In May, CMS released a set of updated clarifications to the often-challenging Anesthesia Services Conditions of Participation (CoP) Interpretive Guidelines.
These updates affected the following areas of Appendix A of the CMS State Operations Manual, section 482.52 a and b...
Briefings on Accreditation & Quality - Volume 21, Issue 8
Survey coordinators are challenged to help their organizations navigate accreditation requirements, assess their organization’s compliance, and coordinate survey visits. Today more than ever, with limited available resources, organizations must be sure that resources used to fix issues...
Briefings on Accreditation & Quality - Volume 21, Issue 7
When Northwest Texas Healthcare System (NWTHS) in Amarillo first made use of a tracer program, the concept was sound. However, obtaining complete buy-in and support turned out to be a challenge.
Briefings on Accreditation & Quality - Volume 21, Issue 7
On July 1, The Joint Commission resumed surveying for the new version of staffing effectiveness. Stating that it is continuing to research the issues related to staffing effectiveness, The Joint Commission expects that facilities have a process in place at this time. Yes, the requirement for...
Briefings on Accreditation & Quality - Volume 21, Issue 7
Education and training for hospital staff has always been time-consuming and costly for both organizations and personnel. When hospitals develop education and training for staff, they must make sure programs improve clinical practice and keep them updated regarding changes that occur in the...
Briefings on Accreditation & Quality - Volume 21, Issue 7
Facilities across the country struggle daily with the challenges inherent to the use of restraints. For Cancer Treatment Centers of America (CTCA) at Midwestern Regional Medical Center, the decision was made in 2005 to deal with restraints by simply going restraint free.
Briefings on Accreditation & Quality - Volume 21, Issue 6
When Heather Forbes, RN, BSN, CEN, CSHA, HACP, accreditation and regulatory coordinator at Southern Maine Medical Center (SMMC) in Biddeford, first took over the role of survey coordinator, she looked at the entire process of accreditation and asked one simple but encompassing question: “...
Briefings on Accreditation & Quality - Volume 21, Issue 6
In 2007, The Joint Commission issued the Focused Professional Practice Evaluation (FPPE) standard as a means to evaluate a privilege-specific competence of a practitioner who does not have documented competency executing the privilege. The October 2008 FAQs on FPPE (often referred to as...
Briefings on Accreditation & Quality - Volume 21, Issue 6
For years, the Medical Staff standard MS.01.01.01 has been a battleground for hospitals—an ongoing issue of bylaws versus rules and regulations and the right way for organized medical staffs, medical executive committees (MEC), and governing boards to interact.
Briefings on Accreditation & Quality - Volume 21, Issue 5
Core measures—they’re a part of the fabric of hospital life, particularly given their connection to CMS reimbursement numbers. All staff will have encountered core measures at some point, and have a basic understanding. But how do you ensure their knowledge level is up to date and sufficient to...