Accreditation

Latest Issue of OR Manager
April 2019

Joint Commission moves THKR performance measures

Editor's Note The Joint Commission on March 6 announced that it is moving the inpatient and outpatient Total Hip and Total Knee Replacement (THKR) implementation guides from the performance measure webpage to the 2019 Specifications Manual for Joint Commission National Quality Measures. The Manual was published in February. The move will…

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By: Judy Mathias
March 11, 2019
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Joint Commission: March 15 is deadline for CY 2018 eCQM data submission

Editor's Note The Joint Commission on March 6 reminded organizations submitting CY 2018 electronic clinical quality measure (eCQM) data that the deadline is 8 pm CT on March 15. Two submission methods are available: Listed ORYX eCQM Vendor. Direct Data Submission Platform. There will be no extensions, and data cannot…

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By: Judy Mathias
March 7, 2019
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Joint Commission reinstates volume requirement for stroke center certification programs

Editor's Note The Joint Commission on January 23 announced that it is reinstating the individual mechanical thrombectomy volume eligibility requirement for the Thrombectomy-Capable Stroke Center (TSC) and Comprehensive Stroke Center (CSC) certification programs. The Joint Commission is also implementing a revised volume requirement in 6 months that expands which physicians…

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By: Judy Mathias
January 24, 2019
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Joint Commission seeks comments on new antimicrobial stewardship requirements

Editor's Note The Joint Commission on January 9 announced that it is seeking feedback on its newly proposed requirements for antimicrobial stewardship at Medication Management (MM) standard MM.09.01.03. The requirements apply to ambulatory healthcare organizations and office-based surgery practices. The proposed requirements align with current recommendations from scientific and professional…

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By: Judy Mathias
January 14, 2019
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Joint Commission: New R3 Report goes in-depth on pain assessment, management standards

Editor's Note The Joint Commission announced on January 9 the publication of a new R3 Report to help organizations better understand the new and revised pain assessment and management standards that will be effective July 1, 2019. The R3 Report, which is for behavioral healthcare organizations, nursing care centers, and…

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By: Judy Mathias
January 10, 2019
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Joint Commission to begin publicly reporting C-section rates

Editor's Note The Joint Commission announced on December 19 that, effective July 1, 2020, it will begin publicly reporting hospitals with consistently high C-section rates on"Quality Check," using hospital data reported during CY 2018 and 2019. The Joint Commission began requiring accredited hospitals to collect and submit data on the…

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By: Judy Mathias
January 3, 2019
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Joint Commission launches webpage covering four high-risk areas

Editor's Note The Joint Commission on December 19 launched a webpage that covers four high-risk areas that surveyors evaluate. The “4-1-1 on Survey Enhancements” interactive page provides resources for: Sterile medication compounding Suicide prevention High-level disinfection and sterilization Hemodialysis. The Joint Commission enhanced its evaluation of these high risk areas…

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By: Judy Mathias
January 2, 2019
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Joint Commission surveys now seek evidence of performance

In the past few months, the Joint Commission has implemented a new process for accreditation surveys and changed the wording and interpretation of some standards, particularly infection control. At the 2018 OR Manager Conference in Nashville, Tennessee, in September, John R. Rosing, MHA, FACHE, executive vice president and principal of…

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By: Judith M. Mathias, MA, RN
December 13, 2018
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Joint Commission announces new requirement for THKR certification

Editor's Note The Joint Commission on November 7 announced a new requirement of participation in a national joint replacement registry for its advanced Total Hip and Total Knee Replacement (THKR) certification, effective July 1, 2019. The Disease Specific Care Performance Measurement (DSPM) standard DSPM.4, element of performance (EP) 2 will…

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By: Judy Mathias
November 8, 2018
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DVN GL announces first US sterile processing certification

Editor's Note Healthcare accreditation organization DNV GL Healthcare on November 7 launched the first sterile processing program certification in the US. The program recognizes excellence in an organization’s sterile processing department within the scope of infection prevention and control, surgical services, endoscopic services, and related departments. An important part of…

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By: Judy Mathias
November 8, 2018
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