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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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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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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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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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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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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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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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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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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Editor's Note The Joint Commission on September 21 announced an update of its policy on notification of changes in accredited organizations, which will take effect October 1. Previously, organizations had to notify the Joint Commission within 30 days after a significant change. The new policy requires organizations to provide written…

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