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Latest Sentinel Event Alert: Disruptive behavior

I just wanted to make you aware of some breaking news: The Joint Commission has issued its latest Sentinel Event Alert today addressing bad behavior by healthcare professionals.

Disruptive behavior was considered as a possible National Patient Safety Goal for 2008 but was not selected. The Joint Commission has stated in this most recent alert that rude behavior, unpleasant language, hostile attitudes and other bad behaviors does not only create an unpleasant environment but are detrimental to patient safety and quality of care.

This alert ties into new standards going into effect January 1, 2009, which will require healthcare organizations to create a code of conduct defining acceptable and unacceptable behaviors as well as crafting a process for dealing with poor behavior.

The Sentinel Event Alert provides 11 steps to curbing disruptive behavior. These range from providing education and training for healthcare providers about professional behavior and appropriate interactions with coworkers; creating accountability for maintaining appropriate behavior; establishing a zero tolerance policy for disruptive behaviors and a means for enforcing this policy; and crafting non-confrontational methods for reporting and addressing inappropriate behavior.

The Joint Commission’s Sentinel Event Alert can be found online here:

2009 National Patient Safety Goals released

Just wanted to let you know that The Joint Commission released the 2009 National Patient Safety Goals earlier today on its Web site:

The first link also has a chart identifying which goals have received changes/deletions/additions, and provides a crosswalk to the new numbering system.

Update: Joint Commission to lose "unique" deeming authority?

Hello, everyone. I just wanted to update you on the developing story in last week’s post. Senator Max Baucus’ (D-MT), chair of the Senate Committee on Finance, bill containing language to revoke the unique deeming authority status held by The Joint Commission failed to find support on the Senate floor. Meanwhile, a competing Medicare reform bill, introduced by Senator Charles Grassley (R-IA), has been introduced, containing similar language regarding The Joint Commission’s deeming authority.

Senator Grassley’s proposed Medicare reform package can be found here. A summary of Senator Baucus’ proposed legislation can be found here.

Joint Commission to lose "unique" deeming authority?

Hello, all. Just wanted to update you on a developing story:

Montana Democratic Senator Max Baucus, chairman of the Senate Committee on Finance, announced proposed legislation last week which included language to revoke the unique deeming authority status held by The Joint Commission.


This change would require all accrediting bodies, including The Joint Commission, to apply for hospital deeming status for hospitals—a process The Joint Commission and other accreditors undergo for other organizations and facilities (for example, laboratories and ambulatory centers). The Joint Commission currently does not need to undergo this application process for hospitals.


The Joint Commission issued a statement on Tuesday, June 10, supporting the legislation, while proposing several amendments. The Joint Commission has requested CMS issue “modernized guidelines and procedures for assessing compliance with existing conditions of participation for hospitals,” according to the official statement. The accreditor also requested a two-year period to undergo the application process following the issue of those guidelines and procedures. Finally The Joint Commission suggests that provisions are made to give the Health and Human Services (HHS) secretary the ability to create up-to-date methodology for assessing the performance of accreditors.


A summary of Senator Baucus’ proposed legislation can be found at


Go to for Senator Baucus’ Web site.


Congrats to our first group of CSHAs!

Congratulations to Dorris Dotson, Jane Bondani, Kathryn Hughley, Bart Wilkinson, Jackie Geeson, and Scotty Carmon–our first group of Certified Specialists in Healthcare Accreditation (CSHA)!

The group all took the exam last month and passed, and a number of other people have since signed up to take the exam.

Click here for more information on the new certification and to download the brochure, application, and candidate handbook.

In case you missed it…

Here’s a great presentation on the top 10 most frequently scored standards from this year’s AHAP conference, which took place May 8-9 at Caesar’s Palace in Las Vegas. We understand there was some confusion regarding the location of this breakout session, entitled “Staying ahead of the top 10 most frequently scored standards.” If you didn’t attend this year’s conference, or if you missed this session, click here to download a PDF of the conference workbook and click here to listen to an MP3 of the presentation. The presenter, Kurt Patton, MS, is a senior consultant for The Greeley Company, a division of HCPro, Inc. in Marblehead, MA, president of Patton Healthcare Consulting, LLC, in Glendale, AZ, and former executive director of accreditation services at The Joint Commission (formerly JCAHO).

In the coming weeks, we will continue posting more presentations from this year’s conference. Of the following, which interests you most?

Critical test results?

Keeping up with the IM standards?


Restraint and seclusion?

Suicide risk assessment?

Post a comment to the blog and let us know. Your feedback will determine the next presentation we provide. And, remember, it’s not too early to sign up for next year’s conference! Click here for more information.

AHAP Conference, Day 2

Hello again from Las Vegas!

I wanted to send you an update from Day Two of the AHAP conference. Members got a chance to learn about a few different topics–restraint and seclusion, the top 10 most frequently cited Joint Commission standards, and the 2009 updates to The Joint Commission’s Leadership standards.

During the restraint and seclusion session, Lisa Eddy, RN, CPHQ, senior consultant for The Greeley Company, discussed some of the changes to CMS’ requirements, as well as the differences between what The Joint Commission and CMS require.

Kurt Patton, MS, prinicpal of Patton Consulting, discussed the 10 most frequently scored Joint Commission standards. The top three of these include MM.2.20 (medication storage), NPSG # 2C (critical tests and values), and NPSG # 2B (unapproved abbreviations). MM.2.20 is so highly cited because of its 15 EPs, with the largest problem being the storage of medicatons.

Lisa Eddy spoke during another session on the updates to The Joint Commission’s Leadership standards for 2009. Some of the updates include new language as far as conflict management, leadership relationships, and leaders’ responsibilities in creating a culture of safety.

Lastly, attendees participated in roundtable sessions in which they got the chance to network with their peers on many topics, including critical test results, medication reconciliation, unannounced surveys, National Patient Safety Goals and suicide risk assessment. Attendees discussed their own barriers and successes in these areas and others.

Greetings from the desert!

The 2nd Annual AHAP Conference kicked off this morning at Caesar’s Palace in Las Vegas with a keynote presentation by Ian Morrison, Ph.D, author, consultant, and futurist on the state of healthcare. AHAP attendees then broke off into a general session on medication reconciliation, presented by Molly McDaniel, PharmD. This year’s conference is off to a great start with almost 100 more accreditation professionals in attendance than last year.

During a standing-room-only presentation by Jean S. Clark, RHIA, CSHA, on struggles facing hospitals dealing with IM standards, she discussed shortening lists for “critical” tests results and values, as “even The Joint Commission recommends you have a short list.” Critical test results and values topped the list of 2007’s top compliance issues with an HIM focus.

During a session updating the status of MS.1.20, Kurt Patton, MS, president of Patton Healthcare Consulting, LLC, recommended keeping your eyes open next week for possible updates on MS.1.20-the Joint Commission’s task force met last week, which could indicate new information in the next week.

Other topics covered today included:

Suicide risk assessment

Critical test results

Rapid response systems and anticoagulant therapy

Joint Commission ongoing professional practice evaluation

Check back tomorrow for more updates from AHAP!

Look Thursday and Friday for live coverage from the conference

The second annual AHAP conference will take place this Thursday and Friday at Caesar’s Palace in Las Vegas.

Over 150 of your peers have already signed up! But if you are unable to attend this year, you don’t have to completely miss out. Watch our new AHAP Blog this week for reports from the conference. In the coming months, we will also be posting podcasts from the conference, as well as additional interviews, presentations, and tools.

Sessions at this year’s conference include:

  • Medication reconciliation
  • Suicide risk assessment
  • Critical test results
  • IM standards
  • 2009 MS.1.20 changes
  • 2009 Leadership standard changes
  • Restraint and seclusion
  • Quality and The Joint Commission and more…I look forward to seeing many of you this week!