Patton Post Newsletter - Patton Healthcare Consulting

Patton Post

The Patton Post is a monthly newsletter that provides healthcare administrators with timely and actionable advice on regulatory and compliance issues from The Joint Commission, CMS, and other leading accreditors and industry decision-makers. It is distributed to over 2,500 healthcare professionals in hospitals, behavioral health facilities, ambulatory clinics, laboratories, pharmacies, and more!

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Issue	Year	Issue Highlights	hf:tax:newsletter_year
October NEW!	2024	TJC Perspectives • Standards & SAG Updates • Off Site Review Option for DSC • Continuity of Operations Plan (COOP) TJC EC News • USP Chapter 797 • Physical Environment Most Frequently Scored • Fire Response Plan • Suicide Prevention Accreditation Resources • ACHC: Resources • DNV: Symposium • CIHQ: Summit CMS • Rural Emergency Hospital Update • Hospice Special Focus Programs	2024 view-all
September	2024	TJC Perspectives • Certification Programs • Get With the Guidelines (GWTG) Upload • The Consent Process TJC EC News • Workplace Violence Standards • Workplace Violence Prevention • Training on De-escalation • ITM of Medical Gas Systems and Shutoff Valves TJC EM Leader • Workplace Violence Response Process • Disaster Supplies • Wildfire Exercise Accreditation Resources • ACHC: Infection Prevention in Surgery Webinar • CIHQ: Accreditation and Regulatory Summit CMS • New EMTALA Sign • Extension Site Locations • Pancreata Reporting Requirements • Initial Accreditation Requirements for Home Health & Hospice	2024 view-all
August	2024	TJC Perspectives • CMS Consent Memo, Revisited • Life Safety Drawings • Texting of Medication Orders TJC EC News • Autism Friendly Spaces Accreditation Resources • ACHC: Assessing Competencies • CIHQ: Incident Reporting Software • DNV: Cybersecurity & AI CMS • ESRD Programs: Medical Director Board Certification	2024 view-all
July	2024	TJC Perspectives • New CAMBHC EPs on Addiction • CAMBHC Physical Hold of a Child • New IC EPs for OME, ALC, & NCC • AHC Standards Changes • Change to the ESC Process? • Staffing Standards TJC EC News • Rural Health Clinic EC Standards • CAMBHC Workplace Violence Standards • Case Study: Workplace Violence • Safety and Security Risk Assessments TJC EM Leader • Top 4 Most Frequently Scored Standards • Case Study: Coping with Civil Unrest Accreditors • ACHC: Free Webinars: AI & Cybersecurity • CIHQ: Medical Record Reviews • DNV: Corrective Action Timeline Update CMS • Surgical Procedure Consent Continued	2024 view-all
June	2024	TJC Perspectives • Rural Health Clinic Accreditation • Hospice Standards Changes • Sprinkler Pipe Non-Compliance • Potential Standards Development TJC EC News • Sustainability • Pest Management • Metal Detectors • Illuminated Exit Signs TJC FAQ • Bronchoscopy Environment ISMP • High Alert Medications and Error Prone Abbreviations Accreditation Resources • ACHC: Joint Ventures Webinar • CIHQ: Sterile Processing CMS • Surgical Procedure Consent • Authorized Service Providers	2024 view-all
May	2024	TJC Perspectives • Most Frequently Cited Certification Standards • Multiple Tenant Occupancies • Fall Precautions • Telehealth Accreditation • Texting Update TJC EC News • Top Scored, High Risk Physical Environment Standards • EOC Management Plans • Laser Safety TJC EM Leader • Free Courses & Webinars • Tornado Readiness ACHC • 2023 Annual Report CMS • Updated SOM Appendix A • QSO Memos CDC • Mandatory Covid Reporting Canceled	2024 view-all
April	2024	TJC Perspectives • 2023 Most Frequent Higher Risk Standards • System Tracer Changes • NHSN Deadline Approaching • Emergency Power System Noncompliance TJC EC News • Fire Door Inspections • ICRA, PCRA, Life Safety Inspections, and ILSM • Spring Cleaning CIHQ • Discharge Planning DNV • Validation Surveys ACHC • Dialysis Surveys CMS • Home Health Manual Rewrite • EMTALA and Release of QIO Reports • Informed Consent Process • QAPI Revisited	2024 view-all
March	2024	TJC Perspectives • Language Updates • History & Physicals TJC EC News • Preventative Maintenance Inspections • ICRA, PCRA, Life Safety Inspections and ILSM TJC EM Leader New Publication • Success After a Flood • EM Survey Session Preparation • Cybersecurity ACHC • Informed Consent CIHQ • Competency Expectations CMS • Texting Orders • Federal Register Proposed Rules	2024 view-all
February	2024	Perspectives • Fire Extinguishers • Kitchen Exhaust Hood • Protecting Kitchen Gas Lines • Automatic Fire Suppression System • Protecting Kitchen Gas Lines EC News • Environmental Sustainability • Age Inclusivity • Sprinkler Escutcheons CMS • Approved Accrediting Bodies • QSO Memo	2024 view-all
January	2024	Perspectives • New IC Standards • New BH Workplace Violence Standards • Revised EM Standards for AHC & OBS • Pre-Anesthesia Assessments • Medicare Deficiency Surveys EC News • AHC Most Frequently Scored EC/LS • EC/LS Kitchen Checklist CMS • QSO-24-02: EMTALA During Disaster • QSO-24-03: Laboratories & CLIA	2024 view-all
December	2023	Perspectives • Sentinel Event Involving Suicide • Summary of Changes- Revisions and Removals • Critical Areas and Ventilation Systems • Quick Safety on Pressure Injuries • Simplification of MS.06.01.05, EP 6 FAQ • Opioid Reversal Agents Extranet • New Sterile Compounding Evaluation Tool EC News • Emergency Management Leader Publication • Behavioral Health Workplace Violence Standards • Sharps Containers Requirements CMS • Rural Emergency Hospitals	2023 view-all
November	2023	Perspectives • 2024 ORYX Reporting Requirements • Certification Document Upload • Managing Complaints • Prevention of Surgical Fires EC News • Environmental Standards in Critical Access Hospitals • Winter and Grounds Maintenance • New USP Chapters	2023 view-all
October	2023	Perspectives • Sentinel Event Data • New Decision Rule • SE Alert on Cyberattack • Managing Utility System Risks • Designated Person EC News • Potential Utility Failures • Most Frequently Scored BHC Environmental Standards • Delayed Egress Doors CMS • Nurse Midwives • Patient Safety Work Products and QAPI Survey Documents • Validation Surveys Resuming	2023 view-all
September	2023	Perspectives • Standards Revisions • Applicability of USP • New Hospice EM Requirement • New Resuscitation Standards EC News • Environment of Care Data Collection • Managing Mass Casualties CMS • New SOM Appendix A Manual • Hospice Billing Investigation • Fentanyl Handling and Exposure	2023 view-all
August	2023	Perspectives • Certification Programs Most Frequently Scored • Total Hip and Knee Performance Measure • New Leaders at Joint Commission • MRI Safety EC News • Medical Devices and Recalls • Active Shooter Exercises • Family Assistance Centers • Preventing Infant Abductions CMS • Vaccine Mandate • Suicide Safety and Workplace Violence	2023 view-all
July	2023	Perspectives • Deleted, Consolidated, and Revised EPs • Healthcare Equity Certification Resource Center • Medication Compounding EC News • Ambulatory Care Environmental Standards • Potential Summer Heat Emergencies • Environmental Tours CMS • Hospital Discharges to Post-Acute Requirements • Eliminated Practices	2023 view-all
June	2023	Perspectives • ORYX Data Submission • Critical Access Hospital Standards • Integrity of the Egress • Preventing Light Source Burns • Single Medical Staff Option Leading to New Burdens EC News • BHC Workplace Violence Standards • Emergency Management Drills and HVA Development • Risk Assessments • Infection Prevention Standards Status USP • Implementation Deadline Approaching CMS • CMS and Accrediting Bodies Compared • Post Pandemic Laboratory Changes	2023 view-all
May	2023	Perspectives • Ethical Issues Requirement • Ventricular Assist Device (VAD) Implant Volume Reinstated • Use of Validated Tools for Suicide Risk Screening • Informed Consent Process • New IC Standards? EC News • Environmental Sustainability Standards • ITM for Diagnostic Imaging Equipment • Top Cited Physical Environment Standards • Electrosurgery Safety CMS • End of the Public Health Emergency CDC • NIOSH Managing Hazardous Medications	2023 view-all
April	2023	Perspectives • Most Frequently Scored 2022 • Sentinel Event Statistics • National Practitioner Data Bank Query EC News • Reducing Noise • Sprinkler Pipe RFI and ESC • Alternative Equipment Maintenance Requirements Other TJC News: • New Requirements for Certified Community Behavioral Health Clinics • Environmental Sustainability CMS: • Discontinued Nursing Home Memos • LSC Memo – Health Care Microgrid Systems • Hospital Memo – Appendix A QAPI Modification	2023 view-all
March	2023	Perspectives • Racial and Ethnic Disparities in Pregnant and Postpartum Patients • Collecting Data on Discrepancies Between Diagnoses • Titrations • Medication Compounding for Home Care FAQs • Accessing Medications at Night EC News • Hyperbaric Chamber Fire Drills • Behavioral Health Crisis Units • Hazard Vulnerability Analysis • EM Chapter for Home Care	2023 view-all
February	2023	2023 Survey Activity Guide • SAG is Now Program Specific • Day One Document List Changes • Safety Briefing and Leadership Session • Updated EC/LS Document Tool Perspectives • ORYX Data Submission Platform Delay • Portable Fire Extinguishers EC News • Deleted Standard Explanations • Cleaning Kitchen Exhaust Systems CMS • End of the Public Health Emergency • Quality Videos • Rural Emergency Hospitals • Hospice Surveyor Training • Aligning Clinical Quality Measures Industry News	2023 view-all
January	2023	PERSPECTIVES • Healthcare Equity Standards • Deleted Standards • Revised EM Standards for Home Care • Food and Nutrition Products EC NEWS • Completing an ESC • Workplace Violence Standards • Home Care Oxygen Safety CMS • Workplace Violence Standards Pharmacy Practice News: • Medication Errors 2022 CDC Health Alert Network: • Dental Water Lines	2023 view-all
December	2022	PERSPECTIVES • Practitioner Privileging Cycle • Eye Wash Station Checks • Health Care Equity • LIP Terminology Removed • Health Information Privacy and Security EC News • Water Management • Business Occupancies Requirements • FGI Guideline CMS • LTC Covid-19 Therapeutics USP Chapter 797 • Sampling and SOPs • New Acronyms and Terminology Changes • Next Steps • FAQs and the One Hour Rule	2022 view-all
November	2022	PERSPECTIVES • New ORYX Performance Measure Requirements for 2023 • New Safety Briefing for 2023 Surveys • 2023 Standards Database and Updates • High-Risk Medical Equipment Preventative Maintenance • New TJC FAQ on Healthcare Worker Masking EC News • Most Problematic EC/LS Standards and EPs • Managing an Evacuation and Lessons Learned CMS • Covid Vaccination Requirements of the Workforce USP • Chapter 797 Has Officially Been Published	2022 view-all
October	2022	PERSPECTIVES • EC and LS Standards: New and Changes • Definition of Sexual Abuse/Assault • Proficiency Testing Regulations for Laboratories • Medical Air vs. Instrument Air EC NEWS • Decarbonization • ED Access and Security CMS • Asymptomatic Covid Testing CDC • Covid Source Control for Healthcare Workers	2022 view-all
September	2022	PERSPECTIVES • Sentinel Events • Climate Pledge • Health Care Worker Well Being • History & Physicals • New Infection Prevention and Control Requirements EC NEWS • Extreme Heat and Power Outages • Decarbonizing the Health Care Sector • EC Risk Assessments CMS • EMTALA and Abortion in Texas • Public Health Emergency Ending?	2022 view-all
August	2022	PERSPECTIVES • Diagnostic Overshadowing • Direct Data Submission Platform EC News • Greenhouse Gases • Top Scored Physical Environment • GFCI Outlets • Emergency Operations Plan Requirements CMS • Covid Vaccination Requirements for State Surveyors • Infection Prevention & Antibiotic Stewardship	2022 view-all
July	2022	PERSPECTIVES • Health Care Disparities • Antimicrobial Stewardship • Interior Spaces EC News • Workplace Violence • Anesthesia-Related Greenhouse Gas Emissions • FAQs on Emergency Management Standards • Commercially Prepared Sterile Supplies and Devices CMS	2022 view-all
June	2022	PERSPECTIVES • Suicide Safety Performance Improvement EC NEWS • Fire Safety Testing • Emergency Power Systems • Medical Equipment Preventative Maintenance • Interim Life Safety Code Measures ASHP • Contrast Shortage CMS • Covid Vaccination Medical Exemptions • Emergency Management Exemptions • Reporting Covid Statistics	2022 view-all
May	2022	PERSPECTIVES • IC.02.04.02 – New Covid Vaccine Standard CMS • Workforce Vaccination EC NEWS • EM Standards Effective July 2022 • Top Scored EC/LS Standards in Ambulatory	2022 view-all
April	2022	2022 Surveys • COVID Vaccine Mandate Scorings • MIFU Noncompliance Findings Perspectives • Top 10 Frequently Scored for 2021 EC News • Causes of Ventilation Failures • Workplace Violence Standards • Fire Department Connections CMS • Surveying Laboratories Resumes	2022 view-all
March	2022	Survey Activity and Vaccination Data PERSPECTIVES •2021 End of Year Analysis •Hospice Changes •Suicide Prevention and Screening EC NEWS • Prevention of Surgical Fires • Protecting Patients at Risk for Suicide CMS • Surveying for Vaccine Compliance • Medication Errors	2022 view-all
February	2022	PERSPECTIVES • Standard Language Changes • ESC and Clarifications •Covid Vaccine Requirements EC NEWS • Smoke Barriers vs. Fire Barriers vs. Smoke Partitions • “New” Emergency Management Chapter CMS • Vaccination Requirements	2022 view-all
January	2022	PERSPECTIVES • New Standards for July 2022 • Patient’s Rights Standards Changes • Environment of Care Standards Changes • New Requirements for Inpatient Hospice • Hand Hygiene Scoring EC NEWS • ITHS Findings • Survey Process for Business Occupancies • Checklist for Assessing Business Occupancies CMS • Validation Survey Process • Vaccine Mandate	2022 view-all
December	2021	PERSPECTIVES • 2022 ORYX Requirements • Cybersecurity • Water Management Requirements • Extranet Access and Security • Standards Interpretation • Future Standards EC NEWS • What’s New for 2022 • ICRA for Construction CMS • COVID Vaccine Mandate Update • Obstetric Emergencies and Maternal Safety	2021 view-all
November (Supplement)	2021	Covid Vaccine Mandates • New Regulations for Employees • Key Dates • Applicability • Vaccination Program Tracking • Exemptions • Questions	2021 view-all
November NEW!	2021	PERSPECTIVES • 2022 Manuals and Workplace Violence & Resuscitation Standards • Influenza Immunization • Non-Ventilator Hospital Acquired Pneumonia • Human Resource Scoring Guidance EC NEWS • EC/LS Most Frequently Cited • Snow Mitigation Efforts • Alternate Care Site Guidance • USP Chapter 797 CMS • Hospice QSO Memo	2021 view-all
October	2021	PERSPECTIVES • Interoperability Requirements • Psychiatric Patient Boarding in the ED • Nutritional Assessments EC NEWS • EOP vs COOP • Home Care – Most Frequently Cited EC, LS, and EM • Preventing Eye and Skin Injuries • Compressed Gas Policies • Surveyors in Multi-Tenant Buildings CMS • Pregnant Patients in the ED</span AHRQ • Maternal Morbidity FDA • Sterile Compounding in the Pharmacy	2021 view-all
September	2021	PERSPECTIVES • Sentinel Event Statistics • Diverse Populations • Home Care SAG Error • Draft Standards Field Review • Building Fire Protection • TJC Advisory Group– Vaccines, Backlogs, & Maternal Standards • TJC & Covid-19 • Covid Vaccine Side Effects EC NEWS • Ligature Hazards • EC/EM System Tracers • Workplace Violence Standards • Training Staff for Emergencies	2021 view-all
August	2021	PERSPECTIVES • Patient Visitation Policies • Insulin Pumps and Continuous Glucose Monitoring Devices • HAP or BHC Manual? • Emergency Power Systems • Requirements in Development EC NEWS • Family Reunification • New Water Management Standards • Planning for Construction • Electrical Hazards in Health Care CMS • COVID-19 Data	2021 view-all
July	2021	PERSPECTIVES • Workplace Violence Standards • Resuscitation Services Standards • Performance Improvement Standards • Spare Sprinkler Heads • Processing Bloody Surface/External Ultrasound Transducers EC NEWS • Emergency Coordinators • Extreme Temperature Preparation • Crash Carts CMS • COVID-19 Data • Emergency Management Exercise Waiver INSPECTOR GENERAL REPORT • Emerging Infectious Disease Preparedness	2021 view-all
June	2021	PERSPECTIVES • Inpatient Insulin Pumps and Glucometers • Insulin Pump/Continuous Glucose Monitor Policy • TJC FAQ on Vaccinated Staff and Masks • TJC FAQ on Medication Autoverification EC NEWS • Hazardous Chemicals and Waste Hauling • Keeping Facilities Safe for Seniors • 2020 Most Frequent EC/LS & Ambulatory Standards CMS • COVID-19 Data • Nursing Home and Covid-19 Vaccinations IN OTHER NEWS • PPP: Hazardous Waste Medications	2021 view-all
May	2021	PERSPECTIVES • Top 10 High & Moderate Risk Findings for 2020 • Interoperability Standard Revision • New Speak Up Video • Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing • Sentinel Event Alert – Infusion Pumps EC NEWS • Alternative Equipment Maintenance (AEM) Strategies • Conventional, Contingency, and Crisis Care Standards • Medical Gas Room Signage CMS • COVID-19 Test Positivity Rates • Interoperability Requirements	2021 view-all
April	2021	PRIORITY NEWS • Surveys are Restarting • CAH Leadership Standards Changes • Full-Service Acute Hospital IM Standards Changes • Water Management Requirements • Emergency Management Standards Guidance • Visitation Rights PERSPECTIVES • Suite Aisle Width • Medical Assessments for Outpatient Procedures EC NEWS • Maintaining Security Systems • BH Environment Most Frequently Scored • EC Top 10 Most Frequently Scored • BH Top 10 Most Frequently Scored • Portable Fire Extinguishers TJC RESUMES SURVEYS • Personal Client Experiences CMS • Suitability for Survey	2021 view-all
March	2021	HIGHLIGHTS • Email from TJC COO PERSPECTIVES • Suicide Sentinel Events • Supporting Health Care Workers • Eye Wash Station Compliance • Dental Services Hazardous Chemicals • Deemed Status Home Care Changes EC NEWS • COVID-19 Vaccination Site Tips • Internal Flooding • NCC Most Frequently Scored EC/LS HEADS-UP REPORT • Reducing the Risk of Suicide CMS • Surveys and COVID-19 ISMP PHARMACY PRACTICE NEWS • Medication Errors AHRQ • National Healthcare Quality and Disparities Report	2021 view-all
February	2021	PERSPECTIVES • Performance Measurement Data • Flammable Antiseptics • Medical Staff Updates • Reduced Volume Requirements • Remote Surveys • New Speak Up™ Materials EC NEWS • EM Standards for 2022 • After-Action Reports • Fire Doors • Hyperbaric Checklist • Wrong-Site Surgeries CMS • QSO 21-12 • Annual Report to Congress • QSO 21-13 • Suspending Surveys	2021 view-all
January	2021	PERSPECTIVES • Standards Changes – APR, EC, LS • EM Changes in Home Care • Certification Performance Measures • Pediatric Cardiovascular Programs • Consistent Interpretation – Thermometers EC NEWS • Spare Circuit Breakers • Elevator Advertising • Fire Drill Matrix • Spare Sprinkler Heads • Reducing Corridor Clutter • Surgical Smoke CMS • Ambulatory Facilities as Hospitals?	2021 view-all
December	2020	PERSPECTIVES • ORYX Requirement Changes • Mandatory COVID Reporting • Sentinel Event Definitions • Medical Staff Tracer Tools • Changes to Standards for 2021 • Medication Storage EC NEWS • Air Handling Requirements • EC/LS Top 10 • Water Management • Non-Waivable ITM Requirements • Issues in the Kitchen CMS • Hospitals Without Walls • Lab Remote Surveys TJC Advisory Group	2020 view-all
November	2020	PERSPECTIVES • Flu Vaccine for Staff and LIPs • Advanced Stroke Requirement Changes • EC Survey Change • Covid and Surveys • Access to Perspectives • New MS Tracer Tools • USP Chapter 825 • Upcoming Changes? EC NEWS • EM Planning and Prep • FEMA & Flooding • Fire Drills • ABHR Fire Safety CMS • Vaccine Resources	2020 view-all
October	2020	PERSPECTIVES • Fluoroscopy Services • Consistent Interpretation – Maternal Safety Standards FAQs • Multimodal Therapy • Expired Credentials EC NEWS • Cybersecurity • Documentation • Medical Gas Checklist CMS • Emergency Preparedness Drills • Covid-19 COPs	2020 view-all
September	2020	PERSPECTIVES • Family Visitations • Clinical Respiratory Services • Consistent Interpretation • Update on USP • Survey Process Modifications EC NEWS • Minneapolis EM Response • Reopening Closed Sites • Rated Walls CMS • Resuming Surveys • New COP	2020 view-all
August	2020	PERSPECTIVES • LSC Surveyors, Scope Expansion • Resuscitation Changes EC NEWS • Survey Requirements Post National Emergency • LSC: Condition Level Findings • Kitchen Tracers • Waiver Tracking Tool & COVID Recovery Prep Checklist CMS • Redeeming Application • CMS & TJC	2020 view-all
July	2020	PERSPECTIVES • Surveys Resuming – More Details • Remote Surveys • New Laboratory Standards • Fire Drills • Promoting Psychological Well-Being • TJC Pandemic Q+A Webinars • Authorizing Less Potent Analgesics • Do You Have a Policy? EC NEWS • Medical Gas Flow • Emergency Room Design and COVID-19 • Fire Sprinklers in Elevator Machine Rooms CMS • Public Health Emergency Being Extended?	2020 view-all
June	2020	LIMITED SURVEYS RESUME PERSPECTIVES • Federal Burden Reduction Updates • Changes in Titrations • Behavioral Health Care Name Change • Falls, New Sentinel Event Definition • Consistent Interpretation – Victims of Abuse EC NEWS • Alternate Care Sites • Most Frequently Scored EM Standards • EM Top 10 Frequently Scored • Elevator Doors – Warning CMS • Nursing Home Industry Memos	2020 view-all
May	2020	PERSPECTIVES • ORYX Temporary Modifications • Direct Data Submission Program • Perinatal Care Delay • Consistent Interpretation • Face Masks • Emergency Management Note EC NEWS • Special Pathogens, Emerging Infectious • Disease Program • COVID-19, Patient Separation and Preparedness CMS • Freestanding EDs • EM Critique Form	2020 view-all
April	2020	• Keeping Up with Essential Information • Perspectives & EC News • More: CMS & State Waivers • CDC • Emergency Management & Infection Control Plans	2020 view-all
March	2020	CMS • Coronavirus Memos CDC • Coronavirus Update PERSPECTIVES • CMS Rules • Sentinel Event Data • Psychiatric Advance Directives EC NEWS • FGI Guidelines 2018 • Slips, Trips, and Falls by Staff	2020 view-all
February	2020	PERSPECTIVES • Changes to Survey Agendas • Home Infusion Deeming • Closed Loop Communication of Test Results • Consistent Interpretation • Sterile Compounding EC NEWS • Mold • Waste Anesthesia Gas CMS • Coronavirus Memos • Correction – Medical Records	2020 view-all
January	2020	PERSPECTIVES • New Dissemination Policy • Safety Goal Changes • Public Reporting • New BHC Standards • Medication Order Changes • Consistent Interpretation EC NEWS • EM Exercise • Fire Drill Requirements CMS • Burden Reduction – A Tags	2020 view-all
December	2019	PERSPECTIVES • Emergency Management • FSA Tool Temporarily Offline • Consistent Interpretation FAQS • Suicide Risk Monitoring • Essential Oils – A Medication? • IFU • Attire in the OR EC NEWS • New Requirements • Fire Risk in Hospital Kitchens • PCRA & ICRA CMS • Restraint Death Reporting • Omnibus Burden Reduction Final Rule 3346-F	2019 view-all
November	2019	PERSPECTIVES • ORYX: Sometimes Forgotten, but Not Gone • Sentinel Event Definitions • The Role of the Consultant • New Payment Address for TJC • BoosterPaks and Leading Practice Library are Retiring • Consistent Interpretation • PDF Manuals are Back! • Quick Safety EC NEWS • Fire Extinguishers • EC & LS Most Frequently Scored • Minimizing Construction Risks IN OTHER NEWS • Vending Machines, Ice Machines, & Water Fountains • CMS A-Tag Review	2019 view-all
October	2019	PERSPECTIVES • ORYX 20-Year Anniversary • Eliminating Redundancy • Heads Up – Nursing & Home Care • ASC Dashboard EC NEWS • Relocatable Power Taps • USP 797 Delay • Medication Compounding Certification Program • USP 797 Track Record • Environmental Surface Sampling EXECUTIVE BRIEFINGS FDA • Disposable Duodenoscope Components CMS • Rural Health Clinics & Emergency Medications	2019 view-all
September	2019	PERSPECTIVES • FPPE/OPPE Requirement Update • Sentinel Event Statistics • HR Requirement for Fluoroscopy Deleted • Frequently Scored Standards • New Standards for Perinatal Safety • Sentinel Event #61 – Direct Oral Anticoagulants • Consistent Interpretation CONSULTANT FORUM • Scoring Patterns EC NEWS • Time Limited Waiver • Mold is on the Radar • Construction Compliance • Active Shooter Drills • ASHE Conference – 6 Commonly Scored CMS • EMTALA Memos IN OTHER NEWS • FDA Dispute	2019 view-all
July	2019	PERSPECTIVES • Square Footage • Patient Feedback – Qualitative Data Collection • E-Prescribing • Patient Self-Management • Anticoagulant Therapy FAQS • Tamper Resistant Electrical Outlets EC NEWS • Interim Life Safety Measures • Heliports? • Laser Safety NEW USP MANUALS • New Requirements Effective December 1, 2019 CMS • Emergency Medical Treatment & Restraints • Opening Conference Documents	2019 view-all
June	2019	PERSPECTIVES • Ophthalmology Disinfection • Preventing Drug Diversion • Consistent Interpretation – Power Strips • Intracycle Monitoring Suspension FAQs • Ligature Risks • Pre-Spiking IV Bags E-EDITION • New Standards to Take Effect July 1 EC NEWS • Emergency Generator – Remote Stop Stations • COOP Requirements • HCID Preparation CMS • Draft QSO Memo – Co-Located Hospitals	2019 view-all
May	2019	PERSPECTIVES • Two New Suicide Safety FAQs • Consistent Interpretation – Range Orders EC NEWS • Danger Zones • Medical Gas Safety CMS • Ligature Hazard QSO Memo • Violence Hazards ELECTRONIC HEALTH RECORDS • Death by 1,000 Clicks	2019 view-all
April	2019	PERSPECTIVES • 2018 Scoring Patterns • Infection Control Requirements EC NEWS • Fire Doors • Fire Sprinkler Systems • Risk Assessment • Preventing Patient Suicide CMS • QSO Memo 19-09	2019 view-all
March	2019	PERSPECTIVES • Sentinel Event Statistics • Quick Safety Issue 47 • Food and Drink Safety • Environmental Risk Assessments • Consistent Interpretation EC NEWS • Eyewash Stations • Equipment Maintenance •Fire Drills TJC FAQs Frequently Scored Standards: • Day-One Documents CMS • QSO Memo • Wall Street Journal	2019 view-all
February	2019	PERSPECTIVES • Disease Specific Care Updates • Hospital Accreditation Standards • Consistent Interpretation Column STERILE COMPOUNDING • USP Chapter 797 • What Can Go Wrong During the Evaluation of Sterile • Compounding? • What Can Be Done About It? Remediation TJC SURVEY PROCESS CHANGES • A-Tag Review • Validation Pilot Survey Update • FSA Requirements Suspended for Some • Pain Standards • Survey Statistics from 2018 EC NEWS • Emergency Management and Preparing 1135 Waivers in Advance • Legionella in a New CMS QSO Memo • Suicide Risk Assessment Tools FREQUENTLY SCORED STANARDS • Testing and Maintenance of Fire Safety Systems CMS • All Hazards Approach	2019 view-all
January	2019	SENTINEL EVENT ALERT • #60 – Developing a Reporting Culture PERSPECTIVES • New CDC Infection Control Resource • Pain Management Standards Changes – Home Care, Behavioral Health, & NCC • Fluoroscopy Standards Modification • Two New FAQs on Suicide Safety – Note Changes • Consistent Interpretation WALL STREET JOURNAL • Continuing Focus on TJC EC NEWS • Top Cited EM Standards • Workplace Violence FREQUENTLY SCORED • Infection Prevention • Dialysis Machine & Water Findings CMS: • Federal Register Announcement EPA • Federal Announcement – Hazardous Drug Waste	2019 view-all
December	2018	PERSPECTIVES • Changes to Safety Goals for July 2019 – Suicide • Changes to Safety Goals for July 2019 – Anticoagulation • Consistent Interpretation Column EC NEWS • Frequently Scored EC/LS Findings • Active Shooter Drill Considerations • Emergency Event Announcements PATTON NEWS • Problematic Standards in our Database CMS UPDATE	2018 view-all
November	2018	PERSPECTIVES • A Quiet Month for Change • 9 New EPs for 2019 • E-Edition • Consistent Interpretation JOINT COMMISSION ONLINE EC NEWS • Reopening After Disaster • Vaccine Storage • Frequently Scored, Higher Risk, Frequent Pattern, Red and Orang• CMS UPDATE	2018 view-all
October	2018	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	2018 view-all
September	2018	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	2018 view-all
July	2018	PERSPECTIVES • 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 Considerations EC NEWS • Means of Egress in Ambulatory Healthcare • Changes to the LS/EC Document and Review Tool CMS UPDATE • Legionella – Revised Recommendations from CMS	2018 view-all
June	2018	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	2018 view-all
May	2018	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	2018 view-all
April	2018	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 MOMOS	2018 view-all
March	2018	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	2018 view-all
February	2018	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 CONSULTANTS FORUM EC NEWS CMS UPADATES • Important Changes – After CMS • Removes Deemed Status	2018 view-all
January	2018	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	2018 view-all
December	2017	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	2017 view-all
November	2017	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	2017 view-all
October	2017	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	2017 view-all
September	2017	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	2017 view-all
July	2017	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 • Filling Your Own Saline Syringes • Cleaning Dialysis Equipment After a Patient Leaves the Space • Screening for Hepatitis C • Revisions to the 2567 Completion Process	2017 view-all
June	2017	PERSPECTIVES • 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	2017 view-all
May	2017	PERSPECTIVES • 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	2017 view-all
April	2017	PERSPECTIVES • Top Scored Standards for all 2016 • Revised Decision Rules • Insights into the 2012 LSC Changes NEWS 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 MULTI SOCIETY GUIDELINE	2017 view-all
March	2017	PERSPECTIVES • 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 • 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	2017 view-all
February	2017	• 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	2017 view-all
January	2017	• 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	2017 view-all
December	2016	• 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	2016 view-all
November	2016	• 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	2016 view-all
October	2016	• 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	2016 view-all
September	2016	• 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	2016 view-all
July	2016	• 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	2016 view-all
June	2016	• 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	2016 view-all
May	2016	• Scoring Logic for 2017 • ESC Deadlines Change in 2017 • PDA Process • Deleted 225 EPs • Texting Orders • Prison Units – CMS Rules • CMS Adopts 2012 LSC	2016 view-all
April	2016	• Numerous Elements of Performance deleted • The FAQ page on the TJC website • Top scored standards for 2015	2016 view-all
March	2016	• 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	2016 view-all
February	2016	• 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	2016 view-all
January	2016	• 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	2016 view-all