RSSAuthor Archive for Matt Phillion

Matt Phillion is the director of the Association for Healthcare Accreditation Professionals and a Senior Managing Editor at HCPro, Inc., where he is the editor of the monthly publication Briefings on The Joint Commission.

Contest entry: Tobacco-free policy

AHAP member Cindy Brooks of Lanier Health Services has sent in a very interesting policy as her entry to the AHAP Conference contest: a tobacco-free policy. Cindy writes:

This is one of the greatest challenges our hospital has faced, but one of the most rewarding at the same time. We provide education and out reach programs to our patients and to the public. We hope to truly make a difference.

Tobacco-Free Policy (1-21-09)[1]

Just a reminder that we will draw one more winner at random from all contest entries on May 1. A full set of rules can be found on the blog here. And please send all entries directly to mphillion@hcpro.com.


April Contest winner!

Hello, everyone. We’d like to announce this month’s winner of a free registration to the AHAP Conferencer 2010: Heather Forbes of Southern Maine Medical Center! Heather’s original contest entry can be viewed here.

Don’t forget, there’s still time to enter to win a registration–we’ll draw one more winner on May 1. If you’ve already entered, keep in mind that you’re still eligible to win in our next drawing. Complete contest rules can be found here. And just a reminder, you can send any entries directly to mphillion@hcpro.com

Contest entry: FMEA

Our latest entry is an FMEA from Nancy Bertling, RN, BSN, MBA, of Healthcare Accuracy. Nancy writes:

A FMEA does not have to be a week-long project. You just need to show you understand the concept. With this simple form, mot other clinicians can grasp the ease and importance of this useful tool.

FMEA RResponse

We’ll randomly draw our next winner on April 1, so there’s still time to enter! Complete contest rules can be found here. And just a reminder, you can send any entries directly to mphillion@hcpro.com.

Contest entry: Tracer tool/sweeper tool

Our latest entry comtes from Heather Forbes, RN, BSN, CEN, CSHA, accreditation and regulatory coordinator at Southern Maine Medical Center, Biddeford, ME. Heather writes:

I would like to submit our Tracer Tool and Response Key to the contest. Wehere I have only been in the accreditation role for ten months, my hope was to create a tool that was effective adn simple to use that would be comprehensive for both our inpatient hospital and outpatient physician practices. I incorporated the NPSGs, standards, and EPs with the highest rates of non-compliance, and our own identified gaps within the organization.

I would also like to submit our sweeper tool. This is a list of ‘quick fix’ items in the event a surveyor team arrives. This is kept in our Joint Commission preparedness binder. We also use this during our internal executive rounds in order to continuously promote a culture of quality and safety.

Inpatient Tracer 2010 v3

Patient Center Tracer Response Key

Sweeper Checklist for all Inpatient and Outpatient Locations

We’ll randomly draw our next winner on April 1, so there’s still time to enter! Complete contest rules can be found here. And just a reminder, you can send any entries directly to mphillion@hcpro.com.

MS.01.01.01: Revisions to troublesome standard receive approval

Revisions to Medical Staff standard MS.01.01.01 have received approval from The Joint Commission and will go into place March 31, 2011, an official announcement from the accrediting organization states.

The standard has gone through several iterations over the years. Once known as MS.1.20, this challenging standard addresses the medical staff’s ability to self-govern, as well as the contents of the medical staff bylaws. Often contentious, the dialogue surrounding this standard culminated in an 18-person special task force with representatives from all sides of the argument to recommend the best course of action. This group unanimously presented its findings to The Joint Commission, which has approved these recommended revisions for implementation next year.

The pre-publication standards and related FAQs to this standard can now be found on The Joint Commission’s Web site here.

What are your thoughts on these changes? Will the address the challenges of years past? What effect will they have on your organization?

Contest entry: Monitoring report

Our latest AHAP contest entry comes from Eileen Pressler, director of quality management at Kingman Regional Medical Center in Kingman, Arizona. Eileen writes:

Our Quality Management Department is working on revising the format of regular reports. Sometimes we have trouble getting committee members do more than report numbers so we devised this format. The neat thing is as they enter the number for the quarter, it automatically creates the bar graph. By adding specific areas for trend/analysis and action plans, committee members become more likely to think about what they report rather than just focusing on numbers. This has been a real learning curve for some. As we receive and review the reports, sometimes we need to discuss them with the report owner to help them identify trends, analyze the trend and/or develop action plans.

We ask them “What’s happening? Why do you think that’s happening? What can we do to make it better?” Slowly, slowly, they’re beginning to think like we do! Or at least when they see us coming they know what we’re going to ask!

CY 09 4th Qtr Patient Safety Goals Monitoring Report

Joint Commission releases small changes to NPSGs

The Joint Commission identified a few small tweaks to a pair of NPSGs yesterday and released the details via their homepage. The changes were:

NPSG.03.04.01, Element of Performance 3. Under this EP, the phrase “preparation date” was removed from medication or solution label required information. The following, according to the EP, need to be included on medication and solutions labels on and off the sterile field in perioperative and other procedural settings:

  • medication name
  • strength
  • quantity
  • diluents
  • volume
  • preparation date
  • expiration date when not used within 24 hours
  • expiration time when expiration occurs in less than 24 hours

NPSG.07.03.01, Element of Performance 3. Under this EP, the word “prevention” was added.

These changes go into effect immediately for ambulatory care, critical access hospitals, hospitals and office-based surgery organizations. They’ll be reflected in the July 2010 CAMH updates (print and electronic).  See The Joint Commission’s home page for more details.

Contest entry: Continual Readiness Plan

Our next entry comes from Clint LaFever RN, BSN, CPN, accreditation coordinator with Northwest Texas Healthcare System. Clint writes:

I am the Accreditation Coordinator for Northwest Texas Healthcare System. We are comprised of 404 acute care licensed beds, 85 behavioral care licensed beds, and several ambulatory clinics. I work in the Quality Management Department and I am responsible for planning, directing, facilitating and coordinating accreditation and regulatory compliance activities. In an attempt to be continually ready for survey activities and improve patient safety and quality of care, we have developed a “Continuous Readiness Plan”, which focuses on the Joint Commission chapters and standards, National Patient Safety Goals and processes or issues that are problematic for our institution.

I am providing documents related to our continuous readiness approach, including our plan, chapter leader assignments, and team leader assignments.

CRR Chapter Leaders

CRR Plan

CRR Teams

We’ll draw our next winner on April 1, 2010. All non-winning entries will also be entered into the and April 1 and May 1 drawings as well.  Complete contest rules can be found here. And just a reminder, you can send any entries directly to mphillion@hcpro.com.

AHAP Contest: Our March 1 winner!

We’re happy to announce our first winner for our contest to win a free registration to the 2010 AHAP Conference in May. By random drawing, our winner is:

The Quality Department of Regional Medical Center of San Jose in San Jose, CA!

Their original entry can be seen on the blog here.

Don’t forget, there are still two more chances to win. We’ll draw our next winner on April 1, 2010. All non-winning entries will also be entered into the and April 1 and May 1 drawings as well.  Complete contest rules can be found here. And just a reminder, you can send any entries directly to mphillion@hcpro.com.

Contest entry: order sets

Our latest entry comes from Pam Ledger, RN, MSN, Service Line Administrator, Surgical Services, St Mary Medical Center, Langhorne, PA. Pam writes:

Our goal is to ensure that every patient receives appropriate care while under our care. We utilize benchmarks and pride ourselves with setting high quality standards.

Our team has been very successful in increasing our overall quality scores within Surgical Care with the use of Surgical Order Sets.

Each order set is printed and placed on the patient’s medical record prior to admission. Many of our surgeons have copies and fax in the order set with their reservation. This ensures that every patient receives care based on evidence based practice. To date we have increased compliance from 65% to over 96%. Hopefully in the future we will be all electronic, but until then these serve as prompters for our surgeons. Upon receiving the preadmission reservation, the clerk enters the procedure code into the order set lookup screen.

This link utilized an access system to bring forward the correct order set for that patient. Order sets are placed into a data base and updated regularly as to changes in the quality specification manual. The project is a collaborative effort with representation from the Medical Staff, Nursing Staff, Pre-Admission Testing staff, Pharmacy and Material Management.

Here is an example of both our data look up screen and a copy of our Order Set for Hysterectomy. We currently have 14 sets for both IP and OP procedures.

Hysterectomy 102009 Order set 14

We will draw our February winner at the end of the day on Friday, February 26th (5 pm EST), and announce our winner on Monday, March 1. All non-winning entries will also be entered into the March and April drawings as well.  Complete contest rules can be found here. And just a reminder, you can send any entries directly to mphillion@hcpro.com.