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 10, October 27, 2002

• Revised standard calls for increased drug formulary discretion

  Although it's nothing new for hospitals to create and maintain a drug formulary, drug shortages...

• Keep staff informed on how to handle safety issues with a pocket guide

  Since a safety director or immediate supervisor may not always be around to direct employees during...

• The Safety goals can shape your quality program

  The JCAHO's patient safety goals give hospitals specific instructions on how to identify patients...

• JCAHO: 2003 will be a quiet year but expect big changes for 2004

  The JCAHO didn't pull any punches regarding any new standards or key process changes for 2003.

• Survey monitor: An Alabama hospital faces medication storage and security scruti

  More so than in years past, surveyors in June zeroed in on how staff at Jacksonville (AL) Hospital...

• Use your colleagues' surveyor questions to prepare for your JCAHO survey!2

  Knowing the questions that surveyors ask other organizations gives you a good idea of what to...

Issue 9, September 4, 2002

• The new draft standard calls for ongoing monitoring of how you handle medication

  Proposed standard TX.3.3 tells organizations to constantly look at medication practices using...

• JCAHO survey changes for 2003

  The JCAHO’s latest message speaks of simplifying the survey process, surveyors having more...

• A simpler survey process for complex organizations

  The JCAHO hopes to streamline the survey process for hospitals that offer a mix of services, such...

• The proposed 18-month survey cycle revisited

  You may have heard about the 18-month survey cycle during the JCAHO’s annual Executive...

• Using software to continually look at your weak spots

  Effective January 2004, a new survey process will entail the use of software that tallies...

• The JCAHO's patient safety goals offer more realistic suggestions

  Your colleagues sighed with relief when they learned that they have already adopted most or...

• Survey monitor: JCAHO surveyors probe compliance with patient safety standards a

  Not just a popular health care buzz word, patient safety was also a focus during a recent survey...

• Quick tip: Seek these attributes in a record completion clerk

  A successful record completion clerk is an outgoing, energetic person who is not shy or...

• Use your colleagues' surveyor questions to prepare for your JCAHO survey!

  Knowing the questions that surveyors ask other organizations gives you a good idea of what to...

Issue 8, August 28, 2002

• JCAHO reviews new emergency credentialing standard

  Does your hospital have a policy for granting privileges to physicians who aren't members of your...

• Portable safety kits keep staff prepared for disasters

  People order food “to go” for its speed and convenience. Why not do the same with...

• Standard of the month: Play limbo with medical record delinquency rates

  How low can you go with IM.7.6?What’s your medical record delinquency rate? Hovering around...

• Sample temporary privileges recommendation form

  Editor’s note: In the June issue, BOJ clarified that the JCAHO allows the use of temporary...

• AHA releases more details on patient safety goals

  There is some more news and details on the JCAHO’s proposed six patient safety goals, which...

• Know how HIPAA affects members of clergy

  The privacy rule provides some exceptions for religious leadersMost hospitals would not...

• Quick tip: Speak up during your survey

  Don’t be afraid to ask your surveyor questions about key survey issues and why he or she...

Issue 7, July 28, 2002

• Have critical medication information at your fingertips

  The JCAHO has historically required hospitals to obtain important patient information when...

• Regularly navigate the JCAHO's Web to avoid stormy seas

  You log onto “BOJ Talk” and see a posting about the JCAHO’s re cent standard...

• Standard of the month: Clarifying who can help with restraint orders according t

  Hospitals have some flexibility with who can write restraint or seclusion orders. The burden no...

• The JCAHO to approve patient safety goals

  Although the high-risk areas within Sentinel Event Alerts carry a new name, your analysis of them...

• Survey monitor: At a Minnesota hospital, the credentialing files tell the story

  Get ready to explain how you evaluate practitioners’ clinical competencies and how you...

• Quick tip: How to rate your fire drill performance to perfect employee skills

  You know how important it is to hold fire drills—not only to avoid getting zapped on...

Issue 6, June 3, 2002

• Standard of the month: Clarifying temporary privileges confusion

  The JCAHO also must have heard the confusion, because on March 15, 2002, it issued its...

• BOJ's annual salary survey: Hard work makes common cents

  Who are your hospital friends?The average respondent profile reads as follows: 90% of the 440...

• Survey monitor: A solid restraint program freed this Virginia hospital from Type

  A sound restraint and seclusion policy, active performance improvement (PI) initiatives on...

• Trends & Tips

  Budget constraints mean fewer validation surveys; JCAHO staffing standards will increase costs...

• Hospitals must replace faulty sprinklers, Feds say

  If your hospital receives Medicare funding, you will need to identify and replace a series of...

• Quick tip: Be prudent with patient information that you post on white boards

  Several of your colleagues say the JCAHO issued supplemental recommendations for hanging white...

Issue 5, May 1, 2002

• Documentation made easier: How one hospital streamlined all of its assessments o

  What really helped Shawnee Mission (KS) Medical Center survive a tough chart review during its...

• The hazard vulnerability analysis can help you select an FMEA topic

  Struggling to come up with a Failure Modes and Effects Analysis (FMEA) topic? If so, why not turn...

• Standard of the month: Watch your back on informed consent to comply with RI.1.2

  Your doctors certainly inform patients of the risks and alternatives of all invasive procedures...

• Quick tip: Know who should perform your FMEA

  Most of you know about the Failure Modes and Effects Analysis (FMEA). Many of you have started or...

Issue 4, April 28, 2002

• Use performance improvement to comply with the JCAHO's new staffing effectivenes

  Is it realistic to say that by July 1 you’ll fully comply with the new staffing...

• JCAHO's random unannounced survey topics for 2002 published

  Get ready for a pop quiz on your environment of care (EC) planning process and...

• Survey monitor: Surveyors zero in on patient safety, staffing, and emergency man

  Hill County Memorial Hospital in Fredericksburg, TX, is a general acute care hospital with 77...

• Standard of the month: EC.1.4 calls for an organized emergency management plan

  If you use the incident command system as part of your emergency management plans, the...

• Trends & Tips

  ‘Patient safety goals’ a new approach to Alert compliance

• Quick tip: Analyzing the pressure sore indicator boils down to comparing outbrea

  During pilot testing of the new staffing standards this fall, many hospitals chose pressure sores...

• Continuing Education Quiz

  A service of Briefings on JCAHODirections:• Complete this continuing education (CE) quiz by...

Issue 3, March 1, 2002

• Revised medication use standards call for systems approach to compliance

  The JCAHO’s draft revisions to the medication use standards will force hospitals to generate...

• Standard of the month: Ensure timely reappointments and avoid Type I's

  Credentialing standard MS.5.11, which requires hospitals to appoint and reappoint physicians...

• The JCAHO ponders extending the reappointment cycle to three years

  Although the JCAHO may extend the reappointment cycle to three years, state regulations for...

• NY hospital reduces asthma-related absenteeism in schools and wins Codman Award

  Prior to 1998, the roughly 3,000 students in the Yonkers, NY, schools who suffered from asthma...

• Trends & tips

  The JCAHO’s quarterly hospital chief executive officer (CEO) telephone opinion polls are...

Issue 2, February 1, 2002

• Annual surveyor conference stresses emergency management, patient safety, staffi

  Carefully read the JCAHO’s Perspectives’ special report on emergency...

• Patient safety focus in EC revisions calls for greater communication

  Consider two notable changes to the environment of care (EC) standards that took effect on January...

• Standard of the month: Here's how to turn around perennially troublesome HR.5

  If your New Year’s resolution is to conquer assessing competency standard...

• Case study: Boston hospital restructures emergency department to create a safe h

  When officials at Massachusetts General Hospital (MGH) compared their emergency room (ER...

• Quick tip: Be prepared for disasters with an emergency credentialing policy

  September 11 taught us that disasters can strike at any time. In the wake of the World Trade...

• Trends & Tips

  EC.1.4 revision clarifies emergency rolesAlthough revised emergency management plan standard...

Issue 12, December 21, 2002 - VIEW THE FULL ISSUE

• A New York pharmacy director describes efforts to improve drug safety

  Northeast Health Systems’ Albany Memorial Hospital and Samaritan Hospital in upstate New...

• NY hospital reduces asthma-related absenteeism in schools and wins JCAHO award

  NY hospital reduces asthma-related absenteeism in schools and wins JCAHO award

• Clarification

  Dear readers,We admit when an article is misleading or inaccurate. But we also feel that...

• It’s up to you to self-report problems between surveys

  How to prepare for the new self-assessment The JCAHO is asking you to dig down and challenge...

• LD.1.6: Consistently screen, test, and treat patients

  Limit the amount of variation in how you treat patients to not only avoid a bad survey score, but...

• New patient tracking survey style entails knowing your patients and how to disc

  The patients that surveyors will likely choose as the subjects in their survey in 2004 will have...

• Quick tip: Consider alcohol-based hand sanitizers

  While it’s not time to cast away antiseptic soap and water, be sure to offer...

Issue 11, November 21, 2002 - VIEW THE FULL ISSUE

• Survey monitor

  On February 13, bright and early, a JCAHO nurse surveyor arrived at the doorstep of St...

• Best practice: Rating physician charts focuses the peer review process

  Physicians at St. John’s Hospital turned defensive when accused of wrongdoing during...

• Clarification:

  The JCAHO is not planning an 18-month survey cycle as written on p. 6 of the September BOJ...

• Handle drug recalls with an organized plan

    Identify and retrieve recalled medications to ensure that you don’t give patients a...

• Quick tip: Simplify the document review

  Since surveyors only have about two hours to as certain how your hospital operates during the...

• The patient safety goals, part II

  The JCAHO has specific recommendations on how to prevent wrong-site surgery, use infusion pumps...

Issue 10, October 21, 2002 - VIEW THE FULL ISSUE

• JCAHO: 2003 will be a quiet year but expect big changes for 2004

  JCAHO: 2003 will be a quiet year but expect big changes for 2004

• Revised medication standards call for systems approach to compliance

  Revised medication standards call for systems approach to compliance

• Keep staff informed on how to handle safety issues with a pocket guide

  Keep staff informed on how to handle safety issues with a pocket guide

• Revised standard calls for increased drug formulary discretion

  Although it's nothing new for hospitals to create and maintain a drug formulary, drug shortages...

• Survey monitor: An Alabama hospital faces medication storage and security scruti

  Survey monitor: An Alabama hospital faces medication storage and security scrutiny

• The safety goals can shape your quality program

  The safety goals can shape your quality program

• Use your colleagues' surveyor questions to prepare for your JCAHO survey!

  Use your colleagues’ surveyor questions to prepare for your JCAHO survey!

Issue 9, September 21, 2002 - VIEW THE FULL ISSUE

• A simpler survey process for complex organizations

  JCAHO changes for 2003The JCAHO hopes to streamline the survey process for hospitals that offer a...

• JCAHO survey changes for 2003

  The JCAHO’s latest message speaks of simplifying the survey process, surveyors having more...

• Be prepared for disasters with an emergency credentialing policy

  Be prepared for disasters with an emergency credentialing policy

• Quick tip: Seek these attributes in a record completion clerk

  A successful record completion clerk is an outgoing, energetic person who is not shy or...

• Survey monitor: JCAHO surveyors probe compliance with patient safety standards

  Not just a popular health care buzz word, patient safety was also a focus during a recent survey...

• The JCAHO’s new patient safety goals offer more realistic suggestions

  Your colleagues sighed with relief when they learned that they have already adopted most or...

• The new draft standard calls for ongoing monitoring of how you handle medicatio

  Proposed standard TX.3.3 tells organizations to constantly look at medication practices using...

• The proposed 18-month survey cycle revisited

  You may have heard about the 18-month survey cycle during the JCAHO’s annual Executive...

• Use your colleagues’ surveyor questions to prepare for your JCAHO survey!

  Knowing the questions that surveyors ask other organizations gives you a good idea of what to...

• Using software to continually look at your weak spots

  JCAHO changes for 2003Effective January 2004, a new survey process will entail the use of...

Issue 8, August 21, 2002 - VIEW THE FULL ISSUE

• AHA releases more details on patient safety goals

  There is some more news and details on the JCAHO’s proposed six patient safety goals, which...

• Here's how to turn around perennially troublesome HR.5

  Here’s how to turn around perennially troublesome HR.5

• JCAHO reviews new emergency credentialing standard

  Does your hospital have a policy for granting privileges to physicians who aren’t members of...

• Know how HIPAA affects members of clergy

  The privacy rule provides some exceptions for religious leadersMost hospitals would not...

• Portable safety kits keep staff prepared for disasters

  People order food “to go” for its speed and convenience. Why not do the same with...

• Quick tip: Speak up during your survey

  Don’t be afraid to ask your surveyor questions about key survey issues and why he or she...

• Sample temporary privileges recommendation form

  Editor’s note: In the June issue, BOJ clarified that the JCAHO allows the use of temporary...

• Standard of the month: Play limbo with medical record delinquency rates

  How low can you go with IM.7.6?What’s your medical record delinquency rate? Hovering around...

Issue 7, July 21, 2002 - VIEW THE FULL ISSUE

• Boston hospital restructures emergency department to create a safe haven for res

  Boston hospital restructures emergency department to create a safe haven for restrained patients

• Continuing Education Quiz

  April through June 2002 Directions:• Complete this continuing education (CE) quiz by...

• Have critical medication information at your fingertips

  Editor’s note: In this issue, BOJ introduces a series that closely examines each new or...

• Quick tip: How to rate your fire drill performance to perfect employee skills

  You know how important it is to hold fire drills—not only to avoid getting zapped on...

• Regularly navigate the JCAHO’s Web site to avoid stormy seas

  You log onto “BOJ Talk” and see a posting about the JCAHO’s re cent standard...

• Standard of the month: Clarifying who can help with restraint orders, according

  Hospitals have some flexibility with who can write restraint or seclusion orders. The burden no...

• Survey monitor: At this Minnesota hospital, the credentialing files tell the s

  About the facility . . .Lakeview Hospital in Stillwater, MN, is a 100-bed community hospital...

• The JCAHO to approve patient safety goals

  Goals to replace Sentinel Event AlertsAlthough the high-risk areas within Sentinel Event Alerts...

Issue 6, June 21, 2002 - VIEW THE FULL ISSUE

• Arm yourself and your staff with information for your next JCAHO survey! >

  Some key surveyor questions to prepare forSeeing what surveyors ask your colleagues will help you...

• Annual surveyor conference stresses emergency management, patient safety, staff

  Annual surveyor conference stresses emergency management, patient safety, staffing

• BOJ’s annual salary survey: Hard work makes common cents

  Editor’s note: Thanks to all the readers who helped make BOJ’s confidential...

• Hospitals must replace faulty sprinklers, Feds say

  If your hospital receives Medicare funding, you will need to identify and replace a series of...

• Quick tip: Be prudent with patient information that you post on white boards

  Several of your colleagues say the JCAHO issued supplemental recommendations for hanging white...

• Standard of the month: Clarifying temporary privileges confusion

  Several articles covering the JCAHO’s clarification on temporary privileges that appeared...

• Survey monitor: A solid restraint program freed this Virginia hospital from Typ

  A sound restraint and seclusion policy, active performance improvement (PI) initiatives on...

• Trends & tips

  Budget constraints mean fewer validation surveysIf the thought of state validation surveys sends...

Issue 5, May 21, 2002 - VIEW THE FULL ISSUE

• Patient safety focus in the EC standard revisions calls for greater communicati

  Patient safety focus in the EC standard revisions calls for greater communication

• Prepare for disasters with an emergency credentialing policy

  Prepare for disasters with an emergency credentialing policy

• Documentation made easier: How one hospital streamlined all of its assessments

  What really helped Shawnee Mission (KS) Medical Center survive a tough chart review during its...

• Standard of the month: Watch your back on informed consent to comply with RI.1.

  Your doctors certainly inform patients of the risks and alternatives of all invasive procedures...

• The Hazard Vulnerability Analysis can help you select an FMEA topic

  Struggling to come up with a Failure Modes and Effects Analysis (FMEA) topic? If so, why not turn...

Issue 4, April 21, 2002 - VIEW THE FULL ISSUE

• Continuing Education Quiz

  A service of Briefings on JCAHODirections:• Complete this continuing education (CE) quiz...

• 2002 ushers in a new compliance priority: HIPAA privacy regulation

  2002 ushers in a new compliance priority: HIPAA privacy regulation

• JCAHO’s random unannounced survey topics for 2002 published

  The usual suspects make the survey focus listGet ready for a pop quiz on your environment of care...

• Quick tip: Analyzing the pressure sore indicator boils down to comparing outbr

  During pilot testing of the new staffing standards this fall, many hospitals chose pressure sores...

• Standard of the month: EC.1.4 calls for an organized emergency management plan

  Do you know who will lead the charge?If you use the incident command system as part of your...

• Survey monitor: Surveyors zero in on patient safety, staffing, and emergency ma

  Hill County Memorial Hospital in Fredericksburg, TX, is a general acute care hospital with 77...

• Trends & tips

  ‘Patient safety goals’ a new approach to Alert compliance Do you wonder what ever...

• Use performance improvement to comply with the JCAHO’s new staffing effe

  Is it realistic to say that by July 1 you’ll fully comply with the new staffing...

Issue 3, March 21, 2002 - VIEW THE FULL ISSUE

• Presedation assessments standard hits top hot button list

  Presedation assessments standard hits top hot button list

• JCAHO ponders extending reappointment cycle to three years

  Editor’s note: This is an abbreviated version of a fax express sent to your facility on...

• NY hospital reduces asthma-related absenteeism in schools and wins Codman Awar

  Prior to 1998, the roughly 3,000 students in the Yonkers, NY, schools who suffered from asthma...

• Revised medication use standards call for systems approach to compliance

  Get ready to revamp your policiesThe JCAHO’s draft revisions to the medication use...

• Standard of the month: Ensure timely reappointments and avoid Type I’s

  Credentialing standard MS.5.11, which requires hospitals to appoint and reappoint physicians...

Issue 2, February 21, 2002 - VIEW THE FULL ISSUE

• Yes, you can grant temporary privileges at reappointment

  Yes, you can grant temporary privileges at reappointment

• Annual surveyor conference stresses emergency management, patient safety, staffi

  Annual surveyor conference stresses emergency management, patient safety, staffing

• Case study: Boston hospital restructures emergency department to create a safe h

  Case study: Boston hospital restructures emergency department to create a safe haven for restrained...

• Patient safety focus in EC revisions calls for greater communication

  Patient safety focus in EC revisions calls for greater communication

• On-site credentialing can be crucial to dealing with mass casualties

  On-site credentialing can be crucial to dealing with mass casualties

• Standard of the month: Here's how to turn around perennially troublesome HR.5

  Standard of the month: Here’s how to turn around perennially troublesome HR.5

Issue 1, January 21, 2002 - VIEW THE FULL ISSUE

• High price of procrastination

• Both competency and initial assessments hinder hospitals in 2001

  Both competency and initial assessments hinder hospitals in 2001

• Assessments

  Assessments

• Yet top problematic standard list has some new additions

  Yet top problematic standard list has some new additions

• Quick tip: Don't leave float nurses hanging

  Quick tip: Don’t leave float nurses hanging

• Standard of the month: Presedation assessments standard hits top hot button list

  Standard of the month: Presedation assessments standard hits top hot button list

• Nursing homes reap ORYX reprieve

  Nursing homes reap ORYX reprieve

• Yes, you can grant temporary privileges at reappointment, but follow the JCAHO's

  Yes, you can grant temporary privileges at reappointment, but follow the JCAHO's criteria