JCR CAMH 2021

$210.71

Comprehensive Accreditation Manual for Hospitals (CAMH)

Published By	Publication Date	Number of Pages
Joint Commission	2021	899

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Category: Joint Commission

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Description

Our best-selling accreditation resource now available as a PDF! The CAMH PDF manual provides you with direct digital access to the elements of performance for hospital standards, National Patient Safety Goals, and Accreditation Participation Requirements (APRs) effective January 1, 2021. All the information you need is here, in one easy-to-use, authoritative, and accessible PDF. The PDF format allows you to easily jump to the key words or standards you need to reference. Please note: This PDF manual is a digital version of the hard copy Comprehensive Accreditation Manual for Hospitals effective January 1, 2021. It will not be updated with July 1, 2021 effective standards. Key Topics: • Accreditation requirements including the standards, National Patient Safety Goals, and Accreditation Participation Requirements effective January 1, 2021 • Standards and elements of performance for optional primary care medical home certification • Accreditation process information about Joint Commission policies and procedures and practical survey preparation information on the Early Survey Policy, documentation requirements, standards applicability, and more • Keys to successfully using the manual for survey preparedness Key Features: • Regulatory requirements for deemed status • Icons to help navigate documentation requirements as well as risk areas • “What’s New” summary of changes made in 2020 Standards: All hospital standards Setting: Organizations accredited under the Hospital Accreditation Program, including general, acute psychiatric, pediatric, medical/surgical specialty, long term acute care, and rehabilitation hospitals Key Audience: Staff responsible for accreditation, compliance, patient safety, or quality improvement

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2021 CAMH
20	Cover
21	The Joint Commission Mission
22	Contents
24	Introduction: How The Joint Commission Can Help You Move Toward High Reliability (INTRO)
25	I. Introduction to Joint Commission Accreditation
27	II. About the
39	This page is blank due to revisions through the update.
43	III. Steps to Achieving and Maintaining Compliance
50	IV. Get Extra Help
54	Patient Safety Systems (PS) Introduction
55	What Does This Chapter Contain?
57	Becoming a Learning Organization
58	The Role of Hospital Leaders in Patient Safety
63	Data Use and Reporting Systems
67	A Proactive Approach to Preventing Harm
70	Encouraging Patient Activation
71	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
73	This page is blank due to revisions through the update.
74	References
77	Appendix. Key Patient Safety Requirements
104	Accreditation Participation Requirements (APR) Overview
105	Chapter Outline
106	Requirements, Rationales, and Elements of Performance
114	Environment of Care (EC) Overview
117	Chapter Outline
118	Standards, Rationales, and Elements of Performance
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166	Emergency Management (EM) Overview
168	Chapter Outline
169	Standards, Rationales, and Elements of Performance
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200	Human Resources (HR) Overview
201	Chapter Outline
202	Standards, Rationales, and Elements of Performance
212	Infection Prevention and Control (IC) Overview
214	Chapter Outline
215	Standards, Rationales, and Elements of Performance
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228	Information Management (IM) Overview
229	Chapter Outline
230	Standards, Rationales, and Elements of Performance
236	Leadership (LD) Overview
239	Chapter Outline
240	Standards, Rationales, and Elements of Performance
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282	Life Safety (LS) Overview
285	Chapter Outline
286	Standards, Rationales, and Elements of Performance
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336	Medication Management (MM) Overview
339	Chapter Outline
340	Standards, Rationales, and Elements of Performance
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366	Medical Staff (MS) Overview
369	Chapter Outline
370	Standards, Rationales, and Elements of Performance
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420	National Patient Safety Goals (NPSG) Chapter Outline
421	Requirements, Rationales, and Elements of Performance
440	Nursing (NR) Overview
441	Chapter Outline
442	Standards, Rationales, and Elements of Performance
446	Provision of Care, Treatment, and Services (PC) Overview
448	Chapter Outline
449	Standards, Rationales, and Elements of Performance
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504	Performance Improvement (PI) Overview
506	Chapter Outline
507	Standards, Rationales, and Elements of Performance
512	Record of Care, Treatment, and Services (RC) Overview
513	Chapter Outline
514	Standards, Rationales, and Elements of Performance
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528	Rights and Responsibilities of the Individual (RI) Overview
530	Chapter Outline
531	Standards, Rationales, and Elements of Performance
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552	Transplant Safety (TS) Overview
554	Chapter Outline
555	Standards, Rationales, and Elements of Performance
564	Waived Testing (WT) Overview
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569	Chapter Outline
570	Standards, Rationales, and Elements of Performance
576	The Accreditation Process (ACC) Notices ACC Chapter Contents
578	Overview
581	Accreditation Policies
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606	Before the Survey
611	During the Survey
630	After the Survey
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645	Between Accreditation Surveys
657	Decision Rules for Organizations Seeking Initial Accreditation
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663	Decision Rules for Organizations Seeking Reaccreditation
667	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
670	Process for Organizations That Meet Decision Rule PDA04 Review and Appeal Procedures
676	Standards Applicability Grid (SAG)
714	Sentinel Events (SE) I. Sentinel Events
718	II. Goals of the Sentinel Event Policy
719	III. Responding to Sentinel Events
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728	IV. The Sentinel Event Database V. Determination That a Sentinel Event Is Subject to Review
729	VI. Optional On-Site Review of a Sentinel Event VII. Disclosable Information VIII. The Joint Commission’s Response
730	IX. Sentinel Event Measures of Success (SE MOS) X. Handling Sentinel Event–Related Documents
731	XI. Oversight of the Sentinel Event Policy XII. Survey Process
732	Appendix. Accreditation Requirements Related to Sentinel Events
736	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
737	What Will My Quality Report Contain?
738	What Is Quality Check?
739	Can My Hospital Comment on Its Quality Report?
740	What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
744	Performance Measurement and the ORYX Initiative (PM) Overview The Continued Role of ORYX
745	Accelerate PI™
746	Use of Performance Measure Data Current Requirements for Hospitals
748	Required Written Documentation (RWD)
749	List of EPs Requiring Written Documentation for Hospitals
754	Early Survey Policy (ESP)
760	Primary Care Medical Home Certification Option (PCMH) Overview Primary Care Medical Home Model
764	Standards, Rationales, Elements of Performance, and Scoring Specific to the Primary Care Medical Home Certification Option
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796	Appendix A: Medicare Requirements for Hospitals (AXA)
812	CoP Requirements Assessed by CMS or the Fiscal Intermediary
816	Appendix B: Special Conditions of Participation for Psychiatric Hospitals (AXB) Subpart E—Requirements for Specialty Hospitals
822	Glossary (GL)
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866	Index (IX)