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Patient dumping scandal may cost accreditation

The Joint Commission has issued preliminary denial of accreditation for Rawson-Neal Psychiatric Hospital, a mental health facility in downtown Las Vegas, over a patient dumping scandal.

State officials with the Nevada Department of Health and Human Services have expressed disappointment in The Joint Commission’s decision, stating: “We are disappointed by the Joint Commission’s decision to move for a Preliminary Denial of Accreditation, which appears to be based on outdated survey information and is not an accurate reflection of the hospital’s current practices and policies.”

For more on this story, click here.

CIHQ receives deemed status for acute care hospitals

The Center for Improvement in Healthcare Quality has announced that it is the latest organization to receive deemed status for acute care hospitals from CMS. This allows CIHQ’s hospital accreditation program to deem hospitals to be in compliance with CMS Conditions of Participation.

For more information on this announcement, visit CIHQ’s accreditation home page here.


Emergency Management standards revised

The Joint Commission has announced revisions to its Emergency Management standards intended to take into account leadership accountability for hospitals and critical access hospitals.

Based upon a field review conducted in 2012, these changes will go into effect as of January 1, 2014 and target leadership involvement and oversight as well as staff input.

For more on the revised standards, which will appear in the e-dition of the standards for both programs in November, visit The Joint Commission’s website.

Joint Commission announces alarm safety NPSG

The Joint Commission has announced the creation of a National Patient Safety Goal (NPSG.06.01.01) addressing growing concerns surrounding alarm safety.

The multi-phase implementation process for this new goal will begin January 1, 2014 with a second phase beginning Junuary 1, 2016.  

For specifics on the goal, including requirements and implementation expectations, visit The Joint Commission website. Our sister newsletter, Briefings on The Joint Commission, will have ongoing coverage of this new NPSG leading up to the implementation deadline as well.

AHAP Networking Call, June 19th

Hello, AHAP members. I wanted to let you know that we have set up a time for our next AHAP networking call and we’d love to invite everyone to attend. The call will take place June 19th at 3 PM EST (2 PM Central, 12 PM PST).

We have a great topic to discuss this quarter. Recently, Briefings on The Joint Commission interviewed Rachel Zastrow, MSN, RN, CCRN, and Six Sigma Black Belt about the work her organization has been doing to prevent drift. Her story is really intriguing and we’re very much looking forward to having her share it with you, as well as hearing about what your own organizations are working on in this area.

The dial-in information for all participants is below—feel free, as always, to invite any of your colleagues to listen in as well! I’d like to ask a favor of you—if you plan to attend, please email me at to let me know. This is simply so I can get a rough estimated headcount to ensure we are properly staffed as members dial in to the call. Anyone who emails ahead of time to confirm will receive an electronic copy of the BOJ article on drift in response.

Here is the dial-in information:

Participant Dial-In (Toll Free): 877-869-3841

Password: 370331

Looking forward to having you join us on the call!

A view from the podium

Our afternoon session at the 7th annual AHAP conference included a series of round table discussions, giving attendees a chance to speak in a smaller group with all of this year’s conference. Here’s a view from above:

AHAP kicks off annual conference

Today’s first few sessions have been a huge success. Our 7th annual conference kicked off with a great keynote address by Kurt A. Patton, MS, RPh, on “Joint Commission and CMS standards requirements: Keeping up with the pace of change,” pictured below, and we are currently listening to AHAP advisor Jean Clark, RHIA, CSHA present on “Solving compliance issues: Regulatory changes in 2013 and top RFIs.”

Later on today we’ll be hearing from Brad Keyes, CHSP, on “The Environment of Care documentation that the accreditation professionals never get to see,” followed by a round table discussion with all of our conference speakers and a tracers-related presentation by Jean as well. 

Joint Commission launches adult depression campaign

The Joint Commission has released the latest of its ongoing “Speak Up ™” campaign, this time intended to provide advice on identifying the warning signs of depression and getting the most out of care and treatment for depression.

The campaign was developed with the collaboration of nearly a dozen nationally recognized mental health organizations.

The Speak Up brochure, as well as supporting materials, can be found on The Joint Commission’s web site here or by clicking the link below:

CMS proposes changes to survey process

CMS has proposed to revise the survey, certification, and enforcement procedures related to CMS oversight of national accreditation organizations (The Joint Commission, DNV Healthcare, and the Healthcare Facilities Accreditation Program or HFAP). These revisions would implement certain provisions under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).

The proposed revisions would also, according to the CMS announcement, clarify and strengthen our oversight of accreditation organizations that apply for, and are granted, recognition and approval of an accreditation program in accordance with the Social Security Act.

The comment period for the proposed rule, which was originally intended to end on June 4, 2013, is extended to July 5, 2013.

The proposed rule can be found in the Federal Register here, or by clicking the link below:

BOJ article: CMS on accreditors

In a recent article by AHAP advisor Elizabeth Geffers, she takes a look at what the regulatory agency has to say about the various accrediting organizations and the work they did last year. Elizabeth also created a number of charts comparing the agencies based on available CMS data. We wanted to make all of those charts available to both BOJ subscribers and AHAP members.

By clicking on the link below, you can download a zipped folder containing all of the charts appearing in the story, as well as a few bonus tools as well. EDIT: Due to request, we have also added the charts in both a single-file Word format and PDF (thank you, Elizabeth, for sharing the alternative version). All three are below to download.

Zip: charts

Word document: 05-24-2013 16_0613_st03_fig01-5

PDF: 05-24-2013 16_0613_st03_fig01-5