDA releases guidelines for reprocessing bronchoscopes

  In the wake of recent outbreaks related to contaminated devices, the Food and Drug Administration...

• Canadian researchers create list of 15 never events

  A new report from Health Quality Ontario and the Canadian Patient Safety Institute details 15...

Issue 37, September 15, 2015

• Core elements of hospital antibiotic stewardship programs

  This guest column from Elizabeth DiGiacomo-Geffers, RN, MPH, CSHA, discusses how to put together an...

• Joint Commission: Surgical errors top latest list of sentinel events

  Wrong-patient, wrong-site, or wrong-procedure errors top the list of sentinel event statistics...

• Guide provides color-coded charts to aid proper IV catheter use

  A guide developed by Michigan researchers provides color-coded charts to help healthcare...

Issue 36, September 8, 2015

• Use gratitude to strengthen your organization

  This guest column from Patrick Pianezza, MHA, discusses the importance of gratitude in improving...

• Joint Commission seeks input on proposed revisions to NPSG on catheter-associated infections

  The Joint Commission is looking for input on revisions to its National Patient Safety Goal on the...

• Joint Commission makes changes to ORYX performance measures

  The Joint Commission has released the latest changes to its ORYX performance measure reporting...

• Reduce clinical alarm fatigue with new HCPro webcast

  An October 14 webcast will help you reduce alarm fatigue in your facility and meet the National...

Issue 35, September 1, 2015

• A day in the life of an accreditation professional

  This month, we are focusing on Paula Brinn, BSN, MBA, CCRN-K, regulatory compliance manager at...

• Joint Commission releases top five most-cited standards for first half of 2015

  Safety, infection control, and medical records top The Joint Commission’s list of most-cited...

• Seattle hospital notifies 12,000 families about improperly sterilized equipment

  Seattle Children’s Hospital is alerting 12,000 families after it found that some surgical...

Issue 34, August 25, 2015

• California announces second phase of licensing and accreditation pilot

  The California Department of Public Health rolled out Phase II of its General Acute Care Hospital...

• University of Michigan hospital uses sound panels to reduce noise

  In an effort to cut down on the high noise level in hospitals, one Michigan facility has tested the...

• Joint Commission to shelve Top Performer program next year

  The Joint Commission is putting its Top Performer on Key Quality Measures program on hiatus in 2016...

• HCPro webcast will help you prevent and respond to active shooter incidents

  Join HCPro for a September 23 webcast that will help your prevent and respond to active shooter...

Issue 33, August 18, 2015

• FDA cites endoscope manufacturers for role in superbug outbreak

  The Food and Drug Administration issued warning letters to three makers of duodenoscopes linked to...

• Joint Commission offers online tool to help hospitals reduce falls

  A new tool released by The Joint Commission is designed to help hospitals prevent inpatient...

• Recruiting and training chapter leaders

  As The Joint Commission shifted to a more integrated survey, many hospitals moved away from the...

Issue 32, August 11, 2015

• Joint Commission updates standards for nursing care centers

  The Joint Commission updated five requirements for accredited nursing care centers.

• FCC allows unlicensed devices to share same band as hospitals

  The Federal Communications Commission (FCC) recently issued a new rule allowing unlicensed devices...

• Join our accreditation and quality book review group

  HCPro is seeking enthusiastic accreditation professionals to join an ad-hoc group interested in...

• Active Shooters in Healthcare Facilities: Your Prevention and Response Plan

  Active shooters and armed violence represent a rapidly growing issue in America’s hospitals...

Issue 31, August 4, 2015

• Joint Commission clarifies LS, EC survey process

  The Joint Commission has clarified its expectations for the Life Safety and Environment of Care...

• Study: Blood clots shouldn't be considered never events

  A new study finds that treating blood clots as a never event under pay-for-performance guidelines...

• Top 10 most-cited Joint Commission standards

  For the last several years, The Joint Commission's semiannual list of the most-cited standards has...

Issue 30, July 28, 2015

• New stroke certification launched by Joint Commission, AHA/ASA

  The Joint Commission and the American Heart Association/American Stroke Association plan to launch...

• Study: Antibiotic-resistant superbugs are stronger than expected

  Antibiotic-resistant superbugs are more resilient than originally believed, according to a new...

• Recruiting and training chapter leaders

  As The Joint Commission shifted to a more integrated survey, many hospitals moved away from the...

Issue 29, July 21, 2015

• Study: Majority of healthcare workers fail to follow PPE removal rules

  A new study finds that 85% of healthcare workers don’t comply with Centers for Disease...

• Joint Commission, ASHE unveil environmental safety portal

  The Joint Commission and the American Society for Healthcare Engineering last week rolled out a new...

• Blog excerpt: The nuts and bolts of antibiotic stewardship programs

  Last month, the White House convened a special forum on antibiotic stewardship in which more than...

Issue 28, July 14, 2015

• CMS proposes paying providers to discuss end-of-life choices with patients

  A new CMS proposal hopes to reduce end-of-life medical costs by paying healthcare providers to...

• Study: Treating sepsis costs more than heart attacks and heart failure combined

  A new study found that not only does sepsis lead to the same amount of readmissions as heart...

Issue 27, July 7, 2015

• Survey: Mistrust of healthcare may lead patients to sue after medical error

  A survey of patients affected by medical errors found that a lack of trust in the healthcare system...

• ED nurses encouraged to report violence

  A recent daylong forum on workplace violence encouraged emergency department nurses to report acts...

• Blog excerpt: AHRQ teeters on brink of extinction

  The Agency for Healthcare Research and Quality is in trouble, having recently been written out of...

Issue 26, June 30, 2015

• CDC updates MERS prevention guidelines

  The Centers for Disease Control and Prevention has updated its guidelines for the prevention and...

• Report: Hospital food mistakes pose danger to patients

  A Pennsylvania Patient Safety Authority report found that mistakes involving patients with special...

• Blog excerpt: Updated perinatal care performance measures

  The Joint Commission extended the mandatory reporting of the Perinatal Care performance measure set...

Issue 25, June 23, 2015

• AHA voices concern over proposed CMS quality reporting requirements

  CMS has proposed new quality metrics, but healthcare providers are raising doubts about the...

• NPSF releases root cause analysis guidelines

  The National Patient Safety Foundation has released new guidelines designed to help hospitals use...

Issue 24, June 16, 2015

• Joint Commission releases prepublication standards for laboratories

  The Joint Commission has released revised laboratory standards that align with CMS...

• Leapfrog Group: Almost a quarter of hospitals fail to meet hand hygiene guidelines

  A new Leapfrog Group report found that 23% of hospitals fail to meet all 10 hand hygiene best...

• Blog excerpt: National Time Out Day

  National Time Out Day encouraged the use of surgical timeouts before procedures.

Issue 23, June 9, 2015

• Joint Commission details how to comply with fire safety requirements

  The Joint Commission offered some tips on how to maintain fire extinguishing equipment, an area...

• Report says patient satisfaction surveys are flawed

  A new Hastings Center report is critical of the patient satisfaction surveys used by CMS to assess...

• July webcast focuses on proper GI scope disinfection

  An upcoming HCPro webcast will help attendees learn everything they need to know to ensure proper...

• Blog excerpt: Joint Commission joins White House to reduce antibiotic overuse

  More than 150 healthcare organizations, food companies, and animal health organizations met at the...

Issue 22, June 2, 2015

• Joint Commission clarifies accreditation decision process

  The Joint Commission has revised its accreditation decision process for hospitals undergoing...

• Study: Readmissions to ED are on the rise and costly

  A new study found that return visits to the emergency department (ED) have doubled and are more...

• Blog excerpt: Briefings on The Joint Commission feedback survey

  Help us get your thoughts on Briefings on The Joint Commission.

Issue 21, May 26, 2015

• California hospitals fined by state for causing patient death or injury

  The California Department of Public Health last week fined 12 hospitals after investigations found...

• Joint Commission revises hospice requirements to align with CMS

  As of July 1, 2015, several revised Joint Commission hospice requirements will go into effect to...

• Blog excerpt: Live accreditation training with Jean Clark

  Next week, HCPro presents a live accreditation boot camp in Boston taught by Jean Clark, RHIA, CSHA.

Issue 20, May 19, 2015

• Joint Commission seeks comments on proposed diagnostic imaging standards changes

  The Joint Commission seeks input on proposed changes to its diagnostic imaging requirements for...

• Study: Antibiotic overuse results from diagnostic errors

  A new study finds that unnecessary prescribing of antibiotics is often due to disagnostic...

• Blog excerpt: Physicians urged to take more active leadership role to improve quality and patient safety

  A Journal of the American Medical Association article calls on physicians to work together and take...

Issue 19, May 12, 2015

• CMS to expand hospital infection reporting

  The CMS announced plans to expand reporting of healthcare-associated infections to provide a...

• Joint Commission updates accreditation status policies

  The Joint Commission recently updated its policies regarding accreditation status following...

• Blog excerpt: CMS announces Physician Quality Reporting Programs Strategic Vision

  When CMS shared the findings of the 2015 Physician Quality Reporting System, it also published a...

Issue 18, May 5, 2015

• Joint Commission updates FAQs

  The Joint Commission recently updated a slew of online FAQs to its hospital standards.

• Study: Hospitals aren't taking right steps to prevent C. diff

  A new study found that almost half of U.S. hospitals are failing to take the required steps to...

• Blog excerpt: CMS updates eCQMs for 2016 reporting

  CMS last week posted the annual update for the 2014 electronic clinic quality measures for eligible...

Issue 17, April 28, 2015

• Joint Commission clarifies imaging equipment evaluations

  The Joint Commission clarified that accredited organizations providing diagnostic imaging services...

• CMS: Physicians choose penalties over participation in quality reporting, e-prescribing programs

  The CMS says more than 400,000 providers accepted pay cuts instead of participate in the federal...

• Blog excerpt: OSHA updates healthcare workplace violence prevention guidelines

  OSHA’s new workplace violence guidelines for healthcare call for increased facility security...

Issue 16, April 21, 2015

• Joint Commission releases sentinel event statistics

  The Joint Commission’s latest roundup of sentinel event statistics found that unintended...

• CMS unveils hospital rating system

  The CMS has introduced a star rating system on its Hospital Compare website that is based on...

• Blog excerpt: 2015 Accreditation Professional salary survey

  Accreditation specialists are invited to take our 2015 salary survey.

Issue 15, April 14, 2015

• Joint Commission proposes hip and knee replacement advanced certification program

  The Joint Commission plans to launch a new optional advanced certification program for...

• Study: Nurse-physician collaboration can help reduce HAIs

  A new study found that nurse-physician collaboration helps reduce healthcare-associated infections.

Issue 14, April 7, 2015

• OSHA revamps healthcare violence prevention guidelines

  The Occupational Safety and Health Administration updated guidance for protection of healthcare...

• ECRI: Alarm hazards, data integrity, violence top patient safety concerns list

  ECRI Institute’s annual list of top patient safety concerns is topped by alarm hazards...

Issue 13, March 31, 2015

• EC, LS dominate 2014 list of most-cited Joint Commission standards

  The Joint Commission’s list of top compliance issues in 2014 features some familiar...

• New Sentinel Event Alert focuses on safe use of health IT

  A new Sentinel Event Alert issued by The Joint Commission today highlights the need for healthcare...

• May webcast examines surgical environment compliance challenges

  Learn about the complex accreditation challenges presented by management of conditions in the...

Issue 12, March 24, 2015

• Joint Commission looks for public comment on patient blood management performance measures

  The Joint Commission seeks public comment on a set of draft patient blood management performance...

• Study looks at how staph infections spread in hospitals

  A study published last week found that close interactions between patients and healthcare workers...

Issue 11, March 17, 2015

• FDA recommends tighter controls on reusable medical devices

  The Food and Drug Administration last week released new recommendations to prevent infections from...

• Leapfrog Group analyzes high-risk surgery survival rates

  A new report from the Leapfrog Group finds that survival rates for patients who undergo high-risk...

Issue 10, March 10, 2015

• Joint Commission revises post-survey processes

  The Joint Commission has revised its post-survey processes for rendering decisions of Accreditation...

• Patient safety advocates: Hospitals withhold info about superbugs

  Patient safety advocates say hospitals and public health authorities keep important information...

Issue 9, March 3, 2015

• Report: Minnesota hospitals made more errors but had fewer deaths in 2014

  A new report about Minnesota’s adverse event reporting system found that the state’s...

• Joint Commission releases prepublication standards for perinatal care certification

  The Joint Commission this week released prepublication standards for a new certification program...

Issue 8, February 24, 2015

• CRE outbreaks lead to FDA warning on duodenoscopes

  The Food and Drug Administration last week issued a warning about duodenoscopes, which are linked...

• Study: Participation in quality initiative doesn't guarantee safety improvement

  A new study found that hospitals participating in a national quality improvement effort were no...

Issue 7, February 17, 2015

• Hand hygiene efforts may lead to increased infection risk

  A U.K. study found that increased emphasis on hand hygiene in hospitals may be increasing...

• CMS plans to relaunch Partnership for Patients program

  CMS is preparing to launch a revamped version of its Partnership for Patients initiative, which...

Issue 6, February 10, 2015

• Study: Infections are most likely cause of readmission after surgery

  A new study finds that infections are the leading cause of post-surgical readmissions.

Issue 5, February 3, 2015

• Joint Commission releases prepub standards for Acute Stroke-Ready program

  The Joint Commission has released prepublication standards for a new Acute Stroke-Ready Hospital...

• Report: Adverse events contribute to physician burnout

  A new study finds that the after-effects of adverse events can contribute to physician burnout.

Issue 4, January 27, 2015

• Contaminated scopes led to superbug outbreak at Seattle hospital

  At least 32 patients fell ill and 11 died after contracting a superbug infection at Virginia Mason...

• Pharmacist-led discharge program helps reduce readmissions by 46%

  A partnership between an Indiana hospital and the Walgreens pharmacy chain eventually led to a...

Issue 3, January 20, 2015

• Police: Teenager posed as doctor in Florida hospital for a month

  Police say a 17-year-old boy impersonated a doctor for a month at a Florida hospital before staff...

• CDC says flu shot was only 12% effective for adults

  The Centers for Disease Control and Prevention estimates that this season’s flu vaccine was...

Issue 2, January 15, 2015

• New and revised diagnostic standards go into effect July 1

  The Joint Commission’s new and revised diagnostic imaging standards will go into effect on...

• Study: Surgical checklists had no effect on reducing adverse events

  A new study found that implementing a checklist-based quality improvement program did not improve...

• Upcoming webcast examines new Joint Commission Patient Safety chapter

  An upcoming HCPro webcast will give attendees an in-depth look at The Joint Commission’s new...

Issue 1, January 6, 2015

• CDC: Flu is widespread in 43 states

  Flu season is hitting the U.S. hard, with widespread outbreaks in 43 states and 21 total flu deaths...

• Joint Commission approves performance measures for advanced certification in heart failure

  The Joint Commission now requires organizations to collect data for six mandatory inpatient...

• Staff Challenge: National Patient Safety Goals

  Surgeries that do not involve the insertion of an implantable device should be monitored for...

Issue 9, February 10, 2015

• Statement clarifies Joint Commission's sentinel event policy

  A joint statement released recently clarifies the definition of severe maternal morbidity in The...