Association for Healthcare Accreditation Professionals

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Solar Eclipse: Prepare for eye injuries

Mon, 08/21/2017 - 20:23
Healthcare providers should be on the lookout (no pun intended) for patients complaining of eye trouble over the next few days.  Monday, August 21, a total solar eclipse will occur over the continental United States, the first one to do so since 1918. Over 12 million of people will be able to see the sun completely [...]

New may not be better: hospital returns to paper and happier docs

Wed, 08/16/2017 - 16:00
The Illinois Pain Institute (IPI) was having trouble with its electronic health records (EHR). So they got rid of them and went back to paper. And they aren’t planning on going back anytime soon. Two years ago, all 70 members of the IPI voted unanimously to get rid of its EHR saying it was slowing down [...]

Fire and smoke: CMS clarifies which doors must be inspected annually

Tue, 08/15/2017 - 23:48
After pushback, federal officials backed away from their claim that smoke barrier doors must be inspected and tested annually. More than three weeks after a well-publicized compliance deadline passed, CMS announced Friday that the deadline would be pushed back nearly six months, giving facilities until New Year’s Day 2018 to comply with an annual testing requirement [...]

Joint Commission revises Medication Management EPs

Wed, 08/09/2017 - 16:34
The Joint Commission has revised Medication Management elements of performance (EP) for several of its programs. The changes will go into effect on January 1, 2018 and will impact hospitals, ambulatory care, behavioral care, home care, nursing care centers, critical access hospitals, and office-based practices accredited by The Joint Commission. The revisions will require organizations to: •    [...]

AAMI takes action on medical cart fires

Tue, 08/08/2017 - 19:30
Last year, the Food and Drug Administration (FDA) released a report warning that mobile medical carts have been overheating, igniting, smoking, burning, or exploding. This July, the Association for the Advancement of Medical Instrumentation (AAMI) responded by convening a group of experts to talk about this new fire hazard. Similar to the infamous Samsung Galaxy 8, [...]

CMS withdraws proposal to have AOs post survey reports online

Thu, 08/03/2017 - 19:24
A proposal by CMS to have accrediting organizations (AOs) post the details of survey reports online was withdrawn by the agency, not because of negative comments — although there were plenty — but because, well, it might be prohibited under federal law. CMS first made the proposal in April, tucking it into the latter pages of [...]

Policies for the Use of Personal Mobile Devices in Surgical Suites

Mon, 07/31/2017 - 20:55
Written by Anne V. Irving, MA, FACHE, CPHRM, DFASHRM and published in PSQH  Human factors studies indicate that distractions and multitasking increase the likelihood of error (Feil, 2013; Wiegmann, ElBardissi, Dearani, Daly, & Sundt, 2007). Allowing personnel to bring their cell phones, smartphones, or other mobile devices into a surgical suite introduces a new distraction into [...]

Celebrating World Hepatitis Day 2017

Sat, 07/29/2017 - 00:23
July 28 is World Hepatitis Day, and the World Health Organization (WHO) and the Joint Commission have reaffirmed their commitment to eradicating Hepatitis B and C by 2030. The WHO says there’s promising data coming out of the 28 countries that represent 70% of the global hepatitis burden. Nearly all of those countries have established high-level [...]

Joint Commission: Half of blood transfusions are unnecessary and cost millions  

Fri, 07/28/2017 - 20:54
Hospitals could save more than $1 million per year by eliminating unnecessary red blood cell (RBC) transfusions, according to a new study. Blood transfusions are the most frequently performed hospital procedure in the country and costs $1,000 per unit of blood. Transfusions also come with potential health risks like allergic reactions, fever, and iron overload. A [...]

NQF launches opioid stewardship initiative

Tue, 07/25/2017 - 00:41
The National Quality Forum earlier this month announced the creation of an Opioid Stewardship Action Team. The team will summon experts together to develop new best practices, strategies, and tactics to curb the opioid epidemic in America. “As an emergency medicine doctor, I’ve seen first-hand the devastating effects of opioid misuse on our nation’s health, and it is [...]

Options to CMS’ proposed transparency rule

Wed, 07/19/2017 - 00:58
This April, CMS sent out a memo with big proposals for accrediting organizations (AO). If passed, The Joint Commission, DNV, HFAP, and others would have to post final survey reports online within 90 days of that information becoming available to the healthcare organization. However, The Joint Commission and accreditation specialists have voiced worries that the move creates an [...]

(TBT) Diffusing disruptive physician behavior

Fri, 07/14/2017 - 02:09
Disruptive behavior can come in a variety of forms, from yelling and inappropriate language to physical altercations in the worst-case scenario. A report released in May by QuantiaMD indicated that disruptive physician behavior is still an issue in hospitals around the country. The report surveyed more than 840 physicians and physician leaders at QuantiaMD and the [...]

Patient Medication Errors Double

Mon, 07/10/2017 - 23:32
The most common errors were taking or giving the wrong medication or incorrect dosage, and inadvertently taking or giving a medication twice. One-third of medication errors resulted in hospital admission. The frequency of serious medication errors by patients or their caregivers outside of a healthcare setting more than doubled from 2000 to 2012, according to a [...]

Uniqueness is not unique

Fri, 06/30/2017 - 01:55
Editor’s Note: This is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation!  With all the regulatory and reimbursement changes occurring in our industry at an ever-increasing rate, one thing is for certain: Your organization is not unique. When speaking to organizations, I often hear [...]

Maintaining security during a Joint Commission survey

Thu, 06/29/2017 - 17:30
Facilities often have questions when surveyors come to visit. Some of the most frequently asked questions involve security and confidentiality, how to make sure surveyors see what they need to without violating hospital safety. In the July issue of Perspectives, The Joint Commission answered some of the most frequent questions. Access to Computer Systems: Surveyors will [...]

Joint Commission: Six EPs deleted for Critical Access Hospitals

Wed, 06/28/2017 - 23:28
Later this year The Joint Commission will delete six elements of performance (EPs) from the Distinct Part Unit (DPU) standards for Critical Access Hospitals. The accreditor says this will streamline the standards and the changes go into effect on September 24, 2017. The deleted EPs are from the Medical Staff, Leadership, and Rights and Responsibilities of [...]

The Focused Standards Assessment tool goes temporarily offline in July

Mon, 06/26/2017 - 23:28
The Focused Standards Assessment (FSA) tool on The Joint Commission’s Intracycle Monitoring (ICM) Profile will be taken offline from June 30, (5:00 PM Central Time) through  July 10 (9:00 PM CT) The FSA is an interactive standards self-assessment tool for facilities that lists the standards applicable to each organization’s accredited programs and services. An extension due [...]

(TBT) Checklists: Easy to take for granted

Thu, 06/22/2017 - 23:04
Editor’s Note: This is a free Briefings on Accreditation and Quality article from yesteryear! If you like it, check out more of our work covering quality and accreditation!  In any organization’s quality department there lives a nefarious, ever-present beast. It’s usually in paper form and comprises a list of seemingly innocuous phrases or sentences and to the far right [...]

CMS releases interpretive guidance on emergency preparedness

Tue, 06/20/2017 - 23:15
CMS unveiled interpretive guidance and survey procedures on its emergency preparedness rule. The emergency preparedness rule went into effect last November. The interpretive guidelines apply to all 17 provider and supplier types. Read the full memo here. 

Joint Commission Updates on HAI-related National Patient Safety Goal on HAIs

Tue, 06/20/2017 - 20:13
The Joint Commission has revised several of its requirements for National Patient Safety Goal (NPSG) 7, which focuses on the issue of healthcare-associated infections (HAI). The revisions go into effect on January 1, 2018, and apply to hospitals, critical access hospitals (CAH), and nursing care centers (NCC). NPSG 07.03.01: Multidrug-resistant organisms (MDRO) •    NCCs are now expected [...]

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