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New benchmarking survey launched!

We’d like to invite you to participate in this quarter’s benchmarking survey here. This quarter, we’re discussing Joint Commission stroke certification. This will also be the topic for our upcoming quarterly working group calls.  Keep an eye on the blog for an upcoming announcement about dates, times, and special guest speakers for the calls.

Joint Commission asking for more input on standards

If you’ve got any opinions or concerns about the Joint Commission’s proposed staffing effectiveness requirements, you’ve got about five weeks to make your voice heard. Field review of the proposed Elements of Performance (EP) for hospitals and long-term care facilities is underway, with the Joint asking for comments to be submitted by July 10 (although the field review will remain open until July 22).

The changes are in response to complaints that compliance with the current staffing effectiveness requirements (standard PI.04.01.01 for hospitals and HR.1.30 for long-term care) consumes substantial resources without providing significant improvement in quality and patient safety. The proposed EPs fall under PI.02.01.01 (currently PI.2.10 for LTC) and are as follows:

  • EP 12 focuses on the use of outcomes data to guide staffing effectiveness analysis
  • EP 13 calls for leadership to review analyses of data related to staffing issues

Click here to review and comment on the proposed EPs.

Joint Commission requests feedback on cultural, communication standards

The Joint Commission asked yesterday for review from the field of its newly released proposed standards in effective communication, cultural competence, and patient-centered care. The standards, which would not be implemented until January 2011 at the earliest, represent an effort by The Joint Commission to place a greater emphasis on addressing disparities in care for certain patient populations. The standards also recognize how important solid communication is to delivering safe patient care, and that often communication can be ineffective with patients who face language, cultural, or physically debilitating barriers.

For the most part, the ideas behind these proposed standards are not completely new to The Joint Commission. There are existing standards that target the need for effective communication, patient-centered care, and cultural sensitivity. However, this will be the first time that these are specifically called out as an area of focus. The proposed standards encompass revisions and additions to 17 chapters for hospitals.

The proposed revisions can be found on The Joint Commission’s Web site.

Seems to me that this is more positive change coming from The Joint Commission. What are your thoughts? Do more standards not always mean good things? In this case, I think it will be a welcome addition to the existing standards.

Check out this HealthLeaders Media article on the topic as well, it provides some more detail, and is written by AHAP’s own Matt Phillion!

Joint Commission says 2010 NPSGs to be published in October

In its June issue of The Joint Commissions Perspectives, the official newsletter of The Joint Commission, the accrediting body says that it will not publish its National Patient Safety Goals applicable for January 2010 until its October issue of Perspectives. Although the NPSGs applicable for January of the following year are usually published in the July issue of Perspectives of the prior year, the NPSGs are currently undergoing a field review that will result in significant revisions. The review is not expected to be completed until early summer 2009.

The Joint Commission has stated that no new NPSGs will be released for 2010, only modifications to existing NPSGs. It is also asking for comment from the field about the proposed set of NPSGs. You can comment on its Web site through June 23.

Does this timeline affect your survey preparation schedule? Hopefully this time will be used well to create a less cumbersome set of requirements that still focuses on key patient safety issues.

AHAP conference 2009 leadership session

For those of you who did not get a chance to attend the 3rd Annual AHAP Conference that took place in Las Vegas two week ago, and for those of you who did attend and would like a chance to listen to the leadership session, here is your chance. The session touched on how best to engage your hospital’s leaders in both creating a culture of safety and demonstrating involvement in patient safety to comply with Joint Commission standards.

The presentation, given by Ken Rohde, consultant for The Greeley Company, opened the 2009 conference.

To find a copy of the slides that accompanied the presentation titled “The 2009 Leadership Standards: A Toolbox Approach,” click here.

To listen to the audio recorded at the session, click the link below. You will first hear Jodi Eisenberg, Chair of AHAP, introduce Ken.

Get the Flash Player to see the wordTube Media Player.

For those who attended the conference, we hope you enjoyed it and would love any additional feedback you’d like to offer for how we can improve the conference in the coming years.

Update from the Vegas conference

Reporting in from the AHAP Conference in Las Vegas: We started the day with a great keynote presentation, followed up by presentations on tracers and critical test results. We’re glad to see so many familiar faces this year, as well as first-time attendees.

Next up: we’re getting ready for the panel discussion this afternoon with The Joint Commission, DNV, and HFAP. Should be a fantastic opportunity for our members to meet with representatives of all three accreditation organizations in person.

For those in attendance: what has been the highlight for you so far? Which discussions did you attend today?

Follow up to a recent post on core measures

A few weeks back, AHAP Member Edward Chilcote submitted a core measures tool and also offered to share two other tools with any other interested members. We’ve had so many requests by email for these tools that I wanted to post them here. Please find below Edward’s great sample core measures tools.



Thanks again, Edward, for sharing this useful information.

DNV updates FAQs

For those of you following DNV/NIAHO accreditation news: DNV recently updated its FAQs to address some confusion abou Medicare reimbursement coverage when a hospital transfers between accrediting organizations.

“This applies regardless of if you’re moving from HFAP to The Joint Commission, or The Joint Commission to DNV,” says Darrel Scott, DNV’s senior vice president of regulatory and legal affairs. “We wanted to try to address in our FAQ the exact mechanic that occurs when a move is made.”

BOJ had a chance to talk with Scott about this process recently, and a full article will appear in the upcoming issue. DNV’s FAQ page can be found here.

Have any AHAP members recently changed accreditation organizations? I recently chatted with the folks at the Healthcare Facilities Accreditation Program (HFAP) who said that they’ve also been hearing from a number of facilities exploring their options. Has your facility looked into HFAP or DNV?

If you’re among the folks attending this week’s AHAP Conference in Las Vegas, don’t forget to check out the panel discussion Thursday with leaders from The Joint Commission, DNV, and HFAP–it will be a great chance to hear from each organization directly. We’re thrilled to have all three organizations represented at our conference.

AHAP giveaway announcement–our final winner

And the final winner in our AHAP Conference registration giveaway: Marina Isaac of  Mount Sinai Hospital & Schwab Rehabilitation Hospital in Chicago, IL!

We’re looking forward to seeing all of our winners at this year’s conference! Thanks to all of the members who participated in this fantastic contest–we were incredibly impressed with the turnout and with the quality of information being shared week to week.

Update to yesterday’s contest entry

After receiving several requests, we wanted to share the progress report Edward mentioned in his tip yesterday. It is downloadable at the link below.


Also, he has offered to to share similar documents on pneumonia and AMI. Please feel free to contact me at if you’re interested!

Thanks for the great tip, Edward. And just a reminder to all our members–tomorrow’s the last day to enter for our free AHAP conference giveaway. Entries can be submitted right up until noon tomorrow. We’ll announce a winner by the end of the day.