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, 2014 - VIEW THE FULL ISSUE

• Joint Commission introduces Patient Safety chapter

  The Joint Commission recently released a new chapter to the Comprehensive Accreditation Manual for...

• The human factor

  Is everything you need to know in the medical record? While we rely on the medical record (be it...

• Ebola-related standards

  Last month, we looked at what the international community could do in the face of the current...

• Month 11 post-survey tips

  Month 11 post-survey tips Editor's note: In this new feature, BOJ advisor Jodi Eisenberg, MHA...

• The importance of the environment

  One of the many facets of any successful hospital is its environment of care and cleanliness...

Issue 11, November 1, 2014 - VIEW THE FULL ISSUE

• CMS targets infection control in latest updates

  CMS develops Conditions of Participation (CoP) that healthcare organizations must meet to...

• Ebola: What accreditation professionals need to know

  We have seen some enormous numbers arising in the current Ebola outbreak in Africa, with...

• Month 10 post-survey tips

  Editor's note: In this feature, BOJ advisor Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, manager of...

Issue 10, October 1, 2014 - VIEW THE FULL ISSUE

• Top-cited standards focus on EC, Leadership

  While The Joint Commission's official top-cited standards don't appear until each fall's Executive...

• Building a better self-reporting structure

  Does your organization have a formalized process for debriefing after an adverse event? And if so...

• Clinician tips for tubing misconnection prevention

  In what could be called one of the better Sentinel Event Alerts (SEA) released in recent years...

• Month nine post-survey tips

  In this era of mergers, acquisitions, and the building of replacement hospital facilities, many...

• Checklists: Easy to take for granted

  In any organization's quality department there lives a nefarious, ever-present beast. It's usually...

Issue 9, September 1, 2014 - VIEW THE FULL ISSUE

• Survey eye in the sky

  Every survey is a little bit different, but during Maine Medical Partners' most recent survey visit...

• What is a risk matrix?

  There has to be a better way of developing risk matrices. This was the theory developed by Alan J...

• Prepublication standards

  The Joint Commission has released its July 2014 prepublication standards referencing changes to...

• Proposed Palliative Care requirements

  The Joint Commission has revealed proposed requirements for its Advanced Palliative Care...

• Month eight post-survey tips

  It is important to realize that, while The Joint Commission gets the most press, there are several...

• Uniqueness is not unique

  When speaking to organizations, I often hear things like, "Well, we don't have the resources that...

Issue 8, August 1, 2014 - VIEW THE FULL ISSUE

• The hospital, physician recruitment, and the community

  How outreach can improve operational efficiency and more

• Additional modules

  Module creates curriculum to de-escalate aggressive behavior

• ECRI releases top 10 concerns

  The ECRI Institute has released its annual "Top 10 Patient Safety Concerns for Healthcare...

• Month seven post-survey tips

  Editor's note: In this new feature, BOJ advisor Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, manager of...

• Lost in translation

  In my experiences coaching medical professionals, sometimes too much knowledge is a bad thing. Even...

Issue 7, July 1, 2014 - VIEW THE FULL ISSUE

• Preventing workplace violence

  After reading this article, you will be able to: Discuss the frequency of incidents of...

• FDA, bar codes, and scanners

  After reading this article, you will be able to: Describe the recent changes to bar codes...

• Accreditation roundup: Joint Commission updates PFI requirements, CMS eyes EHR

  After reading this article, you will be able to: Discuss changes to the PFI process...

• What should I be doing now?

  After reading this article, you will be able to: Describe the CMS Patient Safety...

• ED-CAHPS: What departments can do to succeed

  After reading this article, you will be able to: Discuss the ED's role in inpatient...

Issue 6, June 1, 2014 - VIEW THE FULL ISSUE

• Changing colors

  Rubber wristbands have become a ubiquitous sight in the U.S. Whether supporting a cause or...

• To err is human?to prevent errors is culture

  It's an easy, if incorrect, argument to make: More errors could be prevented if everyone was...

• Addressing the bigger picture of quality and safety (Part 2)

  Editor's note: Previously, Sena Blickenstaff, BSN, MBA, principal with Compass Clinical...

• Medication distribution locations and residential care facilities

  After reading this article, you will be able to: Identify areas where the Facility...

• Month five post-survey tips

  Editor's note: In this new feature, BOJ advisor Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, manager of...

Issue 5, May 1, 2014 - VIEW THE FULL ISSUE

• Addressing the bigger picture of quality and safety (Part 1)

  Expectations of access to high-quality, safe, and affordable healthcare are growing, as are the...

• Finding the money

  Few accreditation or quality improvement specialists would disagree that funding is one of the...

• CMS issues memo on opioids

  On March 14, CMS issued a memorandum to state survey agency directors regarding requirements for...

• Month four post-survey tips

  Editor's note: In this new feature, BOJ advisor Jodi Eisenberg, MHA, CPMSM, CPHQ, CSHA, manager of...

• Joint Commission to update manuals this spring

  The Joint Commission has announced plans for two updates to its accreditation and certification...

• The specialist job search

  It's the bad part about being in leadership, whether you are a unit manager, quality improvement...

Issue 4, April 1, 2014 - VIEW THE FULL ISSUE - VIEW THE FULL ISSUE

• Falls prevention: New solutions to old problems

  Every organization struggles with falls prevention, and finding new, effective, and sustainable...

• CMS releases annual report

  CMS has unveiled its fiscal year (FY) 2013 financial report, a far-ranging document examining not...

• The struggle of advance directives

  When is the right time to die? It's an uncomfortable topic on every level?difficult for patients...

• Month three post-survey tips

  Editor's note: In this new feature, BOJ advisor Jodi Eisenberg, MHA, CPMSM, CPHQ, CSHA, manager of...

• Joint Commission seeks comments on diagnostic imaging standards

  The Joint Commission is soliciting comments as part of a follow-up field review for its diagnostic...

• Joint Commission seeks comments on diagnostic imaging standards

  The Joint Commission is soliciting comments as part of a follow-up field review for its diagnostic...

Issue 3, March 1, 2014 - VIEW THE FULL ISSUE

• New tactics for hand hygiene compliance

  After reading this article, you will be able to:

• Alarms NPSG: What does it really mean for hospitals?

  After reading this article, you will be able to:

• The 'Lovebug' diagram expands risk assessment options

  After reading this article, you will be able to:

• Mattress covers: Avoiding risk of patient infections

  After reading this article, you will be able to:

• Is it time for a changing of the guard?

  After reading this article, you will be able to:

Issue 2, February 1, 2014 - VIEW THE FULL ISSUE

• Building a better culture

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• Informed consent, medical errors, and the law

    The Joint Commission has made both patient education and informed consent priorities in the...

• Month two post-survey tips

    Editor’s note: In this new feature, BOJ advisor Jodi Eisenberg, MHA, CPHQ, CPMSM...

• Reviewing requirements for surgical attire

    Editor’s note: The following report was authored by BOJ advisor Elizabeth Di...

• Using aerospace science to promote safety

    After reading this article, you will be able to...

• How can EMS help with readmission rates?

  Editor’s note: Patrick Pianezza, MHA, has worked with the Studer Group and Johns Hopkins...

Issue 1, January 1, 2014 - VIEW THE FULL ISSUE

• Standards year in review (part 2 of 2)

  Last month, we began our review of the year's most-cited Joint Commission standards by discussing...

• End-of-life care: What we can and should do better

  Hospitals must have written policies on advance directives and the patient's desires with regard to...

• The importance of strong ED and EMS relationships

  When considering community perception of your organization, patient experience, and hospital...

• HIPAA training: Why am I here and why should I care?

  The Office of Civil Rights (OCR) has announced the items of focus during 2014's random audits...

• BOJ 2013 index

  CIHQ receives deeming authority. Oct., p. 10.