RSSAuthor Archive for Jackie Zagami

Jackie Zagami

Jaclyn Beck is the associate director of the Association for Healthcare Accreditation Professionals (AHAP) where she manages AHAP Accreditation Connection, the annual AHAP conference, and contributes to the monthly publication Briefings on The Joint Commission.

AHAP offerings update

I just wanted to give you an update on a few resources that HCPro and AHAP is offering that might be of huge benefit to you. There have been a lot of changes, updates, and new NPSGs coming your way from The Joint Commission and CMS, and we’ve got a lot of good stuff going on in the upcoming months to help you stay on top of it. Here are some things that may be of interest to you:

Speaker Barbara Balik, RN, MS, a senior faculty member at the Institute for Healthcare Improvement (IHI) discusses why just adding another policy isn’t good enough. She will offer candid advice and techniques to give you and your staff a better understanding of the requirements, and share best practices and practical strategies to improve patient- and family-centered care and to communicate the policy to patients and families.

Plus, this webcast provides a great opportunity to get EXACTLY what you want out of it. Barbara has asked that if there is something specific you’re hoping to learn from this show, to please e-mail me ( ahead of time and she will make sure to address it in the live program.


Joint Commission releases Easy-to-Read 2012 NPSGs

Earlier this week The Joint Commission released the National Patient Safety Goals (NPSGs) for 2012 in an easy-to-read version. Goals for 2012 include identifying patients correctly, improving staff communication, using medications safely, preventing infections, identifying patient safety risks, and preventing mistakes in surgery.

Click on the program links below to view/download the 2012 NPSGs.

For more information, visit The Joint Commission Website.

Join us on the podium for the 2012 AHAP conference!

AHAP is currently seeking speakers to present at the 2012 AHAP Sixth Annual Conference to be held May 10-11, 2012 at the Walt Disney World Resort in Orlando, FL.

Is that special person you or a colleague?

We seek speakers to present on all aspects of hospital accreditation and encourage case studies of successful programs. Here is a list of additional topics that would make great conference sessions:

  • Data management
  • Performance improvement: Priorities for measurement
  • Tracer methodology : Improving the patient care process
  • Maximizing your risk assessment to eliminate TJC and CMS vulnerabilities
  • Career ladder for accreditation professionals: Motivation and recruitment strategies

If you don’t see your hot topic here, please write and let us know what expertise you can bring to the podium.

Click this link, complete the form, and submit it to us no later than November 1, 2011. Please be sure to include a brief description of your suggested session topic.

We look forward to hearing from you! If you’d like more information or wish to discuss a speaking topic before applying, please e-mail me at and we’ll set up a convenient time to speak by phone.

HHS encourages equal visitation and representation rights

The Department of Health and Human Services (HHS) issued a press release this week to give added support to The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COP) rules released in November of last year giving patients the right to choose their own visitors during a hospital stay.

The guidance given by the HHS emphasizes that hospitals should respect patients’ wishes concerning their representatives (whether expressed in writing, orally, or through other evidence unless prohibited by state law) in an effort to make it easier for family members, including a same-sex domestic partner, to make informed care decisions for loved ones who are incapacitated.

The CMS also sent a letter this week to State Survey Agencies (SSAs), highlighting the equal visitation and representation rights requirements and directing SSAs to be aware of the guidance when surveying for hospitals’ compliance with CoPs.

Read the full press release here.

Latest Sentinel Event Alert:Radiation risks of diagnostic imaging

The Joint Commission released its latest Sentinel Event Alert this morning highlighting the need for healthcare facilities and staff to maintain radiation doses as low as possible during diagnostic imaging in order to decrease exposure to repeat doses. The Alert asks healthcare organizations to address contributing factors to eliminate avoidable exposure by weighing the medical necessity of a given level of radiation against the risks.

According to the Alert, the US population’s total radiation exposure has nearly doubled over the past two decades, and  studies have estimated that 29,000 future cancers and 14,500 future deaths could develop due to radiation from the 72 million CT scans performed in the US in 2007.

In response, the Centers for Medicare & Medicaid Services (CMS) will require accreditation of all facilities providing advanced imaging services (CT scans, MRI, PET, nuclear medicine) including non-hospital, freestanding settings beginning January 1, 2012. The state of California is also requiring facilities that furnish CT X-ray services to become accredited by July 1, 2013.

The Joint Commission gives some suggested actions leaders can take to raise awareness among staff and patients of the risk associated with aggregate radiation doses and provide proper testing and dosage through effective processes, safe technology, and a culture of safety.

Click here to download the Sentinel Event Alert and the full list of recommendations.

HHS aims to improve health and cost for dual eligible patients

The U.S. Department of Health and Human Services (HHS) has introduced three new initiatives to help states lower the cost of healthcare for patients with dual eligibility for both Medicare and Medicaid, as well as reduce hospitalization for this group.

The three separate proposals include:

  • A demonstration program to test two new financial models in hopes to better coordinate care for individuals enrolled in Medicare and Medicaid
  • A demonstration program aimed at helping states improve the quality of care for people in nursing homes in order to reduce hospitalizations
  • Creating a technical resource center to help states improve care for high-need high-cost beneficiaries

The dual eligible population is represented by approximately nine million Americans, and accounts for more than $300 billion in state and federal healthcare spending every year.

The idea is that these initiatives will bring better care coordination and for this population, which in turn will improve the health of dual eligible beneficiaries making them less frequent consumers of healthcare services in general.

Source: Healthcare Finance News

CMS proposes new rule for community mental health centers

The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would provide conditions of participation for community mental health centers (CMHCs).

Medicare beneficiaries who receive care from a CMHC have an alternative to inpatient treatment, and are provided with partial hospitalization services, including physician services, psychiatric nursing, counseling, and other social services.

CMS’ new rule includes the following standards:

• Establishing qualifications for CMHC employees and contractors.
• Mandating CMHCs to notify clients of their rights and to investigate and report violations of client rights. These proposed requirements also promote continuity of care by highlighting the need for communication of client needs when they are discharged or transferred.
• Organizing a treatment team, developing an active treatment plan, and coordinating services to ensure an interdisciplinary approach to individualized client care.
• Creating a Quality Assessment and Performance Improvement (QAPI) program. This will require CMHCs to identify program needs by evaluating outcome and client satisfaction data and making changes based on that data to improve their quality of care.
• Put into place organization, governance, administration of services, and partial hospitalization services requirements, with special attention to governance structure.

CMS is accepting comments until August 16, 2011. If you’d like to submit one, visit and search for rule “CMS-3202-P.”

To view the press release, click here.

Joint Commission teams up with ASHI

The Joint Commission and the American Society for Histocompatibility and Immunogenetics (ASHI) have entered a cooperative agreement to recognize histocompatibility (HLA) accreditation. Effective July 1, 2011, ASHI will have the authority as a deemed accreditor for transplant testing services in Joint Commission facilities.

The Joint Commission said the agreement will reduce the burdens on health care organizations by eliminating the need for duplicate laboratory surveys for organizations conducting HLA testing, and will also save them money by accepting the ASHI accreditation as evidence of compliance with Joint Commission policies and standards.

Find out more  and see what each organization has to say about the agreement by visiting The Joint Commission Website here.

Hospitals failing on communication compliance

Two former language-expert hospital administrators in conjunction with Language Line Services have released a new report called “The New Joint Commission Standards for Patient-Centered Care,” that finds hospitals are falling short of The Joint Commission’s language access requirements for patients with limited English.

The requirements were announced in 2009, and  put in place on January 1 of this year, but won’t have an effect on accreditation during the year-long pilot phase.

According to the report and The Joint Commission,  communication breakdowns are the cause for nearly 3,000 deaths every  year, and the majority of these breakdowns involve patients with limited English. Studies show that 50 million people speak a language other than English in the home, and according to the report, some hospitals are not making the connection between language services, patient rights, and patient safety.

The report also says that hospitals may think they are being compliant because they have bilingual staff, contract interpreters, and over-the-phone or video interpreters, but the standards require proof of interpreter training and fluency competence for interpreters in spoken languages as well as American Sign Language  for deaf and hard-of-hearing patients.

The report says hospitals that aren’t in compliance with the new regulations could do damage to their reputations and accrue untold expenses.

Visit The Joint Commission’s Hospital, Language, and Culture website for more information.

CMS proposes new rule: Perform well, be rewarded

The Centers for Medicare & Medicaid Services (CMS) has announced a new rule for hospital inpatient value-based purchasing that plans to give monetary incentive for hospitals to meeting and exceed quality and safety measures, and is also intended to make care safer by reducing medical errors.

Under the program, hospitals that do well both in terms of quality of care and the patient experience – or hospitals that have made improvements in their delivery of care – would be rewarded with higher payments. And, the higher a hospital’s performance or improvement during the performance period during any given fiscal year, the higher the hospital’s value based incentive payment.