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AQCC is Live!

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

Visit www.accreditationqualitycenter.com  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 bward@hcpro.com, with the subject line “AQCC Questions.”

 

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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 https://www.surveymonkey.com/r/MSHQPVT.

Remember, all responses are anonymous.

Thank you!

Brian T. Ward

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Checklist: Re-opening after a disaster

On October 10, Hurricane Michael made landfall in Florida, forcing two Florida hospitals to evacuate more than 300 patients due to building damage. On the same day, The Joint Commission (TJC) published a new Emergency Management Health Care Environment Checklist on its website, which helps healthcare organizations reopening their facilities after a disaster.

While the timing of these two events were coincidental, providers should to take time to go over the checklist and their emergency plans in general.

A TJC workgroup developed the checklist at the request of the U.S. Department of Health & Human Services’ Office of the Assistant Secretary for Preparedness and Response. It aligns with the accreditor’s Emergency Management standards, covers both clinical and environmental issues, and addresses crucial post-disaster elements that need addressing before reopening. It should be noted that the checklist isn’t hurricane-specific.

Jim Kendig, TJC’s field director of Life Safety Code surveyors, says it’s critical that hospitals customize the checklist for their needs by examining the relationships they establish in the community, and at the regional and state levels.

“For example, in Florida, a county Office of Emergency Management met with utilities and other emergency support functions to determine hospitals and PSAPS [public safety answering points] are the first to receive power restoration,” he says. “Establishing an unidentified victims process is also a good start, as it the ability to share that information within an hour of a disaster event.”

“The Joint Commission’s Emergency Management Committee continues meeting with organizations after disaster events to glean important information to share with the field through our Environment of Care News and ongoing communications,” he adds. “This also give us the opportunity to ensure that our standards and elements of performance are effective and contemporary.”

Go Vote!

Today is Election Day, and we here at HCPro want to encourage all our readers to get out and vote!

The site below shows you where your local polling places are:

www.vote.org/polling-place-locator

 

 

IHI Launches Maternal Care Improvement Project

The Institute for Healthcare Improvement (IHI) has begun a three-year project that aims to improve maternal outcomes for women and babies in the U.S. Supported by a grant from Merck for Mothers, the project’s goals are to spread the use of evidence-based care practices to reduce complications such as hemorrhaging, hypertension, and blood clots. It also plans to implement strategies to reduce disparities in maternal outcomes, and partner with women, their caregivers, healthcare providers, and community initiatives to better learn and address factors to improve health outcomes for mothers and newborns.

“IHI has proven experience in helping healthcare providers adopt and scale up best practices that save lives across whole systems, regions, and countries,” said Trissa Torres, MD, MSPH, FACPM, chief operations and North American programs officer at IHI, in a release. “We believe that by forging partnerships with others working on these problems and combining existing expertise with IHI’s improvement methodology, we can significantly improve care delivery outcomes for new and expectant mothers.”

Annually, an estimated 750 women die in the U.S. as a result of complications of childbirth, with more than 50,000 suffering serious complications, according to the IHI. African-American women have maternal mortality rates estimated to be three to four times higher than those of white women.

Merck for Mothers is a 10-year, $500 million initiative to help improve maternal mortality rates. The program began in 2011 and has expanded to more than 30 countries.

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.

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Tell us what you’re looking for in Accreditation Books

Hi there!

I’m working on the newest batch of Accreditation books out and I need your help!

This year we’re planning on writing books on:

  • Mock Tracers
  • CMS Compliance Crosswalks
  • Suicide Prevention
  • Survey Readiness

These book will come with with the newest updates to CMS and other Accrediting Orgs. Plus tools, checklists, and quizzes, and more! But before we can get started, we need to get your feedback.

Please answer this 3 minute survey so we can write the best books we can!

Thanks!

Brian Ward, Associate Editor

Joint Commission: Life Safety revisions for behavioral healthcare

The Joint Commission has revised its Life Safety standards LS.04.01.20 through LS.04.02.50 for its Behavioral Health Care Accreditation program. The changes apply to residential behavioral health care facilities and go into effect July 1, 2018. The revisions change the “residential occupancy” requirements so they align with the 2012 edition of the National Fire Protection Association’s NFPA 101: Life Safety Code®.

The accreditor says these changes aren’t major, and they mostly address two things:

•    Updating the NFPA chapter references used in the elements of performance
•    Making it easier to discern between the requirements for existing and new buildings and for small and large organizations.

You can read the prepublication standards here. 

Workplace violence prevention resources

More than 70% of significant WPV injuries occur in healthcare and social service settings. That number has been on the rise, and the victims are primarily healthcare workers. Here are some other free resources and training on workplace violence prevention in your healthcare organization:

1.    The Center for Health Design’s Safety Risk Assessment Toolkit
2.    The CDC’s Workplace Violence Prevention for Nurses  
3.    OSHA’s Guidelines for Preventing Workplace Violence in Healthcare and Social Services    
4.    OSHA’s Preventing Workplace Violence: A Road Map for Healthcare Facilities
5.   The Emergency Nurses Association’s Workplace Violence Page
6.    ASIS International’s Managing Disruptive Behavior and Workplace Violence in Healthcare

Thoughts about all that documentation the CoPs require? CMS wants to know

Have thoughts about the paperwork you have to generate because of Medicare’s Conditions of Participation (CoP)? Or rather, do you have thoughts you’d like to share with the public, as well as the Department of Health and Human Services (HHS)?

Now’s your chance. CMS has posted a call for comments on the paperwork required under the regulations that govern almost every aspect of operations at hospitals nationwide that also want the ability to bill Medicare for their services.

The call for public comment is periodic request, mandated in turn by the Paperwork Reduction Act of 1995. (So yes, it’s a regulatorily required chance to comment on extraneous regulations.)

And it’s one of many CMS puts out through the year. This particular request, according to the formal notice placed in the Federal Register Nov. 13, concerns the regular collection of information “needed to implement the Medicare and Medicaid Conditions of Participation (CoP) for 4,890 accredited and non-accredited hospitals and an additional 101 critical access hospitals (CAHs) that have distinct part psychiatric or rehabilitation units (DPUs). CAHs that have DPUs must comply with all of the hospital CoPs on these units. Thus, this package reflects the burden for a total of 4,991 hospitals (that is, 4,890 accredited/non-accredited hospitals and 101 CAHs which include 81 CAHs that have psychiatric DPUs and 20 CAHs that have rehabilitation DPUs).”

Translated, that’s most of the hospitals in the nation, minus the 1,183 CAHs without distinct part psychiatric or rehabilitation units. They operate under a separate set of CoP, according to the notice.

“The CoPs and accompanying regulatory requirements are used by our surveyors as a basis for determining whether a hospital qualifies for a provider agreement under Medicare and Medicaid. CMS and the health care industry believe that the availability to the facility of the type of records and general content of records is standard medical practice and is necessary to ensure the well-being and safety of patients and professional treatment accountability,” according to the notice.

CMS estimates that the paperwork required to meet the CoPs of the combined 4,991 respondents generates 1,342,424 responses a year, requiring a total of 18,840,617 hours a year.

That’s about 3,775 hours per hospital. Or 72 hours a week. Or basically two full-time positions a year.

(You might not want to ask one of those people to generate the report to send to Medicare, if you do decide to submit a comment.

Or you might.)

Comments must be received by Jan. 12, 2018.

After the notice is published on Nov. 13, to comment electronically — no physical paperwork needs to be generated! — go to www.regulations.gov, search for “2017-24524,” hit the button that says “COMMENT NOW” and follow the instructions.

Note the warning that the comments will be made public.

Or you can send comments by regular mail: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Document Identifier/OMB Control Number 2017-24524, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

To read the request of information first, go to https://www.gpo.gov/fdsys/pkg/FR-2017-11-07/pdf/2017-24134.pdf 

— Written by A.J. Plunkett (aplunkett@h3.group)