Tag: Accreditation

Joint Commission: Changes to post-survey processes, decision rules

Editor's Note The Joint Commission on February 22 announced that recent changes had been made to simplify and streamline the accreditation post-survey process and decision rules. Among the changes: An organization with an accredited with follow-up decision will receive full accreditation once it has successfully submitted evidence of standards compliance.…

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By: Judy Mathias
February 24, 2017
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CMS immediate jeopardy trail may lead to the OR

What makes an OR subject to an immediate jeopardy finding from a Medicare inspection? Immediate jeopardy is cited when a provider’s noncompliance with one or more of the Centers for Medicare & Medicaid’s (CMS) Conditions of Participation causes or is likely to cause serious injury, harm, impairment, or death.  …

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By: Judith M. Mathais, MA, RN
February 17, 2017
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DNV accreditation: A positive spin on survey preparation

There is a lot of buzz in the healthcare community about a newcomer to the accreditation process. For many years, the Joint Commission was the first choice for providing accreditation for hospitals in the US. But Norway-based Det Norske Veritas (DNV) is gaining ground, representing more than 350 hospitals and…

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By: Judith M. Mathais, MA, RN
February 17, 2017
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Joint Commission offers new blog for infection preventionists

Editor's Note A new blog from the Joint Commission on Infection Prevention & Control covers experiences, case studies, and news for infection preventionists. The latest blog post details the BoosterPak for High-Level Disinfection and Sterilization processes, which is applicable to hospitals, critical access hospitals, plus ambulatory and office-based surgery settings.…

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By: Judy Mathias
December 14, 2016
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New Joint Commission cardiac center certification

Editor's Note The Joint Commission on December 7 announced that it is offering a new Comprehensive Cardiac Center Certification, starting January 1. The voluntary program has been developed to recognize accredited hospitals that demonstrate excellence in delivering cardiac care through a combination of standards compliance, performance on targeted metrics, and…

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By: Judy Mathias
December 9, 2016
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Joint Commission survey standards tighten for 2017

Beginning January 1, 2017, the Joint Commission is “making significant changes in its survey methods and its standards manual,” says John R. Rosing, MHA, FACHE, executive vice president and principal, Patton Healthcare Consulting, Milwaukee, Wisconsin, and OR managers need to be prepared for them. The reason, he says, is that…

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By: Judith M. Mathias, MA, RN
November 14, 2016
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Joint Commission Clarification Process changes Jan 1

Editor's Note As of January 1, 2017, the Joint Commission’s Clarification Process will change, with the goal to reduce the amount of post-survey work that has to be done to the Accreditation Decision Report. The changes will affect: Documents not available at the time of survey: Required documents not available…

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By: Judy Mathias
November 3, 2016
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Joint Commission seeking input on HAI revisions

Editor's Note The Joint Commission announced October 12 that it is seeking input on proposed revisions to its National Patient Safety Goals on healthcare associated infections (HAIs) for ambulatory care and office-based surgery and hospitals and critical access hospitals. The proposed revisions address surgical site infections and central line-associated blood…

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By: Judy Mathias
October 13, 2016
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Joint Commission announces 2017 ORYX performance measurements

Editor's Note The Joint Commission on October 5 announced its 2017 ORYX performance measurement requirements, effective January 1. Though the Joint Commission is closely aligned with the Centers for Medicare & Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program, it has not adopted all of the electronic clinical quality measures…

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By: Judy Mathias
October 10, 2016
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Joint Commission deletes 51 EPs

Editor's Note The Joint Commission on September 27 announced that it has deleted 51 Elements of Performance (EPs) from its hospital accreditation standards, effective January 2017. Reasons for deletion include: Similar to, implicit in, or duplicative of other EPs. Address issues that have been covered by standards for many years…

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By: Judy Mathias
September 28, 2016
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