Nobody wants to come to work some morning and find a team of inspectors waiting. There is nothing like a surprise exam to make one nervous. Yet inspections are necessary—and not necessarily evil. Ambulatory surgery center (ASC) inspections are required for Medicare certification by the Centers for Medicare & Medicaid…

Read More

What’s the Joint Commission looking for when it surveys departments where surgery and other invasive procedures are performed? Tips, observations, and lessons were gleaned from a recent 5-day Joint Commission survey by John R. Rosing, MHA, FACHE, who was present for the survey. He consults on Joint Commission and Centers…

Read More

What’s on the Joint Commission’s list of problem standards? The top 10 scored standards didn’t change much in 2011. Five of the top 10 are Environment of Care/Life Safety issues. Here’s a look at the trouble spots as identified at the Joint Commission’s executive briefing in late 2011.   Medical…

Read More

Flexible endoscope reprocessing continues to be a major focus in infection prevention. All of the known cases of pathogen transmission during GI endoscopy have been traced to breaches in accepted cleaning and disinfection guidelines or other infection prevention practices. A revised Multisociety Guideline on Reprocessing Flexible GI Endoscopes, released in…

Read More

There's a new accrediting organization in town, and some hospitals are choosing it as an alternative to the Joint Commission. In 2008, DNV Healthcare, Cincinnati, Ohio, became the first new hospital accrediting body in 30 years granted "deeming authority" by the Centers for Medicare and Medicaid Services (CMS). That gives…

Read More

Two weeks after the Joint Commission surveyors left in December 2006, the president of Massachusetts General Hospital (MGH), Peter Slavin, MD, sat down and wrote a letter about the findings. It's not that he was boasting. In fact, he candidly said the survey was a "wakeup call," and surveyors "had…

Read More