Blogs

The Joint Commission is Returning to Pre-Pandemic Survey Procedures

As of March 15, 2021, The Joint Commission will be reverting back to pre-pandemic survey procedures in light of reduced cases of COVID-19 across the U.S. according to a message that was sent by Mark Pelletier, Chief Operating Officer and Chief Nurse Executive of The Joint Commission today. This return to pre-pandemic survey procedures means […]

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New Requirements on the Horizon: Resuscitative Services

On December 21, 2020, The Joint Commission published a new, updated version of their proposed Resuscitation Standards. Redesign of these standards began in early 2020 with the first opportunity to submit comments being concluded mid-year. While some of the revisions appear to be simple word-smithing opportunities, there are several changes, if adopted as written, that

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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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How to Keep Your Code Carts from Crashing and Burning

Being ready for situations where your patient requires resuscitation is critical. Staff complete training in basic/advanced life support, and some staff complete more advanced skills in pediatric and neonatal resuscitation, as appropriate. There has been increased focus on drills and simulation to better prepare the team in these life-saving measures. However, has anyone looked at

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Are Your Freezer/Refrigerator Logs Giving You Frostbite?

Ensuring that you store medications, food items, lab specimens, blood, and other items and supplies at appropriate temperatures in cold storage is essential to ensure your patients receive safe and effective product. However, maintaining a record of these temperature measurements seem to confound a lot of organizations out there. We frequently observe incomplete refrigerator/freezer logs

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PROPOSED REVISIONS FOR RESUSCITATION STANDARDS

The Joint Commission has proposed changes to the Resuscitation Standards for Hospital and Critical Access Hospitals. These changes were most recently released December 21, 2020. Since then TJC has opened the opportunity to provide feedback on these proposed standard changes. The window to submit your feedback will close on February 22, 2021. To provide feedback,

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Have We Crossed Over the Quality Chasm or Are We Hanging Mid-Air?

In November 1999, the Institute of Medicine (IOM) published their landmark report on the medical error crisis in U.S. healthcare called To Err Is Human: Building a Safer Health System. This was followed in March 2001 with an IOM report on healthcare quality called Crossing the Quality Chasm: A New Health System for the 21st

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Time Sensitive New Survey Guidance from CMS- Survey Suspensions

On January 20, 2021 CMS issued QSO 20-13 announcing new limitations to the conduct of allegation, accreditation and certification surveys. Accrediting Organizations are being advised to suspend their accreditation certification activities for the next 30 days at which point CMS will reevaluate and could extend the suspension for an additional 30-day period. Click here to

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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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Suicide Prevention – Are You Addressing the Risk?

January 2021 marks eighteen months since changes were initiated with more focus on NPSG 15.01.01, Reducing the risk of suicide. The changes in focus were in response to devastating statistics showing a trend of increasing rates of suicide. According to the Centers for Disease Control and Prevention (CDC) WISQARS Leading Causes of Death Reports, in

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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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The TJC and CMS Update 2020

While we have been dealing with Covid for the majority of 2020, some important information about CMS’s expectations of Accreditation Organizations (AOs) with Deeming Authority has come to light and while Covid remains a significant health risk, there are other patient safety focused standards that were slated for implementation in 2020 that were delayed to

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