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, 2018 - VIEW THE FULL ISSUE

• CMS concerned AOs missing fire and smoke barrier, sprinkler deficiencies

  Expect CMS to continue pressuring The Joint Commission (TJC) and other accrediting organizations...

• Joint Commission revises scoring for infection control as of September 1

  On September 5, The Joint Commission (TJC) announced scoring changes for its IC.02.02.01 standard...

• Doctors praise CMS move on "note bloat," oppose payment changes

  A cohort of about 150 physician groups sent a letter both commending and criticizing the Trump...

• CMS making deficiency reports more accessible to the public

  CMS wants to put a stronger spotlight on times when TJC and other AOs fail to find patient safety...

• Joint Commission talks medication management

  There was a far-ranging medication management discussion held at The Joint Commission’s 2019...

• Revisions to hospital deeming EPs

  The Joint Commission (TJC) is revising five elements of performance (EP) following a CMS review of...

• Joint Commission's new emergency management checklist

  On October 10, Hurricane Michael made landfall in Florida, forcing at least two hospitals to...

Issue 11, November 1, 2018 - VIEW THE FULL ISSUE

• Joint Commission surveyor focus remains on EC, LS, ligature risks

  Some of the top takeaways for environment of care and other healthcare and quality professionals...

• Q&A: Joint Commission talks ligature risk

  In a live question-and-answer session, Kathryn Petrovic, MSN, RN-BC, The Joint Commission’s...

• PSS-3: Three-question suicide screener for the ER

  The tool consists of a short introduction and three questions, with an optional fourth item if the...

• Q&A: Patient misidentification

   Brad Truax, MD, is board-certified in both neurology and internal medicine, and has more than...

• Get your governing board involved with water management to meet CMS expectations

  Alert your hospital leadership that CMS and other surveyors are not only looking for water...

Issue 10, October 1, 2018 - VIEW THE FULL ISSUE

• CMS surveyors agree to use Joint Commission recommendations on ligature risk as guide

  In a new memo to its state survey agencies, CMS said it would use Joint Commission ligature...

• HFAP ligature standard remains same after newest CMS memo

  HFAP, one of the oldest accrediting organizations for U.S. hospitals, recently updated 13 of its...

• Surveyor gaze is on dialysis compliance

  Dialysis is one of the three main topics that have come up repeatedly at Joint Commission...

• The pipes are calling: CMS revises Legionella requirements

  You can expect renewed interest in your water management program. This summer, CMS sent out a new...

• The future of infection prevention

  As infection prevention challenges evolve—such as emerging infectious organisms and...

• ECRI: Most wrong-patient errors are preventable

  Despite there being a number of methods to correctly identify patients, wrong-patient procedures...

Issue 9, September 1, 2018 - VIEW THE FULL ISSUE

• Human trafficking and healthcare

  Do you know the likelihood of recognizing a human trafficking victim? One who came to your facility...

• Q&A: The Joint Commission on human trafficking

   In June, The Joint Commission Quick Safety Issue 42: Identifying Human Traf-ficking Victims...

• Is the fight over? AORN to change recommendations in surgical headwear debate

  One of the fiercest fights in surgery is about ears. Do you cover them while conducting surgery...

• HFAP revises ligature risks standards

   To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care...

• CMS delays hospital star ratings update, again

   Citing “stakeholder concerns,” the Centers for Medicare & Medicaid Services...

Issue 8, August 27, 2018 - VIEW THE FULL ISSUE

• HFAP revised standards: Legionella

   To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care...

• Case study: How DeKalb Medical cut its overridden medication safety alerts after fatal accident

  Last October, the hospital was placed under immediate jeopardy following the death of a patient...

• Case study: Automating sepsis alerts at Harborview Medical Center

  Rosemary Grant, BSN, RN, CPHQ, is the sepsis coordinator at Harborview. She says her facility chose...

• Cold weather and drug resistance; tracking seasonal changes in antibiotic misuse

  This March, a team of experts working with the Centers for Disease Control and Prevention (CDC...

Issue 7, July 1, 2018 - VIEW THE FULL ISSUE

• Sentinel Event Alert 59: Workplace violence

  About 75% of workplace assaults occur in the healthcare and social service sector each year, and...

• Case study: Saint Anthony cuts a swath through catheter infections with hospitalwide huddles

  In just two years, Saint Anthony Hospital in Chicago faced down HAIs, cutting its HAI rate by 90...

• NFPA 3000: The newest active shooter standard

   Spurred by coordination problems identified after several recent mass shootings, National...

• SAMHSA: Patient consent now required for substance abuse records

   Appropriate sharing of records for patients with substance abuse disorders should be easier...

• Technology and hand hygiene compliance

  Lutheran is among the healthcare organizations nationwide that in recent years decided to try hand...

Issue 6, June 1, 2018 - VIEW THE FULL ISSUE

• Switching AOs: Kettering Health answers why they changed from Joint Commission to HFAP

   Kettering Health Network (KHN) is a non-profit network of eight hospitals, 10 emergency...

• Longtime accrediting organization to keep its name, continue to expand

   The Healthcare Facilities Accreditation Program—also commonly known as HFAP—will...

• Joint Commission: Sentinel events declined again in 2017

  The Joint Commission recently released its final sentinel event statistics for 2017. The same...

• AORN guidelines on unintended retention of a foreign body focuses on counting and communication

   Patients continue to be stitched closed with surgical sponges, gloves, needles, electrodes...

• Case study: Reducing falls by engaging patients

  The good news is that patient falls are largely preventable. Doing so can save patients undue pain...

• Check(list) your ER for suicide risks

   With the renewed focus on ligature and self-harm, facilities need to undergo a complete...

• Struggling with standards: Almost two-thirds of hospitals are not compliant with EC, LS requirements

   Almost two-thirds of the hospitals surveyed in 2017 were found noncompliant in at least...

Issue 5, May 1, 2018 - VIEW THE FULL ISSUE

• Congress wants answers from CMS, AOs on hospital patient safety

   If you thought The Joint Commission and other accrediting organizations (AO) were already...

• Study: Recounting the cost of CAUTIs

   While most say the average cost of treating a CAUTI is $1,000, that figure is likely too low...

• CMS and Joint Commission clarify door-closing devices standards

   Examine all automatic door arrangements in light of the newest clarification on fire doors...

• Q&A: A little more on texting PHI

   Earlier this year there was some confusion over CMS’ texting policies. The agency later...

• Part 2: ECRI's top tech hazards list 2018

  The ECRI Institute published its annual list of the top 10 health technology hazards for the...

Issue 4, April 1, 2018 - VIEW THE FULL ISSUE

• Joint Commission: Test pregnant women for HIV and syphilis before childbirth

  On July 1, 2018, The Joint Commission will implement three new elements of performance (EP) for...

• Q&A: Dealing with sexual harassment in healthcare

  Ideally, everyone could go to work without having to worry about harassment and reprisal. But since...

• Young and old: Ex-surveyor worries about where CMS applies ligature risk definition

  One of the major concerns former Joint Commission surveyor Ernest Allen has with CMS’ new...

• Part 1: ECRI's top tech hazards list 2018

  The ECRI Institute published its annual list of the top 10 health technology hazards for the...

• Clean hands or RFI: Joint Commission not playing around with hand hygiene

  Thanks to a January rule change, if a Joint Commission surveyor sees anyone who directly cares for...

Issue 3, March 1, 2018 - VIEW THE FULL ISSUE

• When police and physicians clash

  A working relationship with law enforcement is key to the safety, efficacy, and wellbeing of...

• CMS defines ligature risk in new memo

  When it comes to preventing patient suicides, CMS has not been idle. In December 2017, the agency...

• CMS clarifies rules on texting patient info

  CMS confirmed that care team members are allowed to text patient information over a secure...

• Taking a second look at overlapping surgeries

  New studies show overlapping surgery isn’t as risky (or as time saving) as once thought.

Issue 2, February 1, 2018 - VIEW THE FULL ISSUE

• It takes two to tango (or qualify as a hospital)

  The difference between being accredited as a hospital or as an outpatient center can mean a...

• CMS updates State Operations Manual for first time since 2015

  For the first time in two years, the online version of CMS’ State Operations Manual, Appendix...

• Joint Commission updates education, EM requirements

  The latest update to The Joint Commission’s Comprehensive Accreditation Manual for Hospitals...

• Q&A: Patient involvement and representatives

  Involving patients in their care isn’t just polite, it’s a CMS requirement.

• Chain of command: Succession planning must be specific to leadership role, not an individual

  You’re working at a hospital during an emergency (e.g., a hurricane). But the person...

• Six steps to beat computer viruses

  CMS issued a warning to hospitals and other providers to tighten up cybersecurity and issued...

• Using fear to teach cybersecurity

  Hospitals should test staff’s cybersecurity chops by sending them spam emails and seeing who...

Issue 1, January 1, 2018 - VIEW THE FULL ISSUE

• New suicide risk expectations from Joint Commission in aftermath of sentinel events stats

  Review your policies and procedures for treating suicidal patients in general acute inpatient and...

• Not out to pasture: George Mills stays in the game after leaving Joint Commission

  George Mills, MBA, FASHE, CEM, CHFM, CHSP, who had served as director of engineering since The...

• Communication breakdown: Sentinel Event Alert calls out bad patient handoffs

  In September, The Joint Commission published Sentinel Event Alert 58, warning healthcare...

• Hospitals need to test for Legionella

  As we begin 2018, it’s time to crack down on the spread of waterborne pathogens such as...

• BOAQ 2017 Index

  Most would agree 2017 was a long and bizarre year and looking ahead, there’s plenty of news...