Sunday News

October 26, 2025

CEO: Gayle Nash, MPH, RN

COO/CFO: Sam Sheth, PharmD, MBA

Contracts Manager: Kristin Miller, JD

CEO Corner


Hi all, I hope you had a good week.


Included in the document list for this week are corresponding publications from the Joint Commission website for EOC and Life Safety to help with compliance with the Physical Environment Standards. If you have not visited the resource center on the Joint Commission website, then I would take some time to do so. 


This week, I am sending updates (see below) from AORN on the Guidelines Essentials for Autologous Tissue Management. Some of the attachments have updates that may be helpful if you are currently reviewing policies and procedures. In addition to AORN updates, I have included below three recent publications on pediatric mental health and an OSHA publication on lithium batteries. 


A couple of critical access hospitals we work with were cited by their state surveyors for lacking a plan to mitigate safety risks associated with lithium batteries. In the physical environment, if you are Joint Commission accredited, you are no longer required to have individual environmental plans; however, a policy, procedure, instruction, SOP, or plan should be available along with staff education. This link provides comprehensive guidance on various training requirements in the OSHA standards (link here).


Lastly, I periodically receive questions about alternatives to The Joint Commission surveys or (for some facilities) Medicare surveys.  This week, I had the opportunity to speak with leadership at the Accreditation Commission for Healthcare (ACHC) who are also one of the accreditation organizations recognized by Medicare. I invite you to take a look at ACHC (https://achc.org) If you are considering other accreditation options.


[The following article is provided for informational purposes only and does not constitute an endorsement or promotion of any products, services, or organizations by Nash Healthcare Consulting. The content is not intended to serve as marketing or advertising material but rather to inform readers about ACHC’s accreditation programs and related industry topics.]

Know Your Accreditation Options:

Introducing ACHC


The Accreditation Commission for Health Care (ACHC) believes accreditation should do more than check boxes—it should advance healthcare quality, reduce administrative burden, and strengthen trust in healthcare organizations. As a nationally recognized nonprofit accrediting organization, ACHC partners with hospitals, surgery centers, clinical laboratories, and many other providers across the country to simplify the path to meaningful compliance and continuous improvement.


Who They Are


For more than 35 years, ACHC has been recognized by the Centers for Medicare & Medicaid Services (CMS) and respected throughout the industry for its collaborative, education-driven approach. Unlike other accreditors, the ACHC survey process focuses on partnership over policing, helping providers align with standards that are clear, relevant, and rooted in real-world care delivery.


ACHC’s philosophy is simple: accreditation should elevate care, not complicate it.


Acute Care Programs


ACHC offers a family of acute care programs designed to meet the needs of hospitals and healthcare facilities of every size and specialty:


  • Acute Care Hospitals – Streamlined, CMS-aligned standards that reduce survey burden and strengthen operational excellence.
  • Critical Access Hospitals – Tailored guidance that recognizes the unique role these facilities play in serving rural communities.
  • Ambulatory Surgery Centers (ASCs) – Flexible, patient-centered standards that promote safe, efficient outpatient care.
  • Clinical Laboratories – Comprehensive, quality-focused accreditation supporting compliance, accuracy, and reliability.


Each program reflects ACHC’s commitment to clinical quality, operational improvement, and a positive survey experience. ACHC surveyors are peer professionals who are also experienced healthcare leaders. They are dedicated to helping organizations succeed because they understand industry challenges.


Accreditation, Distinction & Certification Across the Continuum


Beyond acute care, ACHC’s portfolio extends across nearly every healthcare setting, offering Accreditation, Distinction, and Certification programs that unify quality under one trusted framework.

ACHC’s Community Care Programs include:


  • Home Health, Hospice, and Palliative Care
  • Private Duty Nursing and Home Care
  • Behavioral Health, Pharmacy,
  • Telehealth, Durable Medical Equipment, and more


Whether serving patients in hospitals or homes, ACHC provides organizations with the flexibility to pursue multiple accreditations or specialty distinctions under a single accreditor, simplifying compliance and reinforcing continuity of care.


Process


The ACHC process is built around partnership:


  • Preparation and Education – Access to consultative resources and readiness materials.
  • Collaborative Survey – Conducted by professionals who share the provider’s discipline and focus on performance improvement.
  • Ongoing Support – Continued guidance, education, and tools that sustain compliance long after the survey.

This modern, outcomes-focused approach ensures that accreditation is not just a one-time event but an ongoing commitment to excellence.


Learn More


Healthcare organizations can discover how ACHC is redefining accreditation for hospitals, surgery centers, and laboratories by exploring Surveyor, ACHC’s flagship publication highlighting best practices, insights, and real-world stories from across healthcare.


👉 Read Surveyor 2025, No. 1 (link here)

👉 Fall Quality Review Editions Coming Soon!


I am posting our Sunday News to my LinkedIn page. Please feel free to engage when you see my post, and thanks to all of those who responded to our latest post. 


Have a good week and see you next Sunday. 

Reach out today!


If you’re preparing for a survey, contact us early for support. Proactive preparation is key to addressing these common issues. Reach out to me via email (gnash@nashhc.com) or give me a call at 915-241-7830 for assistance.


Thank you!


Gayle Nash


Information, Articles, and Resources for You

  1. AORN - 2026 Autologous Tissue Management Guideline Revision - Learn More
  2. AORN Autologous Tissue Takeaways - Learn More
  3. AORN - Back to Basics Autologous Tissue - Learn More
  4. AORN - Cranial Bone Flap Log Book - Learn More
  5. AORN - Neurosurgeon Cranial Bone Flap Audit Letter - Learn More
  6. AORN - Policy Procedure Autologous Tissue All Types - Learn More
  7. APIC - Colorectal Bundle - Learn More
  8. BH - Pediatric Bipolar Disorder - Treatment - UpToDate - Learn More
  9. BH - Suicidal Behavior in children and adolescents - UpTo-Date - Learn More
  10. BH - Suicidal ideation and behavior in children and adolescents - Prevention and Treatment - UpTo-Date - Learn More
  11. CMS QSO - 26-01-all revised - 2025-10-21 - Learn More
  12. Hand Hygiene Push Drives Down C difficile at ICU Rehab - Automated Monitoring May Push It Further - Learn More
  13. OSHA - Lithium Battery Safety - Learn More
  14. OSHA - Lithium-Ion Safety - Learn More