All Entries in the "Accreditation" Category
Verbal Orders in Outpatient Settings
As more care is provided in outpatient settings, where on-site physician presence may be sporadic, the need to obtain verbal or telephone orders is on the rise.
Multi-Dose Vials: Multiple Compliance Targets
The Joint Commission (TJC) recently released answers to many common questions about the correct storage, use, and disposal of multi-dose vials in clinical settings. While this information will settle several uncertainties, achieving compliance may still be a challenge.
New CMS Anesthesia Regulations: Pre- and Post-anesthesia Evaluation
This article discusses pre- and post-anesthesia evaluations and is the fourth installment in a series outlining compliance challenges associated with the new CMS Anesthesia Services CoPs.
New CMS Anesthesia Regulations: Responsibilities of the Anesthesia Services Department
This article discusses responsibilities of the Anesthesia Services Department as part of a four-part series outlining compliance challenges associated with CMS’s new Anesthesia CoPs.
New CMS Anesthesia Regulations: Anesthesia Administration and Privileging Practitioners
This second post in a four-part series discusses who can administer anesthesia and how they should be privileged in order to comply with new CMS Anesthesia Services CoPs.
New CMS Anesthesia Regulations: Defining Anesthesia Services
CMS has issued changes to its Anesthesia Services CoPs. This first post in a four-part series clearly defines both anesthesia and sedation to help hospitals assess vulnerabilities in these areas.
Security for Syringes and Sharps: The Regulatory Expectations
While regulatory standards govern the appropriate use of syringes and sharps, no specific regulations require that syringes be totally absent in any location. The lack of regulations about the location of sharps does not, however, remove the hospital’s responsibility for safeguarding sharps and syringes.
TJC and CMS Survey Expertise Coming to A City Near You
Compass Clinical Consulting’s Practice Leader for Accreditation and Regulatory Compliance, Ruth Elzer, RN, MS, will be speaking at seminars across the country this summer. Check out the following events for the most recent information regarding compliance with the standards of The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS).
Journal of Healthcare Management Features “Guide to CMS Compliance” by Compass Clinical Consulting Accreditation Expert Ruth Elzer
The Journal of Healthcare Management recently featured a column by Compass Clinical Consulting Practice Leader for Accreditation and Regulatory Compliance, Ruth Elzer, RN, MS. The column, which is included in the March/April edition of the journal, offers insight and practical advice and expert analysis on how to comply with regulations from the Centers for Medicare and Medicaid Services (CMS) in 2010.
Joint Commission Medical Staff Changes: A Few Surprises
Since The Joint Commission’s MS.1.20 Implementation Task Force was convened in December 2007, the group has been working to define which aspects of the management of the Medical Staff need to be written specifically into the bylaws, and which items can be adopted through rules, regulations and related documents. The recently announced changes to the MS.01.01.01 standard include a few modifications that will come as a surprise to some hospitals and require action before the March 31, 2011, effective date.
Compass Clinical Consulting CEO Discusses Medicare Termination at ACHE Congress
Kate Fenner, RN, PhD, CEO of Compass Clinical Consulting, will present with Alton Byers, MS, FACHE, at this year’s ACHE Congress on Healthcare Leadership. The presentation, “Medicare Decertification: A Hospital Near-Death Experience,” will focus on one hospital’s real-life crisis when faced with termination by the Centers for Medicare and Medicaid Services (CMS).
Choosing the Right Tool for Hospital Risk Assessment: Failure Mode and Effects Analysis
Parts I and II of this series outlined two tools for risk assessment and how each can assist in evaluating the impact of potential risks within a hospital. This installment will focus on Failure Mode and Effects Analysis (FMEA). This tool can be used to examine an event and its component parts to discover weaknesses and decrease the likelihood that they will occur.
Choosing the Right Tool for Hospital Risk Assessment: Focused Risk Vulnerability Analysis
by Amanda Brown, RN, MSM, CIC Part I of this series outlined the power of simple risk assessment to identify, mitigate, and eliminate hazards in the day-to-day operations of a hospital. Parts II and III will present approaches to risk assessment that are more complex and require more attention from multidisciplinary teams. In this installment, [...]
Choosing the Right Tool for Hospital Risk Assessment: Simple Risk Assessment
How can hospitals ensure that patients, employees, and visitors are safe in an environment rife with its own unique risks? The solution begins with risk assessment. This installment of our three-part series on risk assessment will describe the approach and tools that accompany simple risk assessment.
In 2010, Hospitals Must Take Patient Complaints Seriously
Both The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) require hospitals to arm patients and families with specific instructions about how to register complaints. These expectations have likely increased the volume of complaints processed over the last year. But, even more importantly, subtle changes in the content of complaints may pose a challenge for hospitals in 2010, particularly if the impact of these complaints is underestimated.
Rising Health Care Costs? In California, Sponges Can Cost $50,000 Guide Wires $100,000
There has long been talk of the link between quality of care and health care costs. While quantifying the benefit of improvements in quality and efficiency will continue to be difficult, hospitals in California are living the consequences of not addressing the most basic elements of safety.
Joint Commission Surveys: Unannounced – and in 2010 – Unplanned
So you heard that the survey process was unchanged for 2010. Not so fast. As it turns out, The Joint Commission’s (TJC) 2010 Survey Guide subtlety outlines a survey process that holds some surprises for the new year. The latest surprise includes a new challenge for hospitals, the requirement to develop an agenda with surveyors minutes before the survey begins.
National Patient Safety Goal 7: Three Easy Tips for Compliance
In 2009, three new requirements were added to NPSG 7 to aid in the ongoing campaign to prevent healthcare-associated infections. For each of these new requirements, there are three actions that Nurse Managers can take to facilitate compliance and – even better – protect patients.
Haunted by Hospital-Acquired Conditions?
Increasing the awareness of HACs and their impact on patients and the hospital is an important step toward focusing on HAC risk reduction. As Halloween approaches, consider adopting a “Haunted Ward” for in-service education.
Just When You Thought It Was Safe to Go Tracing
The evolution of other standards and increasing pressure from the Centers for Medicare and Medicaid Services (CMS) will force tracer teams to be more knowledgeable and skilled to protect their hospitals from unexpected survey results.
The Rising Costs of Poor Quality
The fines being levied in California and other states represent only one of the potential costs of poor survey results.
Good News, Bad News for System Surveys
The news from the Joint Commission’s Hospital Executive Briefings is always a mixed bag of information. This year is no different. Hospitals surveyed as part of a healthcare system, though, should brace themselves for a big change.
Deadly Policies, Part III: Communicating the Essential Messages
When caregivers understand policies they are more likely to follow them. Finding ways to efficiently highlight the essential messages ensures that clinicians receive the information they need in a way that supports understanding and compliance.
Deadly Policies, Part II: Writing Effective Policies
Writing policy calls for more than knowledge of the policy content – it requires an understanding of how to communicate the information most effectively.
Deadly Policies, Part I: The Gap Between Policy and Practice
Since The Joint Commission moved to the tracer methodology, forcing surveyors out of the board room and to the bedside, the gap between written policies and their implementation has widened.
Hospital Leaders Face Another Accreditation Challenge
The July edition of “The Joint Commission Perspectives” contained an ominous signal for hospital executives facing survey and accreditation decisions in the coming months. Of particular concern is the mention of situations in which the “surveyor has identified leadership changes over the past 12 to 18 months.”
Labels: Friend or Foe?
Requirements for the appropriate use of labels have been stepped up since the introduction of the National Patient Safety Goals (NPSGs), but hospitals are discovering that the requirements do not end there.
CMS Welcomes Comments on Joint Commission Deemed Status Application
By Ruth Elzer, RN, MS The Joint Commission (TJC) continues to work with the Centers for Medicare and Medicaid Services (CMS) to complete an acceptable deeming application for its hospital program. The Medicare Improvements for Patients and Providers Act for 2008 (MIPPA) revoked the Joint Commission’s statutory deeming status for its hospital program, mandating a [...]
EARN CASH for Joint Commission Compliance?
Earn cash for Joint Commission Compliance?
Well, not in the way that you think.
EARN CASH is a mnemonic device that outlines expectations for patient education in applicable patients. The expectations for the specific elements of patient education have gradually increased over the years and have now been combined under a single standard, PC.02.03.01.
What’s Cookin’ in the Hot Lab? Radioactive Eggs!
Recent consultation with several hospitals concluded with the discovery of radioactive food products being prepared and consumed in the nuclear medicine department. Further investigation and polling of others concluded that this could be happening in your organization.