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 12, December 1, 2003 - VIEW THE FULL ISSUE

• How Kaiser Permanente created a continuous survey readiness mindset

  All 12 of Kaiser Permanente's Southern California centers received high survey scores, with an...

• Committee delegation, survey prep sheets aid workers at Mass hospital

  The JCAHO expects organizations to start switching to a continuous readiness approach to surveys...

Issue 11, November 1, 2003 - VIEW THE FULL ISSUE

• Try these simple tools to forge clear communication

  One of the most vexing issues caregivers face is effective communication. So it's not...

• How to respect cultural differences

  Your facility must comply with the fifth requirement in standard HR.2.10-that organizations must...

• Deck the halls this holiday season, but follow safety requirements

  The holidays are just around the corner. Are you ready to deck the halls with a decoration policy...

• Know your state rules on CRNAs to avoid survey problems

  In 2002, staff at Pullman (WA) Memorial Hospital decided they no longer wanted JCAHO accreditation...

• Survey Trend Watch: Surveyors are eager to test out some new survey approaches i

  Surveyors practiced the 2004 survey process approach of tracking an individual patient's care...

Issue 10, October 1, 2003 - VIEW THE FULL ISSUE

• Ditch old habits: Accreditation is not just a survey score

  Editor's note: This story is adapted from the fax express, sent to your facility on August 25...

• Changes to National Patient Safety Goals are 'logical', your peers say

  Two key changes to the 2004 National Patient Safety Goals are that nursing staff must read back...

• JCAHO is now more consistent with HIPAA requirements with the 2004 IM standards

  Even though all health care organizations must comply with the Health Insurance Portability and...

• Navy hospital raises its score with continuous readiness plan

  During its last JCAHO survey in December 2000, the Naval Hospital in Twentynine Palms, CA, received...

• Use periodic performance reviews to resolve problems before surveyors arrive at

  One of the big changes hospitals will notice when the JCAHO starts its new survey process in...

Issue 9, September 1, 2003 - VIEW THE FULL ISSUE

• Examine your services before revising medication policies

  Create realistic range orders, and don't say you'll do the impossible and remove all concentrated...

• Goals compliance: Hospitals need more time to change behaviors

  Aside from a modification to Goal #2 and the addition of a new goal to reduce the risk of...

• Hospital CEOs gear up for 2004 JCAHO surveys

  Most hospitals are making room in their budgets to train staff for the JCAHO's new survey...

• Patient safety goals compliance dominates surveys in 2003

  Place patient safety goals compliance at the top of your list since surveyors consider this area a...

Issue 8, August 1, 2003 - VIEW THE FULL ISSUE

• Be realistic: Tailor new medication policies to your current practice

  Part one of a two-part series Look at your scope of services and how you treat patients to see what...

• Read the JCAHO's 2004 standards carefully for key changes

  The JCAHO consolidated standards from the assessment, patient care, continuum of care, and...

• Create a form to standardize informed consent

  Editor's note: Many of the JCAHO's 2004 standards feature new requirements. In this issue, we offer...

• Physician leaders set the stage for teamwork and open communication among staff

  Health care teams that communicate well together reap better patient outcomes and reduce adverse...

Issue 7, July 1, 2003 - VIEW THE FULL ISSUE

• The JCAHO offers tips to comply with its patient safety goals

  The Joint Commission has softened its scoring of the most troublesome patient safety goal of...

• Tracer methodology means more attention to patient charts

  Ongoing medical record review is more important than ever, so routinely check complex patient...

• Working overtime on JCAHO compliance

  While the majority of your peers say they are satisfied with their salaries, they also feel that...

• The Greeley Company's new interim staffing program helps a Massachusetts hospita

  Caritas Good Samaritan Medical Center was a year away from its JCAHO survey in July 2002-the time...

Issue 6, June 1, 2003 - VIEW THE FULL ISSUE

• The self-assessment exercise is too subjective, says Virginia hospital

  Editor's note: The Sentara hospital system (comprising four hospitals in the Hampton, Norfolk, and...

• Getting 100% of evaluations completed on time trips hospitals

  Hospitals that don't meet their own deadlines to assess staff performance can get themselves into...

• Nine tips for streamlining your policy process

  Coordinating updates of your policies and procedures can seem like a bad dream-one that threatens...

• HR.2.1: When correlating data indicators, consider all patients without collecti

  During a March audioconference* that outlined the relationship between patient satisfaction data...

Issue 5, May 1, 2003 - VIEW THE FULL ISSUE

• Educate and test pharmacists on age-related drug needs

  Only competent staff can care for patients. And that care includes handling age-specific needs. But...

• The JCAHO will switch to unannounced surveys

  Many of you have resisted last-minute preparations for your triennial survey, but didn't have the...

• Surveyors zero in on safety reports and building maintenance records at a Northw

  Between state department of health surveys, a surprise random unannounced JCAHO inspection, and a...

Issue 4, April 20, 2003 - VIEW THE FULL ISSUE

• Monitor alarms by evaluating staff perception of noise, and more

  When it comes to complying with the JCAHO's patient safety goal to monitor alarms, many people...

• Recognize when you need to turn to external peer review

  Does your hospital have a policy clearly describing when it would seek an external peer review...

• Critical access hospital surveys: Shorter, but more intense

  When conducting a critical access hospital (CAH) survey this winter at Mendota (IL) Community...

• A hospital test-pilots the JCAHO's new self-assessment

  At a Georgia hospital, the most critical change to the JCAHO's new survey process was moving away...

• Continuing Education Quiz

  Complete this continuing education (CE) quiz by writing the letter corresponding to the correct...

Issue 3, March 1, 2003 - VIEW THE FULL ISSUE

• Revised medication standard tackles legibility, abbreviations, and more

  Think about clarifying drug administration times and range orders in your medication policies...

• Get ready for the new patient safety and medication interview

  It's more important than ever to understand and discuss your patient safety initiatives and...

• Gear up for the 2000 version of the Life Safety Code

  The changeover means high costs to hospitals The Centers for Medicare & Medicaid Services (CMS...

• Get ready for the new patient safety and medication interview

  Get ready for the new patient safety and medication interview

Issue 2, February 1, 2003 - VIEW THE FULL ISSUE

Issue 1, January 21, 2003 - VIEW THE FULL ISSUE

Issue 6, February 14, 2003

• The inside scoop on a new infection control focus, telemedicine, and more

  The inside scoop on a new infection control focus, telemedicine, and more

Issue 3, January 24, 2003

• An Ohio hospital system witnesses patient tracking surveying in process

  An Ohio hospital system witnesses patient tracking surveying in process

Issue 2, February 21, 2003

• 2003 RUS topics: Clamp down on IC, PI, and staff orientation

  The JCAHO has determined that infection control (IC), performance improvement (PI), and human...

• Maintaining two-year reappointments and avoiding laundry lists top the credenti

  Reappointment, drug usage evaluation, and peer review were on the forefront of a physician...

• Should you clear up conflicts during survey?

  Your surveyor asks for a trend analysis detailing which anesthesiologists fail to maintain...

• The inside scoop on a new IC focus, clarifying telemedicine, and more

  Editor’s note: This story is an expanded version of the fax express sent to your...

Issue 1, January 21, 2003

• 2003 brings new survey scoring

  On January 1, the JCAHO will start scoring two revisions to the environment of care (EC) standard...

• An Ohio hospital system witnesses the patient tracking survey process in action

  Since the JCAHO will compare medical record information to what patients and staff say about the...

• Briefings on JCAHO 2002 index

  AssessmentsCompetency and initial assessments hinder hospitals in 2001. Jan., p. 1. Here's how to...

• Continuing Education Quiz

  October through December 2002Directions: • Complete this continuing education (CE) quiz by...

• Keep track of narcotics and watch out for drug theft and diversion

  In Cincinnati, the police department’s pharmaceutical diversion unit spends a lot of time...

• Tabletop exercises help to network and strategize with the community

  What is the best way to fulfill your JCAHO requirement for participation in a community emergency...