Q: Our assessment for compliance with the LSC has been made, and some deficiencies have been identified. The problem is that some of these deficiencies will take longer than 45 days to resolve. What should be my plan of action?
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...
The Joint Commission requires healthcare facilities to train employees annually. Part of that training includes best practices for infection control (IC), but effective training requires infection preventionists (IP) to employ training methods based on evidence-based best practices that yield...
The Agency for Healthcare Research and Quality (AHRQ) has released its most recent Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report, which includes responses from 1,128 hospitals and 567,703 hospital staff, 76% of whom have direct interaction with patients...
Despite sustained attention from hospital leaders, wait times in the University of California, San Francisco (UCSF) ED were considerably longer than desired. Knowing that longer wait times means poor patient satisfaction and a higher risk of poor health outcomes, a team of resident physicians...
The National Quality Forum (NQF) recently endorsed two outcomes-based measures from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). The measures, surgical site infections (SSI) and urinary tract infections (UTI), were created in partnership with CMS...
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
By now, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) is well known to the healthcare community. Hospital staff and physicians have long been practicing a strict standard of patient privacy.
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...
