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, 2006 - VIEW THE FULL ISSUE

• Lab, suicide tracers part of hospital surveys in 2007

  An important survey process change that takes effect January 1 was unexpectedly announced by the...

• Goal or not, why you should address disruptive clinician behavior

  When the JCAHO opened its field review last year for the proposed 2007 National Patient Safety...

• Tips to comply with the JCAHO's recently updated look-alike/ sound-alike list

  The Joint Commission recently released an updated list of look-alike/sound-alike (LASA) medications...

• Steps to overturn prohibited abbreviation RFIs

  How to examine a random sample to show compliance Use of unapproved or prohibited abbreviations...

Issue 11, November 1, 2006 - VIEW THE FULL ISSUE

• Strategies to comply with med rec requirements

  Medication reconciliation is one of the JCAHO's top-cited National Patient Safety Goals (NPSG) so...

• An educational, open, and nonpunitive survey experience

  Monday-the day Karen Holland, RN, BSN, religiously checked the JaycoT extranet site to see whether...

• This CEO goes on mock tracers, and yours should, too

  For the past four months, Memorial Hospital CEO Gary Marchand has been conducting mock patient...

• What data are surveyors looking for when they arrive?

  It's one thing to be aware of the data to provide surveyors by reading the Survey Activity Guide...

Issue 10, October 1, 2006 - VIEW THE FULL ISSUE

• Patient care goal easy to meet, but don't dismiss

  If there's one National Patient Safety Goal that isn't causing too much panic in the field, it's...

• Team approach to survey prep helps staff anticipate surveyor questions

  Patient and system tracers played out during survey at Florida Hospital DeLand exactly how staff...

• Revised MS.1.20 'huge improvement', out for comment again

  JCAHO has again revised the proposed language for medical staff standard MS.1.20, which contains...

Issue 9, September 1, 2006 - VIEW THE FULL ISSUE

• Suicide goal applicability unclear for hospitals

  The language of the JCAHO's new 2007 NPSG addressing patient suicide has caused confusion in the...

• Goals scoring stays the same in 2006, relaxes in 2007

  Beginning January 1, 2007, surveyors will score the National Patient Safety Goals (NPSG) during...

• Wiping away RFIs during survey is possible, one hospital discovers

  By Patricia Dolan's count, her facility avoided at least three requirements for improvement (RFI...

• Surveyor guidance clarifies PPR findings and track record

  In July, the JCAHO provided surveyors with guidance about how to handle findings that organizations...

Issue 8, August 1, 2006 - VIEW THE FULL ISSUE

• 2007 goals seem simple, but details are emerging

  The 2007 list of National Patient Safety Goals includes a handful of minor tweaks at first...

• Mock patient and system tracers 'key component' to unannounced survey success

  If you're bracing for your first unannounced survey, Patricia Garvey, MSN, RN, can't overemphasize...

Issue 7, July 1, 2006 - VIEW THE FULL ISSUE

• Test and retest your unannounced survey readiness

  It's one thing to think that you're ready for JCAHO surveyors to arrive tomorrow morning; it's...

• Expect surveyor scrutiny of disaster management plans

  What will your hospital do if there's a community disaster? Although the JCAHO's new emergency...

• JCAHO backs off enforcement of USP 797 requirements

  The USP seeks field comments about proposed changes to its Chapter 797, while the JCAHO is backing...

Issue 6, June 1, 2006 - VIEW THE FULL ISSUE

• JCAHO releases noncompliance data for standards, goals in hospitals

  More medication management (MM) and provision of care (PC) standards populate the JCAHO's hospital...

• Daily check of extranet site buys one hospital two hours of prep time

  Anticipating their unannounced survey in March-the anniversary of their last triennial survey-but...

• A wider view of hand-off communication

  Hand-off communication goes beyond the shift-to-shift, nurse-to-nurse report, according to clinical...

• Learn how to recruit, train, and ultimately share the duty

  Conducting two mock tracers per month at more than two hours each for about two years was more than...

Issue 5, May 1, 2006 - VIEW THE FULL ISSUE

• JCAHO increases number of allowable RFIs during surveys

  The number of RFIs that hospitals may receive has increased, further relaxing the revised...

• Former JCAHO exec talks survey, offers advice and tips

  Editor's note: Kurt A. Patton, MS, RPh,served as executive director of accreditation services at...

• Culture of survey readiness important to preparing for unannounced process

  Year-round preparation culminating in a culture of survey readiness appears to be a key ingredient...

Issue 4, April 1, 2006 - VIEW THE FULL ISSUE

• First unannounced JCAHO survey catches AZ medical center by surprise

  Editor's note: This story is the first in an ongoing series about the experiences of facilities...

• Have a process in place to address patient grievances

  How hospitals address patient rights is a key area highlighted by both the JCAHO's standards and...

• To comply with public notice policy, keep it simple

  Accreditation Participation Requirement (APR) 8 is seemingly straightforward: Hospitals must...

• What to expect from the JCAHO's new EM session

  Although the JCAHO has surveyed hospital disaster plans for years, in the wake of recent calamities...

• IM standards continue to challenge in hospital surveys

  Organizations preparing this year for JCAHO surveys should take a close look at the health...

Issue 3, March 1, 2006 - VIEW THE FULL ISSUE

• Sentinel Event Alert stresses medication reconciliation efforts

  The JCAHO on January 25 issued a Sentinel Event Alert urging hospitals to increase medication...

• Systemwide efforts help hospital prevent drug diversion problems

  Preventing drug diversion begins with a look at the hospital's overall system, not just at the...

• Follow the paper trail to JCAHO survey success

  Although the JCAHO emphasizes individual patient and system tracers, do not underestimate the...

Issue 2, February 1, 2006 - VIEW THE FULL ISSUE

• Hospitals to have full survey option during periodic performance review

  In yet another change to the evolving periodic performance review (PPR) process, hospitals will be...

• Baton transfer aids hospital hand-offs

  Complying with a new National Patient Safety Goal may be as simple as passing the baton. The...

• Providing backup materials helps hospitals prove point after survey

  The devil is in the details, and when it comes to re sponding to deficiencies after a Centers for...

• E-mails help hospital train, get perfect survey score

  A perfect survey was a click of the mouse away for one Florida hospital. Staff at Naval...

• Eight expert tips for medication labeling success

  Cases of unintentional medication and solution swaps are widely covered in the media...

Issue 1, January 1, 2006 - VIEW THE FULL ISSUE

• JCAHO releases proposed 2007 National Patient Safety Goals

  Rapid response teams, patient suicide prevention, worker fatigue, and disruptive behavior are among...

• Include contrast media in monthly inspections

  Pharmacists do not need to review most oral contrast media orders, but they should apply other...

• MD hospital wins award for flow improvements

  Shady Grove Adventist Hospital in Rockville, MD, was suffocating. A backlog of patients clogged...