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I saw Mommy kissing the senior engineer…

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, wrote about recent mid-term release of The Joint Commission’s Survey Activity Guide.

Late last week, The Joint Commission provided information regarding the mid-term edition of this year’s Survey Activity Guide (SAG—and no, I will not make any gratuitous remarks about that particular acronymic confluence…), which includes “new description for Facility Orientation-Life Safety Surveyor and minor revisions to Environment of Care Session and Life Safety Building Tour for hospitals and critical access hospitals.”

While the minor revisions to the Environment of Care session and Life Safety building tour are indeed just that (with one exception that you already know about—more in a moment), it appears that Santa Mills has left us a nice little package under the Christmas in July tree: a new Life Safety and Environment of Care Document List and Review Tool (just think, kids—now you can survey like a real surveyor!). While I jest a wee bit (jester that I am), I do think that this is a pretty useful thing for the good folks in Chicago to be sharing. I think you’ll find the tool may give you a sense of “what” they’re looking for in terms of documentation; it also contains a nifty little typographical error. Let’s see who has the eagle eyes out there in radioland…

The one change that is a little more than minor (if only for its far-reaching consequences in surveys the past 18 months) is the instruction for surveyors to assess operating rooms for proper pressure relationships.

Continue reading this post at Mac’s Safety Space.

The nuts and bolts of antibiotic stewardship programs

Editor’s note: This article appears in the August issue of Briefings on The Joint Commission.

In our lifetime, the creation and expanded use of antibiotics has allowed for the successful treatment of routine infections and safer surgical procedures. However, there has also been an overuse and, in some cases, misuse of antibiotics in both animals and people. This subsequently led to the rise of antibiotic-resistant infections, which have made the use of antibiotics increasingly less effective.

Last month, the White House convened a special forum on antibiotic stewardship in which more than 150 healthcare organizations, including the Centers for Disease Control and Prevention (CDC) and The Joint Commission, and announced increased efforts to promote effective antibiotic stewardship within healthcare facilities.

There is growing evidence that hospital-based programs dedicated to improving antibiotic use, referred to as antibiotic stewardship programs (ASP), can improve treatment as well as reduce antibiotic-related adverse events, according to a report issued by the CDC last fall. The report, Core Elements of Hospital Antibiotic Stewardship Programs, highlights the needed components for a successful stewardship program.

Currently, California (as of July 1, 2015) is the only state to mandate that all hospitals implement a physician-led ASP. Previously, approximately half of California hospitals had an ASP in place, with additional hospitals planning on starting a program, but financial issues were a barrier. A law, Senate Bill 1311, passed last September, improved on a previous 2006 law and provided specific guidelines to help hospitals move forward.

Read the full article or subscribe to BOJ here.

Due to space considerations in BOJ, we couldn’t include the list of references. The references have been provided below:

CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014,

CDC: Checklist for Core Elements of Hospital Antibiotic Stewardship Programs,

FACT SHEET: Over 150 Animal and Health Stakeholders Join White House Effort to Combat Antibiotic Resistance, The White House, Office of the Press Secretary, June 2, 2015,

California Antimicrobial Stewardship Program Initiative activities:

Accreditation Q & A

This question is based on The Joint Commission’s National Patient Safety Goals (NSPGs).

Question: Name two NPSGs that have been moved into the standards.

Answer: Answers may vary, but any of the following are correct: standardize list of abbreviations, acronyms, symbols and dose designations; patient involvement in their care as a handoff procedure; annual review of look-alike, sound-alike drugs; manage as a sentinel event all identified cases of unanticipated death or major permanent loss of function associated with healthcare-associated infections; reduce the risk of harm from falls; encourage patient involvement in their care as a patient safety strategy; improve recognition and response to changes in patient conditions – staff can ask for additional assistance; Universal Protocol.

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.

Assessing Nursing Quality and Patient Safety

Interest in using a variety of nursing engagement surveys as a reportable quality indicator is growing

This article, written by Cheryl Clark, appears in the June 2015 issues of HealthLeaders magazine.

Do your hospital’s nurses feel empowered? Are re nurses’ relationships with physicians strong enough that nurses can call out errors or ask questions without fear? Do they think their hospital hires enough nurses with appropriate skills and provides enough resources to provide safe and timely care? Are nurses involved in making policy?

When nurses are surveyed on these and related questions, which they increasingly are, poor scores may indicate troublesome systemic issues that could, directly or indirectly, affect quality of care, even adverse events. A drop in scores can often be tracked down to a specific hospital unit, research has shown. And poor scores may correlate to “nursing sensitive” patient outcomes, such as patient falls, lengths of stay, pressure ulcers, and infections.

Simply put, this measure is asking nurses what they think about the organization for which they work and how well they trust the care they deliver in their work environments.

Read the full article at

Oh no, Mr. Bill!

Editor’s note: My colleague Steve MacArthur, an expert on accreditation standards related to hospital safety, emergency management, and life safety, wrote about the recent OSHA updates of key hazards.

I always view with great interest the weekly missives coming from The Joint Commission’s various house organs, particularly when there’s stuff regarding the management of the physical environment. And one of the more potentially curious/scary “relationships” is that between the good folks in Chicago and the (I shan’t editorialize) folks at the Occupational Safety & Health Administration. They’ve had a nodding acquaintance over the years, but there is evidence in some quarters (I’ve seen a decided uptick in survey findings relating to hazardous materials and waste inventories—as we’ve noted before, a list of your Safety Data Sheets is not going to be enough on its own to satisfy a finding of compliance with the Hazard Communications standard), that concerns relative to occupational health and safety are becoming a target area during Joint Commission surveys.

At any rate, last week, buried in last Wednesday’s action-packed edition of Joint Commission Online, there was an item highlighting the OSHA updates of key hazards for investigators to focus on during healthcare inspections.

Now I can’t imagine that the list of key hazards would come as a surprise to anyone in the field (in case you were wondering, they are: musculoskeletal disorders (MSD) related to patient or resident handling; bloodborne pathogens; workplace violence; tuberculosis; and slips, trips and falls—surprise!), as these are pretty typically the most frequently experienced occupational risks in our industry.

Continue reading this post at Mac’s Safety Space.

Editor’s Choice: Proper GI Scope Disinfection: How to Avoid Becoming a Statistic

Thursday, July 14, 2015

1:00pm-2:30pm EST

Presented by Peggy Prinz Luebbert, MS, (MT)ASCP, CIC, CHSP, CBSPD, and Terry Micheels, MSN, RN, CIC

Patient deaths related to improperly reprocessed endoscopes have hit the national media. If your endoscopes and other diagnostic GI scopes aren’t properly cleaned and disinfected, they can expose future patients to antibiotic-resistant diseases such as carbapenem-resistant Enterobacteriaceae or (CRE) that can kill up to 50% of infected patients.  Don’t let your facility be the next statistic. Join infection control experts Peggy Prinz Luebbert, MS, (MT)ASCP, CIC, CHSP, CBSPD, and Terry Micheels, MSN, RN, CIC, as they discus everything your organization needs to know to ensure proper GI scope disinfection and protect the lives of your patients.  This 90-minute webcast covers the critical steps of high-level disinfection that must be met each and every day. Don’t miss out on this opportunity to ensure your organization complies with requirements set by The Joint Commission and CMS.

Learn more and register for the webcast here.

We need your feedback on Briefings on The Joint Commission!

Are you a subscriber to Briefings on the Joint Commission? We would like your feedback on our monthly newsletter. Is there something you wish had more coverage? Less coverage? Something you would like us to do differently? Now is your chance to let us know!

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Send me an email at if you would like to take advantage of this offer.

AHRQ teeters on brink of extinction

Editor’s note: My colleague Tinker Ready with HealthLeaders Media, recently wrote an article about the possible dissolution of the AHRQ, approved by a congressional subcommittee last week, that I thought you might find interesting.

The Agency for Healthcare Quality Research says its mission “is to produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable.” But that mission may soon be over.

This column was slated to be titled “Ten things you don’t know about the AHRQ.” But, in reality, there are probably a lot more than ten things you don’t about the agency, including its name: The Agency for Healthcare Quality Research.

The AHRQ says its mission “is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable.” But that mission may soon be over.

A congressional subcommittee wrote the agency out of the 2016 Health and Human Services budget last week, and the full committee approved the plan on Wednesday. Despite lobbying efforts by health service researchers and their supporter, the future of AHRQ, pronounced “ARK” by those in the know, is uncertain.

So why should people who run hospitals care? A search of a HHS grants database turns up 603 active projects funded by the AHRQ. A lot of them look as if they would be useful to providers looking for tools to improve quality in the pay-for-value age.

Read the full article at

Updated perinatal care performance measures

The Joint Commission extended the mandatory reporting of the Perinatal Care (PC) performance measure set from 1,100 births per year to a minimum of 300 births per year. All accredited hospitals will need to report on all five measures in the PC measure set. This change applies to over 80% of accredited hospitals with labor and delivery units.

While these changes are effective January 1, 2016, hospitals that meet these new requirements are encouraged to begin using the new PC set as soon as possible.

Read the full update here.

NPSF releases root cause analysis guidelines

The National Patient Safety Foundation (NPSF) released new guidelines developed to help healthcare organizations use root cause analysis (RCA) to learn how medical errors, adverse events, and near misses occur.

The report, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm was written by a panel of experts that examined best practices around RCAs and develop guidelines to help health professionals standardize the process.

“We’ve renamed the process RCA2 – RCA squared – with the second A meaning action, because unless real actions are taken to improve things, the RCA effort is essentially a waste of everyone’s time,” said James P. Bagian, MD, PE, member of the NPSF Board of Governors and co-chair of the expert panel. “A big goal of this project is to help RCA teams learn to identify and implement sustainable, systems-based actions to improve the safety of care.”

Although RCA is typically conducted after the harm occurs, the guidelines call for organizations to prioritize hazards based on potential risk before the risk occurs.

Bagian, and panel co-chair Doug Bonacum, CSP, CPPS, will discuss the NPSF report in a free webcast on July 15 (Register for the webcast here.).

Read the full NPSF report here.