Index

Index references should be interpreted in the following manner: "Jan 2006, 10" means page 10 of the January issue of The Source for the year 2006.

Abuse

identifying, Mar 2003, 5

risk reduction, Aug 2003, 3

staff education, Dec 2003, 1-2, 10

zero tolerance, Apr 2003, 7

Abbreviations

handwritten, Jan 2005, 11; Dec 2006, 6-7

medication errors and, Sept 2004, 1–2, 10; Dec 2006, 6-7

read-back process, Sept 2004, 7

unacceptable

tips for reducing, Jan 2005, 1–2, 10

Abduction of infants, Aug 2006, 6-7

Accident/incident investigation, Aug 2003, 9

Accreditation manuals, Oct 2004, 10

Accreditation Participation Requirements, Dec 2003, 6

Periodic Performance Review (PPR), July 2004, 6

Accreditation process. See also Shared Visions—New Pathways; Continous systems improvement; Tracer methodology

clarification, Oct 2004, 11

new, in 2005, Dec 2004, 6

new policies, June 2003, 3

orientation and training, Mar 2005, 3–4

physicians' roles, June 2003, 6

pilot tests, Jan 2003, 10

Quality Report, Oct 2004; 6

self-assessment, Mar 2003, 7, 10

tracer methodology, May 2003, 7

2003 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH), May 2003, 2

2004 accreditation manuals, July 2003, 2; Aug 2003, 6

Accreditation survey. See also Self-assessment process

business associate agreement, Apr 2003, 4

implementation of corrective actions, Jan 2003, 2

JCAHO consultants, June 2003, 3

mock surveys, June 2003, 3

observers, Jan 2003, 7

online application, Jan 2003, 7

performance trends, May 2003, 7

presurvey data, June 2003, 4; Aug 2003, 1

process changes, Jan 2003, 7

random unannounced surveys, June 2003, 4

self-assessment, Jan 2003, 1

special type I recommendation, Jan 2003, 4

tracer methodology, June 2003, 3-4; Oct 2004, 8-9

tracking readiness, Jan 2003, 5

Action plans

implementation, Mar 2005, 7

Acute care organizations

waived testing, Feb 2005, 3

Addictions, July 2003, 4

Administration of medication, Jan 2007, 1, 2, 5, 8

Admission cycle times, Jun 2005, 8-9

Advance directives, June 2003, 5; July 2005, 1, 2, 11

Joint Commission requirements, July 2005, 1, 2, 11

Adverse drug events

measurement, Sept 2005, 8-9

prevention, Sept 2004, 5; Sept 2005, 8-9; Oct 2006 8-10

reporting, Jan 2007, 3, 4

responding to, Jan 2007, 3, 4

Adverse events

risk reduction, Aug 2003, 3; Sept 2005, 3, 4, 11

Agency for Healthcare Research and Quality (AHRQ)

role of care recipients, May 2003, 5

AHPs (allied health professionals)

credentialing and privileging, Jan 2003, 11

Alcohol abuse, July 2003, 4 Alcohol-based hand rubs, Oct 2003, 3-4

Alzheimer's disease

staff education, Apr 2003, 8-9

Ambulances

diversion methods to improve patient flow, May 2006, 6-7, 11

treatment delays, May 2003, 6

Ambulatory care

competency standards, July 2004, 4

compliance issues, July 2004, 3; Aug 2004, 1-2, 10

information management, June 2003, 1-2, 10

management of sentinel events, Nov 2004, 6

medication management, Mar 2003, 1-2

nutritional assessment, Nov 2003, 6

pain assessment standards, July 2003, 3

patient safety, Aug 2003, 3-4

performance improvement, Dec 2003, 3

Periodic Performance Reviews, Dec 2003, 6; July 2004, 6; Dec 2004, 3-5; Mar 2005, 6–7

postoperative telephone interviews, Nov 2003, 10

Priority Focus Process (PFP), Apr 2003, 6

redesigning, Dec 2003, 3-4

regular resurveys, June 2003, 3

sentinel events, Oct 2003, 6

Shared Visions—New Pathways target dates, Jan 2003,10

staff orientation, Aug 2003, 7; Dec 2003, 1

standards

credentialing, Mar 2005, 1

granting privileges, Mar 2005, 1

information management, Jan 2005, 5

standards in development, Jan 2003, 4; Feb 2003, 2

Universal Protocol, Sept 2004, 3–4, 6

waived testing, Feb 2005, 3–4

American Academy of Family Physicians and American Dietetic Association, Nov 2003, 5

American Association of Nurse Anesthetists, Feb 2005, 2

American Health Lawyers Association

educational resources, May 2003, 4

American Hospital Association

bed shortages, May 2003, 10

emergency plans, Mar 2003, 3

privacy brochure, Apr 2003, 4

American Society of Addiction Medicine (ASAM), dimensions of assessment, Feb 2005, 8

American Society of Anesthesiologists (ASA), Feb 2005, 2

definitions, Apr 2003, 1

physical status classification system, Apr 2003, 2

American Society of Directors of Volunteer Services (ASDVS), Oct 2003, 1-2

American Society for Healthcare Human Resources Administration (ASHHRA), June 2003, 10

American Society for Healthcare Risk Management

“Perspective on Disclosure of Unanticipated Outcome,” July 2003, 6

American Telemedicine Association, Oct 2003, 5

Analgesia (deep sedation), Apr 2003, 1

Ancillary testing

delays, May 2003, 6, 10

Anesthesia

administration, Apr 2003, 1-2, 10; Oct 2005, 3, 4

Anesthesia awareness

challenges, Feb 2005, 2

strategies, Feb 2005, 1–2, 10

Antipsychotic medications, Aug 2004, 8

Anxiolysis (minimal sedation), Apr 2003, 1

Apothecary symbols, Jan 2005, 2

Assessment process

staff competency, Feb 2005, 7

Assessment standards

compliance issues, Aug 2004, 1–2, 10

"Provision of Care, Treatment, and Services" (PC) chapter, July 2003, 2

Assisted living. See also Long term care

competency standards, July 2004, 4

compliance issues, Aug 2004, 1–2, 10

staffing effectiveness, June 2003, 7; Sept 2003, 3-4

standards

waived testing, Feb 2005, 3–4

Association for Professionals in Infection Control and Epidemiology (APIC), Oct 2003, 3; Nov 2003, 4

Automated tool

or Periodic Performance Review (PPR), July 2004, 6–7

Avian influenza, May 2006, 1, 2, 10

Baptist Outpatient Services (BOS), Oct 2003, 8-9

Bar code point-of-care (BPOC), Sept 2004, 5–6

Bar code technology, Sept 2004, 5–6

Bed rail entrapment, Jun 2006, 6-7

Bed shortage, May 2003, 6, 10

Behavioral health care

competency requirements, Jan 2004, 3–4

compliance issues, July 2004, 3; Aug 2004, 1-2, 10

emergency response to methadone dispensing, Sept 2004, 8–9

hyperglycemia screening, Aug 2004, 8–9

infection control, Jan 2004, 8–9

information management, June 2003, 1-2, 10

nutritional needs of clients, Mar 2006, 5

management of sentinel events, Nov 2004, 6

medication management, Mar 2003, 2

new and revised safety standards, Jan 2003, 3

nutritional assessment, Nov 2003, 6

pain assessment standards, July 2003, 3

performance improvement, Dec 2003, 3

Periodic Performance Reviews, Dec 2003, 6; July 2004, 6; Dec 2004, 3-5; Mar 2005, 6–7

postdischarge follow-up, Nov 2003, 10

Priority Focus Process (PFP), Apr 2003, 6

regular resurveys, June 2003, 3

revised standards, Aug 2003, 6

rights function, Jan 2003, 3

risk assessment, Jan 2004, 5

sentinel events, Oct 2003, 6

Shared Visions—New Pathways target dates, Jan 2003, 10

staff orientation, Aug 2003, 7; Dec 2003, 1

standards

credentialing, Mar 2005, 1

granting privileges, Mar 2005, 1

information management, Jan 2005, 5

waived testing, Feb 2005, 3–4

standards in development, Jan 2003, 4

survey process, Jan 2003, 7

Benchmarking

confidentiality issues, June 2003, 1

consumer satisfaction, Dec 2003, 4

Blood transfusions

patient safety, Aug 2003, 4

Brainstorming, for creative problem-solving, Dec 2003, 5

Business associate agreement, Apr 2003, 4

Care recipient feedback, Dec 2003, 3-4

Care and Treatment (TX)

anesthesia and sedation, Apr 2003, 2

management of information, Apr 2003, 3-4

Medication Management, Mar 2003, 1-2, 10

patient rights, Apr 2003, 4

Centers for Disease Control and Prevention (CDC), June 2003, 11

hand-hygiene guidelines, Oct 2003, 3-4

hospital-acquired infection statistics, Nov 2003, 3

infection control recommendations, Aug 2004, 3

infection statistics, Feb 2003, 5

Centers for Medicare & Medicaid Services (CMS)

Speak Up^SM brochure, May 2003, 5

CFAs (See critical focus areas)

Change agent teams (CATs)

building, July 2004, 8–9

philosophy, July 2004, 8

staff education, July 2004, 9

success factors, July 2004, 9

Cleanliness, Feb 2003, 6

Clinical Laboratory Improvement Act of 1988 (CLIA '88), June 2003, 3-4; Feb 2005, 3

Clinical practice guidelines, Jun 2005, 6-7

Clinical privileges

granting, renewing, or revising, Aug 2005, 1, 2, 10

Clinical records, Jan 2005, 5 See also Medical records

Clinical/service groups (CSGs), Apr 2003, 6; May 2003, 7

effect on survey, Aug 2003, 2

example, Aug 2003, 2

tracer methodology, Jan 2004, 1

types of, Aug 2003, 1

CME (continuing medical education), Feb 2003, 7

Code Save-a-Heart program, Nov 2005, 8-10

Collaboration

between pharmacists and physicians, Apr 2003, 5

Color-coded folder program, Oct 2003, 8-9

Command post, community planning, Mar 2003, 4

Communication, Jun 2005, 1, 2, 10; Mar 2006, 6-7

assessment and improvement, Mar 2006, 6-7

leadership responsibility, Jun 2005, 1, 2, 10

prescription recalls, Jan 2005, 8

privacy and confidentiality, Jan 2005, 7

Communication skills. See alsoStaffing effectiveness

cultural competence, Sept 2003, 10

fall prevention, Nov 2004, 3–4

fire prevention, Nov 2004, 10

focus areas, July 2003, 6

humor, Jan 2004, 8–9

infection control, Aug 2004, 4

as a National Patient Safety Goal, Jun 2005, 1, 2 10

outreach communication activity, Sept 2003, 7

with patients, Feb 2003, 11

as a Priority Focus Area, Jun 2005, 1, 2 10

quality of life process, Dec 2003, 8, 10

reducing medication errors, Sept 2004, 1–2, 10

root cause analysis, Oct 2003, 7

storytelling techniques, Dec 2005, 3, 4

training, Sept 2004, 10

Community planning

collaboration issues, Mar 2003, 4

emergency management, Mar 2003, 3–4

emergency plans, Mar 2003, 4; Feb 2006, 4

Competence assessment programs, Oct 2006, 6-7

Competency. See Staff competence

standards by program, July 2004, 4

Competency-based training, Nov 2006, 4

Comprehensive Accreditation Manual

FAQ on sample drugs, July 2003, 5

Computer-based training, Mar 2005, 4

Computer cleanliness, May 2006, 5

Computerized prescriber order entry (CPOE), Jan 2006, 1, 2, 10

Conference call for the Periodic Performance Review, Feb 2006, 11

Confidentiality issues

HIPAA compliance, Jan 2004, 11; July 2005, 6-7

information management, June 2003, 1-2, 10; July 2005, 6-7

patient privacy, Oct 2003: 8-9; July 2005, 6-7

policies, Jan 2005, 6–7

standards, Jan 2005, 7; July 2005, 6-7

verbal and written information, June 2003, 4

Continuity of care

definition, Aug 2003, 4

Continuum of care

and medication reconciliation, Apr 2005, 3, 4

Continuous quality improvement (CQI), Nov 2003, 8

Continuous systems improvement

maintaining, July 2004, 10

monitoring processes, July 2004, 1–2

strategies, July 2004, 2, 10

Continuous Survey Readiness program, July 2003, 11

Contracted services, May 2003, 1-2, 10

Contracted staff

ensuring safety in nonclinical departments, Jul 2006, 1-3, 10

orientation and training, Mar 2005, 4; Apr 2006, 8-9, 11; Jul 2006, 1-3, 10; Sep 2006, 7

and patient safety, Jun 2005, 3, 4

Control charts, Oct 2005, 6

Conscious sedation (moderate sedation/analgesia), Apr 2003, 1

“Corporate Responsibility and Corporate Compliance: A Resource for Health Care Boards of Directors,” May 2003, 4

Corrective Action Plans (CAPs), Jan 2003, 2

Corrective Action Taken, Evidence of Compliance (ESC), Dec 2004, 7, 10

Cost effectiveness

strategies, Oct 2004, 3–5

Counting policy, Oct 2005, 2, 11

Credentialing. See also Privileging

barriers, Mar 2005, 10–11

contracted services, May 2003, 1-2

credentialing verification organization (CVO), Mar 2005, 11

definition, Mar 2005, 1

fine-tuning, Mar 2005, 10

meeting JCAHO standards, Jan 2003, 11; Feb 2003, 3-4

standards

improving compliance, Mar 2005, 1–Mar 2005,2, Mar 2005, 10–11

success stories, June 2003, 8-9

timeliness, Mar 2005, 2, Mar 2005, 10

uniform criteria, Mar 2005, 2

Critical access hospitals

competency standards, July 2004, 4

compliance issues, Aug 2004, 1–2, 10

compliance Universal Protocol, Sept 2004, 3–4

standards

information management, Jan 2005, 5

Critical Care patients

uniform level of care, May 2003, 6

Critical focus areas (CFAs), Apr 2003, 6; May 2003, 7

Cross Cultural Health Care Program, Sept 2003, 10

Cross training, July 2003, 11

Crosswalks, Aug 2003, 6

CSGs (See clinical service groups), Apr 2003, 6

Cultural issues

end-of-life care, Nov 2003, 11

language barriers, Apr 2003, 11

training, Sept 2003, 1-2, 10

Cultural and linguistic training, Jun 2006, 1-3, 10

Culturally and linguistically appropriate health care, Jun 2006, 1-3, 10

Culturally and Linguistically Appropriate Services (CLAS) standards, Apr 2003, 11

Customer service

strategies, July 2004, 10

Cyr Wartman Screen, July 2003, 4

Data aggregation, Oct 2005, 5-7

tools, Oct 2005, 5-7

Data analysis. See also Root cause analysis

advantages, Jan 2003, 6

Data collection

ORYX core measures, Jan 2003, 7

Pareto chart to determine root causes, Sept 2003, 5

for performance improvement, Jan 2003, 6; Apr 2006, 3-5, 7

performance measurements, Dec 2003, 3

radar charts, Jan 2003, 5

safety indicators, Sept 2003, 4

strategies, July 2004, 10; Oct 2005, 5-7

Data loops

in continuous systems improvement, July 2004, 1

Delaware Valley Community Health, June 2003, 7, 10

Delays, preoperative

causes, Aug 2006, 8

reducing, Aug 2006, 8-9, 11

Delegate to Assistive Staff High-mindedly (DASH), June 2003, 7

Dementia care, Apr 2003, 8–9

Demographic data, June 2003, 4; Sept 2003, 1-2

Department Directors Interview, Jan 2003, 7

Departmental orientation, Aug 2003, 10

Devereux Florida Viera Campus, July 2003, 8-10

Dignity of patients, Aug 2005, 11

Disinfection of medical equipment, May 2005, 3-5

Discharge planning, Nov 2003, 1-2, 10

Disclosure, Dec 2006, 1, 2, 5, 10

Disease-Specific Care Certification by The Joint Commission, Jan 2007, 8

Documentation. See also Medical records

accreditation essentials, Jan 2005, 3–4

anesthesia awareness, Feb 2005, 2, 10

of assessment and reassessment results, July 2003, 4

assessment strategies, Aug 2004, 2, 10

challenges, Feb 2005, 5, Feb 2005,11

corrections to, Jan 2005, 4

dangerous abbreviations, Jan 2005, 10

discharge instructions, Aug 2003, 4

electronic signatures, Jan 2005, 11

fall prevention, Aug 2003, 8-9

information dissemination, July 2003, 6

informed consent, Aug 2003, 5

operative reports, Jan 2005, 5

orientation and training, Mar 2005, 4

patient education, Sept 2003, 8-9

postoperative telephone interviews, Nov 2003, 10

preprinted forms, Jan 2005, 11

primary source verification, Mar 2005, 2

privacy and confidentiality policies, Jan 2005, 6–7

related to sample drugs, July 2003, 5

security issues, June 2003, 1-2, 10

staff education, Dec 2003, 4

survey readiness, Oct 2004, 8–9

systems and processes, Feb 2005, 5

testing-related processes, Feb 2005, 4

types of, Jan 2005, 3

verbal orders, Sept 2004, 7

Domestic violence, staff education, Dec 2003, 10

Drug abuse, July 2003, 4

Drug Enforcement Agency

methadone dispensing, Sept 2004, 8

Drug names

verbal orders, May 2003, 11

Drug samples, July 2003, 5

Dual diagnosis, treatment planning, Feb 2005, 8–9

80/20 rule, Sept 2003, 5

Education (PF)

care recipients’ responsibilities, May 2003, 5

Eisenberg Award, seeJohn M. Eisenberg Award

Electronic medical records, Nov 2003, 8-9; Feb 2006, 1, 2, 10, 11

Electronic signatures, Jan 2005, 11

Elements of performance (EPs), Feb 2003, 3–4; July 2003, 10; Aug 2003, 6

accreditation manuals, Oct 2004, 1–2, 10

Accreditation Report, Nov 2003, 7

documentation, Jan 2004, 6

management of sentinel events, Nov 2004, 6

scoring page, Dec 2004, 5

Elopement

prevention, Nov 2004, 8–9

Emergency department

medication management, Mar 2003, 2

overcrowding, Oct 2005, 8-10; May 2006, 6-7, 11

treatment delays, May 2003, 6, 10; May 2006, 6-7, 11

Emergency management

and enhanced Joint Commission survey process, Feb 2006, 3-5

flood protection planning, Aug 2005, 8-9

infection control (IC), Aug 2004, 3–4

methadone dispensing, Sept 2004, 8–9

planning, Aug 2005, 3, 4, 7; Feb 2006, 3-5

preparation checklist, Sept 2004, 9

requirements, Mar 2003, 3-4; Aug 2005, 3, 4, 7

compliance with Joint Commission standards, Feb 2006, 3-5

Empathy, Sept 2003, 10

Employee competence. See Staff competence

Employee Performance Assessment System, Jan 2004, 4

Employee satisfaction, Dec 2003, 3

End-of-life care

creating policies, July 2005, 1, 2, 11; Jan 2006, 8-9

spiritual assessment, Aug 2003, 11

staffing effectiveness, Nov 2003, 11

Entrapment in bed rails, Jun 2006, 6-7

Environment of care

and infection control, May 2005, 3-4

managing, Aug 2005, 5, 9

Equipment maintenance

anesthesia equipment, Feb 2005, 2

Ergonomics policy, Apr 2003, 7

Error reduction

physicians’ roles, Feb 2003, 7

proactive error reduction strategies, Jan 2003, 3

survey process, Jan 2003, 7

e-SOC. SeeStatement of Conditions

Ethnic issues. See Cultural issues

Evidence of Standards Compliance (ESC)

Accreditation Report, Nov 2003, 7

compliance issues, Aug 2004, 6–7

developing, Dec 2004, 7

example, Dec 2004, 10

guidelines, Jan 2004, 6; Dec 2004, 11

strategies, Dec 2004, 1–2

submitting, July 2003, 7, 10

Failure mode and effects analysis (FMEA), Nov 2004, 7, 10, 11; Nov 2006, 1-2, 7

to improve patient safety, Nov 2006, 1-2, 7

steps involved, Nov 2006, 2, 7

Fall prevention

accident/incident investigation form, Aug 2003, 9

case study, Sep 2006, 8-9, 11

documentation, Aug 2003, 8-9

interventions, Aug 2003, 8

questionnaire results, Sept 2003, 5

risk factors, Aug 2003, 3

root causes, Nov 2004, 3–4

staff involvement, Sep 2006, 8-9, 11

strategies, Mar 2003, 11; Sep 2006, 8-9, 11

FAQ on sample drugs, July 2003, 5 Find, Organize, Clarify, Uncover, Start-Plan, Do, Check, Act (FOCUS-PDCA) cycle, Sept 2004, 8

Federal Register 42 CPR, Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records, Jan 2005, 7

Fire

and risk reduction, Aug 2003, 3

safety training, Oct 2003, 2; Nov 2006, 5-6

Fire prevention

strategies, Nov 2004, 1–2, 10; Nov 2006, 5-6

and the Life Safety Code, Feb 2006, 6-7; Nov 2006, 5

Five "rights" of medication administration, Jan 2007, 1

Flood protection planning, Aug 2005, 8-9

Food and Drug Administration (FDA)

final rule on bar code labels, Sept 2004, 5

testing methods, Feb 2005, 3–4

tissue standards, Feb 2005, 5

Foreign bodies, Oct 2005, 1, 2, 11

Glucose levels, Aug 2004, 8–9

Good Samaritan Hospital (Dayton, Ohio), case study, Sep 2006, 8-9, 11

Governing boards. See also Leadership

compliance questions, May 2003, 4

duty of care responsibilities, May 2003, 3-4

H&P. See History and physical examination

Hand hygiene, Feb 2003, 6; Oct 2003, 3-4; May 2005, 1, 2, 8-10

Handwriting, illegible, Sept 2004, 11; Dec 2006, 6-7

penalties for, Dec 2006, 7

Handwritten abbreviations, Jan 2005, 11; Dec 2006, 6-7

Hazard vulnerability

assessing, Mar 2003, 3

Hazard vulnerability analysis (HVA), Aug 2005, 3, 4, 7; Feb 2006, 3-5

and the Joint Commission's survey process, Feb 2006, 3-5

Health care-acquired infections, Oct 2003, 3

Health care networks

Shared Visions—New Pathways target dates, Jan 2003, 10

standards in development, Jan 2003, 4

Health care organizations See also Credentialing; Privileging

accreditation manual, Oct 2004, 1–2, 10

advance directives, June 2003, 5

failure mode and effects analysis (FMEA), Nov 2004, 11

high-risk processes, Nov 2004, 7, 10

infection control, Aug 2004, 3–4

internal tracers, Oct 2004; 7

job design strategies, June 2003, 7

Periodic Performance Review (PPR), Aug 2004, 11

privacy issues, June 2003, 1-2, 10

privacy and confidentiality policies, Jan 2005, 6–7

quality care, Mar 2005, 3–4

standards

information management, Jan 2005, 5

training programs, Jan 2005, 9

treatment planning, Feb 2005, 8–9

unacceptable abbreviations, Jan 2005, 1–2, 10

Health care quality

contracted services, May 2003, 1-2, 10

“Corporate Responsibility and Corporate Compliance: A Resource for Health Care Boards of Directors,” May 2003, 4

enhanced standards, Jan 2003, 1

governing board’s responsibilities, May 2003, 4

Human Resources standards, Jan 2003, 6

measuring effectiveness, May 2003, 10

proactive error reduction strategies, Jan 2003, 3

radar charts, Jan 2003, 5

role of care recipients, May 2003, 5

staffing effectiveness, Feb 2003, 1–2, 10

standards, Nov 2003, 9

Health Insurance Portability and Accountability Act (HIPAA)

guidelines, Jan 2004, 11

patient privacy, Oct 2003, 8-9

privacy rule, Apr 2003, 3-4; Jan 2005, 6-7; July 2005, 6-7

processes, June 2003, 1

High-risk medications, May 2003, 11

High-risk procedures

anesthesia awareness, Feb 2005, 2, 10

High-risk processes, Nov 2004, 7

identifying, Jan 2003, 4

patient safety standards, Aug 2003, 3

Histogram, Oct 2005, 6

History and physical examination (H&P)

purpose, Sep 2006, 7

transcribing, Sep 2006, 7

Home care

competency standards, July 2004, 4

compliance issues, July 2004, 3

emergency management, Mar 2003, 3

infection control, Jan 2004, 8–9

information management, June 2003, 1-2, 10

management of sentinel events, Nov 2004, 6

medication management, Mar 2003, 2

nurse preceptor program, Mar 2005, 8–9

nutritional assessment, Nov 2003, 6

pain assessment standards, July 2003, 3

patient safety, Aug 2003, 3-4

performance improvement, Dec 2003, 3

Periodic Performance Reviews, Dec 2003, 6; July 2004, 6; Dec 2004, 3-5; Mar 2005, 6–7

PFP (Priority Focus Process), Apr 2003, 6

regular resurveys, June 2003, 3

revised standards, Aug 2003, 6

sentinel events, Oct 2003, 6

Shared Visions-New Pathways target dates, Jan 2003, 10; Feb 2003, 2

staff orientation, Aug 2003, 7; Dec 2003, 1

standards

waived testing, Feb 2005, 3–4

standards in development, Jan 2003, 4

Hospice

and pain management, July 2005, 8-9

Hospitals

bar code technology, Sept 2004, 6

competency requirements, Jan 2004, 3–4; July 2004, 4

compliance issues, Aug 2004, 1–2, 10

elopement prevention, Nov 2004, 8–9

emergency management, Mar 2003, 3

infection control, Feb 2003, 5–6; Jan 2003, 8–9

information management, June 2003, 1-2, 10

management of sentinel events, Nov 2004, 6

performance improvement, Dec 2003, 3

Periodic Performance Reviews, Dec 2003, 6; July 2004, 6; Dec 2004, 3-5; Mar 2005, 6–7

Priority Focus Process (PFP), Apr 2003, 6

regular resurveys, June 2003, 3

revised standards, Aug 2003, 6, 10

spiritual assessment, Aug 2003, 11

staff as agents of change, July 2004, 8–9

staff orientation, Aug 2003, 7; Dec 2003, 1

staffing effectiveness, Feb 2003, 1-2, 10

clinical/service screening indicators, Feb 2003, 1, 10

human resource indicators, Feb 2003, 1, 10

Shared Visions—New Pathways target dates, Jan 2003, 10

standards

waived testing, Feb 2005, 3–4

standards in development, Jan 2003, 4; Feb 2003, 2

survey process, Jan 2003, 7

Universal Protocol, Sept 2004, 3–4, 6

Human Resources (HR) standards

challenges, Jan 2003, 6

and clinical/service indicators, Aug 2006, 4-5

competency requirements, Jan 2004, 3–4; July 2004, 4

data collection, Aug 2006, 4-5

education for volunteers, Oct 2003, 1-2, 10

nursing, June 2003, 7

related to contracted services, May 2003, 1-2

screening indicators, July 2003, 11; Aug 2006, 4-5

for staff competence, July 2004, 3–4

staff shortages and, May 2003, 6

Hyperglycemia screening, Aug 2004, 8–9

Immunization

influenza, Sep 2006, 4-5

Infant abduction, Aug 2006, 6-7

Infection control

assessing your IC program, Sep 2006, 1-3, 10; Oct 2006, 1, 2, 5, 10-11

and Avian influenza, May 2006, 1, 2, 10

and data collection, Sep 2006, 1-3, 10

and the environment of care, May 2005, 3-5

goals, Oct 2003, 3-4

guidelines, Jan 2004, 9

hand hygiene, May 2005, 1, 2, 10; May 2005, 8-9

humor and, Jan 2004, 8–9

planning an IC program, Sep 2006, 1-3, 10

preceptor program, Dec 2006, 8-9, 11

programs, May 2005, 6-7; Mar 2006, 1, 2, 11; Sep 2006, 1-3, 10; Dec 2006, 8-9, 11

risks assessment, Sep 2006, 1-3, 10

sentinel events and, Nov 2003, 3-4

standards, Feb 2003, 5; May 2005, 6-7; Sep 2006, 1-3, 10

strategies, Aug 2004, 3–4

tissue-borne infections, Feb 2005, 5, 11

wound infections, Sept 2004, 4

Influenza

immunization of staff, Sep 2006, 4-5

standards, Sep 2006, 4-5

Information Accuracy and Truthfulness, June 2003, 3

Information management

documentation, Jan 2005, 5

medical records, Jan 2005, 11

Informed consent, July 2005, 3, 4, 11

components, Aug 2003, 5; July 2005, 3, 4, 11

documentation, July 2005, 3, 4, 11

Joint Commission standards, July 2005, 3, 4, 11

Institute for Healthcare Improvement (IHI)

Collaborative on Patient Flow, Oct 2005, 8

Institute of Medicine

To Err Is Human, Building a Safer Health System, Sept 2004, 5

Institute for Safe Medication Practices (ISMP), July 2003, 5

dangerous abbreviations, Jan 2005, 1–2

Integrated summary, Jan 2005, 4. See also Medical records

Interdisciplinary teams

fall prevention, Nov 2004, 4

Internal tracers, Oct 2004; 7, Dec 2004, 4

Interpreter services, Apr 2003, 11

Intraoperative awareness. See Anesthesia awareness

Jayco® extranet site, July 2004, 7

and the PPR tool, Jul 2006, 7

Job descriptions, July 2004, 3

Job responsibilities, Jan 2004, 4. See also Staff competence

Job-specific orientation, Aug 2003, 10

John M. Eisenberg Award

2006 winner, The Wichita Citywide Heart Care Collaborative, Jan 2007, 9

John Muir Health

case study, Nov 2006, 8-11

Joint Commission standards. See also Accreditation process; Shared Visions-New Pathways

accreditation manuals and, Oct 2004, 1–2, 10

advance directives, June 2003, 5

Care and Treatment (TX), Apr 2003, 2

management of information, Apr 2003, 3-4

Medication Management, Mar 2003, 1-2, 10

patient rights, Apr 2003, 4

competence strategies, Jan 2004, 3–4

compliance issues, Dec 2004, 1–2, 7, 10–11

continuous compliance strategies, Sept 2004, 3–4, 6, Oct 2004, 3–5

credentialing and privileging, Jan 2003, 11; Mar 2005, 1–2, 10–11

cultural competence, Sept 2003, 2

Education (PF), May 2003, 5

electronic medical records, Nov 2003, 9

Evidence of Standards Compliance (ESC), Jan 2004, 6; Aug 2004, 6-7

frequently asked questions (FAQs), Sept 2003, 6

HIPAA requirements, Jan 2005, 7

Human Resources (HR), Jan 2003, 6; May 2003, 1-2, 6; June 2003, 7; Jan 2004, 3-4

Infection Control (IC), Feb 2003, 5–6; Aug 2004, 3-4

informed consent policies, Aug 2003, 5

interpreting, June 2003, 5

Leadership (LD), Jan 2003, 4; May 2003, 1-2, 3

Leadership and Governance (GO), May 2003, 3

Management of Information (IM), June 2003, 1-2, 10

HIPAA compliance, Jan 2004, 11

IM.6.10, Jan 2005, 11

IM.6.30, Jan 2005, 5

licensed independent practitioners, Jan 2005, 11

management of sentinel events, Nov 2004, 6

Medical Staff (MS), May 2003, 1-2

Medication Management (MM)

integrated standards, Mar 2003, 1-2, 10

review strategies, Apr 2003, 5

modifications, Jan 2003, 1

new format for, July 2003, 2

nutritional assessment, Nov 2003, 6

orientation and training, Mar 2005, 3–4, 8–9

pain assessment and management standards, Jan 2003, 8

peer reviews, Dec 2003, 11

Periodic Performance Review (PPR), July 2004, 6–7; Aug 2004, 11; Mar 2005, 6–7

prepublication edition, Aug 2003, 10

privacy and confidentiality, Jan 2005, 6–7

"Provision of Care, Treatment, and Services" (PC) chapter, July 2003, 1-2, 10

quality control checks, Feb 2005, 4

quality of life process, Dec 2003, 8

revisions, June 2003, 3-4; Aug 2003, 6; Dec 2004, 6

Rights (RI), May 2003, 5

safety and error reduction, Jan 2003, 4

self-assessment, Jan 2003, 1

sentinel events, Oct 2003, 6-7

Speak Up^SM brochure, May 2003, 5

spiritual assessment process, Feb 2005,6–7

staff education, Dec 2003, 1

staffing effectiveness, Jan 2003, 7; June 2003, 7; Sept 2003, 3

standards in development, Feb 2003, 2

Standards Interpretation Group (SIG), Feb 2003, 4; Sept 2003, 6; Dec 2003, 7

strategies for meeting new requirements, Jan 2003, 3

tissue standards, Feb 2005, 5

waived testing, Feb 2005, 3, Feb 2005, 3–4

Joint Commission on Accreditation of Healthcare Organizations

dangerous abbreviations, Jan 2005, 1–2, 10

definitions

procedures, Jan 2005, 5

Periodic Performance Review (PPR)

compliance strategies, Mar 2005, 6–7

Standards Interpretation Group, Jan 2005, 1; Feb 2005, 5

Kaiser Permanente case study, Dec 2006, 8-9,11

Laboratories

standards

waived testing, Feb 2005, 3–4

Laboratory services

competency requirements, Jan 2004, 3–4

infection control, Jan 2004, 8–9

information management, June 2003, 1-2, 10

Priority Focus Process (PFP), Apr 2003, 6

regular resurveys, June 2003, 3

sentinel events, Oct 2003, 6

management of, Nov 2004, 6

Shared Visions—New Pathways target dates, Jan 2003, 10

staff orientation, Aug 2003, 7; Dec 2003, 1

standards in development, Jan 2003, 4; Feb 2003, 2

survey process, Jan 2003, 7

Language barriers, Jun 2006, 1-3, 10

interpreters, Apr 2003, 11

Language skills

orientation and training, Mar 2005, 4

Leadership

in continuous systems improvement, July 2004, 1–2

culture of retention, June 2003, 7

duty of care responsibilities, May 2003, 3

electronic medical records, Jan 2005, 8–9

Periodic Performance Reviews, Dec 2003, 6

proactive error reduction priorities, Jan 2003, 3

for staff competence, July 2004, 3–4

standards, Jan 2003, 4; May 2003, 1-2, 3

Leadership and Governance (GO), May 2003, 3

Legacy beds and bed rail entrapment, Jun 2006, 6-7

Legal issues

advance directives, June 2003, 5

Legislative issues

privacy regulations, Apr 2003, 3-4

Level of consciousness (LOC)

presedation assessment, Apr 2003, 2

strategies, Apr 2003, 10

Licensed independent practitioners

contracted services, May 2003, 1-2

credentialing and privileging, Jan 2003, 11; Oct 2003, 10

evaluating competence, Jan 2006, 4-5

medical records, Jan 2005, 11

overseeing, Aug 2005, 6-7; Jan 2006, 4-5

peer reviews, Dec 2003, 11; Aug 2005, 6-7

progress notes, Jan 2005, 5

Life Safety Code^®, Feb 2006, 6-7

and the Statement of Conditions^TM, Feb 2006, 6-7

Long term care

competency requirements, Jan 2004, 3–4

compliance issues, Aug 2004, 1–2, 10

elopement prevention, Nov 2004, 8–9

emergency management, Mar 2003, 3

infection control, Jan 2004, 8–9

information management, June 2003, 1-2, 10

management of sentinel events, Nov 2004, 6

medical records, Mar 2003, 8-9

medication management, Mar 2003, 1-2

new and revised safety standards, 3

nutritional assessment, Nov 2003, 6

pain assessment standards, July 2003, 3

performance improvement, Dec 2003, 3

Periodic Performance Reviews, Dec 2003, 6; July 2004, 6; Dec 2004, 3-5

Priority Focus Process (PFP), Apr 2003, 6

regular resurveys, June 2003, 3

revised standards, Aug 2003, 10

rights function, Jan 2003, 3

sentinel events, Oct 2003, 6

Shared Visions—New Pathways target dates, Jan 2003, 10

spiritual assessment, Aug 2003, 11

staff orientation, Aug 2003, 7; Dec 2003, 1

staffing effectiveness, June 2003, 7; Sept 2003, 3-4

standards in development, Jan 2003, 4; Feb 2003, 2

survey process, Jan 2003, 7

Long term care organizations

Periodic Performance Review (PPR), Mar 2005, 6–7

standards

credentialing, Mar 2005, 1

granting privileges, Mar 2005, 1

waived testing, Feb 2005, 3–4

Long term oxygen therapy (LTOT), Dec 2005, 5, 11

Management of Human Resources (HR), Aug 2003, 7

Management of information

HIPAA compliance, Jan 2004, 11

privacy regulations, Apr 2003, 3-4

standards

revised, June 2003, 1-2, 10

Marion General Hospital, Oct 2006, 8-10

Mary Grote, DDS Office-Based Surgery practice, Feb 2006, 8-9

Mass casualties, Mar 2003, 3

Measure of success (MOS)

definition, July 2003, 7

evaluating, Mar 2005, 7

goals, Dec 2004, 10

strategies, Jan 2004, 6

Medical equipment

fire prevention, Nov 2004, 2

infection control, Aug 2004, 4

patient education, May 2003, 8-9

Medical errors. See also Error reduction

disclosure to patients and families, Dec 2006, 1,2, 5, 10

physicians’ roles, Feb 2003, 7

statistics, May 2003, 6

verbal orders, May 2003, 11

Medical gas

risk reduction, Aug 2003, 3

Medical history and physical examinations (H&P), Aug 2005, 6-7

Medical outcomes

disclosure to patients and families, Dec 2006, 1,2, 5, 10

Medical records

challenges, Feb 2005,5, 11

confidentiality issues, June 2003, 1–2, 10

contents, Jan 2005, 3

electronic, Nov 2003, 9; Sept 2004, 11; Jan 2005, 4, 8-10

interdisciplinary review process, Mar 2003, 8-9

outpatient settings, Apr 2003, 10

privacy regulations, Apr 2003, 3-4

progress notes, Aug 2003, 5

standards, Jan 2005, 5, Jan 2005, 11

Medical staff standards, May 2003, 1-2

Medicare/Medicaid Certification Based Long Term Care accreditation, Jan 2003, 7

Medication administration and monitoring, Jan 2007, 1, 2, 5, 8

Medication errors, Jan 2006, 1, 2, 10

bar code technology, Sept 2004, 5–6

and computerized prescriber order entry (CPOE), Jan 2006, 1, 2, 10

cultural issues, Apr 2003, 11

reducing, Sept 2004, 1–2, 10, 11

risk reduction, Aug 2003, 3

tracer methodology, Oct 2004, 8–9

transfusion errors, Sept 2004, 5

Medication management

administration and monitoring checklist, Jan 2007, 1, 2, 5, 8

after-hours access to medications, Jun 2006, 4-5

antipsychotic medications, Aug 2004, 8

case study, Apr 2005, 8-10; Oct 2006, 8-10

current medications, Apr 2003, 10

drug samples, July 2003, 5

methadone dispensing, Sept 2004, 8–9

and patient-specific information, Apr 2006, 6-7

pediatric medications, Aug 2004, 5

prescription recalls, Jan 2005, 8

reconciliation across the continuum of care, Apr 2005, 3, 4

storage standards, Apr 2005, 1, 2, 11

Medication Management (MM) standards

evaluating your medication management system, Dec 2006, 3-5

integrated standards, Mar 2003, 1-2, 10

medication orders, Dec 2006, 6-7

monitoring strategies, Apr 2005, 6-7

review strategies, Apr 2003, 5; Apr 2005, 7

verbal orders, May 2003, 11

Medications

muscle relaxants, Feb 2005, 1

Medication reconciliation, Apr 2005, 3, 4

Medication storage standards, Apr 2005, 1, 2, 11

Melmedica Children's Healthcare, May 2005, 8-9

Mentoring program, Dec 2004, 8–9

Methadone dispensing, Sept 2004, 8–9

Miami Valley Hospital (Dayton, Ohio), case study, Sep 2006, 8-9, 11

Missouri Rehabilitation Center

medication management case study, Apr 2005, 8-10

Motivational strategies, Dec 2003, 5

Muscle relaxants

anesthesia awareness and, Feb 2005, 1

Myocardial infarction

improving patient outcomes, Nov 2005, 8-10

National Fire Protection Association

infection control, Oct 2003, 4

National Kidney Foundation (NKF), Feb 2005,11

National Patient Safety Goals, Jan 2003, 4, 7; Mar 2003, 1; June 2003, 11; Oct 2003, 3-4; Nov 2003, 3; Sept 2005, 1, 2, 5, 10, 11

accreditation process and, Dec 2004, 6

bar code technology, Sept 2004, 5

compared to Universal Protocol, Sept 2004, 3

fall prevention, Nov 2004, 3

fire prevention, Nov 2004, 2

hand hygiene, May 2005, 1, 2, 10

medication reconciliation across the continuum of care, Apr 2005, 3, 4

read-back process, Sept 2004, 7, 10

reducing medication errors, Sept 2004, 1–2, 10

requirements, Aug 2004, 5

for 2006, Sept 2005, 1, 2, 5, 10, 11

Needlestick

injuries in the operating room, June 2003, 11

prevention program, Aug 2003, 4

Neglect

identifying, Mar 2003, 5

risk reduction, Aug 2003, 3

staff education, Dec 2003, 1-2, 10

Neonatal intensive care unit (NICU)

compliance issues, July 2004, 3

Nonemployee qualifications and competence, Jan 2006, 6-7

Nonindependent practitioners, Jan 2005, 11

Nosocomial infections, Feb 2003, 6; Oct 2003, 3; Nov 2003, 4

Nurses

assessing suicide risk factors, Jan 2004, 5, 7

culture of retention, June 2003, 7, 10

education for temporary nurses, Apr 2006, 8, 9, 11

mentoring program, Dec 2004, 8–9

needlestick injuries, June 2003, 1

nursing shortages, Nov 2003, 8

Nutrition

for clients in behavioral health care organizations, Mar 2006, 5

Joint Commission standards related to, Mar 2006, 5

risk assessment, Nov 2003, 5-6

Nutrition Screening Initiative (NSI), Nov 2003, 5

Office-based surgery

standards

credentialing, Mar 2005, 1

granting privileges, Mar 2005, 1

information management, Jan 2005, 5

strategies for continuous compliance, Feb 2006, 8-9

Universal Protocol, Sept 2004, 3–4

Office of Inspector General (OIG), May 2003, 4

Office of Minority Health, Culturally and Linguistically Appropriate Services (CLAS) Standards for Health Care, Sept 2003, 1

Operating room scheduling, Oct 2005, 8-10

Operative progress notes, Jan 2005, 5

Operative reports, Jan 2005, 5

Organ donation, Nov 2005, 3, 4, 7

Joint Commission standards, Nov 2005, 3, 4, 7

procurement, Nov 2005, 3, 4, 7

Organ transplant center certification program, Nov 2005, 4

Organizational systems

in continuous systems improvement, July 2004, 2

ORYX

core measures, Jan 2003, 7; Oct 2003, 11

for self-assessment process, Jan 2003, 2

Outcomes

communication strategies, Jan 2003, 3

disclosure to patients and families, Dec 2005, 1, 2, 5

patient knowledge about, Aug 2003, 4

Outpatient settings

medical records, Apr 2003, 10

Outreach communication activity, Sept 2003, 7

Overcrowding in emergency departments, Oct 2005, 8-10

Overlook Hospital/Atlantic Health System, Jun 2005, 8-9

Oxygen in surgical settings, Nov 2004, 10

Oxygen therapy

patient education, May 2003, 8-9

nurses' role, Jul 2006, 4-5

performance improvements, Jan 2003, 9

related standards, July 2003, 3-4; Jul 2006, 4-5

team solution, Jan 2003, 8

Pain management

in hospice care, July 2005, 8-9

nurses' role, Jul 2006, 4-5

related standards, July 2005, 5, 7

strategies, Aug 2004, 10; July 2005, 5, 7

Pareto chart, Oct 2005, 6

to determine root causes, Sept 2003, 5

Part-time staff

orientation and training, Mar 2005, 4

Partners in Your Care^SM initiative, May 2005, 11

Pastoral care resources, Feb 2005,6

Patient confidentiality, Nov 2003, 7

Patient education

determining learning needs, Aug 2003, 5

documentation, Sept 2003, 8-9

drug samples, July 2003, 5

equipment use, May 2003, 8-9

recovery process, Feb 2005,11

role in risk reduction, Aug 2003, 4

staff-to-care recipient communication, July 2003, 6

Patient flow, Jun 2005, 8-9; Oct 2005, 8-10; May 2006, 6-7, 11; Jun 2006, 8-9

Patient privacy. See Privacy issues

Patient rights

care recipients’ responsibilities, May 2003, 5

privacy regulations, Apr 2003, 4

Patient safety. See alsoMedication management

accreditation process, Jan 2004, 1–2, 10

anesthesia awareness, Feb 2005, 10

2002 John M. Eisenberg Patient Safety Award for Individual Lifetime Achievement, Jan 2003, 3

2003 National Patient Safety Goals and Recommendations, Jan 2003, 4; Oct 2003, 3-4

2004 National Patient Safety Goals, Nov 2003, 3

data collection, Sept 2003, 4

enhanced standards, Jan 2003, 1

failure mode and effects analysis (FMEA), Nov 2004, 11

fire prevention, Nov 2004, 1–2, 10

governing board’s responsibilities, May 2003, 3

implementing standards, Aug 2003, 3-4

management of sentinel events, Nov 2004, 6

National Patient Safety Goal 2 for 2003, May 2003, 11

Patient Safety and Medication Management Evaluation, Jan 2003, 7

reducing restraint use, Feb 2003, 11

staff education, Dec 2003, 1-2, 10

strategies for meeting new requirements, Jan 2003, 3

suicide risk factors, Jan 2004, 5, 7

survey process, Jan 2003, 7

tissue-borne infections, Feb 2005, 5, 11

Universal Protocol, Sept 2004, 4

Patient satisfaction rankings, Dec 2003, 3-4

Patient Self-Determination Act (PSDA), June 2003, 5

Patient-specific information, Apr 2006, 6-7

Patient uniformity myth, July 2003, 4

Pediatric medications, Aug 2004, 5

Peer organizations

staffing effectiveness, Feb 2003, 10

Peer reviews, Dec 2003, 11

professional and clinical performance, Mar 2005, 2

Performance improvement

care recipient feedback, Dec 2003, 3-4

confidentiality issues, June 2003, 1

data collection, Jan 2003, 6; Apr 2006, 3-5, 7

Devereux Florida Viera Campus, July 2003, 8-10

elopement prevention, Nov 2004, 8–9

internal tracers, Oct 2004; 7

medical records review, Mar 2003, 8-9

overcoming illegible handwriting, Sept 2004, 11

peer reviews, Dec 2003, 11

radar charts, Jan 2003, 5

root cause analysis, Nov 2004, 5

sentinel events, Oct 2003, 6

setting targets, Feb 2003, 2, 10

staffing effectiveness, Feb 2003, 10

standards, Dec 2003, 3

suicide assessment, Feb 2003, 8–9

team solution, Jan 2003, 8

treatment planning process, July 2003, 8-10

Performance measurements

consumer satisfaction, Dec 2003, 4

data collection, Dec 2003, 3; Sep 2005, 6-7

indicator selection, Feb 2003, 2

Periodic Performance Reviews, June 2003, 3-4

Periodic Performance Review (PPR), June 2003, 3-4; Aug 2003, 1, 6; Dec 2003, 6-7; Apr 2005, 5; July 2005, 10-11; Nov 2005, 1, 2, 11; Jul 2006, 7; Nov 2006, 8-11

accreditation process and, Dec 2004, 6

benefits, July 2004, 7

case study, Nov 2006, 8-11

compliance strategies, Mar 2005, 6–7

conference call process, Feb 2006, 11

evaluating elements of performance, Oct 2004, 3–5

full PPR requirements, July 2004, 6

measure of success (MOS), July 2004, 6–7

overview, Jul 2006, 7

plan of action, Jul 2004, 6–7

preparation for, Aug 2004, 11, Oct 2004, 11

strategies, July 2004, 5; Dec 2004, 3-5

submitting and navigating, Jul 2006, 7

tracer methodology, Jan 2004, 2

unannounced survey process and, Nov 2005, 1, 2, 11

Personal identifiers, June 2003, 1

PFA (see Priority focus areas)

PFP (see Priority Focus Process)

Pharmacists

collaboration with physicians, Apr 2003, 5

role in after-hours access to medications, Jun 2006, 4-5

Pharmacy-prepared IVs, Aug 2004, 5

Physicians

assessing suicide risk factors, Jan 2004, 5, 7

collaboration with pharmacists, Apr 2003, 5

need-to-know information, July 2003, 5

overcoming illegible handwriting, Sept 2004, 11; Dec 2006, 6-7

participation in the accreditation process, June 2003, 6

role in error reduction, Feb 2003, 7

role in Periodic Performance Review (PPR), July 2004, 5

Universal Protocol, Sept 2004:3–4, 6

Pilot testing

strategies, July 2004, 10

Plan-Do-Study-Act (PDSA), Nov 2006, 11

Point-of-Care testing (POCT), Mar 2003, 6; Feb 2005, 4

Policies and procedures, Jun 2005, 5, 11

Population-specific education, May 2006, 3-4

Postdischarge follow-up, Nov 2003, 1-2, 10

Postoperative follow-up, Nov 2003, 10

Postprocedure assessment, Apr 2003, 10

Post-traumatic stress disorder (PTSD)

anesthesia awareness, Feb 2005, 1

Preceptor program, Mar 2005, 8–9

Preoperative delays

causes, Aug 2006, 8

data collection, Aug 2006, 8, 9

evaluation tools, Aug 2006, 8-9

reducing, Aug 2006, 8-9, 11

Prescription recalls, Jan 2005, 8

Presedation assessment, Apr 2003, 2

Preventing surgical fires, Jan 2007, 6-7

Primary source verification, Mar 2005, 2

Priority focus areas (PFAs), Aug 2003, 1; Nov 2006, 10

communication, Jun 2005, 1, 2, 10

orientation and training, Mar 2005, 4

patient safety, Jan 2004, 2

Priority Focus Process (PFP)

for critical processes, Jan 2003, 2, 10

links to critical focus areas, Apr 2003, 6

presurvey data, Aug 2003, 1

Priority Focus Tool, Feb 2003, 4

tracer methodology, May 2003, 7; Jan 2004, 1

Privacy issues

HIPAA compliance, Jan 2004, 11; July 2005, 6-7

information management, June 2003, 1-2, 10

policies, Jan 2005, 6–7

protecting patient privacy, Oct 2003, 8-9

standards, Jan 2005, 7

strategies, July 2005, 6-7

verbal and written information, June 2003, 4

Privacy regulations, Apr 2003, 3-4

Privileging See also Credentialing

barriers, Mar 2005, 10–11

contracted services, May 2003, 2

definition, Mar 2005, 1; Aug 2005, 1, 2, 10

environment-specific considerations, Mar 2005, 2

fine-tuning, Mar 2005, 10

granting, Aug 2005, 1, 2, 10

Licensed independent practitioners (LIPs), Oct 2003, 10

meeting JCAHO standards, Jan 2003, 11

setting-specific, Aug 2005, 1, 2, 10

standards, Mar 2005, 1–2

improving compliance, Mar 2005, 10–11

success stories, June 2003, 8-9

timeliness, Mar 2005, 2, 10

Proactive analysis

leadership strategies, Jan 2003, 3, 4

Problem-solving strategies, Dec 2003, 5

Process design, Oct 2004, 4

Progress notes, Aug 2003, 5; Jan 2005, 5

Provena Health, Dec 2005, 8, 9, 10

and unannounced survey process, Dec 2005, 8, 9, 10

Provision of Care, Treatment, and Services (PC) chapter

core elements, July 2003, 1-2, 10

pain assessment standards, July 2003, 3-4

Provisional accreditation, Jan 2004, 6

Psychiatric information

privacy and confidentiality, Jan 2005, 7

Psychological assessment

strategies, Apr 2003, 10

Psychotropic medications, Oct 2004, 9

Quality Assurance and Improvement Committee, July 2003, 10

Quality assurance (QA)

measuring success, July 2003, 9-10

Quality control

procedures, Feb 2005, 4

for waived testing, Nov 2005, 5

Quality of care, mentoring program, Dec 2004, 8–9

Quality of life process, Dec 2003, 8-9, 10

Quality Report, Oct 2003, 11; Oct 2004, 6

Queuing theory, May 2003, 6

Racial, ethnic, and language-based disparities in health care, Jun 2006, 1-3, 10

Radar charts, example, Jan 2003, 5

Random unannounced surveys, June 2003, 4; Nov 2003, 7

Rapid improvement process, Aug 2006, 8-9, 11

Read-back process, Sept 2004, 7, 10

Reappointment process, Mar 2005, 10

Recovery-oriented care standards, Nov 2005, 6-7

Redirection of care

policy at University of Arkansas for Medical Sciences, Jan 2006, 8-9

Religion, vs. spirituality, Feb 2005, 7

Reprivileging

policies, June 2003, 8-9

Restraint use

alternative approaches, Feb 2003, 11; May 2006, 8-9; Nov 2006, 3, 4

leadership's role, Nov 2006, 3, 4

reducing, May 2006, 8-9; Nov 2006, 3, 4

Resurveys, June 2003, 3

Reviewable sentinel events, Oct 2005, 2

Rights (RI)

care recipients’ responsibilities, May 2003, 5

and Ethics standard, Aug 2003, 3

Rights function, Jan 2003, 3

Risk assessment, Jul 2006, 8-9

fall prevention, Mar 2003, 11

nutrition, Nov 2003, 5-6

patient safety, Aug 2003, 3

suicide risk factors, Feb 2003, 8–9; Jan 2004, 5, 7

Risk management

communication gap, July 2003, 6

workplace environment, Apr 2003, 7

Risk reduction

sentinel events, Oct 2003, 6

Role playing, Dec 2003, 1-2, 10

Root cause analysis

and adverse drug events, Jan 2007, 3

conducting, Nov 2004, 5

confidentiality issues, Oct 2003, 6

elopement, Nov 2004, 8–9

falls, Nov 2004, 3–4

and improving patient safety, Nov 2006, 1,-2, 7, 11

medication errors, Sept 2004, 2

with Pareto chart, Sept 2003, 5

sentinel events, Nov 2003, 3-4

steps involved, Nov 2006, 2

surgical fires, Nov 2004, 1–2, 10

Rule of Six, phasing out, Aug 2004, 5

Run charts, Oct 2005, 6

SAD PERSONS Scale, Feb 2003, 9

Safety. See Patient safety

of health care workers, Apr 2006, 1, 2, 10

Safety management plan, Oct 2006, 3-5

environmental tours, Oct 2006, 4

role of the safety officer, Oct 2006, 3-4

worker safety, Oct 2006, 4

Safe zone, June 2003, 11

Sampling

following Evidence of Standards Compliance (ESC), Jan 2004, 6

Scatter diagram, Oct 2005, 6

Scheduling

staffing strategies, June 2003, 10

Scope of care

determining, July 2003, 11

Seclusion, Nov 2006, 3-4

Security issues

information management, June 2003, 1-2, 10

safety of health care workers, Apr 2006, 1, 2, 10

Sedation

administration, Apr 2003, 1-2, 10; Oct 2005, 3, 4

Joint Commission standards, Oct 2005, 3, 4

Self-assessment data, July 2004, 6

Self-assessment grid, Aug 2003, 6

Self-assessment process, Jan 2003, 1; Feb 2003, 3-4

corrective action plans, Mar 2003, 7, 10

Self-reporting, Oct 2003, 6-7

Sentinel Event Alerts, Oct 2003, 7

anesthesia awareness, Feb 2005, 1

fire prevention, Nov 2004, 1

Sentinel events. See also Error reduction

and communication, Jun 2005, 1, 2, 10

facts and trends, Oct 2003, 6

in home care, Oct 2003, 6

information links, Oct 2003, 7

and laboratory services, Oct 2003, 6

and long term care

and long term oxygen therapy (LTOT), Dec 2005, 5, 11

relevant standards, Nov 2004, 6

reviewable by Joint Commission, Oct 2005, 2

risk assessment, Jan 2004, 5, Jan 2004, 7

suicide risks, Mar 2005, 5, 11

types of, Oct 2003, 7

Sentinel Event Database, Oct 2003, 6

Sentinel event policy

review of events, Oct 2003, 6

survey process, Jan 2003, 7

Shaken baby syndrome, Mar 2006, 3, 4, 10

Shared Visions-New Pathways. See alsoPriority Focus Process; Joint Commission standards; Tracer methodology

clarification option, Evidence of Standards compliance, Aug 2004, 6–7

components, Jan 2003, 1

Corrective Action Plans, Mar 2003, 7, 10

duty of care responsibilities, May 2003, 3

Evidence of Standards Compliance (ESC), July 2003, 7, 10

implementation in 2004, Aug 2003, 1

Periodic Performance Reviews, Dec 2003, 6-7; July 2004, 5

physicians' roles, June 2003, 6

process design, Jan 2004, 1–2

Quality Report, Oct 2003, 11

regular resurveys, June 2003, 3-4

risk management issues, July 2003, 6

role of account representatives, Sept 2003, 7

self-assessment process, Feb 2003, 3-4

Staff communication

standards revision process, Aug 2003, 6

Standards Review Project, June 2003, 1

Surveyors as consultants, June 2003, 3-4

survey process, Jan 2003, 10

tracer methodology, May 2003, 7

Society for Human Resource Management, Sept 2003, 2

Southern Tennessee Medical Center (STMC), Jan 2005, 3–4

Speak Up^SM

brochure, May 2003, 5

hand hygiene, May 2005, 10

Spider diagrams

example, Jan 2003, 5

Spiritual assessment, Aug 2003, 11

Spiritual assessment process

evaluating, Feb 2005,6–7

St. Mary's Hospital Medical Center, Mar 2006, 8, 9, 11

Staff communication

risk management issues, July 2003, 6

Staff competence. See also Credentialing; Privileging

assessing, Jan 2003, 6; Sept 2003, 11; Oct 2006, 6-7

assessment process, Feb 2005, 7

challenges, Jan 2004, 3–4

measuring effectiveness, Mar 2003, 9

new providers, June 2003, 8–9

orientation and training, Mar 2005, 3–4

patient safety, Aug 2003, 4

Periodic Performance Reviews, June 2003, 3-4

reappraisal process, Jan 2003, 11

for specific patient populations, July 2004, 3–4

standards, Sept 2003, 11

waived testing, Feb 2005, 3–4

Staff education, Jan 2006, 3, 11

abuse and neglect policies, Mar 2003, 5

accreditation essentials, Mar 2005, 3–4

change agent teams (CATs), July 2004, 9

confidentiality issues, Apr 2003, 4

continuing education, Feb 2003, 7

cross training, July 2003, 11

cultural competence, Sept 2003, 1-2, 10

dementia care, Apr 2003, 8-9

documentation, Sept 2003, 8-9

domestic violence issues, Dec 2003, 10

“Education and Motivational Programs for Health Care Workers,” Feb 2003, 6

fall prevention, Nov 2004, 3–4

fire prevention, Nov 2004, 10

improving patient education, May 2003, 9

infection control, Feb 2003, 5–6

Internet resources, Feb 2005,11

management of abuse and neglect cases, Dec 2003, 1-2, 10

mentoring program, Dec 2004, 8–9

National Patient Safety Goals, Aug 2004, 5

needlestick injuries, June 2003, 11

orientation, Jan 2003, 6; orientation and training, Mar 2005, 8–9

orientation and training general requirements, Aug 2003, 7

Periodic Performance Review (PPR) process, July 2004, 5

spiritual assessment process, Feb 2005, 7

standards, Dec 2003, 1

suicide assessment, Feb 2003, 8–9

suicide risks, Mar 2005, 5, 11

tracer methodology, July 2004, 11

treatment planning, Feb 2005, 8

types of, Feb 2005,11

Universal Protocol, Sept 2004, 4

Staffing effectiveness

as agents of change, July 2004, 8–9

assessing orientation and training, Mar 2005, 4

competency requirements, July 2004, 4

culture of retention, June 2003, 7

infection control, Aug 2004, 3

patient safety, Aug 2003, 4

peer reviews, Dec 2003, 11

roles and responsibilities, Jan 2006, 3, 11

scheduling and, June 2003, 10

skill mix, July 2003, 11

standards, Jan 2003, 7; Feb 2003, 1-2, 10

strategies for assisted living and long term care, Sept 2003, 3-4

verbal orders, Sept 2004, 7

Staphylococcus aureus (MRSA), May 2006, 5

Statement of Conditions^TM, Feb 2006, 6-7

electronic version, Sep 2006, 6

and the Life Safety Code^®, Feb 2006, 6-7

Storing medications, Apr 2005, 1, 2, 11

Storytelling techniques, Dec 2005, 3, 4

Suicide intervention, Mar 2005, 5, 11

Surgical fires, Nov 2006, 5; Jan 2007, 6-7

Surveyor identification and authorization procedures, Aug 2006, 1

Systems research, July 2004, 10

workplace environment strategies, Apr 2003, 7

Staff orientation

three-phase approach, Aug 2003, 7, 10

Standards. See Joint Commission standards

Standards Review Project, June 2003, 1; July 2003, 1-2, 10

Strategic planning

duty of care responsibilities, May 2003, 4

Stereotypes, Sept 2003, 2

Substance abuse, July 2003, 4

treatment planning, Feb 2005, 8–9

Suicide assessment, Jan 2004, 5, 7

risk factors, Feb 2003, 8–9

Surgery

preventing surgical fires, Nov 2004, 1–2, 10

scheduling, Oct 2005, 8-10

site-marking process, Sept 2004, 4, 6

Survey. See Accreditation survey

Systems integration

assessing, Mar 2003, 2, 10

Teamwork approach

culture of retention, June 2003, 7

end-of-life care, Nov 2003, 11

error prevention, Feb 2003, 7

multidisciplinary teamwork, July 2003, 6

role of care recipients, May 2003, 5

Technology

increasing productivity, Nov 2003, 8-9

Telemedicine, Oct 2003, 5, 10

Telephone interpreter services, Apr 2003, 11

Telephone orders, Jul 2006, 6, 10

Testing processes

waived testing, Feb 2005, 4

Tissue standards, Feb 2005, 5; Dec 2005, 6, 7

Tracer methodology, Jan 2003, 10; May 2003, 7; June 2003, 3-4; Aug 2003, 2; Nov 2003, 7; Oct 2004, 8-9; Mar 2006, 8, 9, 11

advantages, Jan 2004, 2

example on cardiac stent patient, Jan 2004, 10

guidelines, Jan 2004, 2, 10

implementation case study, Mar 2006, 8, 9, 11

process design, Jan 2004, 1–2, 10

questions and answers, July 2004, 11

Tracking systems, May 2003, 10

Training. See Staff education

Transfusion errors, Sept 2004, 5

Treatment delays, May 2003, 6, 10

Treatment planning process

streamlining, July 2003, 8-10

Treatment plans, Feb 2005, 8–9

Turnaround times (TAT), May 2003, 6

2003 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH), May 2003, 2

Unannounced survey process, Nov 2005, 1, 2, 11; Dec 2005, 1, 2, 10; Aug 2006, 1-3, 10-11

letter of notification, Aug 2006, 2

maintaining continuous compliance, Dec 2005, 1, 2, 10

nofifying staff, Aug 2006, 3, 10

and the Periodic Performance Review, Nov 2005, 1, 2, 11

pilot testing, Dec 2005, 8, 9, 10

sample communication plan, Aug 2006, 10

sample survey agenda, Aug 2006, 10-11

strategies, Dec 2005, 1, 2, 10

Unanticipated outcomes, Dec 2006, 1, 2, 5, 10

Standard RI.2.90, Dec 2006, 1

Unintentionally retained foreign bodies, Oct 2005, 1, 2, 11

Universal Protocol, Sept 2004:3–4, 6

University of Arkansas for Medical Sciences (UAMS), Jan 2006 8-9

U.S. Census Bureau, demographic data, Sept 2003, 1-2

U.S. Department of Health and Human Services (DHHS)

Culturally and Linguistically Appropriate Services (CLAS) standards, Apr 2003, 11

Office of Inspector General (OIG), May 2003, 4

U.S. Pharmacopeia, May 2003, 11

Vaccination of staff against influenza, Sep 2006, 4-5

Verbal orders, May 2003, 11; Jan 2005, 11; Jul 2006, 6, 10

guidelines for accepting, Jul 2006, 6, 10

medication errors and, Sept 2004, 1

read-back process, Sept 2004, 7

Violence in the workplace, Apr 2006, 1, 2, 10

Vital signs

presedation assessment, Apr 2003, 2

Voice mail orders, Sept 2004, 7, 10

Volunteers

education for, Oct 2003 1-2, 10

orientation and training, Mar 2005, 4

Waived testing, Nov 2005, 5 Walk-through

in continuous systems improvement, July 2004, 2

Warfarin dosing, Oct 2006, 8-11

The Wichita Citywide Heart Care Collaborative, Jan 2007, 9

Workplace environment

staffing effectiveness, Apr 2003, 7

violence in the workplace, Apr 2006, 1, 2, 10

Wound infections, Sept 2004, 4

Wrong-site surgery, Sept 2004, 3–4, 6

Zero tolerance

abuse, Apr 2003, 7