by dawnconrey
PHC Newsletters


Library of past publications of our highly regarded Patton Healthcare Newsletter.

Our Newsletter is distributed monthly to over 1300 industry professionals and summarizes Joint Commission and CMS publications and regulatory announcements. The newsletter provides healthcare administrators with timely and actionable advice.

PHC Newsletter Inventory by Date/Topic

2018 Newsletters

Oct 2018 Newsletter

  • Perspectives
    • The Pendulum Swings: More Changes for High Level Disinfection & Sterilization
    • When to Document the Biologic Indicator & Re-usable Brushes
    • Cleaning Ultrasound Transducers
    • Keeping Instruments Moist – Simplified
    • TJC Webinar on Sterilization/HLD
    • Correction: No Need to Update the Address to TJC Office of Quality on your Posters
    • Incidence and Method of Suicide in Hospitals
    • New CMS Requirements in Standards
    • Change Needed to Fire Response Plan
    • Periodic Conversation Between Board and Lead of Organized Medical Staff Needed
    • An RN Needs to Supervise Perioperative Services
  • EC News
    • Frequently Scored EC/LS Standards Graphically Displayed
    • TJC Defines Timeframes in Standards
  • CMS Update
    • Important New Memo from CMS – Compliant Surveys Published & New Validation Survey Pilot

Sept 2018 Newsletter

  • Perspectives
    • A Change in Quality and Patient Safety Reporting
    • New Perinatal Care Measure
    • New Guidance on Using Scribes
    • Mandated Equipment in Operating Room Suites
    • Top 10 Most Frequently Scored Standards Updated
    • Sentinel Events
    • Consistent Interpretation – More Guidance on Sterile Compounding
    • Air Pressure Monitoring and Documentation
    • Chemotherapy Compounding
    • 411 Initiative
  • TJC Consultant Forum News
    • The Pendulum Swings, We Think
    • Adverse Decisions
  • EC News
    • Hazardous Chemical and Medication Compliance
    • BAS Compliance
    • Fire Safety Requirements
  • CMS Update
    • CMS Not Developing Ligature Risk Task Force!
    • Outpatient Dialysis Center Compliance Expected

July/August 2018 Newsletter

  • New FAQs on Ligature Safety
  • Consistent Interpretation – More Guidance on
    Sterile Compounding

New Standards for 2019

  • Naming Newborns – A Standardized Process
  • New Requirement for Fluoroscopy
  • EP Review Project, Phase IV – More

EC News

  • Means of Egress in Ambulatory Healthcare
  • Changes to the LS/EC Document and Review

CMS Update

  • Legionella – Revised Recommendations from

June 2018 Newsletter

  • Perspectives
    • Leadership Session – Be Prepared for Changes
    • SAFER™ Matrix Placement Under Review – # RFIs Still Important
    • Not to Miss – New APR Requires You to Notify TJC if You Lose Deeming
    • Action Item: Exacting Competency Requirements for USP797 Listed
    • Changes to Ligature Scoring and an OSHA Reporting Requirement
    • Pediatric Hospitals to Get Experienced Specialized TJC Teams
    • Intracycle Monitoring (ICM) Calls Suspended by TJC
  • EC News
    • Active Shooter
    • Suggestions for Sprinkler Pipe – Avoid Common Findings
  • Quick Safety
    • Action Item – Ensure you have a Continuity of Operations Plan
  • CMS Update

May 2018 Newsletter

  • Perspectives
    • Staying Safe – New SEA on Workplace Violence
    • E-Edition Update – Finding what Changed
    • Welcome Changes for Telehealth Applicability Grid
    • Sterile IV Compounding Compliance Details
  • EC News
    • Scorecard and Strategy for Creating and Managing the Physical Environment Steering Committee
    • Managing Utility Risks Related to General Anesthesia
    • Sample Design and Construction Partner Checklist
  • CMS Update
  • AHRQ Action Planning Toolkit
    • 3 Useful Resources for Culture of Safety Survey

April 2018 Newsletter

  • Perspectives
    • Top Scored Standards
    • Self-Assess Your Compliance with HLD & Sterilization
    • Challenges Posed by EC & LS
    • Sentinel Event Statistics
  • Joint Commission Online
    • Proposed Changes to Suicide Goal NPSG.15.01.01 – Out for Field Review
  • EC News
    • Keep Your Life Safety Drawings Current
    • Details on Fire and Smoke Prevention
  • CMS Quality and Safety Memos

March 2018 Newsletter

  • Perspectives
    • Suicide Prevention
    • Field Review for New Standards
    • Clinical Contract for Pharmacies is Focus of Increased Attention
    • Deletion of Old EP Regarding the Patient’s Right to Pain Management
    • Additional Detail on New EC Requirements
  • EC News
    • Documentation Checklist Required by the Life Safety Code Surveyors
  • CMS Updates
  • Additional Resources

February 2018 Newsletter

  • Perspectives
    • New Focus on Fluoroscopy Service
    • Update on Door Requirements
    • Oxygen Cylinder Storage – Change
    • Effective Now
    • New FAQs on Sterile Medication Compounding and USP 797
  • Consultant’s Forum
  • EC News
  • CMS Updates
    • Important Changes – After CMS
      Removes Deemed Status

January 2018 Newsletter

  • Perspectives
    • New Suicide Risk Recommendations for Partial, Day Treatment, and IOP Services
    • Change to the Credentialing and Privileging for Pathologists at Contracted Labs
    • New PC Requirements for Maternal and Newborn Care
    • Things to Share with Facilities Leadership: Consistent Interpretation
  • EC News
    • Revisions and Issues with LS.02.01.35 – Review and Self-Assess
    • Lessons Learned from Hurricane Harvey – EOP Committee Take Note
  • 2018 Customer Survey Activity Guide
    • Changes to the Day One Document List: Action Required Now
    • Revisions to System Tracers and Patient Tracers Focus on Pain and Emergency Management
  • CMS Updates
    • CMS Memo Summarizes Ligature Risks in Hospitals
    • CMS Offers a Modification to the Texting Prohibition
  • Happy New Year!

2017 Newsletters

December 2017 Newsletter

  • Perspectives
    • Survey Report Enhancements
    • 2018 Prepublication Standards
    • Scoring for Hand Hygiene Lapses
    • Looking for Hospitals to Meet CMS Definition of a Hospital
    • New Decision Rule for PDA
  • EC News
    • Managing Sprinkler Systems
    • Changes for the Behavioral Health Organizations
    • Another Vincristine Alert
    • Suicide Risk Algorithm
  • CMS Updates
  • Ready for 2018?
    • Medication Relation Standards
    • Pain Management Standards

November 2017 Newsletter

  • Perspectives
    • Recommendations for Reducing Suicide Risk
      • Inpatient Psychiatric Units
      • General Acute Inpatient Setting
      • Emergency Department
    • FAQs
      • 10 new pain management standard FAQ’s taking effect January 2018
    • CMS Updates
    • Trends on Survey Findings
      • Dialysis Focus
      • Open Electrode Packages
      • Protocols
      • Clarity on Clarifications

October 2017 Newsletter

  • Perspectives
    • Changes to Emergency Management Standards
    • Succession Planning – Delegation of Authority – Transplant Centers
    • Maintaining Contact Information
    • Training
    • System-Wide Preparation
    • 7 Recommended Steps for Handoff Communication
    • Increased Scrutiny of Sterile Compounding During Next Survey
    • To Do: Self-Assess Handling of Hazardous Medications
    • Trial Version Available on TJC Website
  • EC News
    • Infection Prevention During Construction
  • CMS Updates
    • Defining “Hospital”
    • CDC on Flexible Endoscopes
    • Ligature Hazards Once Again

September 2017 Newsletter

  • Perspectives
    • New Medication Management Standards
    • Essential Medication Refrigerators Need Emergency Electrical Backup
    • Approved Method for Wasting Medications
    • “Signed and Held” Medication Orders
    • Medication Overrides to Review
    • Top 5 Scored Standards—Scoring Frequently Accelerates
    • New to the Top 10
    • More Focus on LSC & EC
    • Sentinel Event Statistics: First Half 2017
  • EC News
  • Joint Commission Online—Monitoring BH Patients Progress Requirement and Database of Tools
  • CMS Updates
    • Another Look at Legionnaires Disease
  • Links

July 2017 Newsletter

  • Perspectives:
    • New Pain Management Standards
    • 4 Tricky Life Safety Clarifications:
      • Door Inspections
      • ED Occupancy Type
      • Door Ratings
      • Fire Drill Timing Patterns
    • New Behavioral Health Standards
    • Sterile Product Preparation
    • Ligature Risks, Again
  • EC News:
    • Active Shooter Recommendations and Resources
  • CMS Update — New S&C Memos on:
    • Filling Your Own Saline Syringes
    • Cleaning Dialysis Equipment After a Patient Leaves the Space
    • Screening for Hepatitis C
    • Revisions to the 2567 Completion Process

June 2017 Newsletter

  • Modifications to the National Patient Safety Goals
  • Egress, Clutter, and Exiting Focus
  • Improving HLD & Sterilization
  • FAQ on Syringe and Needle Safety
  • EC News:
    • Helpful tip on Medical Equipment Tracking and PM
  • CMS Update:
    • Emergency Management Interpretative Guidelines
  • New K-Tag requiring a Time out for OR Fire Safety

May 2017 Newsletter

  • Deletion of EPs for Nonhospital Programs
  • Blood Glucose Meter Advice
  • Medication Titration Requirements
  • Details about Doors
  • New Signage Requirement
  • Consistent Interpretation-Informed Consent
  • SAFER™ Matrix: A Look Back at Psychiatric Hospitals
  • New ESC Format for Ambulatory Care
  • EC News: A Document Prepared by the FBI on Active Shooter Situations
  • CMS Update
    • Emergency Management Planning
  • Still More on Ligature Risks and Resources


April 2017 Newsletter

  • Top Scored Standards for all 2016
  • Revised Decision Rules
  • Insights into the 2012 LSC Changes
  • New FAQ’s
    • History and Physical
    • Titration Orders
    • Linen Managements
    • Storage of Sterile Supplies Outside of Central Sterile
  • Feedback on the SAFER™ Matrix
  • More on Ligature Risks
  • EC News
  • CMS Update
  • SGNA Multisociety Guideline

March 2017 Newsletter

  • TJC New Survey Notification Email
  • Recall on Powdered Glove Reminder
  • EC News on Infection Control and Hazardous Medications
  • Sentinel Event Alert #57 on the Role of Leadership in Safety Culture
  • Insights from Survey Findings Seen in 2017 including:
    • Longer Reports, More LS/EC Findings, Scoring on the SAFER™ Matrix
    • New Requirements: Inspection of Exit Signs & Testing Battery Specific Gravity
    • Installing Manual Stop Station on Generator
    • Continued Focus on Air Pressure, Temperature, Humidity
    • More Sophistication Mandated in High-level Disinfection & Sterilization
    • Emphasis on Ligature Risks in Behavioral Health Areas
    • New Focus on Waste Medication Security

February 2017 Newsletter

  • TJC Survey Activity Guide
  • SAFER™ Matrix Guide
  • LSC Updates
  • Lab Accreditation Changes
  • Alarm Reduction Highlighted
  • Malignant Hyperthermia
  • Concurrent Surgeries
  • Summary of EC News
CMS K-Tags Published
  • CMS Memo on Cyber Security and End Stage Renal Disease
  • AHRQ Informed Consent Training

January 2017 Newsletter

  • The new 2017 Survey Activity Guide (SAG) has six new mandatory Day 1 documents
  • Survey focus on your Antimicrobial Stewardship Program
  • SAFER Matrix explained
  • ILSM Requirements highlighted
  • Changes to the Behavioral Health Manual – standards changes for July 2017
  • Bigger changes to the Behavioral Health Manual coming Jan. 2018 – start now!
  • Immediate Post Op Note – two thorny issues clarified
  • Refresher on portable fire extinguishers
  • CMS UPDATE: Small change for small critical access hospitals

2016 Newsletters

December 2016 Newsletter

• Revised ILSM expectations for life safety violations
• New Governing Body EP for COP level noncompliance
• Revised life safety expectations – details for LS.01.01.01
• Changes to the clarification process for 2017
• Final word on text messaging physician orders
• Helpful links on falls prevention & sterile compounding
• Catheter Associated UTI National Patient Safety Goal changes
• New CDC Guideline on vaccine storage
• CMS still testing the Infection Control Worksheets

November 2016 Newsletter
• The new EC and LS chapters have been published.
• Project Refresh Update – 51 EPs to be deleted
• Revised disease certification requirements
• Focus on air pressure differentials
• Cyber security addressed
• Suggestions for managing medical waste
• New emergency management requirements
• Surveyor focus areas

October 2016 Newsletter

• The TJC SAFER Matrix and changes to the ESCs
• Changes to the clarification process in 2017
• The Measure Of Success (MOS) gone in 2017
• ORYX Requirements Updated
• Changes your facilities leadership team
• Equipment management recommendations
• CMS new Emergency Management Regulations
• Summary of the TJC Executive Briefings
• Changes to the Day One Document list for 2017

September 2016 Newsletter

• Changes to the Statement of Condition and PFIs.
• New processes for waivers and equivalencies
• Sentinel Event Statistics for 2016
• Top hot spots for 2016
• Helpful Tool for tracking fire drills published in EC News
• New CMS S&C memo on Emergency Preparedness

July 2016 Newsletter
• Antimicrobial Stewardship Standard
• Capturing medical device identifiers
• Diagnostic imaging standards,
• Implementation date of the 2012 LSC
• EC tracer to the laboratory by your life safety code surveyor
• “Physician Favorite” order sets

June 2016 Newsletter

• Adoption of the 2012 LSC
• Fire hoses, dampers and more
• Response to violence in in healthcare
• Orders sets, protocols and standing orders
• Air pressure relationships and high level disinfection

May 2016 Newsletter
• Scoring Logic for 2017
• ESC Deadlines Change in 2017
• PDA Process
• Deleted 225 EPs
• Texting Orders
• Prison Units – CMS Rules
• CMS Adopts 2012 LSC

April 2016 Newsletter
• Numerous Elements of Performance deleted
• The FAQ page on the TJC website
• Top scored standards for 2015

March 2016 Newsletter
• Diagnostic imaging standards
• Pain assessment standards
• Fire Drill observations tool
• Infant Security
• Sentinel Event Alert is available on suicide
• Eligibility criteria for critical access hospitals (CAH) CMS

February 2016 Newsletter
• Interim Life Safety compliance
• High level disinfection booster pack
• Simulation for donning and doffing PPE
• Tips for Succeeding in a Life Safety Code survey”
• CMS memo on infection prevention
• CMS memo for the long term care industry
• OR temperature, humidity, air exchange & pressure
• SGNA clinical practice guidelines

January 2016 Newsletter
• Patton Healthcare Changes
• Risk icon elements of performance
• Additional team leader identified on some tailored surveys
• Behavioral Health standards effective July 1, 2016
• EC.02.02.01
• OSHA hazards enforcement policy
• Getting your plans set for 2016

2015 Newsletters

December 2015 Newsletter
• High Level Disinfection and Sterilization Booster Pack
• Draft antimicrobial stewardship standards
• Management of hazardous materials
• ORYX requirements in 2016

November 2015 Newsletter
• Executive Briefings
• CMS memo on sterile compounding and USP 797

October 2015 Newsletter
• 2016 decision rules
• Fire extinguisher testing
• Patients in police custody or forensic patients.
• CMS survey report findings from across the country
• Restraints

September 2015 Newsletter
• EC and LS portal launched by the TJC & ASHE
• Top scored standards
• Defibrillators – what is being scored
• National Patient Safety Goal for CAUTIs.

July 2015 Newsletter
• Perinatal core measure set
• Antibiotic stewardship update
• OSHA Tool Kit
• Protecting patients from self harm in BH settings
• Defining distance criteria for CAH designation
• Clinical contracting standard in the leadership chapter

June 2015 Newsletter
• CMS memo – radiology services safety requirements
• Severe maternal mortality in the sentinel event policy
• Breast feeding core measure
• Infant and child abduction risk tool

May 2015 Newsletter
• Summary of some standards changes
• TJC rules for organizations that stop serving patients
• Environmental rounding
• Antimicrobial stewardship
• Joint Commission FAQs

April 2015 Newsletter
• Top Scored findings for all 2014 hospital program
• Frequently cited findings from the behavioral health program
• Sentinel Event statistics for 2014
• Managing Ebola waste
• CMS memo on cleaning duodenoscopes & endoscopes

March 2015 Newsletter
• Decision rule changes for AFS & PDA
• Patient call bells, chemotherapy gloves & sterile supplies
• Copy and paste forward function in electronic health records
• CMS memo on blood glucose meters
• Duodenoscope surveillance and cleaning
• High level disinfection.

February 2015 Newsletter
• Diagnostic imaging standards 2015
• Ambulatory surgery centers – ASC’s
• CMS memo on dietitians
• Utilization review
• Preparation of radioactive isotopes
• LIPs without privileges that order outpatient services
• Swing bed requirements
• Coverage for ASC’s

January 2015 Newsletter
• E Cigarettes
• Targeted Solutions Tool for Safe Surgery
• Environment of Care compliance tracking
• Clinical practice guidelines for sterilization in dental clinics
• CMS Surveyor Worksheets

Oct PHC Newsletter


The Pendulum Swings: More Changes for High Level Disinfection & Sterilization: Last month we wrote an article in this newsletter entitled “The pendulum swings, we think.” Well, our conclusion, and yours after reading the October issue of Perspectives will be that there definitely is a new orthodoxy at Joint Commission regarding requirements for high level disinfection and sterilization.

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