Your Complete Policy Management Partner
Everything your healthcare organization needs to confidently maintain accreditation compliance.
Robust document control and workflow management software solution
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
Last October, The Joint Commission announced the addition of a new chapter, Patient Safety Systems, to their 2015 Comprehensive Accreditation Manual for Hospitals (CAMH). According to TJC, this new chapter is intended to assist hospitals to understand how TJC requirements are related to and can be used to enhance patient safety.
TJC recently clarified that the Patient Systems Chapter contains no added standards. The goal of this chapter is to "...educate hospital leadership about the importance of an integrated patient-centered system that aims to improve quality of care and patient safety."
TJC is underscoring the following about the Patient Safety Systems Chapter:
- There are no added standards. The chapter describes how applying existing requirements can enhance patient safety.
- In both the paper version and the E-dition, the chapter is located after the "How to Use this Manual" chapter.
- Any organizations, not just hospitals, can view the new chapter on TJC's website.
Follow the links below for additional information.
Unintended Retention of a Foreign Object Tops Joint Commission List of Most Frequently Reported Sentinel Events in 2014
The Joint Commission recently released its Sentinel Event statistics summary for 2014. Unintended retention of foreign object was reported 112 times between January 1, 2014 and December 31, 2014 making it the most often reported sentinel event for this time period. TJC's root cause analysis identified Leadership issues as the top contributing factor for this Sentinel Event.
According to TJC, "Leadership" encompasses areas including but not limited to:
- Organizational planning
- Organizational culture
- Standardization (e.g., clinical practice guidelines)
Unintended retention of foreign objects can have catastrophic consequences including the need for additional surgery or even death. Best practices to consider for the prevention of unintended retention of foreign body include:
- Using a multidisciplinary team to develop policies and procedures that are applicable to all operative and other invasive procedures.
- Ensuring policies are evidenced based using resources published by organizations such as TJC, the World Health Organization, the American College of Surgeons and the Association of periOperative Nurses, No Thing Left Behind.
- Ensuring policies and procedures address the following topics:
o Standardized Counting Procedure
o Wound Opening and Closing Procedures
o Intra-operative Radiographs
o Effective Communication
o Appropriate Documentation
o Safe Use of Assistive Technologies
Included with today's notice are example policies and procedures related to the prevention of unintended retention of a foreign object.
FDA Safety Communication: Problem with Quality of Mammograms at Coastal Diagnostic Center in Pismo Beach, California
The US Food and Drug Administration (FDA) is alerting patients and health care providers who may have referred patients who had mammograms at Coastal Diagnostic Center located in Pismo Beach, California anytime on or after February 24, 2013, about possible problems with the quality of their mammograms.
According to the FDA the results of the mammograms are not necessarily inaccurate, but 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.
Patients have the right to request their mammogram and copies of their medical reports from Coastal Diagnostic Center.
The FDA recommends the following for patients who had a mammogram at Coastal Diagnostic Center any time on or after February 24, 2013:
- If you have had a more recent mammogram at a MQSA-certified facility since then, you should follow the recommendations from that facility.
- If you have not had a mammogram at an MQSA-certified facility since then, follow these guidelines:
Please follow the link below for additional information.
- Talk with your health care provider as soon as possible about the need for a follow-up exam.
- If your health care provider recommends a repeat mammogram, it should be done at an MQSA-certified facility to ensure quality and accuracy. A database of MQSA-certified facilities in your area is available online or by calling the National Cancer Institute's (NCI) information number at 1-800-422-6237.
- If you need a repeat mammogram and your health insurance will not pay for it, you can call the National Cancer Institute's (NCI) information number at 1-800-422-6237 for a listing of MQSA-certified facilities near you that will provide free or low- cost mammograms
Featured Policy Library Manuals
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 »
MCN Healthcare’s Home Health Policy and Procedure Manual provides over 400 policies and procedures addressing administration, emergency management, human resources, medical records, infection control, safety and security, equipment management, medication management, performance improvement, patient rights and responsibilities, waived testing as well as patient care. The Home Health Policy and Procedure Manual is cross referenced to CMS regulations, TJC, ACHC, and CHAP standards.Read more »
The Medical Office Policy and Procedure Manual is cross referenced to Joint Commission standards for Ambulatory Care and Primary Care Medical Homes and NCQA standards for Patient Centered Medical Homes. This manual includes policies that meet OSHA requirements for safety and infection control, Human Resources policies and Medical Office Compliance Plan and much more!Read more »