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

Inside Accreditation & Quality

- Volume

Issue

A patient complaint investigation is likely—what are your first steps?

December 18, 2025

Accreditation & Survey Preparation

If you have reason to believe your hospital may be subject to a complaint investigation by your accrediting organization (AO) or CMS, the best strategy is to be prepared with documentation, including ...

Inside Accreditation & Quality

- Volume

Issue

Quality review: Most frequent ACHC deficiencies fall under infection control

February 26, 2024

Accreditation & Survey Preparation, Infection Control

Almost 90% of hospitals surveyed by the Accreditation Commission for Health Care (ACHC) between June 1, 2022, and May 31, 2023, were cited for deficiencies under one of the accrediting organization’s ...

Inside Accreditation & Quality

- Volume

Issue

The transformation of healthcare accreditation: Milestones and future directions

January 16, 2024

Accreditation & Survey Preparation

In this Q&A session, we delve into the intricate world of healthcare accreditation with Kurt Patton, MS, RPh, founder and president emeritus of Patton Healthcare Consulting. With a rich history at...

Inside Accreditation & Quality

- Volume

Issue

Get hospital lawyer to help set parameters of QAPI program disclosures

November 20, 2023

Accreditation & Survey Preparation, Quality & Errors

Determining how your facility addresses requests for information about how it complies with CMS’ Quality Assessment and Performance Improvement (QAPI) Conditions of Participation (CoP) while protectin...

Inside Accreditation & Quality

- Volume

Issue

Address healthcare worker compassion fatigue and secondary traumatic stress

November 27, 2023

Leadership & Finance, Behavioral & Mental Health, Healthcare Staff

Healthcare workers are no strangers to burnout and suicide as many suffer from emotional exhaustion and mental and physical stress due to the demanding nature of their job, including long working hour...

Inside Accreditation & Quality

- Volume

Issue

Decoding the language of care: How accreditation leaders uphold healthcare excellence

December 05, 2023

Accreditation & Survey Preparation

The pivotal role of accreditation leaders is undeniable in ensuring patient outcomes and institutional integrity. Tasked with navigating the maze of regulations and standards, these leaders are fundam...

Inside Accreditation & Quality

- Volume

Issue

TJC: Place focus on clinical care as much as mitigating physical self-harm risks

December 11, 2023

Accreditation & Survey Preparation

Reducing physical risks for self-harm remains a key part of meeting CMS requirements to provide patient care in a safe setting, but don’t focus everything on ligature risk. ...

Inside Accreditation & Quality

- Volume

Issue

CMS, accreditors update part of process for ligature risk deficiencies

December 19, 2023

Accreditation & Survey Preparation, Patient Safety

Hospitals no longer must worry about new—or in some cases even old—ligature risk extension requests (LRER) for deficiencies that cannot be corrected within 60 days. However, hospitals still need to pe...

Inside Accreditation & Quality

- Volume

Issue

Monitor your accreditation compliance continuously

January 22, 2024

Accreditation & Survey Preparation, Quality & Errors

Continuous readiness, including a mock survey approach that fully integrates the tracer methodology, is a good way to take a snapshot of the organization’s compliance, remind staff of the survey proce...

Inside Accreditation & Quality

- Volume

Issue

ACHC highlights cited deficiencies at ambulatory surgery centers

February 12, 2024

Accreditation & Survey Preparation

Ambulatory surgery centers (ASC) accredited by the Accreditation Commission for Health Care (ACHC) are being reminded of the importance of having complete documentation in patients’ medical records. ...

A patient complaint investigation is likely—what are your first steps?

Quality review: Most frequent ACHC deficiencies fall under infection control

The transformation of healthcare accreditation: Milestones and future directions

Get hospital lawyer to help set parameters of QAPI program disclosures

Address healthcare worker compassion fatigue and secondary traumatic stress

Decoding the language of care: How accreditation leaders uphold healthcare excellence

TJC: Place focus on clinical care as much as mitigating physical self-harm risks

CMS, accreditors update part of process for ligature risk deficiencies

Monitor your accreditation compliance continuously

ACHC highlights cited deficiencies at ambulatory surgery centers

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