Your Complete Policy Management Partner
Everything your healthcare organization needs to confidently maintain accreditation compliance.
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Simplify & automate policy access, review and approval across your organization
Web-based library of more than 18,000 customizable policy documents
Instantly access up-to-date policies, procedures & forms authored by MCN experts
Automated regulatory notification system of daily email or mobile alerts
Keep current with regulatory changes from more than a dozen federal regulatory bodies, including TJC & NIAHO
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Helpful MCN Healthcare Resources
FDA Alert - Problem with Quality of Mammograms at J. Bruce Jacobs M.D., Inc., doing business as Huntington Radiology in Huntington Park, California
The U.S. Food and Drug Administration (FDA) has issued a Mammography Safety Notification alerting patients who had mammograms at J. Bruce Jacobs M.D., Inc., doing business as Huntington Radiology, located in Huntington Park, California, any time on or after September 8, 2014 about possible problems with the quality of their mammograms. This does not mean that the results of the mammograms were inaccurate, but it does mean that the patients should consider having their mammograms re-evaluated at a Mammography Quality Standards Act (MQSA)-certified facility to determine if the patients need a repeat mammogram or additional medical follow-up.
This facility was the subject of a prior FDA Safety Notification issued on March 10, 2011. The FDA again became aware of problems after the American College of Radiology (ACR) conducted a review for the purposes of accreditation reinstatement following the August 31, 2010 ACR revocation of the facility's accreditation.
On September 8, 2014, the facility was provisionally certified to provide mammography services; however, a subsequent ACR clinical image review indicated problems with the quality of the mammography at the facility. The ACR revoked the facility's application for accreditation effective February 20, 2015. The FDA suspended the facility's certificate on March 6, 2015.
Please follow the link below for additional information.
The Joint Commission (TJC) has released its annual list of top cited standards for their various accreditation programs. Over the next week StayAlert will review the most frequently cited standards for specific accreditation programs.
Today's notice reviews HR.02.01.03 for TJC's Ambulatory Care Accreditation Program. This standard requires ambulatory care organizations to ensure that they grant initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. According to TJC, in 2014, 50% of ambulatory care organizations surveyed demonstrated non-compliance with this standard.
Standard HR.02.01.03 is focused on the collection and verification of independent practitioner credentials to ensure that practitioner's licensure, training, and competence are appropriate for the privileges being requested.
The key to compliance with this standard is having a standardized process for granting and denying initial, renewed or revised clinical privileges. Every practitioner should be put through the same process for privileging. Primary sources should be used for verification of information.
Included with today's notice are example policies and procedures related to the privileging process.
Baxter International Inc. is voluntarily recalling select lots of intravenous (IV) solutions to the hospital/user level due to the potential presence of particulate matter. Intravenous administration of a solution containing sterile particulate matter may lead to adverse health consequences. The extent and severity of harm depends on the size, number, and composition of the foreign material, and patient's underlying medical condition. In the absence of in-line filtration, these particles may cause: local vein irritation, inflammatory reaction, aggravation of preexisting infections, allergic reactions, and systemic embolization. In high-risk patients this may lead to serious adverse health consequences. There have been no adverse events or product complaints associated with this issue reported to Baxter.
The lots being recalled were distributed to customers and distributors in the United States and Bermuda between January 14, 2015 and March 5, 2015. Follow the link to the Baxter press release for a listing of affected products.
Customers have been directed not to use products from the recalled lots. Recalled products should be returned to Baxter for credit by contacting Baxter Healthcare Center for Service at 1-888-229-0001, Monday through Friday, between the hours of 7:00 a.m. and 6:00 p.m., Central Time. Unaffected lots of product are available for replacement.
Featured Policy Library Manuals
MCN’s Utilities and Equipment Management Policy and procedure Manual is a reference guide that is compliant with Joint Commission, NIAHO and CIHQ standards and CMS regulations. MCN provides easy-to-use policies and procedures that are field tested and proven - you need only to customize them to your healthcare organization. Policies and procedures include Utility Systems Management Plan, Alternative Equipment Maintenance Program, Clinical Alarms, Emergency Power and much more!Read more »
MCN Healthcare’s Administrative Manual for Critical Access Hospitals is specifically designed to assist critical access hospitals meet CMS, TJC and NIAHO standards for CAHs. This manual provides over 275 ready-to-implement policies, procedures and forms in an easy-to-customize Word format, and is designed to demonstrate compliance with CAH regulations. Transplant Safety polices are also included in this manual.Read more »
MCN's NEW Ambulatory Surgical Center/Outpatient Surgery Department Policy and Procedure Manual is cross referenced to TJC standards, AAAHC standards and CMS regulations. Policies and procedures meet AORN and CDC recommendations and guidelines. This comprehensive reference guide has over 290 policies and procedures that are ready to customize to your organization. See also the Administrative Manual for Ambulatory Care Facilities and the Ambulatory Services EOC Manual.Read more »