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

Inside Accreditation & Quality

- Volume

Issue

Rely on CMS memos to keep updated on CoP expectations

February 08, 2022

Accreditation & Survey Preparation

Expect hospital accrediting organizations to continue to update their standards, especially to align more with the language in CMS Conditions of Participation. ...

Inside Accreditation & Quality

- Volume

Issue

(Updated) Are your surveyors vaccinated? Probably, but please don’t ask

February 15, 2022

Accreditation & Survey Preparation

CMS has officially put out guidance to its own state survey agencies that all its on-site surveyors should be fully vaccinated, and it expects the same of accrediting organizations (AO). However, acco...

Inside Accreditation & Quality

- Volume

Issue

Should you centralize credentialing through a CVO?

February 22, 2022

Accreditation & Survey Preparation

by Dom Nicastro Is it time to move toward a centralized verification organization (CVO)? Many organizations are doing so to streamline the credentialing process, reduce administrative redundancies,...

Inside Accreditation & Quality

- Volume

Issue

Expert resources and tips for vaccine mandate compliance

February 01, 2022

Accreditation & Survey Preparation

The Joint Commission (TJC) surveyors have been true to their promise to begin surveying to the new COVID-19 vaccine requirement as soon as it became effective, and hospitals are already being scored f...

Inside Accreditation & Quality

- Volume

Issue

Avoid deficiencies for COVID-19 staff vaccinations with tracking, documentation

February 01, 2022

Accreditation & Survey Preparation

by A.J. Plunkett (aplunkett@decisionhealth.com) Understand who is supposed to be vaccinated and when, and establish a way to securely track and update your list of vaccinated staff as you anticipat...

Inside Accreditation & Quality

- Volume

Issue

Improve your document control to increase survey efficiency

December 18, 2025

Accreditation & Survey Preparation, Policies and Procedures

One of the hardest parts of being a compliance officer can be keeping track of policies, procedures, logs, maintenance, equipment checks, and other documents that can mean the difference between a suc...

Inside Accreditation & Quality

- Volume

Issue

CMS warns they expect vaccine requirements to be enforced or will impose penalties on states

March 15, 2022

Accreditation & Survey Preparation

One way or another, CMS is promising states that it will enforce its recent interim final rule requiring hospital and other healthcare staff caring for COVID-19 patients to be fully vaccinated. CMS pu...

Inside Accreditation & Quality

- Volume

Issue

Master physician performance reviews

March 22, 2022

Accreditation & Survey Preparation, Quality & Errors

Short of terminating a physician’s employment, appraising a physician’s performance is often the responsibility that administrative and medical staff leaders hate most. For many physicians, the phrase...

Inside Accreditation & Quality

- Volume

Issue

Guest columnist: Asking the wrong safety questions

December 18, 2025

Many years ago, I was hired to perform a safety audit for a laboratory. As I walked through one department, an employee asked what I was doing. When I remarked that I was looking for safety issues to ...

Inside Accreditation & Quality

- Volume

Issue

Review endoscope cleaning policies now that AAMI has updated its standard

April 05, 2022

Accreditation & Survey Preparation, Infection Control

You may need to update your policies, processes, and procedures for the cleaning and storage of endoscopes now that the Association for the Advancement of Medical Instrumentation (AAMI) has an updated...

Rely on CMS memos to keep updated on CoP expectations

(Updated) Are your surveyors vaccinated? Probably, but please don’t ask

Should you centralize credentialing through a CVO?

Expert resources and tips for vaccine mandate compliance

Avoid deficiencies for COVID-19 staff vaccinations with tracking, documentation

Improve your document control to increase survey efficiency

CMS warns they expect vaccine requirements to be enforced or will impose penalties on states

Master physician performance reviews

Guest columnist: Asking the wrong safety questions

Review endoscope cleaning policies now that AAMI has updated its standard

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

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