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

Inside Accreditation & Quality

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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

Roundup: Survey tips, changes, and news

July 25, 2023

Accreditation & Survey Preparation

The Joint Commission (TJC) has announced staff members are no longer required to wear a mask during surveys and that standards revisions continue. ...

Inside Accreditation & Quality

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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...

Inside Accreditation & Quality

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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

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

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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

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

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Issue

Ask your pharmacy team about USP compliance ahead of November 1 deadline

September 05, 2023

Accreditation & Survey Preparation

Sit down with pharmacy leadership and review section-by-section compliance with the revised U.S. Pharmacopeia (USP) standards on medication compounding because The Joint Commission (TJC), the Accredit...

Inside Accreditation & Quality

- Volume

Issue

Use available databases to track drug shortages in wake of disasters and international events

September 12, 2023

Natural & Manmade Disasters, Quality & Errors

With the scarcity of many drugs reaching an all-time high, 99% of hospital pharmacists surveyed recently said they were seeing shortages, and a third of those said the shortages were having a critical...

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

Roundup: Survey tips, changes, and news

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

CMS stresses unannounced surveys, wants complaints investigated on-site

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

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

TIps for getting leadership to act on lab safety issues

Ask your pharmacy team about USP compliance ahead of November 1 deadline

Use available databases to track drug shortages in wake of disasters and international events

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