Denise E. Smith, RN, MS, CLNC, HACP-CMS, Head of Consulting & Senior Consultant

Is Your Staff Competent and Can You Prove It?

The definition of competent is having the necessary ability, knowledge, or skill to do something successfully. Being competent on paper and being able to perform a necessary skill or job responsibility are two different things. Before you can be competent you must be educated, trained and a competency assessment performed. You need to have the […]

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Enzymatic Spraying of Instruments at Point of Use

You have finished the procedure, now what’s next? Prior to sending instruments to Sterile Processing, it is important to remember to remove as much blood and bioburden from the instruments and keep them moist during transport. With Personal Protective Equipment on, rinse or wipe the instruments with water. Never use saline as it will damage

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Managing Your Medical Staff’s OPPE and FPPE

  In 2008, The Joint Commission (TJC) implemented a new standard, MS.08.01.03, requiring detailed evaluation of practitioners’ professional performance as part of the process of granting and maintaining practice privileges in a healthcare organization. Although the standard took effect in 2008, many organizations continue to struggle to establish meaningful indicators and ensure these processes are

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Is Glove Disinfection Acceptable and Safe?

Since COVID-19, the shortage of personal protective equipment has become an issue for many organizations throughout the country. Disposable gloves are being disinfected between tasks using alcohol-based hand sanitizer. It might sound like an acceptable practice under the circumstances, but did you ever think about what the alcohol does to the gloves that you are

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What Does Contact Time or Wet Time Really Mean?

During mock surveys I always ask staff what the contact or wet time is for a particular disinfecting wipe. Unless they have changed products recently or are frequently getting different brands due to availability (a result of COVID-19) staff are able to verbalize the correct contact or wet time. The question is, do they know

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Cleaning and Preparing Ultrasound Transducers Between Patients

A frequently asked question on mock surveys is, “How do I know what type of cleaning and disinfection process is needed for my ultrasound transducers (probes)?” The use of diagnostic ultrasound imaging continues to expand beyond the conventional settings of radiology, cardiology, and obstetrics. Today, point-of-care ultrasound (POCUS) is widely utilized at the bedside throughout

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Get Ready for Your Next Survey

In preparing for your Joint Commission survey, it is always helpful to review the Survey Activity Guides published by the Joint Commission annually. These guides will not only assist you in preparing for survey but will also provide you with an abstract of each survey activity that includes logistical needs, session objectives, an overview of

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Cybercrime – Is Your IT System Secure?

Recently there has been a lot of news about cybercrime related to hospital IT systems. The American Hospital Association published a Special Bulletin recently updating hospitals of these attacks and the need to make sure that their IT systems are secure. This information comes from the Cybersecurity and Infrastructure Security Agency, the FBI and the

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Credentialing: How to Succeed

Credentials are documented evidence of licensure, education, training, experience, or other qualifications. Credentials can be in the form of a certificate, letter, official identification, or experience that confirms a practitioner is qualified to perform specific procedures or services. Once credentials are submitted along with the application and all other requested paperwork, the organization needs to

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Are Daily Anesthesia Machine Checks Needed?

To provide safe and reliable anesthesia to all patients undergoing surgery it is important to make sure that the anesthesia machine used is working properly.  Anesthesia outcome claims have decreased over the past two decades to less than 1% of claims according to the American Society of Anesthesiology (ASAHQ), with the most recent data publicized

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Why Antibiotic Stewardship is Important in the Ambulatory Care Setting

Understanding the Issue “Inappropriate antibiotic use and antibiotic resistance are major public health threats. In the United States, most antibiotic use occurs in ambulatory care and 30% to 50% may be inappropriate. The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotics by 50% by 2020. “    TA Rowe

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