The Source Blog

The Source blog features news and insight from Jim Parker, Senior Editor for The Joint Commission: The Source newsletter. This blog gives readers an opportunity to give their feedback about the newsletter and voice their opinions on the accreditation compliance issues discussed in the blog and in print.



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February Issue of The Source Now Available!

• 1/20/2012
• Author: Jim Parker
• 138 Views
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The February issue of The Source is available now, including the following articles: • Managing Health Care Worker Fatigue: Maximizing Alertness to Keep Patients Safe • 5 Sure-Fire Methods: Complying with Standard PC.02.03.01 • Tracer Methodology 101: Fall Reduction Tracer in the Ambulatory Setting • The CREW Initiative: Veteran’s Health Administration Civility Program Improves Safety and Qua... more >>

January 2012 issue of The Source Coming Soon!

• 12/16/2011
• Author: Jim Parker
• 319 Views
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The January 2012 issue of The Source is coming soon, including the following articles: • Looking Ahead: What to Expect from The Joint Commission in 2012 • Welcome to the New Source5 Sure-Fire Methods: Complying with NPSG.03.04.01 • Tracer Methodology 101: Infection Prevention and Control System Tracer • Creating and Implementing a Utilization Review Plan: Meeting CMS Expectations Under LD.04.0... more >>

December issue available in print and online!

• 12/9/2011
• Author: Jim Parker
• 214 Views
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The December 2011 issue of The Joint Commission: The Source newsletter is now available, including the following articles: • Immediate Threat to Health and Safety: Complying with APR.09.04.01 • 5 Sure-Fire Methods: Complying with WT.03.01.01 • Managing Patient Flow: Is High Hospital Occupancy a Root Cause of Ambulance Diversion? • Tracer Methodology 101: Medication Management in an Opioid ... more >>

Your New Source: Expanded and Enhanced for 2012!

• 10/12/2011
• Author: Jim Parker
• 363 Views
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You, the readers, have told us that you’d like all the information you need on Joint Commission accreditation requirements, the accreditation process, performance measurement, and patient safety conveniently delivered, affordably priced, and in one place. To better meet your needs, JCR will introduce an improved, expanded version of The Source in January 2012.   The new Source will be en... more >>

Visit the JCR Ambulatory Care Conference in Chicago

• 8/26/2011
• Author: Jim Parker
• 487 Views
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Greetings! With more than 1 billion patient visits to ambulatory health care organizations taking place every year, safe, high-quality ambulatory health care is of critical importance. I hope all the readers from ambulatory health care organizations will consider attending Joint Commission Resources’ Annual Ambulatory Care Conference 2011, October 3-5 in Chicago. This year features a one-day p... more >>

Home Care Executive Briefing

• 8/1/2011
• Author: Jim Parker
• 515 Views
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Every year Joint Commission Resources invites home care organization administrators, directors, and managers to this critical update on the home care accreditation. This year, this one-day event will take place October 13 at The Joint Commission headquarters, located just outside of Chicago in Oakbrook Terrace, IL. The event will focus on recent and forthcoming changes to the accreditation pro... more >>

Hospital Executive Briefings

• 6/22/2011
• Author: Jim Parker
• 641 Views
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For the most in-depth and up-to-date information about revisions to Joint Commission standards, the accreditation and on-site survey process, and strategies for complying with standards that many hospitals find challenging, come to one of JCR’s Hospital Executive Briefings. At the briefings, health care providers have the unique opportunity to talk face-to-face with Joint Commission experts about... more >>

New Resources for Understanding Tracers

• 6/17/2011
• Author: Jim Parker
• 791 Views
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Understanding tracer methodology is critical to your Joint Commission accreditation and survey process. Tracer methodology is also a valuable tool that organizations can use to assess their own processes. In addition, tracer methodology is also helpful during your risk assessments for infections prevention and control and other potential threats. The Source includes a mock tracer ... more >>

Visit the Joint Commission/JCR Annual Conference!

• 5/20/2011
• Author: Jim Parker
• 557 Views
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Make sure you have registered for the upcoming Joint Commission and Joint Commission Resources Annual Conference on Quality and Patient Safety, June 8–10. Several of my fellow editors and I will be in the exhibit hall and attending sessions. We are eager to meet as many of our readers as we can! This year’s conference includes the following expected keynote presentations: • Human Factors in... more >>

Happy National Medical Laboratory Professionals Week!

• 4/29/2011
• Author: Jim Parker
• 660 Views
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This week The Joint Commission and health care organizations nationwide recognize National Medical Laboratory Professionals Week. To commemorate this observance, Ann Scott Blouin, Ph.D., R.N., executive vice president, The Joint Commission and Jennifer F. Rhamy, M.B.A., M.A., MT (ASCP) SBB, HP, executive director of the Laboratory Accreditation Program, wrote a letter [http://www.jointcommis... more >>

Check out the JCR Accreditation Summit!

• 4/7/2011
• Author: Jim Parker
• 701 Views
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For those of you looking for face-to-face authoritative guidance on Joint Commission accreditation and standards compliance, I hope you’ll attend the Third Annual Accreditation Summit in Lombard, IL, on May 3-4. (And, you’ll earn continuing education credits in the process!) At the summit, experts from The Joint Commission’s Standards Interpretation Group, surveyor cadre, and business developme... more >>

DELETECheck out the JCR Accreditation Summit!

• 4/7/2011
• Author: Andrew Bernotas
• 670 Views
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For those of you looking for face-to-face authoritative guidance on Joint Commission accreditation and standards compliance, I hope you’ll attend the Third Annual Accreditation Summit in Lombard, IL, on May 3-4. (And, you’ll earn continuing education credits in the process!) At the summit, experts from The Joint Commission’s Standards Interpretation Group, surveyor cadre, and business developme... more >>

New Resource for Standards Information

• 3/4/2011
• Author: Jim Parker
• 957 Views
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Every wonder how The Joint Commission comes up with all those standards? Now accredited organizations and other interested health care professionals can get a behind-the-scenes look The Joint Commission recently released its first R3 Report, covering the three R’s of requirement, rationale, and reference. These reports reveal the rationales and references that The Joint Commission uses in its ... more >>

Revised Standard MS.01.01.01: Are you ready?

• 2/1/2011
• Author: Jim Parker
• 1115 Views
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Just a friendly reminder: Revisions to Standard MS.01.01.01 become effective on March 31. The revisions were announced last year and organizations had a one year period in which they could make any preparations they needed to adjust to the new requirements, some of which are based on Centers for Medicare & Medicaid Services Conditions of Participation (CoP). The revisions to the standard a... more >>

Joint Commission Names New Chief Medical Officer

• 1/7/2011
• Author: Jim Parker
• 1174 Views
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Some big news is on the horizon for The Joint Commission and accredited organizations should be among the first to know. The Joint Commission has a new Chief Medical Officer as of Valentine’s Day—Feb. 14, 2011. Ana Pujols-McKee, M.D., will be executive vice president and chief medical officer of The Joint Commission enterprise, which includes Joint Commission Resources, Joint Commission Inter... more >>

Joint Commission Standards Support Efforts to Curb Smoking

• 12/6/2010
• Author: Jim Parker
• 1583 Views
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New developments from health care policymakers provide a good opportunity to examine how your organization complies with Joint Commission standards that address smoking cessation. The U.S. Department of Health and Human Services recently announced a new national effort to curb smoking among the U.S. population. The Joint Commission quickly issued a statement about these new measures. The state... more >>

A Closer Look at Handoff Communications

• 11/2/2010
• Author: Jim Parker
• 2093 Views
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Chester, a 47-year-old registered nurse at a 200-bed hospital, is stressing out. He has to leave early to get to his daughter’s high school graduation, and the nurse scheduled to relieve him hasn’t shown up yet. They have to discuss a 69-year-old male diabetic patient who arrived in the ER the previous night with a suspected stroke. At last, he spots the nurse he’s been waiting for coming down... more >>

Meet Your New Editor

• 10/5/2010
• Author: Jim Parker
• 3055 Views
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My name is Jim Parker. Since March 2006, it’s been my privilege to participate in the sharing of critical patient safety information with the health care community through The Joint Commission’s Perspectives on Patient Safety newsletter. Now, I will have the honor of helping organizations work through accreditation-related challenges in The Source, beginning with the upcoming November 2010 issue.... more >>

Safe Injection Practices Added to On-site Surveys

• 8/31/2010
• Author: Janet Pimentel
• 5510 Views
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No matter how old I am, I can’t help but be afraid whenever I receive a shot from a nurse or physician. I have always hated the pinch of the needle and always will – no matter how nicely the nurse or physician talks to me or makes me laugh beforehand. But, my fears have another focus. Articles in recent years have described health care professionals causing outbreaks by reinserting used needles in... more >>

By Request, Continuum of Care Tracers Addressed

• 8/25/2010
• Author: Janet Pimentel
• 5240 Views
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I enjoyed meeting several of our readers when I attended The Joint Commission Accreditation Summit this April in Lombard. A few summit attendees asked me to cover continuum of care tracers in the “Tracer Methodology 101” column in The Source. I’m happy to say that we delivered on that request in the August 2010 issue. In fact, Dr. Joel Yohai, senior vice president for medical affairs and chief med... more >>

Time to Comment on Preventing Surgical Site Infections

• 8/13/2010
• Author: Janet Pimentel
• 5997 Views
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Whenever an accredited health care organization has an opportunity to comment on a standard or requirement, they should do so because their input can make a difference on what future changes are considered or ultimately made. So if you have any comments or input regarding surgical site infections, you’ll be interested to know that The Joint Commission wants to hear from you. In this situation, you... more >>

Physical Holding of Children Standards Are a Good Idea

• 7/28/2010
• Author: Janet Pimentel
• 6710 Views
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Sometimes children with special needs can’t express themselves so they act out more aggressively than they should. As the aunt of a special needs child, I’ve seen my young nephew be physically held because there was concern that his head banging would harm himself. It’s never easy to see a family member--especially a child--physically held, but I understood that it was a way to help keep him safe.... more >>

Displaying Your Accreditation Award Makes a Difference

• 7/19/2010
• Author: Janet Pimentel
• 6900 Views
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It’s been so hot and humid in the Chicago area recently that I fainted during a 4-mile bike ride. (I know, I know, I shouldn’t have attempted such a feat in the first place but I thought I would have some fun!) I ended up seeking emergency medical attention at the nearest healthcare center that was open and, at first, felt a little uneasy about what to expect when I slowly walked through the door... more >>

Patient Flow Wait Times Discourage Trust

• 7/6/2010
• Author: Janet Pimentel
• 7740 Views
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A crowded emergency room--and feeling like you are waiting too long--can sure make a patient and their loved ones feel frustrated. I experienced it recently when accompanying a sick elderly parent to a hospital emergency room. I kept looking down at my watch and kept asking the nurse at the desk how long it will be before my mom could see someone. Waiting in line at the grocery store or movie thea... more >>

Interim Staffing Requirements Take Effect Soon

• 6/18/2010
• Author: Janet Pimentel
• 9260 Views
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Don’t forget that interim requirements to the staffing effectiveness standards will go into effect for hospitals and long term care organizations on July 1, 2010. The interim standards (which are the last bullet under Standard LD.04.04.05, EP 13, and Standard PI.02.01.01, EPs 12, 13, 14) will remain in effect while The Joint Commission continues to research staffing effectiveness issues. Those hos... more >>

Take Advantage of Resources about Revised Medical Staff Standard

• 6/9/2010
• Author: Janet Pimentel
• 9146 Views
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I don’t know if any of you had an opportunity to participate in the free April 22 conference call about the revised Medical Staff Standard MS.01.01.01. I did and found it to be very helpful because Chuck Mowll, executive vice president of Business Development, Government, and External Relations for The Joint Commission, led the discussion by summarizing each element of performance and outlining th... more >>

JCR’s e-Books Worth Checking Out!

• 5/19/2010
• Author: Janet Pimentel
• 9673 Views
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I recently discovered the joy of reading an electronic book on my laptop. I’m someone who has always enjoyed holding the actual book, smelling its pages, and keeping it on a bookshelf for later reference. But it was really convenient to download the book on my computer and conduct a search for the information that I wanted to know right away. It was also cheaper to download the book since I didn’t... more >>

Interrupting a Nurse Increases Chances for Medication Errors

• 5/13/2010
• Author: Janet Pimentel
• 11064 Views
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I recently accompanied my 72-year-old father to the hospital for eye surgery. While waiting in the pre-op area before the procedure, my dad decided he wanted his wallet from a locked cabinet so he called out to a nurse he saw in the hallway. He failed to realize that the nurse was standing at a medication cart and closely looking over a clipboard, as she may have been double checking the medicat... more >>

More How-To Help Coming for Ongoing Professional Practice Evaluations

• 5/7/2010
• Author: Janet Pimentel
• 11069 Views
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Ongoing professional practice evaluations (OPPEs) was the lead article for the April 2010 issue of The Source and you can expect it to be covered in future issues later this year. Many Joint Commission accredited hospitals and critical access hospitals have questions about this standard (MS.08.01.03) and find it to be challenging to comply with. Many of you who attended the Joint Commission’s ... more >>

Time to Provide Feedback on Suggested Medication Reconciliation Changes

• 4/14/2010
• Author: Janet Pimentel
• 12725 Views
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Don’t forget to review the latest draft of the revised Medication Reconciliation National Patient Safety Goal, also known as NPSG.08.01.01, which has been posted on The Joint Commission’s Web site. The proposed changes include critical risk points associated with maintaining and communicating patients’ medication information in the medication reconciliation process. Since medication reconciliation... more >>

Your Tracer Feature Feedback Has Been Helpful

• 3/29/2010
• Author: Janet Pimentel
• 12924 Views
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I sometimes get calls from The Source readers asking for help finding a specific tracer topic that published in the newsletter. I enjoy helping you track down a specific “Tracer Methodology 101” article and hearing what you think about it. Your comments have helped me improve this monthly feature over the past year by making such tweaks as providing more sample questions and focusing on tracer... more >>

Share Your Success Stories

• 3/24/2010
• Author: Janet Pimentel
• 13260 Views
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I’m glad to share a health care organization’s success story with you in the April 2010 issue of The Joint Commission: The Source, which is in the mail to subscribers. The article highlights how Crystal Run Healthcare, an ambulatory care/office-based surgery practice in the state of New York, developed an “in-the-trenches” training program to achieve and sustain staff and physician buy-in for ac... more >>

Field Review Postponed for Revised Medication Reconciliation Requirement

• 2/11/2010
• Author: Janet Pimentel
• 14984 Views
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Those of you interested in commenting on the revised Medication Reconciliation National Patient Safety Goal, also known as NPSG.08.01.01, will need to wait just a little while longer. The Joint Commission originally planned to post this revised NPSG in February so health care organizations could share their opinions, but has decided to postpone it so an advisory board and board committee can revie... more >>

Smoke-free Campus Trend Growing

• 2/1/2010
• Author: Janet Pimentel
• 15329 Views
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I don’t know if you heard, but a Joint Commission-accredited hospital in Chattanooga, Tennessee has decided to stop hiring workers who smoke. The hospital has been a smoke-free campus since around 2008, but hospital leaders decided to implement a smoker-free hiring policy beginning this month (February) because they think a hospital should set a healthy example for its community. The new rule won’... more >>

New Survey Agenda Process Allows Flexibility

• 1/25/2010
• Author: Janet Pimentel
• 16003 Views
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I don’t know if you’ve heard yet, but The Joint Commission is implementing a new approach for developing the agenda for on-site surveys that is more customer friendly. The survey agenda will still look similar to what it has been in the past; no survey activities are changing. The major change is that The Joint Commission will inform organizations before their survey about the survey length and th... more >>

H1N1 Forum Gaining Momentum

• 1/19/2010
• Author: Janet Pimentel
• 22183 Views
• 2 Comments
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I’m impressed with the comments that have already been posted on the H1N1 electronic forum that The Joint Commission launched in mid-December. In case you haven’t heard, the January 2010 issue of The Source had an article about how this new forum was established for health care organizations to freely exchange information about challenges associated with the H1N1 pandemic and the seasonal flu. Thi... more >>

Staff Vaccinations Important to Patients

• 1/8/2010
• Author: Janet Pimentel
• 15816 Views
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Happy 2010! I hope your new year has started better than mine. I had the stomach flu for five days over the holidays and ended up visiting my doctor. I’m pleased to note that the nurse who collected my latest medical information and took my temperature wore an “I got my flu shot. Did you?” button. I felt relieved that she received her flu vaccination and wore evidence to let me and others know. ... more >>

Feedback Wanted on Effective Working Relationships

• 12/22/2009
• Author: Janet Pimentel
• 16697 Views
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Joint Commission accredited organizations that want clearer direction on the relationship between medical staff and hospital leaders will be interested in reviewing the latest draft of Standard MS.01.01.01 (formerly known as MS.1.20). This draft standard was posted for field review December 17 on The Joint Commission’s Web site and has some significant improvement over the June 2007 version of Sta... more >>

White Paper Clarifies Leadership Expectations

• 12/11/2009
• Author: Janet Pimentel
• 17853 Views
• 2 Comments
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A few times a year I work at the Publications booth at JCR conferences and I am always asked which books on the table contain more information about the Leadership standards. Those of you interested in more guidance on this topic will be happy to know that The Joint Commission recently published a free white paper titled, “Leadership in Healthcare Organizations: A Guide to Joint Commission Leaders... more >>

E-dition Compliance Monitor Provides Special Resource for Hospitals

• 11/19/2009
• Author: Janet Pimentel
• 18714 Views
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Guest blog by Michelle McDonald, RN, MPH, Product Manager Healthcare Software, Joint Commission Resources Prior to working for JCR, I was the Vice President of Clinical Affairs and was responsible for maintaining regulatory requirements for various healthcare programs within a large healthcare system. For sometime now, healthcare organizations have stated that they wish there was a tool... more >>

More Clarification about Sterilizing Equipment

• 10/22/2009
• Author: Janet Pimentel
• 20889 Views
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In late August I wrote a blog about The Joint Commission’s latest statement regarding steam sterilization. Questions from the field have prompted The Joint Commission to provide more clarification and specific direction for the requirements for Standard IC.02.02.01, which addresses reducing the risks associated with medical equipment, devices, and supplies. Organizations will notice the clarificat... more >>

Making the Most of Your HR Processes

• 10/9/2009
• Author: Janet Pimentel
• 21195 Views
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One of the most challenging standards for hospitals right now is HR.01.02.05, which requires hospitals to verify staff qualifications. About 25% of hospitals surveyed during the first six months of this year have received Requirements for Improvement for this standard, according to data from The Joint Commission. One of the reasons that many hospitals are struggling with this requirement and simil... more >>

Clarifying Steam Sterilization Requirements

• 8/27/2009
• Author: Janet Pimentel
• 24489 Views
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Standard IC.02.02.01, EP 2 requires organizations to implement infection prevention and control activities when sterilizing medical equipment, devices, and supplies. However, many health care organizations are unsure of the appropriate way to clean, disinfect, and sterilize the equipment, devices, and supplies. As a result, The Joint Commission recently issued a statement about steam steriliza... more >>

Joint Commission Ventures Into Social Media

• 8/5/2009
• Author: Janet Pimentel
• 23418 Views
• 1 Comments
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Don’t be surprised if more of your patients understand what The Joint Commission’s Gold Seal hanging in your lobby means or if patients ask you questions about whether you are an accredited organization. The Joint Commission has a video posted on social media site YouTube called “A World of Difference” that discusses its mission to work behind the scenes with health care organizations to ensure th... more >>

Proposed Requirements to Advance Communication

• 7/23/2009
• Author: Janet Pimentel
• 24805 Views
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Anyone with loved ones who are learning English or have a hearing or speech problem knows how difficult it can be for that person to communicate well with a doctor or nurse. My grandfather spoke only Spanish and always needed someone to accompany him to the doctor’s office to make sure his thoughts and symptoms were communicated properly. Something so simple to us was terrifying for him to do by h... more >>

Linking Vaccinations to a Required Activity

• 7/16/2009
• Author: Janet Pimentel
• 25012 Views
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In 2007, The Joint Commission implemented a new standard in hospitals and long term care facilities requiring that influenza vaccinations be offered to staff and licensed independent practitioners.  For the hospital program, I’m referring specifically to Standard IC.02.04.01 and for the long term care program I’m referring to IC.4.15.  These requirements include organizations annually evaluati... more >>

Thanks for the Feedback

• 6/26/2009
• Author: Janet Pimentel
• 25277 Views
• 2 Comments
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I enjoyed talking with many of you at the JCR Publications table at the recent Joint Commission Accreditation Summit. I also appreciated how many of you saw my nametag and acknowledged that I am the new editor for The Source newsletter. Your recognition and kind words about the new monthly features, especially Tracer Methodology 101, means more than you know. Some of you were also kind eno... more >>

CMS-Related Requirements Reduced

• 3/26/2009
• Author: Janet Pimentel
• 30452 Views
• 2 Comments
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Good news for accredited hospitals that use Joint Commission accreditation for deemed status! The Joint Commission has been able to significantly reduce the number of new and revised standards and elements of performance as part of its hospital deeming application to the Centers for Medicare & Medicaid Services (CMS). Back in January 2009, The Joint Commission posted 165 new and re... more >>

Wanted: Voices From The Field

• 3/5/2009
• Author: Janet Pimentel
• 30881 Views
• 2 Comments
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Hello again. I know it’s been a while since I’ve posted a new blog, but we’ve been making some Web site enhancements to better serve you. In the meantime, I’ve been thinking and it occurred to me that I’ve learned a lot from my peers over the last 20 years. While working as a crime reporter for daily newspapers, my peers taught me how to get a stubborn police chief to comment on ... more >>

Look Forward To Change

• 12/12/2008
• Author: Janet Pimentel
• 36823 Views
• 7 Comments
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My godfather often joins me for coffee and shares pearls of wisdom in a calm, raspy voice kind of like Don Corleone. (The Godfather is my favorite movie, by the way!) The best advice I've received from him lately is that change isn't a bad thing. It's an opportunity for growth, to try something different, to see routine things through a new perspective. Right after that late-summer... more >>