AHAP Blog

MS.01.01.01: Revisions to troublesome standard receive approval

Matt Phillion — Thu, 18 Mar 2010 18:18:26 +0000

Revisions to Medical Staff standard MS.01.01.01 have received approval from The Joint Commission and will go into place March 31, 2011, an official announcement from the accrediting organization states. The standard has gone through several iterations over the years. Once known as MS.1.20, this challenging standard addresses the medical staff’s ability to self-govern, as well as [...]

Contest entry: Monitoring report

Matt Phillion — Fri, 12 Mar 2010 10:08:37 +0000

Our latest AHAP contest entry comes from Eileen Pressler, director of quality management at Kingman Regional Medical Center in Kingman, Arizona. Eileen writes: Our Quality Management Department is working on revising the format of regular reports. Sometimes we have trouble getting committee members do more than report numbers so we devised this format. The neat thing is [...]

Joint Commission releases small changes to NPSGs

Matt Phillion — Thu, 11 Mar 2010 11:21:29 +0000

The Joint Commission identified a few small tweaks to a pair of NPSGs yesterday and released the details via their homepage. The changes were: NPSG.03.04.01, Element of Performance 3. Under this EP, the phrase “preparation date” was removed from medication or solution label required information. The following, according to the EP, need to be included on [...]

Contest entry: Continual Readiness Plan

Matt Phillion — Mon, 08 Mar 2010 14:54:54 +0000

Our next entry comes from Clint LaFever RN, BSN, CPN, accreditation coordinator with Northwest Texas Healthcare System. Clint writes: I am the Accreditation Coordinator for Northwest Texas Healthcare System. We are comprised of 404 acute care licensed beds, 85 behavioral care licensed beds, and several ambulatory clinics. I work in the Quality Management Department and I am [...]

AHAP Contest: Our March 1 winner!

Matt Phillion — Mon, 01 Mar 2010 14:28:57 +0000

We’re happy to announce our first winner for our contest to win a free registration to the 2010 AHAP Conference in May. By random drawing, our winner is: The Quality Department of Regional Medical Center of San Jose in San Jose, CA! Their original entry can be seen on the blog here. Don’t forget, there are still two [...]

Contest entry: order sets

Matt Phillion — Tue, 23 Feb 2010 15:00:08 +0000

Our latest entry comes from Pam Ledger, RN, MSN, Service Line Administrator, Surgical Services, St Mary Medical Center, Langhorne, PA. Pam writes: Our goal is to ensure that every patient receives appropriate care while under our care. We utilize benchmarks and pride ourselves with setting high quality standards. Our team has been very successful in increasing [...]

Contest entry: timing and dating

Matt Phillion — Fri, 19 Feb 2010 17:47:29 +0000

Another contest entry, this time from Shelia Hull, RN, Joint Commission Specialist at Pikeville Medical Center. Shelia writes: I am attaching a couple of tools that I use in monitoring compliance from our physician’s with timing and dating of orders. The first tool is a simple audit tool, which we use weekly until we have [...]

Contest entry: Unannounced survey policy

Matt Phillion — Fri, 19 Feb 2010 15:03:06 +0000

Our latest contest entry comes from Linda M. Glaeser, RN, MS, manager of healthcare accreditation and regulatory affairs at Seattle Cancer Care Alliance. Linda writes: At Seattle Cancer Care Alliance we carry multiple accreditations, beyond The Joint Commission, including CAP, ASHI, FACT, ACR, and Committee on Cancer. As a result, we must be prepared for [...]

Contest entry: Tracer tool

Matt Phillion — Wed, 17 Feb 2010 14:44:01 +0000

Our latest entry comes from Tricia Elliott, coordinator, accreditation and licensure in teh Quality/Patient Safety Department at St. Alexius Medical Center. Tricia writes: Continuing with the theme that has evolved on the blog site, I have a tracer tool to share from our facility. We have three different teams that perform tracers in our organization. [...]

Contest entry: Tracer tool

Matt Phillion — Tue, 16 Feb 2010 16:53:27 +0000

Our latest contest entry comes from Carol Carach, BSN, RN, MPH, regulatory and accreditation survey supervisor with Medical City Dallas Hospital. Carol writes: We currently have about 35 tracer teams consisting of two people at least one of whom is clinical. Our goal is to trace each unit monthly and in 2009 we conducted approximately [...]