Association for Healthcare Accreditation Professionals

The requirements of standard LD.04.04.05 EPs 1, 7, and 13 mandate that governance receives an annual report encompassing not only system and process failures, but also sentinel event information, degree of family involvement, and actions taken to improve safety as well as the adequacy of staffing. Although the former indicators are available to track, such as patient/family complaints and a number of falls, it is not necessary to track them specifically.

The Joint Commission has unveiled its latest entry in its Speak Up ™program. Released on February 1, 2012, this latest educational campaign will focus on “What you should know about stroke.” Developed in conjunction with the American Academy of Neurology, American Association of Neuroscience Nurses, American Heart Association/American Stroke Association, National Stroke Association and NIH/National Institute [...]

CMS has updated its Hospital Compare website in order to include central line-associated bloodstream infection (CLABSI) data provided by hospitals. Hospitals must report CLABSI rates for adult, pediatric and neonatal intensive care unit patients to receive a full payment update in fiscal year 2013 under the inpatient prospective payment system. Hospitals with ICUs and are participating [...]

The 6th Annual AHAP Conference, to be held May 10–11, 2012, at the Hilton at The Walt Disney World Resort® in Orlando, FL, will include a poster session as part of its conference offerings. It’s an informal way for hospitals to share their accreditation- and survey-related successes with each other, network, and exchange ideas and information.

The American Association of Clinical Chemistry Clinical Point of Care Testing (CPOCT) Division is accepting nominations for their 2012 Point of Care Coordinator of the Year Award. Nominations are due March 15. For more information on how to nominate a colleague, visit here.

The Joint Commission has released communication guidelines for the organization’s Certified Primary STroke Centers and Advanced Certification in Heart Failure programs. These guidelines are intended to help organizations in these programs accurately and credibly portray their certifications. The guidelines can be downloaded here.

Not-for-profit hospitals in the US face increasing financial pressures, two top credit rating agencies reported n January. Moody’s Investors Service reports that the outlook for hospitals looks negative for 2012, and Standard & Poor’s Rating Service says that “an increasingly difficult operating environment” will adversely impact hospital credit quality and ratings. Among the challenges identified by [...]

The Centers for Medicare and Medicaid Services (CMS) will, beginning this month, require some organizations to report specific quality indicators, such as healthcare-associated infections (HAI). The requirements come through the Center for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN). The requirements vary depending on the type of facility. For example, acute care facilities [...]

The Joint Commission has unveiled prepublication standards, effective July 1, 2012, to Leadership chapter standard LD.03.01.01. LD.03.01.01 addresses leadership’s role in maintaining a culture of safety and quality. The revisions effect The Joint Commission’s ambulatory, behavioral, critical access, hospital, home care, laboratory, long term care, and long term care (Medicare/Medicaid certification-based), and office-based surgery programs. For more [...]

The Joint Commission has released revisions to the elements of performance (EP) of application for deeming authority for clinical laboratories. The changes followed a review of the application and are intended to help meet Clinicial Laboratory Improvement Amendments of 1988 (CLIA) and apply to the LD and QSA standards. For more information, visit The Joint Commission’s website.

I just wanted to give you an update on a few resources that HCPro and AHAP is offering that might be of huge benefit to you. There have been a lot of changes, updates, and new NPSGs coming your way from The Joint Commission and CMS, and we’ve got a lot of good stuff going on in the upcoming months to help you stay on top of it. Here are some things that may be of interest to you:

The Joint Commission has announced the names of its incoming Board of Commissioners for 2012. The organization has also decided this year to make its field representatives in three areas–long term care, behavioral health, and home care–all full voting members. “Our new Commissioners all have a deep understanding of the complexities and challenges facing health care [...]

According to a report released by the Illinois Hospital Association, Illinois hospitals contributed over $4.6 billion in community benefits between 2009 and 2010. This was an increase of 26% since 2005. The report looks at 109 hospitals in the state which are required to to file community benefit reports with the state. The benefits identified in [...]

The California Department of Public Health (CDPH) has released six reports on data from California hospitals on a range of healthcare-associated infections, including central-line associated bloodstream infections (CLABSI), Methicillin-resistant Staphylococcus aureus (MRSA), and surgical site infections (SSI), among others. “These reports provide the most detailed picture yet of healthcare-associated infections in California’s hospitals,” Ron Chapman, MD, [...]

Effective January 1, 2012, two new accreditation decision rules have been approved by The Joint Commission for the Contingent Accreditation decision category. Both require the organization in question to resolve its Contingency Status within one year. The first of these new rules applies to an organization has completed its first Joint Commission survey for deemed status and [...]

The Joint Commission has released the 2012 Survey Activity Guide. This annual publication, made available directly through The Joint Commission’s website, is intended to help hospitals prepare for their on-site survey. The guide also includes a list of activities during an on-site, suggested participants, objectives, and a general overview of the session. For more information on the [...]

National Patient Safety Goals (NPSG) for 2012 in an easy-to-read version. Goals for 2012 include identifying patients correctly, improving staff communication, using medications safely, preventing infections, identifying patient safety risks, and preventing mistakes in surgery.

One of AHAP’s sister blogs, the Patient Safety Monitor Blog, has a fantastic post by writer Tami Swartz we wanted to share: Everyone knows that texting while driving is dangerous—and illegal in many states. It’s obvious why: The driver gets distracted and takes his or her eyes–and mind–off the road. But what about frontline care staff? Can [...]

The federal government has agreed to pay a 47 year old veteran $275,000 after two towels were left behind inside him after surgery to remove a cancerous kidney. The surgery occurred at Louis Stokes VA Medical Center in Cleveland, OH, in May of 2008. The hospital has since implemented a radio frequency identification chip system that tracks [...]

The Joint Commission’s latest Sentinel Event Alert targets an issue that has been oft-discussed in recent years: healthcare worker fatigue and patient safety. Many studies have shown not only that extended work hours not only lead to worker fatigue, and from there, a loss of productivity–they also increase the opportunity for adverse events. The Joint Commission’s Sentinel Event [...]