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
What Our Customers are Saying
MCN Healthcare has been indispensable to our accreditation compliance efforts. With Policy Manager, Policy Library and StayAlert!, we have peace of mind that our policies will always be up-to-date and easy to locate.
Beverly McKenzie, Compliance Programs Director, IASIS Healthcare
Helpful MCN Healthcare Resources
Review of Joint Commission New and Revised Elements of Performance for Diagnostic Imaging Services, Effective July 1, 2015 â€“ Part Five
The Joint Commission (TJC) recently released new and revised elements of performance (EPs) for their Diagnostic Imaging Services requirements. The changes are applicable to accredited hospitals, critical access hospitals and ambulatory health care facilities that provide diagnostic imaging services and are effective July 1, 2015. Today's notice is the fifth in a series that is reviewing the new requirements and also providing updated example policies.
Updates to Medication Management (MM.06.01.01) for Hospitals and Critical Access Hospitals:
This TJC standard requires hospitals and critical access hospitals to safely administer medications. TJC has added an element of performance to this standard that requires staff, before the administration of a radioactive pharmaceutical for diagnostic purposes, to verify that the dose to be administered is within 20% of the prescribed dose, or, if the dose is prescribed as a range, verify that the dose to be administered is within the prescribed range.
Updates to Performance Improvement (PI.01.01.01) for Hospitals and Critical Access Hospitals:
This TJC standard requires hospitals and critical access hospitals to collect data to monitor its performance. TJC has added two new elements of performance to this standard that require the organization to collect data on:
- Patient thermal injuries that occur during magnetic resonance imaging exams.
- Incidents where ferromagnetic objects unintentionally entered the magnetic resonance imaging (MRI) scanner room.
- Injuries resulting from the presence of ferromagnetic objects in the MRI scanner room.
Updates to Performance Improvement (PI.02.01.01) for Hospitals and Critical Access Hospitals:
This TJC standard requires hospitals and critical access hospitals to compile and analyze data. TJC has added an element of performance to this standard that requires the organization to review and analyze incidents where the radiation dose index (CTDIvol, DLP, or size-specific dose estimate [SSDE]) from diagnostic CT examinations exceeded expected dose index ranges identified in imaging protocols. Data compiled from these incidents must then be compared to external benchmarks.
Included with today's notice are example policies that reflect these changes.
CMS Updates State Operations Manual, Appendix W, Interpretive Guidance, for Critical Access Hospitals (CAHs)
The Centers for Medicare & Medicaid Services (CMS) has updated pertinent portions of the Critical Access Hospital (CAH) interpretive guidelines, found in SOM Appendix W, to reflect the following rule changes.
- CMS-3267-F, published on May 12, 2014; portions related to CAHs became effective July 11, 2014. Among other provisions, this final rule revised the CAH Conditions of Participation (CoP) requirements related to the responsibilities of doctors of medicine (MDs) and doctors of osteopathy (DOs).
- CMS-1599-F, published August 19, 2013; effective October 1, 2013. This final rule revised the CAH CoP requirements related to provision of inpatient acute care services.
- Revision of §485.631(b)(2), effective July 11, 2014, to remove the requirement that an MD or DO must be present in the CAH at least once every two weeks. CAH MDs/DOs are now required to be present for sufficient periods of time to provide medical direction.
- Revision of §485.635(a)(2), effective July 11, 2014, to remove the requirement for the CAH's patient care policies to be developed with the advice of at least one individual who is not a member of the CAH's professional healthcare staff.
- Revision of §485.635(a)(3)(vii), effective October 1, 2013, to remove the conditional language that could have been misunderstood as making it appear optional for a CAH to provide acute inpatient services.
In addition to modifications related to the above final rules, CMS has also updated interpretive guidance for the portions of 42 CFR 485.635 addressing the following topics, in order to bring them into alignment with current accepted standards of practice: pharmacy services; infection prevention and control; dietary services; services under arrangement; nursing services; and, rehabilitation services.
CDC Issues Health Advisory Regarding the U.S. Multi-State Measles Outbreak, December 2014-January 2015
The U.S. Centers for Disease Control and Prevention (CDC) has issued a Health Advisory regarding the multi-state outbreak of measles associated with travel to Disneyland Resort Theme Parks (which includes Disneyland and Disney California Adventure). The purpose of this HAN Advisory is to notify public health departments and healthcare facilities about this measles outbreak and to provide guidance to healthcare providers.
According to the CDC, the current multi-state outbreak underscores the ongoing risk of importation of measles, the need for high measles vaccine coverage, and the importance of a prompt and appropriate public health response to measles cases and outbreaks. Because of the success of the measles vaccine program, most young physicians have never seen a case of measles and may not take a detailed history of travel or potential exposure and initially may not consider the diagnosis in a clinically compatible case. Therefore the CDC is making the following recommendations for Health Care Providers:
- Ensure all patients are up to date on MMR vaccine and other vaccines.
o Note: Children 1 through 12 years of age may receive MMRV vaccine for protection against measles, mumps,
rubella, and varicella.
- For those who travel abroad, CDC recommends that all U.S. residents older than 6 months be protected from measles and receive MMR vaccine, if needed, prior to departure.
o Infants 6 through 11 months old should receive 1 dose of MMR vaccine before departure.
Note: Infants who receive a dose of MMR vaccine before their first birthday should receive 2 more doses of MMR vaccine, the first of which should be administered when the child is 12 through 15 months of age and the second at least 28 days later.
o Children 12 months of age or older should have documentation of 2 doses of MMR vaccine (separated by at least
o Teenagers and adults without evidence of measles immunity should have documentation of two (2) appropriately
spaced doses of MMR vaccine.
Note: One of the following is considered evidence of measles immunity for international travelers: 1) birth before 1957, 2) documented administration of 2 doses of live measles virus vaccine (MMR, MMRV, or measles vaccines), 3) laboratory (serologic) proof of immunity or laboratory confirmation of disease.
- Consider measles as a diagnosis in anyone with a febrile rash illness and clinically compatible symptoms (cough, coryza, and/or conjunctivitis) who has recently traveled abroad or who has had contact with someone with a febrile rash illness.
- Immunocompromised patients may not exhibit rash or may exhibit an atypical rash. The incubation period for measles from exposure to fever is usually about 10 days (range, 7 to 12 days) and from exposure to rash onset is usually 14 days (range, 7 to 21 days).
- Isolate suspect measles case-patients and immediately report cases to local health departments to ensure a prompt public health response.
- Obtain specimens for testing, including viral specimens for confirmation and genotyping. Contact the local health department for assistance with submitting specimens for testing.
The Health Advisory, link below, includes additional resources and information for health care professionals.
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 »