Ever since it was first introduced to The Joint Commission's Medical Staff standards in 2007, the concept of focused professional practice evaluation (FPPE) has been something of a bugbear for hospitals. In theory, this sort of quality analysis and review makes perfect sense, but implementation...
Briefings on Accreditation & Quality - Volume 23, Issue 6
In the quest to meet Joint Commission standards, it is very helpful to have a highly engaged medical staff. While usually not employed by the hospital, the medical staff is key to the hospital's success in meeting many of the Joint Commission standards. But how does a healthcare facility get...
Briefings on Accreditation & Quality - Volume 23, Issue 5
As Hurricane Irene came sweeping up the East Coast last summer, it was hard to imagine how widespread the storm's effects would be, particularly on states not usually heavily impacted by hurricanes. To be safe, precautions were made, but expectation for damage were low....
Briefings on Accreditation & Quality - Volume 23, Issue 5
In November 2011, The Joint Commission issued a revised version of standard IC.02.04.01, regarding the influenza vaccine for licensed independent practitioners (LIP) and staff. This standard applied to all accreditation programs.
It is once again time to take a close...
Briefings on Accreditation & Quality - Volume 23, Issue 5
Why is review of "other contraindications" important and what are some examples? Who is required to check for them? What tools can make identifying them easier, increasing the likelihood of both patients' safe use of medications and compliance with applicable elements of performance (...
Briefings on Accreditation & Quality - Volume 23, Issue 5
Two U.S. senators have called for the Department of Health and Human Services to convene a task force to develop strategies to reduce unnecessary hospitalization related to adverse drug events.
CMS recently amended tag number 508 in the hospital Conditions of Participation (CoP), which...
Briefings on Accreditation & Quality - Volume 23, Issue 4
In 2009, The Joint Commission added Leadership standard LD.03.01.01, ”Leaders create and maintain a culture of safety and quality throughout the hospital,” to recognize that behavior that intimidates others and affects staff morale and turnover can also be damaging to patient care, and to...
Briefings on Accreditation & Quality - Volume 23, Issue 4
Recently in this space, we talked about CMS’ changing stance on the so-called ”30-minute rule.” To follow up, we thought it was time to take a look at the Institute for Safe Medication Practices (ISMP) and its recently developed Acute Care Guidelines for Timely Administration of...
Briefings on Accreditation & Quality - Volume 23, Issue 4
During summer 2011, AHAP surveyed hospitals coast to coast to gauge how tracer methodology has evolved in recent years and how effective hospitals are finding this challenging, but often pivotal process. Seventy-two percent of respondents reported that they maintain formal tracer...
Briefings on Accreditation & Quality - Volume 23, Issue 4
Fatigue has recently been recognized in the medical literature to increase the incidence of adverse events. Fatigue is a widely recognized patient safety issue. Nurses who worked over 12 hours per day or 60 hours per week were found to have made three times the number of medical...
