RSSRecent Articles

Contest entry: Mini-handbook

The latest tip comes from Michael Neiman, senior director of accreditation with Thomas Jefferson University Hospitals in Philadelphia, PA. Michael writes:

We create a mini-handbook every year called Q and A for staff which fits in pocket for a reference guide. It includes HR, IC, Patient Safety, PI, Patient Rights, Privacy and Safety. These are given out to all new employees and staff every year. Staff find these education and valuable.

Contest entry: Survey experience

Our latest entry into our free AHAP giveaway comes from Karen A. Beck, CPHQ, quality manager at Sacred Heart Visiting Nurses & Hospice. She writes:

We were surprised the first week of February when TJC surveyors showed up at our hospital. We are a hospital based agency that provides home health and hospice services. We were not totally unprepared, though. I had been working from the Survey Activity Guide using the Preliminary Information sheet provided in this document. I compiled all of our information and had it housed in a binder ready on my bookshelf.

I also had the most current measure of success data I informed our management team and quality nurse of it’s location in the event I was not available. Our plan included assigning specific personnel to be responsible for running current patient lists and serving as “gophers” for any requests. As soon as the call arrived from the hospital accreditation coordinator we put our plan into action.

All the information we needed to get our surveyor started was readily available. This was not always the case in the past where we were scrambling to pull information together.

Revised revisions receive scoring guidelines

Those of us who stopped by the Joint Commission’s Standards landing page today received a bit of a shock–a bolded notice that additional updates had been made to the revised standards and EPs released on March 26. When the initial shock wore off, though, it turned out to be good news–the standards and EPs were not revised (again), but rather, the PDF had been updated to include (drum roll please) scoring guidelines! This much-awaited announcement indicates which standards are A versus C, where all the “circle M’s” and “circle D’s” are.

You can find the latest PDF of revisions here.

Keep in mind there’s no guarantees that we won’t see additional revisions leading up to July 1–the Joint Commission’s deeming authority application is still in process and we could, potentially see more changes.

Contest entry: Patient Safety Handbook

Our latest entry comes from  Leslie Whitaker, accreditation manager with NWTHS. She passed along the attached Patient Safety Handbook .pdf. Leslie writes: The following standards are addressed through the use of a Patient Safety Handbook recently implemented at NWTHS in Amarillo, Texas:

  • NPSG.01.01.01 EP1 (patient ID)
  • NPSG.07.05.01 EP6 (patient education)
  • NPSG.08.01.01 (Medication reconciliation – home medication list)
  • NPSG.09.02.01 EP5 (patient/family education on the fall reduction program)
  • NPSG.13.01.01 EP1,2.3,and 4 (patients/families involvement in care)
  • NPSG.15.01.01 EP3 (suicide risk)
  • NPSG.16.01.01 EP4: (The hospital encourages patient/family to seek assistance when the patient’s condition worsens)
  • UP.01.01.01/UP.01.02.01 & UP.01.03.01 (patient expectations from hospital staff regarding surgery procedures)
  • Patient Rights and Responsibilities standards

The book will be given and explained to all patients when they are admitted to the acute care hospital. This book is an effort to get patient’s involved in their care, as well as to provide valuable information about their hospital stay. This has information from Joint Commission’s speak up campaign, as well as IHI’s infection prevention program. Staff have received this well because prior to the handbook, we had developed numerous brochures to address education, and now we are using this all-inclusive document.


Contest entry: Tracer process

Another contest entry! This one comes from Robin R. Agnew, RN, BSN, MPH, senior accreditation analyst of St. Mary’s Health System, Evansville, IN. Robin writes:

To streamline the tracer process we developed a three page Core Tracer format that includes as medical record review section, a staff interview section and a brief dpt. observation section. Areas include TJC/CMS/State/NPSG as well as Magnet areas vs. having multiple tracers. The last three pages include small dpt. sections which have area specific staff interview questions pertinent for that specialty area (eg. ER, Surgery).

Tracer teams consist of a Clinical Manager or Director and a Team Partner. We find it more efficient to schedule all areas to be traced vs. have one tracer trace multiple areas. Our inpatient areas are traced twice in 6 months and ambulatory areas once in 6 months. We send reminders to each team one week prior to their scheduled time.

They review findings with the Director/Manager and send completed Tracer form to Accreditation. We post the schedule and the Quality Tracer form With answers on the Intranet so all staff knows when their area is to be traced and what will be addressed.

We plan to regularly seek feedback re. how improve process (questionnaire to Tracer teams) and input data so that reports can be run to track areas out of compliance, need follow-up, revision to tool, etc. and will review these at a monthly regulatory oversight committee.

Contest entry: Infection control staff education

Our second entry of the week comes from Megan Rose, who writes:

We improved staff education for infection control by making it fun! During International Infection Prevention Week our department hosted a POP (Protect our Patients) educational campaign. We made rounds throughout the hospital and distributed crossword puzzles and quizzes to all staff. Those that were able to complete them and turn them in received a tootsie pop.

All completed quizzes/puzzles were submitted into a drawing at the end of the week for great prizes like free meals, gift certificates for manicures/pedicures, the movie theater and more. New badge holders were distributed that said “wash your hands” and static stickers were made with the same handwashing logo and placed in the patient rooms. On the final day of the POP campaign, we had a popcorn and movie day.

We played a variety of infection control and patient safety videos throughout the day and served fresh popped popcorn. The final drawing was held at the end of the day and all were truly excited. We had great participation from all and got the message across. Thank you for the opportunity to share our story!

Contest entry: Monkey business

Our first entry of the week comes from Amy Mehlhaff, medical staff coordinator with Sheridan Memorial Hospital, Sheridan, WY. Amy writes:

In preparation for the Joint Commission Survey our Joint Commission Task Force, comprised of leaders from each of the Standard Departments, write up 10 questions they feel Joint Commission surveyors will focus on when they arrive on-site. These questions range from the NPSGs, specific standards, hand-off communication processes, etc. that all staff should be prepared for. These 10 questions are then given to our QS/MSS Administrative Assistant to type up with multiple choice answers (not that surveyors will give us that opportunity) and use to prepare an online survey through an easy, cheap, and professional tool –

Each survey is then distributed to the appropriate staff via mass email and the responses are tracked so we can assess areas that need further education. We love it so much that we now have made surveys for clinical staff, non-clinical staff, and our physicians! I encourage other facilities to utilize this tool -not promising you’ll eliminate all the other “monkey” business that goes on in the office, but at least we’ll be prepared for TJC.

This week’s winner!

I’m happy to announce that the winner of this week’s free AHAP Registration drawing is:

Janelle Holth of Altru Health System in Grand Forks, ND! Congratulations, Janelle, on winning this week’s drawing. As for all our other contestants–we’ll continue our weekly random drawings for anyone who submits a tip or tool for the blog up until Friday, April 24th!

Many Medicare patients readmitted to hospitals, study says

A study out yesterday from The New England Journal of Medicine shows that 20% of Medicare patients are readmitted to the hospital at which they recently stayed within a month. That percentage jumps to 34 when looking at a three month time period. The data, representing Medicare claims collected between 2003 and 2004, show that more and more discharge is becoming a time at which it is crucial to have a good communication plan in place among caregivers and patients.

Hospitals may soon have a financial incentive to make patient care at discharge a priority. The Wall Street Journal Health Blog reports that part of President Obama’s Medicare budget plan involves not further reimbursing hospitals for patients who are readmitted for the same condition that they had at discharge. Of course, there are many factors to why patients are readmitted: being extremely sick, and perhaps having a primary care doctor who jumps to hospitalization rather than other treatment could lead to repeat visits. A stronger continuum of care that involves better communication on the part of all of a patient’s doctors would also help lower these rates. Also, involving the patient and his or her family (and evaluating if they are health literate) in the discharge process would help lower readmission rates, researchers say.

To read the NEJM article, click here.

Just a reminder…

We’ll draw a name for tomorrow’s winner of a free AHAP registration at noon. (As long as your entry is received before noon, it’s eligible for this week’s drawing, even if it’s not immediately posted.) We’ll continue to draw new winners every Friday until April 24th.

On a related note–let your friends and colleagues in the Medical Staff and Credentialing office know that the Credentialing Resource Center Symposium is holding a similar contest over on their blog right now for their annual convention (coincidentally happening the same time as the AHAP Conference). If you know anyone who was considering attending, you might want to send them to this link: