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, 2004 - VIEW THE FULL ISSUE

• Survey hot spots: Five problem areas and how to avoid them

  Speakers during a Joint Commission Resources (JCR) conference told attendees of five areas where...

• A tale of two hospitals: How to decide which PPR option is right for you

  If you've just wrapped up a survey, you're probably in no mindset to launch into the periodic...

• What your leadership team needs to know about LD.2.20 and LD.2.50

  This year, the JCAHO took leadership standards, which were previously located in the governance and...

• Safely storing medications

  Hospitals are failing to adequately comply with MM.2.20, which requires hospitals to safely store...

Issue 11, November 1, 2004 - VIEW THE FULL ISSUE

• JCAHO surveyor seal of approval: Documentation binders

  Editor's note: A smooth survey requires advance planning with current, organized information about...

• Prevent prohibited abbreviations from creeping into your records

  IM.3.10 continues to top the charts as the most challenging JCAHO standard. Thirty-one percent of...

• What should you do if you find yourself face to face with a difficult surveyor?

  Most of your colleagues report that their JCAHO surveyors are pleasant and informative. However, at...

Issue 10, October 1, 2004 - VIEW THE FULL ISSUE

• What you need to know about the changes to the 2005 standards

  The profound changes to the accreditation processes and standards that began in 2003 with the...

• Learn what got JCAHO surveyors all fired up in one hospital

  With continued news about threats of bioterrorism and weapons of mass destruction (WMD), expect to...

Issue 9, September 1, 2004 - VIEW THE FULL ISSUE

• What the JCAHO's unannounced survey is really like

  Surprise! You've got four surveyors in your lobby, and you had no idea they were coming. This...

• Heads up: EP scoring guidelines leave room for interpretation

  There's never been a more important time to learn the ABCs of elements of performance (EP) scoring...

• Learn what the experts say about the new 2005 National Patient Safety Goals

  Now that the new goals are finally out, we asked accreditation and patient safety experts to share...

Issue 8, August 1, 2004 - VIEW THE FULL ISSUE

• Surveyors' approach takes one hospital by surprise

  You can spend months planning for a JCAHO survey, and staff may have every Patient Safety Goal down...

• Three cost-cutting ways to improve patient flow

  Improving your patient flow doesn't have to be expensive. Just ask the emergency department (ED...

Issue 7, July 1, 2004 - VIEW THE FULL ISSUE

• Infection control slides under the JCAHO microscope

  With the first half of the year's surveys complete under the JCAHO's new Shared Visions-New...

• Twelve tips for three of the JCAHO's most challenging standards

  If your hospital management continues to have problems meeting performance evaluation deadlines...

• Money talks: The results of BOJ's annual salary survey

  Editor's note: In May, BOJ conducted its annual salary survey. We received 96 anonymous responses...

Issue 6, June 1, 2004 - VIEW THE FULL ISSUE

• The top five concepts I learned during my February survey

  The ultimate lesson that Mary Jaco, RN, MSN, learned during her February survey is that the new...

• Look at the big picture when analyzing patient flow patterns

  The JCAHO wants you to look at various processes that affect patient flow, such as the number of...

• The JCAHO's proposed Patient Safety Goals make for improvement, but at a price

  Your colleagues say that if the JCAHO approves its 2005 National Patient Safety Goals as is, some...

• What the JCAHO's clarifications to the scoring guidelines mean to you

  The JCAHO's February update to the Comprehensive Accreditation Manual for Hospitals contains...

• Survey Trend Watch

  Since the JCAHO threw the formal survey agenda out the window with the advent of tracer...

Issue 5, May 1, 2004 - VIEW THE FULL ISSUE

• Multiple-service hospitals must communicate among departments

  Heads up for complex organizations: Now that the JCAHO surveys you as one entity, the on-site...

• How to foster team training: Honor fellow staff members' feedback

  Departments can no longer function independently of each other now that the JCAHO expects hospitals...

• How to figure out which PPR option is best for you

  Many hospitals continue to wrestle with which option of the JCAHO's Periodic Performance Review...

Issue 4, April 1, 2004 - VIEW THE FULL ISSUE

• February survey offers better snapshot on patient care

  The Hospital of Saint Raphael will likely receive a few requirements for improvements-formerly...

• How one hospital improved interdisciplinary patient care

  Halifax Regional Medical Center in Roanoke Rapids, NC, received a frustrating recommendation during...

• Heads up: Unapproved abbreviations lurk in more clinical documents

  Don't forget to check patient medical records for the JCAHO's unapproved abbreviations and monitor...

• Clearly identify who is in charge of your EC plans

  Complying with the JCAHO's 2004 Environment of Care (EC) standards means more than conducting...

Issue 3, March 4, 2004 - VIEW THE FULL ISSUE

• Surveyors quiz staff at length on how they care for patients

  The start of 2004 ushered in the JCAHO's much-talked-about Shared Visions-New PathwaysT process...

• Build double-checks into your preop procedures

  Standardize your preoperative procedures with a system of double-checks to guard against the third...

• Accreditation alternatives: Why some hospitals leave the JCAHO

  Pressure to contain costs is one challenge that compels some hospitals to consider less expensive...

Issue 2, February 2, 2004 - VIEW THE FULL ISSUE

• Get ready to discuss your hospital's systems during your next survey

  The bottom line for 2004 surveys: Focus on patients, and not so much on policies and procedures...

• Use mock tracer methodology exercises to improve services

  Using tracer methodology exercises, the accreditation and regulatory standards department for the...

• The JCAHO scrutinizes how a Texas hospital handled unacceptable drug abbreviatio

  Surveyors closely examined the use of unacceptable drug abbreviations during the November 2003...

Issue 1, January 6, 2004 - VIEW THE FULL ISSUE

• Check with your state for telemedicine licensing questions

  Physicians routinely rely on practitioners in other cities or states to interpret lab results and...

• An aggressive continuous survey readiness campaign makes accreditation relevant

  For the first time ever, staff at Kaiser Foundation Hospital-Bellflower, in Bellflower, CA, talked...

• Continuing Education Quiz

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