In the first article of this series, Are You Doing Enough to Ensure Compliance with CMS’ Conditions of Participation (CoPs?), we discussed early warning signs for Board Members that would indicate their organizations are not doing enough to ensure compliance with CMS’ Conditions of Participation. Because there are many requirements within the Conditions of Participation, [...]
For-cause, complaint and unannounced surveys performed by the Centers for Medicare & Medicaid Services (CMS), State Departments of Health and The Joint Commission (TJC) are now regular features of hospital life. In states with vigorous departments of health, or those where the state has recognized financial penalties from noncompliant institutions as a revenue source, surveys [...]
The article, “Accreditation Options: National Integrated Accreditation for Healthcare Organizations,” recently posted in this journal, presented some of the ways that National Integrated Accreditation for Healthcare Organizations (NIAHO), offered by Det Norske Veritas, differs from accreditation by The Joint Commission (TJC). TJC has since provided further information to clarify their formula for reaching an accreditation [...]
by Amanda Brown, RN, MSM, CIC Part I of this series outlined the power of simple risk assessment to identify, mitigate, and eliminate hazards in the day-to-day operations of a hospital. Parts II and III will present approaches to risk assessment that are more complex and require more attention from multidisciplinary teams. In this installment, [...]
The July edition of “The Joint Commission Perspectives” contained an ominous signal for hospital executives facing survey and accreditation decisions in the coming months. Of particular concern is the mention of situations in which the “surveyor has identified leadership changes over the past 12 to 18 months.”
Requirements for the appropriate use of labels have been stepped up since the introduction of the National Patient Safety Goals (NPSGs), but hospitals are discovering that the requirements do not end there.
By Ruth Elzer, RN, MS The Joint Commission (TJC) continues to work with the Centers for Medicare and Medicaid Services (CMS) to complete an acceptable deeming application for its hospital program. The Medicare Improvements for Patients and Providers Act for 2008 (MIPPA) revoked the Joint Commission’s statutory deeming status for its hospital program, mandating a [...]
Recent consultation with several hospitals concluded with the discovery of radioactive food products being prepared and consumed in the nuclear medicine department. Further investigation and polling of others concluded that this could be happening in your organization.