Issue Browser | .accreditationqualitycenter

185

ARTICLES IN Inside Accreditation & Quality - VOLUME 6 ISSUE 4 - PRINT FULL ISSUE

Inside Accreditation & Quality

- Volume

Issue

Be prepared to discuss health equity efforts now that they are a National Patient Safety Goal

June 27, 2023

Accreditation & Survey Preparation

Remember health equity is now an NPSG and surveyors will want to discuss your hospital's ongoing plan. ...

Inside Accreditation & Quality

- Volume

Issue

Survey survival: Act to correct deficiencies before team departs for smoother plan of correction

July 04, 2023

Accreditation & Survey Preparation

Have a plan of action to correct as many deficiencies as possible before the survey team leaves your facility, recommends a compliance manager at a Midwest hospital that was surveyed earlier this spri...

Inside Accreditation & Quality

- Volume

Issue

Dog days: Training, clear policies, and procedures needed when using K-9s in hospitals

July 11, 2023

Accreditation & Survey Preparation

Consider carefully if your facility wants to add K-9 teams to enhance security, especially if those dogs may be used in patient restraint. ...

Inside Accreditation & Quality

- Volume

Issue

CMS reminds hospitals, survey agencies of discharge planning and procedure requirements

July 18, 2023

Accreditation & Survey Preparation

Brush up on discharge procedures and requirements, and review communication with post-acute care (PAC) providers, CMS says, including discharges to home health care. ...

Inside Accreditation & Quality

- Volume

Issue

Surveyors told to look beyond the ligature point to evaluate patient risk for self-harm

August 15, 2023

Accreditation & Survey Preparation

A new CMS Quality, Safety & Oversight group memo on suicide prevention urges hospitals to go above and beyond to help protect patients from themselves. Accrediting organizations like ACHC and TJC ...

Inside Accreditation & Quality

- Volume

Issue

TIps for getting leadership to act on lab safety issues

August 29, 2023

Environment and Facilities, Laboratory Safety

It can be frustrating to see safety issues go unnoticed or unattended, especially after they have been reported. The apparent roadblocks to solutions may be a lack of funds, busy or disinterested lead...

Inside Accreditation & Quality

- Volume

Issue

MRSA numbers growing: Review updated SHEA recommendations with leadership to control infections

August 22, 2023

Accreditation & Survey Preparation

Review the latest recommendations for controlling methicillin-resistant Staphylococcus aureus, more commonly known as MRSA, with your infection prevention and control team as well as your medical staf...

Inside Accreditation & Quality

- Volume

Issue

Beware of category 3: TJC executive offers update on sterile compounding requirements, Part 2

November 13, 2023

Accreditation & Survey Preparation

This is Part 2 of our coverage of revisions to U.S. Pharmacopeia (USP) <797> requirements for compounding sterile medication, which were discussed by Robert Campbell, PharmD, BCSCP, The Joint Co...

Inside Accreditation & Quality

- Volume

Issue

CMS stresses unannounced surveys, wants complaints investigated on-site

August 08, 2023

Accreditation & Survey Preparation

CMS is worried that hospitals have too much advance notice of when surveyors will be on the premises to audit patient safety practices and identify problems, including those found while investigating ...

Inside Accreditation & Quality

- Volume

Issue

CMS memo tightens requirements on unannounced surveys, catching AOs and hospitals by surprise

August 01, 2023

Accreditation & Survey Preparation

Keep required documents up to date and ready for surveyors, and have someone within the hospital leadership team available to come in on short notice once your hospital is within six months of its tri...

Be prepared to discuss health equity efforts now that they are a National Patient Safety Goal

Survey survival: Act to correct deficiencies before team departs for smoother plan of correction

Dog days: Training, clear policies, and procedures needed when using K-9s in hospitals

CMS reminds hospitals, survey agencies of discharge planning and procedure requirements

Surveyors told to look beyond the ligature point to evaluate patient risk for self-harm

TIps for getting leadership to act on lab safety issues

MRSA numbers growing: Review updated SHEA recommendations with leadership to control infections

Beware of category 3: TJC executive offers update on sterile compounding requirements, Part 2

CMS stresses unannounced surveys, wants complaints investigated on-site

CMS memo tightens requirements on unannounced surveys, catching AOs and hospitals by surprise

Resource/w tools selected

STET CMS & tools

OSHA Dental Facilities Update - November 2023

OSHA Medical Facilities Update - November 2023

Tab 2, Medical Facilities OSHA Manual- August 2023

Tab 2, Dental Facility OSHA Manual- August 2023

Chapter 2: Chapter Format and Tracer Planning