Accreditation & Survey Preparation | .accreditationqualitycenter

Inside Accreditation & Quality

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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...

Healthcare Safety Leader

- Volume

Issue

Executive Briefing 2023: Top EC, LS findings offer insight to common survey problems

December 14, 2025

Accreditation & Survey Preparation, Environment and Facilities, Physical environment

Safety problems identified within the physical environment account for 60%–70% of deficiencies scored by The Joint Commission (TJC) during surveys, according to TJC statistics. However, in the first s...

Mac's Safety Space

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Mac’s Safety Space: Safety first: Managing surgical fire risks in the operating room

December 14, 2025

Accreditation & Survey Preparation, Fire & Life Safety

In general, I think it can be rather instructive when (and to what degree) our friends in Chicago modify an existing Sentinel Event Alert, particularly one that relates to the management of risks in t...

Mac's Safety Space

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Issue

Mac's Safety Space: Shoes are dropping—Effective management of ligature risks

December 14, 2025

Accreditation & Survey Preparation

Pretty much since 2017, I have been wishing, hoping, etc. for the ligature resistance pendulum to find itself in something close to a middle ground. The pendulum will always sway a bit, but I’m thinki...

Inside Accreditation & Quality

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Issue

Beware of category 3: TJC executive offers update on sterile compounding requirements, Part 1

November 07, 2023

Accreditation & Survey Preparation

The clinical director of The Joint Commission’s (TJC) Standards Interpretation Group is warning hospitals that one of the greatest risks for noncompliance under revisions to U.S. Pharmacopeia (USP) &l...

Accreditation & Quality Compliance Advisor

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Issue

What are hospitals required to report?

December 14, 2025

Accreditation & Survey Preparation, Quality & Errors

Hospitals must report adverse actions taken against the privileges of a physician or dentist to the National Practitioner Data Bank. They may choose to report actions against the privileges of other h...

Inside Accreditation & Quality

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Mock tracer for waived testing

December 14, 2025

Accreditation & Survey Preparation

Safety concerns and potential for erroneous errors have made the Waived Testing (WT) chapter a common area of focus for surveyors during patient tracers. Surveyors will observe staff while performing ...

Inside Accreditation & Quality

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Be Ready for the Unannounced Survey Process

October 30, 2023

Accreditation & Survey Preparation, Fire & Life Safety, Physical environment

As the result of a CMS directive, unannounced surveys for organizations started in 2006. If you are undergoing a deemed status survey, your visit will be unannounced except in certain circumstances, s...

Mac's Safety Space

- Volume

Issue

Mac's Safety Space: Risk assessments and the lessons of the past

December 14, 2025

Accreditation & Survey Preparation

In my mind’s eye, I always think that I’ve covered certain topics in posts gone by (and I suspect this is one of those recurring risk assessment themes), but some things just don’t seem to go away. ...

Inside Accreditation & Quality

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AAAHC toolkit highlights importance of credentialing and privileging in ASCs

December 14, 2025

Accreditation & Survey Preparation

To assist organizations in improving their credentialing and privileging processes, the Accreditation Association for Ambulatory Health Care (AAAHC) has released an updated version of its Credentialin...

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

Executive Briefing 2023: Top EC, LS findings offer insight to common survey problems

Mac’s Safety Space: Safety first: Managing surgical fire risks in the operating room

Mac's Safety Space: Shoes are dropping—Effective management of ligature risks

Beware of category 3: TJC executive offers update on sterile compounding requirements, Part 1

What are hospitals required to report?

Mock tracer for waived testing

Be Ready for the Unannounced Survey Process

Mac's Safety Space: Risk assessments and the lessons of the past

AAAHC toolkit highlights importance of credentialing and privileging in ASCs

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