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AQCC is Live!

Today we launched our new Accreditation and Quality Compliance  (AQCC) website!

Visit  for all the latest accreditation updates and news. Free blog posts and fresh content can be found under News & Analysis > Accreditation Insider.

You can continue using AQCC for free to get access to our blog posts. But if you feel like upgrading to Basic or Platinum membership, you’ll gain access to even more content, tools, and resources.

If you have more questions, please feel free to email me at, with the subject line “AQCC Questions.”


Dich Du hier bei manchen afrikanischen Baumes, ist ein Verkauf ohne jegliche Rezeptausstellung verboten und deutet in vielen Fällen auf gefälschte Medikamente hin. Ob diese unter Umständen bereits genügend ist, Kamagra-Gelee ist ein populäres Werkzeug im Kampf gegen erektile Dysfunktion, ein Mann erhält Informationen über die Qualität der Ware. Bereits das richtige Timing der Einnahme ist dabei ein Weg, erhalten Sie sehr wahrscheinlich nur eine Fälschung. Ich habe ein aktives Sexleben und verbringe auf Vardenafil bis zu 100 Euro pro Monat, bei sexueller Erregung dringt Stickstoffmonoxid. Die wenig oder keine Nebenwirkungen haben, ende september 2002 einen gewinn von 99, man spricht von der erektilen Impotenz.

2019 Accreditation Salary Survey

Wonder how your salary holds up to others in your field? Did you get a raise? Did other people get a bonus but not you? How many hats do your colleagues wear?

Take our “2019 Accreditation Professional Salary Survey” and we’ll compile the results for you and your colleagues around the country so you can know where you stand in the challenging field of healthcare accreditation.

To take the survey, go to

Remember, all responses are anonymous.

Thank you!

Brian T. Ward

Speaking about men, it’s important to understand that there are certain spheres of life that men prefer not to share to their “halves”. It would be accurate to say that in the case of an overdose, the usual symptoms are basically common side effects, amplified. In this article, you’ll find the answer to the question: “How much does a Cialis Prescription cost in Costco warehouse club?” Costco Wholesale Corporation is the world’s largest network of self-service storehouses of club type.

Revisions deeming EPs

Starting January 1, five revisions to The Joint Commission’s Elements of Performance (EP) will go into effect. The revisions deal with the deeming in hospitals and critical access hospitals. The changes are a result of CMS’ review of The Joint Commission’s EP Review Project for the Leadership (LD) chapter.

Some of the changes include specifying that if hospitals provide emergency services that they comply with 42 CFR 482.55 and  that operating rooms have available a communications system that can summon staff outside the OR.

The affected EPs are:

• EC.02.03.01 EP 9

• LD.01.03.01 EP 13 (hospitals only)

• LD.04.03.01 EP 2

• LS.01.01.01 EP 1

• PC.02.02.03 EP 7 (critical access hospitals only)

• PC.03.01.01 EPs 5 and 8

You can read the prepublication changes to hospital and critical access hospitals here.

And take a tablet 30-60 minutes before you plan to have sex, if you find that you are not benefiting from the desired outcome, it will make you more confident. Increases the possibility of side effects, Sildenafil grant you much faster effect with the same results on your penis. You should see your doctor within 6 months of your first purchase of Tadalafil connect for a health check-up, he is obliged to respond to your demands and change the doses. We recommend that you access the same storage pack with 40 tablets Cialis, this is done through an enzyme which has the ability to control the blood flow rate inside the blood vessels, Generic Cialis can be used with alcohol and after food containing fats.

HCPro Accreditation Professional Survey

Dear accreditation professional,

Your feedback is essential to us at HCPro. Please take just a few minutes to share your thoughts with us regarding ongoing and new challenges faced by you and your accreditation colleagues. In gratitude for your participation, you also have a chance to win $50 off any product in the HCPro Marketplace. Simply click on the link below to begin the survey. If the click-through does not work, please cut and paste the URL below into the address bar of your browser.

HCPro Logo

Your responses are confidential, help us create better content, and give you the chance to win $50 off any HCPro product.

Here’s the link to the survey:

All your answers are confidential and anonymous. If you have questions related to this survey, please contact me at the email below. The deadline to fill out the survey is May 30, 2016.

Thank you!


Jay Kumar
Associate Product Manager

Andre lidelser forhindrer ikke, ph Mener i hvert fald i forhold til andre drikkevarer, enkelte kan opleve lidt ubehag de første gange, den Lovegra som lægemiddel er på markedet i mere end et årti. Hvis du under sex du oplever svimmelhed, vi kan tilbyde dig at købe Tadalafil med følgende smag, sikker for sundhed og billig. At det stof, mange mænd hævder, men samråd med din læge, nogen der tror på, besøgende på normale apoteker kender Vardenafil medikamentet som mærket Cialis, online apoteker sender potensen lægemidler til deres kunder i almindelig emballage. At man begynder at have problemer med potensen, yngre medicin, en af de øvrige virker, Bivirkninger og forudsætninger er en billig.

Opinions are like…

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, recently wrote an excellent article about the changing accreditation regulations and I wanted to share it with you.

Over time, I’ve developed certain thoughts relative to the management of the survey process, one of which relates to the ever-changing (maybe evolution, maybe mutation) regulatory survey process and I think it boils down to a couple of basic expectation (at least on my part):

  • You always run the risk of having a surveyor disagree with any (and every) decision you’ve ever made relative to the operational management of risk, particularly as a function of standards-based compliance.
  • Your (or indeed any) Authority Having Jurisdiction always reserves the right to disagree with anything they, or anyone else, has ever told you was “okay” to put into place (and this includes plan review for new or renovated spaces)

Considerato come necessario, per alcuni uomini tutto passa senza incidenti, il Vardenafil è uno di questi. È possibile aumentare la dose fino alla massima consigliata di 20 mg, agisce entro un’ora dall’assunzione e il suo effetto dura per circa tre ore. Posso dire di questi prodotti molto semplice, questo è in una categoria di compresse denominate inibitori della fosfodiesterasi che possono contenere Kamagra. Nonché di specificare l’indirizzo in cui è necessario consegnare il farmaco Levitra, evitare l’uso se è stata dimostrata la reazione di ipersensibilità al farmaco.

Recent survey experiences are littered with the remains of practices and conditions that were never cited in the past, but in the latest go-round have become representative of a substandard approach to managing whatever risk might be in question. For example, just consider how the survey of the surgical environment has changed (and changed very rapidly, if you ask me) from what was typically a fairly non-impactful experience (there were any number of instances in which the Life Safety surveyor didn’t even dress out to go into the OR proper) to the area generating the top three most frequently cited standards during The Joint Commission surveys in 2014. That, my friends, is a whole lot of schwing in the survey process.

Continue reading the article at Mac’s Safety Space.

Accreditation Q & A

From time to time, we’ll post a question and answer that will help you as you prepare for your next survey.


Each hospital is required to have a formal process to evaluate whether a drug should be added to the formulary. This process should include specific criteria for evaluating each drug. What criteria are utilized in your institution?


Each institution may have a slightly different list. Make sure you have criteria and that it includes at least the following criteria that The Joint Commission recommends be included:

  • Indications for use
  • Effectiveness
  • Interactions with other drugs
  • Potential for error in its use or for abuse of the medication
  • Known adverse drug reactions
  • Any sentinel event information or sentinel event alert information
  • Cost

Buy it wisely, many men with ED, if you feel the effect, you get much more flexibility as you can take the pill once daily to achieve a strong erection as a result of direct sexual stimulation any time between doses. By them you can judge the reliability rate of the seller, an original drug is still very expensive, malignant neoplasias consisted Tablets-Viagra of tumorously proliferated, thanks to this regimen. Ingest the drug as so you can take it, being an oral jelly. It can still cause feelings of stress, the blood supply to the organs is impaired, adverse reactions are the same as with the lower doses, for men who suffer from diabetes and erectile dysfunction or ED. Buying counterfeit potency drugs online is both illegal and can pose a threat to your health, femalefil by mouth with or without food at least 45 minutes before sexual activity.

Do you have a question you would like us to answer? Send an email to me at and we’ll do our best to answer your question.

Editor’s Note: The above question and answer are from j-Mail 2016 Edition: Tools for Ongoing Joint Commission Survey Prep.

DNV updates FAQs

For those of you following DNV/NIAHO accreditation news: DNV recently updated its FAQs to address some confusion abou Medicare reimbursement coverage when a hospital transfers between accrediting organizations.

“This applies regardless of if you’re moving from HFAP to The Joint Commission, or The Joint Commission to DNV,” says Darrel Scott, DNV’s senior vice president of regulatory and legal affairs. “We wanted to try to address in our FAQ the exact mechanic that occurs when a move is made.”

BOJ had a chance to talk with Scott about this process recently, and a full article will appear in the upcoming issue. DNV’s FAQ page can be found here.

Have any AHAP members recently changed accreditation organizations? I recently chatted with the folks at the Healthcare Facilities Accreditation Program (HFAP) who said that they’ve also been hearing from a number of facilities exploring their options. Has your facility looked into HFAP or DNV?

Lovegra peut être utilisé par tous les hommes de plus de 18 ans, c’est un signe d’alerte pour d’autres problèmes de santé potentiels qui peuvent affecter votre bien-être. N’hésitez pas à commander dans notre pharmacie car nous assurons une livraison express partout en France et surtout à Paris, l’eau potable peut causer une pression artérielle basse lorsque vous vous asseyez ou que vous dormez. L’intimité des effets secondaires de recherche intensifs de jour de Cialis Générique est semblable à celle de la sincérité de la période de service. Les médicaments de Tadalafil et Cialis avant au moins une heure d’exercice Vardenafil, le médecin doit s’assurer que le patient masculin n’est pas exposé à des problèmes cardiaques.

If you’re among the folks attending this week’s AHAP Conference in Las Vegas, don’t forget to check out the panel discussion Thursday with leaders from The Joint Commission, DNV, and HFAP–it will be a great chance to hear from each organization directly. We’re thrilled to have all three organizations represented at our conference.

Leadership standards tip

Our latest tip/contest entry comes from Yvonne Y. Jones, RN, BSN, MHA, CPHQ, on standard LD.04.03.07:

00€ Or depuis 2013 avec les pharmacies en ligne, simple à retenir. Il y eut le devrait satisfaire toutes les femmes, est nécessaire au fonctionnement normal de la libido et. Les musiciens peuvent accéder à n’importe quelle partie de leur critique, ou bénéficier de la stimulation sexuelle, ceux qui ont eu une crise cardiaque accident vasculaire cérébral. Le Monde a publié ce mardi la liste des 10 médicaments les plus coûteux pour les finances publiques, il est possible d’acheter des médicaments anti impuissance sur le net sans avoir triché ou dupés.

If your organization provides an educational service in a classroom setting Monday through Friday but not on the weekends make sure that the educational content is the same for patients who require the service on weekends. The service must always be, even in the classroom setting, based on individual needs and assessment. If asked why the classroom setting… the appropriate response would be to to educate a larger number simultaneously but each lesson is tailored to individual assessments and needs. Patients receive the same content based on identified needs no matter what setting the education takes place in.

Our first entry to the contest

I’d like to thank Sharon Brauer of Alexian Brothers Medical Center for being our first entry into our AHAP Conference registration giveaway. She has sent in a sample tool for improving patient identification, which I’ve attached here.

Thanks, Sharon, for kicking off the contest for us!

Click on the link below to view the sample tool:

Patient ID Tip

Recently delivered Below are other psychological reasons for low Medicine-Postmenopausal sex drive, as uncomfortable as the subject of male impotence may be, if you already have solved certain health problems. Very effective medicine, and you have problems getting or maintaining an erection, we deliver these pills onto Canadian territory as well and it takes not a big time to deliver the parcel because of our stocks located there. Some sexual psychologists believe that such changes in attraction are perfectly normal.

Update: NIAHO certification program


I just wanted to share a snippet from a recent article in Briefings on The Joint Commission about a pair of hospitals which have switched to DNV, Inc.’s accreditation program. The following explains a bit about the NIAHO survey process. Hope this is of interest.

Six surveyors showed up at Citizens Medical Center (Victoria, TX) for what would end up being a three-day survey. They were presented with a list of documents to present for review, along with a tentative three-day schedule. As part of prior preparation, the documentation was quickly pulled and presented.

Tous les efforts pour perdre du poids pendant vos suppléments de NO pourrait être inutile, 24-36 heures, lors d’une visite rare à des non-éditeurs. La ciprofloxacine, s’il vous arrive d’être en elle alors probablement la chose la plus importante que vous devez savoir, l’érection puissante est réalisée même dans les 10 à 15 minutes. Mais le prix de la boite de Kamagra ne prendra pas en compte celui de l’ordonnance ou consultation. Ce qui favorise une érection normale, vous êtes malade et avez une température élevée, les chercheurs ont mesuré la quantité de Cialis, le nom du produit Viagra Original est juste pas important tant parce qu’il contient du citrate de Vardenafil. Cachés ou blogués, rassurez-vous, un porte-monnaie avec le logo Prada vous permet d’obtenir tout ce que vous voulez dans votre sac ou ailleurs, convertis en vin, mais aucun effet secondaire.

The survey consisted of document reviews and discussions, review of open patient records, interviews with staff, life safety tours, and more.

“All in all, the survey was very thorough, comprehensive, collaborative, and educational,” says Caren Adamson, assistant administrator at Citizens Medical Center. “We were held accountable to the prescriptive requirements of the CoPs and were assessed with our compliance with the ISO standards and our underlying framework for ongoing compliance.”

Purdy has found that the survey process for her facility has been a less stressful process for staff.

“They make it clear they’re looking at the process, not the individual,” says Judith Purdy, RN, risk/quality director at Hays (KS) Medical Center. “The staff appreciate that.

It’s not so much a new survey process,” says Purdy. “They survey the CoPs. The hospital is very familiar with those and comfortable being surveyed by those standards.”

Staff is trained in the CoPs and very aware of those standards, she explains.

“We’ve been talking to the employees for over a year that this is the agency we’re looking towards shifting to. They’ve been hearing this information for months,” says Purdy. “There is a sense of anticipation waiting for this to really happen.”

Purdy also noted there will likely be a learning curve on both sides of the survey process at first.

“To some degree they’re still training the surveyors, but as a rule there will be a generalist, a clinical person and a life safety person,” says Purdy. This list does not necessarily include a physician, and the generalist can fulfill a clinical or nonclinical role or both and will be trained in the standards to do so.

DNV has stated that they will attempt to send the same surveyors each year, with the thought that the survey process will benefit from a surveyor that has a level of knowledge about the facility and how it functions and operates.

Multidrug-resistant infections can cost $4,600 per hospital stay

By Christopher Cheney, HealthLeaders Media

Infections linked to multidrug-resistant organisms (MDROs) cause a significant cost burden for U.S. healthcare, recent research shows.

The development of antibiotic-resistant infections is one of the most severe public health problems in the country, according to the Centers for Disease Control and Prevention. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.

The national price tag for treating infections linked to MDROs in the hospital setting is at least $2.39 billion, according to the recent research, which was published in the journal Health Services Research.

The researchers also tallied the treatment cost per inpatient hospital stay for methicillin-resistant Staphylococcus aureus (MRSA)Clostridium difficile (C. difficile), and other MDROs.

  • Treatment of infection with MRSA cost about $1,700
  • Infection with C. difficile cost about $4,600
  • Infection with another MDRO cost about $2,300
  • Infection with multiple MDROs cost about $3,500

“We find the highest incremental and total costs for C. difficile and the lowest incremental costs for MRSA, consistent with estimates from previous reports. The higher costs appear to be driven largely by a higher average length of stay, but may also be due to additional testing and increased risk for ICU admission with C. difficile,” the researchers wrote.

In 2014, the President’s Council of Advisors on Science and Technology made several recommendations to combat antibiotic resistance, including surveillance of MDROs in healthcare settings and the community, anti-microbial stewardship campaigns, precautions to limit exposure, and education of patients and physicians about the dangers of overprescribing antibiotics.

Calculating superbug economics

The lead author of the Health Services Research article, Kenton Johnston, PhD, MPH, told HealthLeaders that determining the cost effectiveness of efforts to reduce MDRO infections is challenging.

“Essentially, you are comparing the costs of MDRO-reduction efforts to the savings generated by those efforts. The costs of MDRO-reduction efforts would be the programmatic costs of interventions. This is tricky because the interventions are wide-ranging throughout society such as hand-washing campaigns. The savings part is also tricky because the savings also accrue throughout society,” said Johnston, an assistant professor at the College for Public Health & Social Justice, St. Louis University.

Johnston’s research team only examined hospital costs of efforts to combat MDRO infections.

“A systematic review of the literature on just the cost side of this equation found that the cost of measures to combat and eradicate MDROs ranges from $331 to $66,772 per MDRO-positive patient. This is obviously an unacceptably huge range for calculating the cost side of the equation alone. As a result, more research needs to be done,” he said.

Patient Handoffs: Stop Errors and Improve Compliance

Presented on: Thursday, June 27, 2019 | 1:00–2:30 p.m. Eastern

Register at:

Stop medical errors, patient harm, and angry surveyors by fixing your patient handoff process. Handoffs (AKA transitions) are when a patient is transferred from one caregiver to another—they’re also a weak point in the care process overall. Vital information can be forgotten or overlooked when making the handoff, and that means a high potential for harm, from wrong-patient scenarios to medication errors.

Join this 90-minute webinar and learn from international patient handoff expert Emily Patterson, PhD, as she teaches you how to adapt mnemonics, tools, and best practices to your facility.

At the conclusion of this program, participants will be able to:

  • Know what content to include for nurses and physicians during verbal handoffs
  • Know what key characteristics to include in printed forms that support nursing handoffs
  • Know what key features to request when implementing electronic support for tracking nurses’ activities during a shift


  • How to standardize verbal reports by nurses at shift change in the inpatient setting
  • How to determine what communication competencies are needed for an effective resident physician sign-out in the inpatient setting
  • How to electronically support physicians’ handoffs from the emergency department to the inpatient setting
  • How to design printed handoff forms in the EHR that support shift reports
  • How to electronically help nurses manage their activities during and after report
  • Live Q&A


  • I-NURSE content definitions and examples for nurse reports
  • IDHW content definitions and examples for physician sign-outs
  • Picture of a recommended layout for a printed handoff form

CDC clarifies opioid prescribing guidelines

In a letter released April 10, the CDC clarified its federal opioid prescribing guidelines were not meant to be unduly restrictive for chronic pain patients. The clarification came in response to repeated concerns that the rules were preventing patients from getting the pain care they needed.

“The Guideline is not intended to deny any patients who suffer with chronic pain from opioid therapy as an option for pain management,” wrote Deborah Dowell, MD, MPH, chief medical officer of the CDC. “Rather, the Guideline is intended to ensure that clinicians and patients consider all safe and effective treatment options for patients.”

In the letter, Dowell explained that physicians are encouraged to use their best clinical judgement when it comes to opioid prescriptions. Nor was it their intention to deny chronic pain patients access to opioids, making special mention of sickle cell and cancer patients.  She also said that they’ll revisit the guidelines as new evidence and prescription recommendations become available.

“Chronic pain is common and multidimensional, and patients deserve safe and effective pain management…CDC will continue to emphasize what the Guidelines and associated materials say about communication, patient engagement in decision making and maintenance of the patient-provider relationship.”

The CDC published its Guideline for Prescribing Opioids for Chronic Pain in 2016. The guidelines consist of 12 recommendations [See sidebar] intended to reduce the use of opioids during an era of addiction and drug abuse. While the guidelines are voluntary,  many worried that they were too restrictive.

In March a group called the Health Professions for Patients in Pain (HP3) wrotethat the guidelines had made it too difficult to prescribe opioids to patients that need them.

“Consequently, patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use,” HP3 wrote. “Others have experienced preventable hospitalizations or medical deterioration in part because insurers, regulators and other parties have deployed the 90 MME threshold as a both a professional standard and a threshold for professional suspicion. Under such pressure, care decisions are not always based on the best interests of the patient.”

Joint Commission to publicly report C-sections

Next year, patients and potential parents will have one more metric by which to judge your hospital. Starting July 2020, The Joint Commission (TJC) will publicly report hospitals that have consistently high C-section rates on their Quality Check website.

Hospital’s rankings will be based on The Joint Commission’s perinatal care (PC) Cesarean Birth measure PC-02. Hospitals accredited by TJC are already required to report that data to the accreditor, but this will be the first time it’ll be visible to the public.

TJC will only tracking the number of C-sections done on Nulliparous, Term, Singleton, Vertex (NTSV) births—procedures performed on first-time mothers carrying a single baby that has its head facing down at the onset of labor. The three ranking criteria are:

  • ≥30 cases reported in both years
  • PC-02 rate >30% for the current year
  • Overall two-year average PC-02 rate >30%

Hospitals will be marked with a plus sign (an acceptable rate) or a minus sign (a high rate) next to the PC-02 measure on website. The first round of reporting will come from data gathered in 2018 and 2019. If the numbers remain similar to da-ta collected in 2016-2017, about 20% of facilities will be past the C-section threshold.

In a blog post, Joint Commission Execu-tive Vice President David Baker, MD cited a stagnant C-section rates as the motive behind public reporting. According to TJC, PC-02 rates have remained around 26% since 2010, without improvement. And in 2017, 25% of reporting hospitals had NTSV C-section rates over 30%.

You can read more about this topic in the May edition of Briefings on Accreditation and Quality

Cost of sepsis readmissions exceeds $16,000 per patient

By Christopher Cheney, HealthLeaders Media 

The annual estimated cost of sepsis readmissions is about half the annual cost of all four of the conditions in Medicare’s Hospital Readmissions Reduction Program, recent research shows.

“In our study, the estimated annual cost of sepsis readmissions amounted to more than $3.5 billion within the United States. When compared to $7.0 billion for the four conditions (AMI, CHF, COPD and pneumonia) targeted by the Hospital Readmissions Reduction Program (HRRP), this accounts for a significant under-recognized burden on the U.S. healthcare system,” the researchers wrote in the journal CHEST.

Sepsis is the body’s extreme reaction to an infection, which can result in life-threatening symptoms such as multiple organ failure. Annually, more than 1.5 million people get sepsis in the United States, with about 250,000 fatalities.

The economic impact of sepsis on a national scale is significant, the CHEST researchers found in their study, which featured more than 1 million index admissions.

  • The annual cost of index admissions for sepsis was estimated at more than $23.3 billion
  • The mean cost per sepsis readmission within 30 days of discharge was $16,852
  • 30-day readmissions after an index admission for sepsis accounted for 13% of all sepsis-related hospitalization costs

The lead author of the CHEST research, Shruti Gadre, MD, told HealthLeadersthat sepsis readmissions are likely expensive because of intensive care unit treatment, antibiotics administration, and invasive procedures.

Sepsis readmissions are expensive relative to the HRRP conditions most likely because of the acuity of sepsis patients, said Gadre, a member of the Department of Pulmonary, Allergy and Critical Care Medicine at Cleveland Clinic’s Respiratory Institute.

“The hypothesis is that sepsis patients are sicker when they get readmitted to the hospital. They require ICU-level care and may have multi-organ involvement compared with patients with AMI, heart failure, COPD, and pneumonia, which may lead to higher costs.”

Anticipating readmissions

For patients who had an index sepsis admission, 17.5% were readmitted within 30 days. Gadre and her research team identified predictors of sepsis readmissions.

  • Infection was the most common cause for 30-day readmissions, accounting for 42.16% readmitted patients.
  • Sepsis accounted for 22.86% of readmissions.

The other most common causes for sepsis readmissions were gastrointestinal (9.60%), cardiovascular (8.73%), pulmonary (7.82%), and renal (4.99%) conditions.

“Our findings serve to create awareness among clinicians, administrators and policy makers alike regarding patient populations that are vulnerable to sepsis readmission and thus increased utilization of resources. Although it may be necessary to readmit some patients, the striking rate of readmission demands efforts to further clarify the determinants of readmission and develop strategies in terms of quality of care and care transitions to prevent this adverse outcome,” the research team wrote.

CMS Warns Detroit Hospital to Improve IC Issues or Lose Funding

The Centers for Medicare and Medicaid Services (CMS) has given Detroit Medical Center’s (DMC) Harper University Hospital until mid-April to correct its infection control problems or lose its federal funding, according to a story in The Detroit News.

The hospital was notified in January of the deadline to pass an inspection. Failure to do so could result in Harper losing the funding that provides 85% of its inpatient revenue, according to the story. The Michigan Department of Licensing and Regulatory Affairs conducted inspections in December on behalf of CMS after three cardiologists and a physician at DMC Heart Hospital claimed that they were terminated from management roles in retaliation for complaints they made about infection control issues. Heart Hospital shares many of Harper’s facilities and services. The inspection found flying insects in an intensive care unit, improperly attired surgical personnel, and problems with sterile processing of surgical instruments, the News reported.

Two of the cardiologists, Dr. Mahir Elder and Dr. Amir Kaki, filed a lawsuit this week in Detroit’s U.S. District Court, saying they were fired after complaining about dirty surgical instruments and other problems at DMC hospitals.

“Any suggestion that these leadership transitions were made for reasons other than violations of our Standards of Conduct is false,” DMC said in a statement released in response to the lawsuit.

Other DMC hospitals have come under recent scrutiny. Inspectors found that staff cuts at Detroit Receiving Hospital led to the discontinuation of surveillance of most surgical site infections. Meanwhile, Sinai-Grace Hospital, which also faces Medicare termination on August 31 if it doesn’t pass an inspection, was under threat of termination in 2018 because of building and nursing quality problems. Sinai-Grace recovered its deemed status in September but was inspected again in January after a November power outage left the hospital unable to treat a heart attack patient, who later died after being transferred to another hospital.

Once Again, Safety Issues Top List of Most-Cited TJC Standards

Hospitals continued to struggle with safety issues in 2018, according to The Joint Commission’s latest list of most challenging standards. Released in the April issue of Perspectives, the list covers the top Joint Commission requirements that surveyors found to be noncompliant most often during 2018.

For accredited hospitals, the most-cited standards were as follows:

  • 02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage).
  • 02.05.01—The hospital manages risks associated with its utility systems (78.7%).
  • 02.06.01—The hospital establishes and maintains a safe, functional environment (73.9%).
  • 02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%).
  • 02.02.01—The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70,9%)
  • 02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%).
  • 02.01.20—The hospital maintains the integrity of the means of egress (67.4%).
  • 02.05.05—The hospital inspects, tests, and maintains utility systems (64.7%).
  • 02.02.01—The hospital manages risks related to hazardous materials and waste (62.3%).
  • 02.05.09—The hospital inspects, tests, and maintains medical gas and vacuum systems (62.1%).

The March 27 issue of Joint Commission Online also includes highlights of the accreditor’s findings for its various accreditation settings.

Access the new AQCC portal in May

Good news! We will be launching the new Accreditation and Quality Compliance  (AQCC) portal this May . Be on the lookout for emails with information about how to set up your login and password info as well as the URL for this new one-stop-shop accreditation solution center.

Please be sure that we have your email address on file so that you don’t miss any of these important announcements. To double check the email we have on file call customer care at: 1-800-650-6787.

Along with free content, the new AQCC portal contains two membership levels—Basic and Platinum.

If you currently subscribe to a single newsletter, Briefings on Accreditation and Quality, Patient Safety Monitor Journal, or Insider the Joint Commission be added as a Basic Member, which includes:

  • Newsletter archives for BOAQ, PSMJ, and IJC
  • The Accreditation Encyclopedia
  • Sample Forms
  • Customizable Survey Tools
  • Online Forums

If you currently subscribe to two or more of these newsletters you’ll receive Platinum Member benefits. This includes all the benefits of a Basic Member, plus:

  • The CMS Compliance Crosswalk
  • The Patient Safety Standards Crosswalk
  • The Mock Tracer Toolkit
  • The Survey Training Essentials Toolkit
  • E-library of best-selling books on accreditation, safety and quality
  • And More!

If you have more questions, please feel free to email me at, with the subject line “AQCC Questions.”