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, 2010 - VIEW THE FULL ISSUE

• Flu prevention: Methods to reach staff, community

  Sometimes it’s all about the marketing.  Take flu shots, for instance. How do you best...

• Revisiting the Universal Protocol for simple, one-person procedures

  Did you notice a significant change in the Universal Protocol™ (UP) recently? No? We’re...

• Ensuring compliance at your organization

  When addressing anesthesia and sedation guidelines, the best advice is not to follow the letter of...

• Continued discussion and focus on standing orders

  If you stay around long enough in this field, the issues just cycle back. This year in the annual...

• Methods to improve tracking nurse education and training

  How quickly can you call up data on your nurses’ training and skill sets?  Midland (TX...

Issue 11, November 1, 2010 - VIEW THE FULL ISSUE

• Life Safety, EOC top 2010 most challenging standards list

  Every September at Executive Briefings, The Joint Commission announces its most commonly cited...

• Are you ready for the new patient-centered communication standards?

  Starting in 2011, Joint Commission surveyors will begin looking at—but not scoring—new...

• Joint Commission expectations for 2011

  Several major issues have been addressed or streamlined headed into 2011, The Joint Commission...

• Survey finds medication restraints among the most troublesome challenges, concerns for AHAP members

  Has your facility considered going restraint free? Have you succeeded? According to the most recent...

Issue 10, October 1, 2010 - VIEW THE FULL ISSUE

• Improved utilization policy upgrades patient safety

  When Fredonia (KS) Regional Hospital looked into updating its utilization review program, it...

• Social media and hospitals: Don't overlook the potential

  In July, the Association for Healthcare Accreditation Professionals (AHAP) established a Facebook...

• Fire evacuations in the procedural areas

  One of the key activities in any survey—mock or the real thing—are those precious...

• Don't underuse your education department

  Brookwood Medical Center (BWMC), a Tenet facility in Birmingham, AL, has an active, cohesive, and...

• Continuous Readiness Review plan: The payoff

  Previously, BOJ spoke with Northwest Texas Healthcare System (NWTHS) in Amarillo about its...

Issue 9, September 1, 2010 - VIEW THE FULL ISSUE

• PPR: The hard road leads to better survey prep

  Hospitals have multiple options when it comes time to undergo their PPR. The most extensive option...

• Specialist nurses trained to obtain informed consent

  If a procedure has been shifted from the physician to the nurse, can informed consent then be...

• Lessons learned from MGH's Joint Commission lab survey

  Are you confident enough about your Joint Commission survey results to post them online...

• Required life safety survey

  The Joint Commission took a giant step forward in 2009 when it began to include the D icon next to...

Issue 8, August 1, 2010 - VIEW THE FULL ISSUE

• Report card helps track timing and dating success

  Shelia Hull, RN, Joint Commission specialist at Pikeville (KY) Medical Center, was with the...

• Hospital nearly doubles medication scanning rates

  In April 2008, Baystate Medical Center (BMC), a 653-bed teaching hospital in Springfield, MA, began...

• Success in a fall reduction strategy

  Systemic change does require visionary leadership. The board of trustees for our facility...

• Medication Management and pharmacist first-dose review

  Patients expect that every safeguard is in place when receiving healthcare services. The challenge...

• CMS anesthesia update: What are the latest requirements?

  In May, CMS released a set of updated clarifications to the often-challenging Anesthesia Services...

• RFIs: When is the right time to clarify?

  Survey coordinators are challenged to help their organizations navigate accreditation requirements...

Issue 7, July 1, 2010 - VIEW THE FULL ISSUE

• Learn methods to improve continual readiness

  Sometimes, it’s all about implementation. When Northwest Texas Healthcare System (NWTHS) in...

• It's time to dust off staffing effectiveness: Take steps to prepare for the July 1 implementation date

  On July 1, The Joint Commission resumed surveying for the new version of staffing effectiveness...

• Keeping up with education and training with The Joint Commission and CMS

  Education and training for hospital staff has always been time-consuming and costly for both...

• Patients benefit at CTCA from restraint-free care

  Facilities across the country struggle daily with the challenges inherent to the use of restraints...

Issue 6, June 1, 2010 - VIEW THE FULL ISSUE

• Start from the beginning

  When Heather Forbes, RN, BSN, CEN, CSHA, HACP, accreditation and regulatory coordinator at Southern...

• Focused Professional Practice Evaluation: Keep it simple

  In 2007, The Joint Commission issued the Focused Professional Practice Evaluation (FPPE) standard...

• MS.01.01.01 changes spell end to standard controversy

  For years, the Medical Staff standard MS.01.01.01 has been a battleground for hospitals—an...

Issue 5, May 1, 2010 - VIEW THE FULL ISSUE

• Hospital uses pocket-sized handout to improve core measures compliance

  Core measures—they’re a part of the fabric of hospital life, particularly given their...

• A look at CMS' newest anesthesia standards

  The new guidelines contain information on the supervision of a certified registered nurse...

• Demystifying Ongoing Professional Practice Evaluation

  In 2007, when The Joint Commission issued the Ongoing Professional Practice Evaluation (OPPE...

• Ongoing safety assessment in the psychiatric milieu

  National Patient Safety Goal NPSG.15.01.01 requires that patients being treated for emotional or...

• MS.01.01.01: Revisions to standard receive approval

  Medical Staff standard MS.01.01.01 has undergone quite a journey over the years. The standard, once...

Issue 4, April 1, 2010 - VIEW THE FULL ISSUE

• Joint Commission Survey Activity Guide for Hospitals

  Did you happen to note that the Survey Activity Guide (SAG) was last updated by The Joint...

• A look at CMS' newest anesthesia standards

  The Centers for Medicare & Medicaid Services (CMS) published revised interpretive guidelines...

• Issues surrounding the PPR

  The Periodic Performance Review (PPR) is an annual self-assessment process aimed at supporting...

• Applying standards to pharmaceutical management of ectopic pregnancy

  Ectopic pregnancy will be used throughout this article to illustrate some of the 2010 standards...

• Slow year for wage increases for survey coordinators

  In a year that saw budgets cut, travel expenses slashed, and jobs lost, it is unsurprising to...

Issue 3, March 1, 2010 - VIEW THE FULL ISSUE

• Standards changes and deeming CMS requirements: what this means to hospitals

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• Flash sterilization: Back to basics

  Imagine this scenario: The Joint Commission surveyor arrives in the surgical services suite and...

• Hospital educates patients on dangers of PAD

  Hospitals look for ways to improve patient education all the time. Once in a while, this education...

• Survey terminology update: A look at CMS terms, medical records review, and more

  Many hospitals still struggle with understanding the CMS survey process—particularly...

• Staffing effectiveness in 2010: The interim standards

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Issue 2, February 1, 2010 - VIEW THE FULL ISSUE

• Joint Commission top-cited standards: Toughest challenges of the year

  The Joint Commission officially announced the most-cited standards for the first half of 2009 and...

• Risk assessments for unclear standards

  When the Joint Commission released its "Power Pack" on medication storage it suggested at...

• New code of conduct improves employee outlook, patient satisfaction

  In 2006, Pam Harmon, RN, legal nurse consultant and chief nursing officer at Fredonia (KS) Regional...

• Patient and family education: a continued item on the problematic standards

  Patient and family education is one of those problematic standards and requirements for improvement...

• CMS approves Joint Commission's application for deeming authority

  The Joint Commission’s hospital accreditation program has been approved for continued deeming...

Issue 1, January 1, 2010 - VIEW THE FULL ISSUE

• Targeting trouble areas with Six Sigma tactics shows major results

  Let’s throw a pair of numbers out there: 26% and 3%. Those are the percentages for emergency...

• ‘Going to Gemba’—an accreditation specialist relates how Lean Six Sigma experience can work in healthcare

  As a healthcare accreditation consultant and quality management professional, I have been exposed...

• Key methods for simplifying medication storage

  Collective experience from The Greeley Company’s consultants supports the Joint...

• Missouri health center survives thorough lab inspection

  On September 23, 2009, Cindy McKeon, BS, BSMT, MS, MBA, ASEP, lab director of Bothwell Regional...

• Briefings on the Joint Commission 2009 index

  Accreditation alternatives Documentation control highlights ISO certification. July, p...