JCR CAMH 2022

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Comprehensive Accreditation Manual for Hospitals (CAMH)

Published By	Publication Date	Number of Pages
Joint Commission	2022

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Category: Joint Commission

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Description

Get the official Joint Commission standards and accreditation policies in the 2022 Comprehensive Accreditation Manual for Hospitals (CAMH). A portable, updatable 3-ring binder includes color-coded tabs that allow you to find exactly what you need for standards compliance when you need it. Key Topics: “Gold tab” standards requirements including the standards, National Patient Safety Goals, and Accreditation Participation Requirements effective January 1, 2022 Standards and elements of performance for optional primary care medical home certification “Blue tab” 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: Integrated regulatory requirements for deemed status Icons to help navigate documentation requirements as well as risk areas Color-coded blue and gold tabs allow you to find exactly what you need when you need it “What’s New” summary of changes made since the previous edition Easily update with the CAMH Update Service 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 2022 CAMH
19	Cover
20	Copyright
21	Contents
23	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
24	I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation
26	The Joint Commission’s Hospital Accreditation Program
27	II. About the
28	How Is This Manual Organized? Table 1. Acronyms Used in This Manual
29	Table 1.
31	Accreditation Requirements
33	Accreditation Process Information
35	Identifying Applicable Standards
37	Understanding the Organization of the Standards Chapters
38	Understanding the Icons Used in the Manual
41	III. Steps to Achieving and Maintaining Compliance Become Familiar with the Standards Use the Standards to Improve Care, Treatment, and Services
42	Assess Compliance with the Standards
44	Stimulate Improvement
47	Keep Current with Standards Changes via Perspectives
48	IV. Get Extra Help Getting Started with Accreditation Account Executive
49	Contacting The Joint Commission Standards Questions Requesting Permission to Share Content from the Manual
51	Patient Safety Systems (PS) Quality and Safety in Health Care Sidebar 1. Key Terms
52	Sidebar 1.
53	Goals of This Chapter
54	Becoming a Learning Organization
55	The Role of Leaders in Patient Safety Safety Culture
59	Sidebar 2. Assessing Staff Accountability
60	Sidebar 2. Data Use and Reporting Systems
61	Effective Use of Data
62	Table 1. Defining and Comparing Analytical Tools
63	A Proactive Approach to Preventing Harm
66	Sidebar 3. Strategies for an Effective Risk Assessment Encouraging Patient Activation
68	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
70	References
73	Accreditation Participation Requirements (APR) Overview
74	Chapter Outline
75	Requirements, Rationales, and Elements of Performance APR.01.01.01 Elements of Performance for APR.01.01.01 APR.01.02.01 Rationale for APR.01.02.01
76	Elements of Performance for APR.01.02.01 APR.01.03.01 Elements of Performance for APR.01.03.01
77	APR.02.01.01 Elements of Performance for APR.02.01.01 APR.04.01.01 Elements of Performance for APR.04.01.01
78	APR.05.01.01 Rationale for APR.05.01.01 Elements of Performance for APR.05.01.01 APR.06.01.01
79	Elements of Performance for APR.06.01.01 APR.07.01.01 Elements of Performance for APR.07.01.01 APR.08.01.01 Elements of Performance for APR.08.01.01 APR.09.01.01
80	Elements of Performance for APR.09.01.01 APR.09.02.01 Rationale for APR.09.02.01 Elements of Performance for APR.09.02.01 APR.09.03.01
81	Elements of Performance for APR.09.03.01 APR.09.04.01 Elements of Performance for APR.09.04.01
83	Environment of Care (EC) Overview About This Chapter
84	Other Issues for Consideration
86	Chapter Outline
87	Standards, Rationales, and Elements of Performance Standard EC.01.01.01 Rationale for EC.01.01.01
88	Elements of Performance for EC.01.01.01 Standard EC.02.01.01 Rationale for EC.02.01.01
89	Elements of Performance for EC.02.01.01
90	Standard EC.02.01.03 Elements of Performance for EC.02.01.03
91	Standard EC.02.02.01 Elements of Performance for EC.02.02.01
93	Standard EC.02.03.01 Elements of Performance for EC.02.03.01
94	Standard EC.02.03.03 Elements of Performance for EC.02.03.03
95	Standard EC.02.03.05
96	This page is blank due to revisions through the update.
97	Elements of Performance for EC.02.03.05
101	Standard EC.02.04.01 Elements of Performance for EC.02.04.01
103	Standard EC.02.04.03 Elements of Performance for EC.02.04.03
109	Standard EC.02.05.01 Elements of Performance for EC.02.05.01
115	Standard EC.02.05.02 Elements of Performance for EC.02.05.02
117	Standard EC.02.05.03 Elements of Performance for EC.02.05.03
119	Standard EC.02.05.05 Elements of Performance for EC.02.05.05
121	Standard EC.02.05.07 Rationale for EC.02.05.07 Elements of Performance for EC.02.05.07
124	Standard EC.02.05.09 Elements of Performance for EC.02.05.09
127	Introduction to Standard EC.02.06.01
128	Standard EC.02.06.01 Elements of Performance for EC.02.06.01 Standard EC.02.06.05 Elements of Performance for EC.02.06.05
129	Standard EC.03.01.01 Rationale for EC.03.01.01
130	Elements of Performance for EC.03.01.01 Standard EC.04.01.01 Elements of Performance for EC.04.01.01
131	Standard EC.04.01.03 Elements of Performance for EC.04.01.03 Standard EC.04.01.05 Elements of Performance for EC.04.01.05
133	Emergency Management (EM) Overview About This Chapter
135	Chapter Outline
136	Standards, Rationales, and Elements of Performance Standard EM.01.01.01 Rationale for EM.01.01.01 Elements of Performance for EM.01.01.01
138	Standard EM.02.01.01 Rationale for EM.02.01.01
139	Elements of Performance for EM.02.01.01
141	Standard EM.02.02.01 Rationale for EM.02.02.01 Elements of Performance for EM.02.02.01
143	Standard EM.02.02.03 Rationale for EM.02.02.03
144	Elements of Performance for EM.02.02.03
145	Introduction to Standard EM.02.02.05
146	Standard EM.02.02.05 Elements of Performance for EM.02.02.05 Standard EM.02.02.07
147	Rationale for EM.02.02.07 Elements of Performance for EM.02.02.07
148	Standard EM.02.02.09
149	Rationale for EM.02.02.09 Elements of Performance for EM.02.02.09
150	Standard EM.02.02.11 Rationale for EM.02.02.11 Elements of Performance for EM.02.02.11
151	Introduction to Standards EM.02.02.13 and EM.02.02.15
152	Standard EM.02.02.13 Elements of Performance for EM.02.02.13
154	Standard EM.02.02.15 Elements of Performance for EM.02.02.15
156	Standard EM.03.01.01 Rationale for EM.03.01.01 Elements of Performance for EM.03.01.01
157	Standard EM.03.01.03 Rationale for EM.03.01.03 Elements of Performance for EM.03.01.03
160	Introduction to Standard EM.04.01.01 Standard EM.04.01.01 Elements of Performance for EM.04.01.01
163	Human Resources (HR) Overview About This Chapter
164	Chapter Outline
165	Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01
168	Standard HR.01.02.01
169	Elements of Performance for HR.01.02.01 Standard HR.01.02.05 Elements of Performance for HR.01.02.05 Standard HR.01.02.07 Elements of Performance for HR.01.02.07
170	Standard HR.01.04.01 Elements of Performance for HR.01.04.01 Standard HR.01.05.03 Elements of Performance for HR.01.05.03
172	Introduction to Standards HR.01.06.01 and HR.01.07.01
173	Standard HR.01.06.01 Elements of Performance for HR.01.06.01 Standard HR.01.07.01 Elements of Performance for HR.01.07.01
175	Infection Prevention and Control (IC) Overview
176	About This Chapter
177	Chapter Outline
178	Standards, Rationales, and Elements of Performance Introduction to Standards IC.01.01.01 Through IC.01.06.01 – Planning Standard IC.01.01.01 Elements of Performance for IC.01.01.01
179	Standard IC.01.02.01 Elements of Performance for IC.01.02.01
180	Standard IC.01.03.01 Elements of Performance for IC.01.03.01 Standard IC.01.04.01 Elements of Performance for IC.01.04.01
181	Standard IC.01.05.01 Elements of Performance for IC.01.05.01 Standard IC.01.06.01 Elements of Performance for IC.01.06.01
182	Introduction to Standards IC.02.01.01 Through IC.02.03.01 – Implementation Standard IC.02.01.01 Elements of Performance for IC.02.01.01
184	Standard IC.02.02.01 Rationale for IC.02.02.01
185	Elements of Performance for IC.02.02.01 Standard IC.02.03.01
186	Elements of Performance for IC.02.03.01 Introduction to Standard IC.02.04.01
187	Standard IC.02.04.01 Elements of Performance for IC.02.04.01
188	Standard IC.02.05.01 Elements of Performance for IC.02.05.01
189	Introduction to Standard IC.03.01.01 – Evaluation and Improvement Standard IC.03.01.01 Elements of Performance for IC.03.01.01
191	Information Management (IM) Overview About This Chapter
192	Chapter Outline
193	Standards, Rationales, and Elements of Performance Introduction to Standard IM.01.01.01 Standard IM.01.01.01 Elements of Performance for IM.01.01.01
194	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
195	Introduction to Standard IM.02.01.01 Standard IM.02.01.01 Elements of Performance for IM.02.01.01
196	Introduction to Standard IM.02.01.03 Standard IM.02.01.03 Elements of Performance for IM.02.01.03
197	Standard IM.02.02.01 Elements of Performance for IM.02.02.01
198	Introduction to Standard IM.02.02.03 Standard IM.02.02.03 Elements of Performance for IM.02.02.03 Standard IM.02.02.07
199	Rationale for IM.02.02.07 Elements of Performance for IM.02.02.07
200	Standard IM.03.01.01 Elements of Performance for IM.03.01.01
201	Leadership (LD) Overview
202	Proactive Risk Assessment
203	About This Chapter
204	Chapter Outline
205	Standards, Rationales, and Elements of Performance Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01
206	Standard LD.01.01.01 Rationale for LD.01.01.01 Elements of Performance for LD.01.01.01 Standard LD.01.02.01 Rationale for LD.01.02.01 Elements of Performance for LD.01.02.01
207	Standard LD.01.03.01 Rationale for LD.01.03.01 Elements of Performance for LD.01.03.01
210	Standard LD.01.04.01 Elements of Performance for LD.01.04.01 Standard LD.01.05.01 Elements of Performance for LD.01.05.01
211	Introduction to Leadership Relationships, Standards LD.02.01.01 Through LD.02.04.01 Standard LD.02.01.01 Rationale for LD.02.01.01 Elements of Performance for LD.02.01.01 Standard LD.02.02.01
212	Rationale for LD.02.02.01 Elements of Performance for LD.02.02.01 Introduction to Standard LD.02.04.01
213	Standard LD.02.04.01 Elements of Performance for LD.02.04.01 Introduction to Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
215	Standard LD.03.01.01 Rationale for LD.03.01.01
216	Elements of Performance for LD.03.01.01 Standard LD.03.02.01 Rationale for LD.03.02.01 Elements of Performance for LD.03.02.01
217	Standard LD.03.03.01 Rationale for LD.03.03.01 Elements of Performance for LD.03.03.01
218	Standard LD.03.04.01 Rationale for LD.03.04.01 Elements of Performance for LD.03.04.01 Standard LD.03.05.01 Rationale for LD.03.05.01 Elements of Performance for LD.03.05.01
219	Standard LD.03.06.01 Rationale for LD.03.06.01 Elements of Performance for LD.03.06.01 Introduction to Operations, Standards LD.03.07.01 Through LD.04.03.11
220	Standard LD.03.07.01 Elements of Performance for LD.03.07.01 Standard LD.03.08.01
221	Elements of Performance for LD.03.08.01 Introduction to Standard LD.03.09.01 Standard LD.03.09.01
222	Elements of Performance for LD.03.09.01
224	Standard LD.03.10.01 Rationale for LD.03.10.01 Elements of Performance for LD.03.10.01 Standard LD.04.01.01 Elements of Performance for LD.04.01.01
226	Standard LD.04.01.03 Elements of Performance for LD.04.01.03
227	Standard LD.04.01.05 Rationale for LD.04.01.05 Elements of Performance for LD.04.01.05
228	Standard LD.04.01.06 Elements of Performance for LD.04.01.06 Standard LD.04.01.07
229	Elements of Performance for LD.04.01.07 Standard LD.04.01.10 Elements of Performance for LD.04.01.10 Standard LD.04.01.11
230	Rationale for LD.04.01.11 Elements of Performance for LD.04.01.11 Standard LD.04.02.01 Elements of Performance for LD.04.02.01 Standard LD.04.02.03
231	Elements of Performance for LD.04.02.03 Standard LD.04.02.05 Rationale for LD.04.02.05
232	Elements of Performance for LD.04.02.05 Standard LD.04.03.01 Elements of Performance for LD.04.03.01
233	Standard LD.04.03.07 Rationale for LD.04.03.07
234	Elements of Performance for LD.04.03.07 Introduction to Oversight of Care, Treatment, and Services Provided Through Contractual Agreement, Standard LD.04.03.09 Monitoring Contracted Services
236	Standard LD.04.03.09 Elements of Performance for LD.04.03.09
238	Introduction to Standard LD.04.03.11
240	Standard LD.04.03.11 Rationale for LD.04.03.11 Elements of Performance for LD.04.03.11
241	Introduction to Standard LD.04.03.13 Standard LD.04.03.13
242	Elements of Performance for LD.04.03.13
243	Life Safety (LS) Overview About This Chapter
246	Chapter Outline
247	Standards, Rationales, and Elements of Performance Introduction to Standard LS.01.01.01 Standard LS.01.01.01 Elements of Performance for LS.01.01.01
249	Standard LS.01.02.01 Elements of Performance for LS.01.02.01
251	Standard LS.02.01.10 Rationale for LS.02.01.10 Elements of Performance for LS.02.01.10
254	Standard LS.02.01.20 Rationale for LS.02.01.20
255	Elements of Performance for LS.02.01.20
256	This page is blank due to revisions through the update.
263	Standard LS.02.01.30 Rationale for LS.02.01.30
264	Elements of Performance for LS.02.01.30
268	This page is blank due to revisions through the update.
271	Standard LS.02.01.34 Elements of Performance for LS.02.01.34
273	Standard LS.02.01.35 Elements of Performance for LS.02.01.35
275	Standard LS.02.01.40
276	This page is blank due to revisions through the update.
277	Elements of Performance for LS.02.01.40 Standard LS.02.01.50 Elements of Performance for LS.02.01.50
279	Standard LS.02.01.70 Elements of Performance for LS.02.01.70
281	Standard LS.03.01.10 Elements of Performance for LS.03.01.10
283	Standard LS.03.01.20
284	Rationale for LS.03.01.20 Elements of Performance for LS.03.01.20
286	Standard LS.03.01.30
287	Elements of Performance for LS.03.01.30
290	Standard LS.03.01.34 Elements of Performance for LS.03.01.34
292	Standard LS.03.01.35 Elements of Performance for LS.03.01.35
293	Standard LS.03.01.40
294	Elements of Performance for LS.03.01.40 Standard LS.03.01.50
295	Elements of Performance for LS.03.01.50
296	Standard LS.03.01.70
297	Elements of Performance for LS.03.01.70
298	Standard LS.05.01.10 Elements of Performance for LS.05.01.10
299	Standard LS.05.01.20 Elements of Performance for LS.05.01.20
300	Standard LS.05.01.30
301	Elements of Performance for LS.05.01.30
302	This page is blank due to revisions through the update.
303	Standard LS.05.01.34 Elements of Performance for LS.05.01.34
304	Standard LS.05.01.35 Elements of Performance for LS.05.01.35
307	Medication Management (MM) Overview
308	About This Chapter
310	Chapter Outline
311	Standards, Rationales, and Elements of Performance Standard MM.01.01.01 Rationale for MM.01.01.01 Elements of Performance for MM.01.01.01 Standard MM.01.01.03 Rationale for MM.01.01.03
312	Elements of Performance for MM.01.01.03
313	Standard MM.01.02.01 Elements of Performance for MM.01.02.01 Standard MM.02.01.01 Elements of Performance for MM.02.01.01
315	Standard MM.03.01.01 Rationale for MM.03.01.01 Elements of Performance for MM.03.01.01
316	Standard MM.03.01.03 Rationale for MM.03.01.03 Elements of Performance for MM.03.01.03
317	Standard MM.03.01.05 Rationale for MM.03.01.05 Elements of Performance for MM.03.01.05 Introduction to Standard MM.04.01.01
318	Standard MM.04.01.01 Elements of Performance for MM.04.01.01
320	Standard MM.05.01.01 Elements of Performance for MM.05.01.01
321	Standard MM.05.01.07 Elements of Performance for MM.05.01.07
322	Standard MM.05.01.09 Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09
323	Standard MM.05.01.11 Elements of Performance for MM.05.01.11
324	Standard MM.05.01.13 Rationale for MM.05.01.13 Elements of Performance for MM.05.01.13 Standard MM.05.01.17
325	Elements of Performance for MM.05.01.17 Standard MM.05.01.19 Rationale for MM.05.01.19 Elements of Performance for MM.05.01.19
326	Standard MM.06.01.01 Elements of Performance for MM.06.01.01
327	Standard MM.06.01.03 Elements of Performance for MM.06.01.03 Standard MM.06.01.05
328	Rationale for MM.06.01.05 Elements of Performance for MM.06.01.05 Standard MM.07.01.03 Rationale for MM.07.01.03 Elements of Performance for MM.07.01.03
329	Standard MM.08.01.01 Elements of Performance for MM.08.01.01
330	Standard MM.09.01.01 Elements of Performance for MM.09.01.01
335	Medical Staff (MS) Overview
336	Organized Medical Staff Structure
338	Chapter Outline
339	Standards, Rationales, and Elements of Performance Introduction to Standard MS.01.01.01
340	Standard MS.01.01.01 Elements of Performance for MS.01.01.01
347	Standard MS.01.01.03 Rationale for MS.01.01.03 Elements of Performance for MS.01.01.03 Standard MS.01.01.05 Elements of Performance for MS.01.01.05
348	Standard MS.02.01.01 Rationale for MS.02.01.01 Elements of Performance for MS.02.01.01
349	Introduction to Standard MS.03.01.01 Management of Patient Care, Treatment, and Services Standard MS.03.01.01
350	Rationale for MS.03.01.01 Elements of Performance for MS.03.01.01
352	Standard MS.03.01.03 Rationale for MS.03.01.03 Elements of Performance for MS.03.01.03
353	Standard MS.04.01.01 Rationale for MS.04.01.01
354	Elements of Performance for MS.04.01.01
355	Standard MS.05.01.01 Rationale for MS.05.01.01 Elements of Performance for MS.05.01.01
357	Standard MS.05.01.03 Elements of Performance for MS.05.01.03 Introduction to Standard MS.06.01.01 Credentialing and Privileging
360	This page is blank due to revisions through the update.
361	Standard MS.06.01.01 Rationale for MS.06.01.01 Elements of Performance for MS.06.01.01 Introduction to Standard MS.06.01.03 Credentialing
363	Standard MS.06.01.03 Rationale for MS.06.01.03 Elements of Performance for MS.06.01.03
364	Introduction to Standard MS.06.01.05 Privileging
365	Standard MS.06.01.05 Elements of Performance for MS.06.01.05
367	Standard MS.06.01.07 Elements of Performance for MS.06.01.07
368	Standard MS.06.01.09 Elements of Performance for MS.06.01.09
369	Standard MS.06.01.11 Elements of Performance for MS.06.01.11
370	Standard MS.06.01.13 Rationale for MS.06.01.13 Elements of Performance for MS.06.01.13
372	This page is blank due to revisions through the update.
373	Standard MS.07.01.01 Elements of Performance for MS.07.01.01
374	Standard MS.07.01.03 Rationale for MS.07.01.03 Elements of Performance for MS.07.01.03
375	Introduction to Standard MS.08.01.01 Focused Professional Practice Evaluation Standard MS.08.01.01 Rationale for MS.08.01.01
376	Elements of Performance for MS.08.01.01
377	Introduction to Standard MS.08.01.03 Ongoing Professional Practice Evaluation
378	Standard MS.08.01.03 Elements of Performance for MS.08.01.03 Standard MS.09.01.01 Rationale for MS.09.01.01 Elements of Performance for MS.09.01.01
379	Standard MS.10.01.01 Rationale for MS.10.01.01 Elements of Performance for MS.10.01.01
380	Standard MS.11.01.01 Rationale for MS.11.01.01 Elements of Performance for MS.11.01.01
381	Standard MS.12.01.01 Rationale for MS.12.01.01 Elements of Performance for MS.12.01.01
382	Introduction to Standard MS.13.01.01 Telemedicine
383	Standard MS.13.01.01 Rationale for MS.13.01.01 Elements of Performance for MS.13.01.01
384	Standard MS.13.01.03
385	Rationale for MS.13.01.03 Elements of Performance for MS.13.01.03
387	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals® Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
388	Requirements, Rationales, and Elements of Performance Goal 1 NPSG.01.01.01 Rationale for NPSG.01.01.01 Elements of Performance for NPSG.01.01.01
389	Goal 2 NPSG.02.03.01 Rationale for NPSG.02.03.01 Elements of Performance for NPSG.02.03.01
390	Goal 3 NPSG.03.04.01 Rationale for NPSG.03.04.01 Elements of Performance for NPSG.03.04.01
391	NPSG.03.05.01
392	Rationale for NPSG.03.05.01 Elements of Performance for NPSG.03.05.01
393	Introduction to Reconciling Medication Information
394	NPSG.03.06.01 Rationale for NPSG.03.06.01
395	Elements of Performance for NPSG.03.06.01
396	Goal 6 NPSG.06.01.01 Rationale for NPSG.06.01.01 Elements of Performance for NPSG.06.01.01
397	Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01
398	Elements of Performance for NPSG.07.01.01 Goal 15 NPSG.15.01.01 Rationale for NPSG.15.01.01
399	Elements of Performance for NPSG.15.01.01
400	Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
401	UP.01.01.01 Rationale for UP.01.01.01
402	Elements of Performance for UP.01.01.01 Introduction to UP.01.02.01
403	UP.01.02.01 Elements of Performance for UP.01.02.01
404	UP.01.03.01
405	Rationale for UP.01.03.01 Elements of Performance for UP.01.03.01
407	Nursing (NR) Overview
408	Chapter Outline
409	Standards, Rationales, and Elements of Performance Standard NR.01.01.01 Rationale for NR.01.01.01 Elements of Performance for NR.01.01.01 Standard NR.01.02.01
410	Elements of Performance for NR.01.02.01 Standard NR.02.01.01 Elements of Performance for NR.02.01.01 Standard NR.02.02.01
411	Elements of Performance for NR.02.02.01 Standard NR.02.03.01 Elements of Performance for NR.02.03.01
413	Provision of Care, Treatment, and Services (PC) Overview
414	About This Chapter
415	Chapter Outline
416	Standards, Rationales, and Elements of Performance Standard PC.01.01.01 Elements of Performance for PC.01.01.01
417	Introduction to Standard PC.01.02.01 Standard PC.01.02.01 Elements of Performance for PC.01.02.01
419	Standard PC.01.02.03 Elements of Performance for PC.01.02.03
421	Standard PC.01.02.05 Elements of Performance for PC.01.02.05 Introduction to Standard PC.01.02.07
422	Standard PC.01.02.07 Elements of Performance for PC.01.02.07
423	Standard PC.01.02.08 Elements of Performance for PC.01.02.08 Introduction to Standard PC.01.02.09 Standard PC.01.02.09
424	Elements of Performance for PC.01.02.09 Introduction to Standard PC.01.02.11
425	Standard PC.01.02.11 Elements of Performance for PC.01.02.11
426	Introduction to Standard PC.01.02.13 Standard PC.01.02.13 Elements of Performance for PC.01.02.13
428	Standard PC.01.02.15 Elements of Performance for PC.01.02.15
430	Introduction to Standard PC.01.03.01 Standard PC.01.03.01 Elements of Performance for PC.01.03.01
432	Introduction to Standard PC.01.03.03 and Standard PC.01.03.05 Standard PC.01.03.03 Elements of Performance for PC.01.03.03
433	Standard PC.01.03.05 Elements of Performance for PC.01.03.05
434	Standard PC.02.01.01 Elements of Performance for PC.02.01.01
435	Standard PC.02.01.03 Elements of Performance for PC.02.01.03
436	Standard PC.02.01.05 Elements of Performance for PC.02.01.05 Standard PC.02.01.11 Elements of Performance for PC.02.01.11
437	Standard PC.02.01.19 Rationale for PC.02.01.19 Elements of Performance for PC.02.01.19
438	Standard PC.02.01.20 Elements of Performance for PC.02.01.20
439	Standard PC.02.01.21 Rationale for PC.02.01.21 Elements of Performance for PC.02.01.21
440	Introduction to Standard PC.02.02.01 Standard PC.02.02.01 Elements of Performance for PC.02.02.01
441	Standard PC.02.02.03 Elements of Performance for PC.02.02.03
442	Introduction to Standard PC.02.02.13 Standard PC.02.02.13 Elements of Performance for PC.02.02.13 Introduction to Standard PC.02.03.01
443	Standard PC.02.03.01 Elements of Performance for PC.02.03.01
444	Standard PC.02.04.01 Elements of Performance for PC.02.04.01
445	Standard PC.02.04.03 Elements of Performance for PC.02.04.03
446	Standard PC.02.04.05 Elements of Performance for PC.02.04.05
447	Introduction to Standards PC.03.01.01 Through PC.03.01.07 Standard PC.03.01.01 Elements of Performance for PC.03.01.01
449	Standard PC.03.01.03 Elements of Performance for PC.03.01.03 Standard PC.03.01.05
450	Elements of Performance for PC.03.01.05 Standard PC.03.01.07 Elements of Performance for PC.03.01.07
451	Standard PC.03.01.08 Elements of Performance for PC.03.01.08 Standard PC.03.01.09 Elements of Performance for PC.03.01.09 Standard PC.03.05.01
452	Elements of Performance for PC.03.05.01 Standard PC.03.05.03 Elements of Performance for PC.03.05.03 Standard PC.03.05.05 Elements of Performance for PC.03.05.05
453	Standard PC.03.05.07 Elements of Performance for PC.03.05.07 Standard PC.03.05.09 Elements of Performance for PC.03.05.09
455	Standard PC.03.05.11 Elements of Performance for PC.03.05.11 Standard PC.03.05.13
456	Elements of Performance for PC.03.05.13 Standard PC.03.05.15 Elements of Performance for PC.03.05.15
457	Standard PC.03.05.17 Elements of Performance for PC.03.05.17
458	Standard PC.03.05.19 Elements of Performance for PC.03.05.19
459	Standard PC.04.01.01 Elements of Performance for PC.04.01.01
461	Standard PC.04.01.03 Elements of Performance for PC.04.01.03
463	Standard PC.04.01.05 Elements of Performance for PC.04.01.05
464	Standard PC.04.01.07 Elements of Performance for PC.04.01.07 Standard PC.04.02.01
465	Elements of Performance for PC.04.02.01 Standard PC.05.01.09 Elements of Performance for PC.05.01.09
466	Standard PC.06.01.01 Elements of Performance for PC.06.01.01
467	Standard PC.06.03.01 Elements of Performance for PC.06.03.01
469	Performance Improvement (PI) Overview About This Chapter
471	Chapter Outline
472	Standards, Rationales, and Elements of Performance Introduction to Standard PI.01.01.01 Standard PI.01.01.01 Elements of Performance for PI.01.01.01
474	Standard PI.02.01.01 Rationale for PI.02.01.01 Elements of Performance for PI.02.01.01
475	Introduction to Standard PI.03.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
478	Standard PI.04.01.01 Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
479	Record of Care, Treatment, and Services (RC) Overview About This Chapter
480	Chapter Outline
481	Standards, Rationales, and Elements of Performance Standard RC.01.01.01 Elements of Performance for RC.01.01.01 Standard RC.01.02.01 Elements of Performance for RC.01.02.01
482	Standard RC.01.03.01 Elements of Performance for RC.01.03.01 Standard RC.01.04.01
483	Elements of Performance for RC.01.04.01 Standard RC.01.05.01 Elements of Performance for RC.01.05.01 Standard RC.02.01.01 Elements of Performance for RC.02.01.01
486	Standard RC.02.01.03 Elements of Performance for RC.02.01.03
488	Standard RC.02.03.07 Elements of Performance for RC.02.03.07
489	Standard RC.02.04.01 Elements of Performance for RC.02.04.01
491	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
493	Chapter Outline
494	Standards, Rationales, and Elements of Performance Introduction to Standard RI.01.01.01 Standard RI.01.01.01 Elements of Performance for RI.01.01.01
496	Introduction to Standard RI.01.01.03
497	Standard RI.01.01.03 Elements of Performance for RI.01.01.03 Standard RI.01.02.01 Elements of Performance for RI.01.02.01
499	Standard RI.01.03.01 Rationale for RI.01.03.01 Elements of Performance for RI.01.03.01
500	Standard RI.01.03.05 Elements of Performance for RI.01.03.05
501	Standard RI.01.04.01 Elements of Performance for RI.01.04.01 Standard RI.01.04.03
502	Elements of Performance for RI.01.04.03
503	Standard RI.01.05.01 Elements of Performance for RI.01.05.01
504	Standard RI.01.06.01 Elements of Performance for RI.01.06.01 Standard RI.01.06.03 Elements of Performance for RI.01.06.03
505	Standard RI.01.06.05 Elements of Performance for RI.01.06.05
506	Standard RI.01.06.09 Elements of Performance for RI.01.06.09 Standard RI.01.06.11 Elements of Performance for RI.01.06.11 Standard RI.01.07.01
507	Rationale for RI.01.07.01 Elements of Performance for RI.01.07.01
508	Standard RI.01.07.03 Elements of Performance for RI.01.07.03 Standard RI.01.07.05 Elements of Performance for RI.01.07.05
509	Standard RI.01.07.07 Elements of Performance for RI.01.07.07 Standard RI.01.07.13 Elements of Performance for RI.01.07.13 Standard RI.02.01.01
510	Rationale for RI.02.01.01 Elements of Performance for RI.02.01.01
511	Transplant Safety (TS) Overview
512	About This Chapter
513	Chapter Outline
514	Standards, Rationales, and Elements of Performance Introduction to Standard TS.01.01.01 Standard TS.01.01.01 Elements of Performance for TS.01.01.01
516	Standard TS.02.01.01 Elements of Performance for TS.02.01.01
517	Introduction to Standards TS.03.01.01, TS.03.02.01, and TS.03.03.01 Examples of Tissue and Cell Products
518	Standard TS.03.01.01
519	Elements of Performance for TS.03.01.01
520	Standard TS.03.02.01 Elements of Performance for TS.03.02.01
521	Standard TS.03.03.01
522	Elements of Performance for TS.03.03.01
523	Waived Testing (WT) Overview
524	About This Chapter
526	This page is blank due to revisions through the update.
528	Chapter Outline
529	Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01
530	Standard WT.02.01.01 Elements of Performance for WT.02.01.01
531	Standard WT.03.01.01 Elements of Performance for WT.03.01.01
532	Standard WT.04.01.01 Elements of Performance for WT.04.01.01 Standard WT.05.01.01
533	Elements of Performance for WT.05.01.01
535	The Accreditation Process (ACC) Notices ACC Chapter Contents
537	Overview General Eligibility Requirements
539	Eligibility Requirements for Initial Surveys
540	Scope of Accreditation Surveys Accreditation Policies Tailored Survey Policy
542	Organizational and Functional Integration
545	Inclusion of Physician Practices in Survey Multiorganization Option Concurrent Survey Option
546	Contracted Services Integrated Care Certification Option
547	Primary Care Medical Home Certification Option
548	Patient Blood Management Certification Option
549	Accrediting in Accordance with CMS Certification Numbers Survey Postponement Policy
550	Information Accuracy and Truthfulness Policy
552	Good Faith Participation in Accreditation/ Certification
553	Public Information Policy Process for Responding to a Complaint
554	Early Survey Policy Sidebar 1. Early Survey Policy
557	Before the Survey An Organization’s Secure Joint Commission Connect Extranet Site
559	Role of the Account Executive Electronic Application for Accreditation (E-App)
560	Accreditation/Certification Contract and Business Associate Agreement
561	Annual and Survey Fees
562	During the Survey
563	Survey Notification Table 1. Exceptions to Unannounced Surveys#
565	Initial and Full Survey Team Composition
566	Survey Agenda
571	Tracer Methodology Table 2. Hospital-Specific Tracer Applicability and Objectives
572	Table 2.
576	Immediate Threat to Health or Safety
580	Summary of the Accreditation Reports
581	After the Survey The Scoring Process
587	Evidence of Standards Compliance (ESC) Process
590	Accreditation Award Display and Use
592	Recommendation Letter for Hospitals That Use Joint Commission Accreditation for Deemed Status Purposes Between Accreditation Surveys Duration of Accreditation Award
593	Continuous Compliance Intracycle Monitoring (ICM)
594	Focused Standards Assessment (FSA)
595	Sidebar 2. Focused Standards Assessment (FSA) Options
596	Sidebar 2. Sentinel Event Follow-up Notifying The Joint Commission About Organization Changes
598	Accreditation Status of Organizations That Cease Services After a Disaster\|\|\|\|\|\|\|\|\|\|\|\|
600	Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time
601	Reentering the Accreditation Process Additional Surveys
603	Decision Rules for Organizations Seeking Initial Accreditation
604	Accredited Primary Care Medical Home Certification
605	Limited, Temporary Accreditation Evidence of Standards Compliance (ESC) One-Month Survey Medicare Deficiency Follow-up Survey
606	Denial of Accreditation
607	Decision Rules for Organizations Seeking Reaccreditation Accredited Primary Care Medical Home Certification
608	Evidence of Standards Compliance (ESC) One-Month Survey Medicare Deficiency Follow-up Survey
609	Accreditation with Follow-up Survey
610	Preliminary Denial of Accreditation
611	Denial of Accreditation
612	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
614	Process for Organizations That Meet Decision Rule PDA04
615	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
616	II. Accreditation with Follow-up Survey
617	III. Review Hearings
618	IV. Following a Review Hearing
619	V. Final Review &Appeal Request
621	Standards Applicability Grid (SAG)
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671	Sentinel Event Policy (SE)
672	Goals of the Sentinel Event Policy
673	Identifying Sentinel Events
675	Sidebar 1. Key Terms
676	Sidebar 1.
677	Determining That a Sentinel Event Is Subject to Review
678	Relationship to the Survey Process
679	Required Organization Response to a Sentinel Event
680	Reporting a Sentinel Event to The Joint Commission
682	Conducting a Comprehensive Systematic Analysis
683	Developing a Corrective Action Plan
684	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
685	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
686	Table 1.
687	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
688	Follow-up Activities
690	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
691	Overseeing the Sentinel Event Policy
693	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
694	What Will My Quality Report Contain?
695	What Is Quality Check?
696	Is a Quality Report Available for My Accredited Hospital? Can My Hospital Comment on Its Quality Report? How Does My Hospital Submit a Commentary? Are There Any Criteria That Must Be Met in a Commentary?
697	What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
698	Guidelines for Publicizing Compliance with the National Patient Safety Goals Information Released by The Joint Commission
699	Guidelines for Publication
701	Performance Measurement and the ORYX Initiative (PM) Overview The Continued Role of ORYX
702	Accelerate PI™
703	Use of Performance Measure Data Current Requirements for Hospitals
705	Required Written Documentation (RWD)
706	List of EPs Requiring Written Documentation for Hospitals Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
707	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM) Medical Staff (MS)
708	National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) Nursing (NR) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
709	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Transplant Safety (TS) Waived Testing (WT)
711	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Environment of Care (EC)
712	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
713	Leadership (LD) Life Safety (LS) Medication Management (MM)
714	Medical Staff (MS) National Patient Safety Goals (NPSG) Nursing (NR)
715	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Transplant Safety (TS)
716	Waived Testing (WT)
717	Primary Care Medical Home Certification Option (PCMH) Overview Primary Care Medical Home Model
718	I. Patient-Centered Care II. Comprehensive Care
719	III. Coordinated Care
720	IV. Superb Access to Care V. Systems-Based Approach to Quality and Safety
721	Standards, Rationales, Elements of Performance, and Scoring Specific to the Primary Care Medical Home Certification Option I. Patient-Centered Care Leadership (LD) Standard LD.03.04.01 Elements of Performance for LD.03.04.01 Standard LD.03.07.01 Elements of Performance for LD.03.07.01
722	Standard LD.03.08.01 Elements of Performance for LD.03.08.01 Standard LD.04.01.11 Elements of Performance for LD.04.01.11
723	Provision of Care, Treatment, and Services (PC) Standard PC.01.03.01 Elements of Performance for PC.01.03.01 Standard PC.02.01.01 Elements of Performance for PC.02.01.01
724	Standard PC.02.01.21 Elements of Performance for PC.02.01.21 Standard PC.02.02.01 Elements of Performance for PC.02.02.01 Standard PC.02.03.01 Elements of Performance for PC.02.03.01
726	Standard PC.02.04.05 Elements of Performance for PC.02.04.05 Record of Care, Treatment, and Services (RC) Standard RC.02.01.01 Elements of Performance for RC.02.01.01
727	Rights and Responsibilities of the Individual (RI) Standard RI.01.01.01 Elements of Performance for RI.01.01.01
728	Standard RI.01.01.03 Elements of Performance for RI.01.01.03
729	Standard RI.01.02.01 Elements of Performance for RI.01.02.01
731	Standard RI.01.03.01 Elements of Performance for RI.01.03.01
732	Standard RI.01.04.01 Elements of Performance for RI.01.04.01 Standard RI.01.04.03 Elements of Performance for RI.01.04.03
733	Standard RI.01.05.01 Elements of Performance for RI.01.05.01
734	Standard RI.01.07.01 Elements of Performance for RI.01.07.01
735	II. Comprehensive Care Leadership (LD) Standard LD.04.01.06 Elements of Performance for LD.04.01.06 Medical Staff (MS) Standard MS.03.01.01 Elements of Performance for MS.03.01.01 Provision of Care, Treatment, and Services (PC) Standard PC.02.01.05
736	Elements of Performance for PC.02.01.05 Standard PC.02.04.03 Elements of Performance for PC.02.04.03 Standard PC.02.04.05
737	Elements of Performance for PC.02.04.05 III. Coordinated Care Human Resources (HR) Standard HR.01.02.07 Elements of Performance for HR.01.02.07
738	Medical Staff (MS) Standard MS.03.01.01 Elements of Performance for MS.03.01.01 Provision of Care, Treatment, and Services (PC) Standard PC.01.03.01 Elements of Performance for PC.01.03.01
739	Standard PC.02.02.01 Elements of Performance for PC.02.02.01 Standard PC.02.04.03 Elements of Performance for PC.02.04.03
740	Standard PC.02.04.05 Elements of Performance for PC.02.04.05 Standard PC.04.01.01 Elements of Performance for PC.04.01.01
741	Standard PC.04.01.03 Elements of Performance for PC.04.01.03
742	Standard PC.04.01.05 Elements of Performance for PC.04.01.05 Standard PC.04.02.01 Elements of Performance for PC.04.02.01
743	Record of Care, Treatment, and Services (RC) Standard RC.01.01.01 Elements of Performance for RC.01.01.01 IV. Superb Access to Care Provision of Care, Treatment, and Services (PC) Standard PC.02.04.01
744	Elements of Performance for PC.02.04.01 V. Systems-Based Approach to Quality and Safety Leadership (LD) Standard LD.01.03.01 Elements of Performance for LD.01.03.01
745	Standard LD.03.04.01 Elements of Performance for LD.03.04.01 Standard LD.03.07.01 Elements of Performance for LD.03.07.01
746	Standard LD.03.08.01 Elements of Performance for LD.03.08.01 Standard LD.03.09.01 Elements of Performance for LD.03.09.01
748	Standard LD.03.10.01 Elements of Performance for LD.03.10.01
749	Standard LD.04.01.11 Elements of Performance for LD.04.01.11 Medication Management (MM) Standard MM.04.01.01 Elements of Performance for MM.04.01.01 Provision of Care, Treatment, and Services (PC) Standard PC.01.03.01 Elements of Performance for PC.01.03.01 Performance Improvement (PI) Standard PI.01.01.01
750	Elements of Performance for PI.01.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
751	Standard PI.04.01.01 Elements of Performance for PI.04.01.01
753	Appendix A: Medicare Requirements for Hospitals (AXA) Part 409 Subpart B—Inpatient Hospital Services and Inpatient Critical Access Hospital Services 409.17: Physical Therapy, Occupat
754	482.12 Condition of Participation: Governing Body
756	482.22 Condition of Participation: Medical staff
760	482.24 Condition of Participation: Medical Record Services
761	482.27 Condition of Participation: Laboratory Services
765	482.30 Condition of Participation: Utilization Review
768	482.51 Condition of Participation: Surgical Services
769	CoP Requirements Assessed by CMS or the Fiscal Intermediary
773	Appendix B: Special Conditions of Participation for Psychiatric Hospitals (AXB) Subpart E—Requirements for Specialty Hospitals 482.60 Special Provisions Applying to Psychiatric Hospitals
774	482.61 Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals
776	482.62 Condition of Participation: Special Staff Requirements for Psychiatric Hospitals
779	Glossary (GL)
821	Index (IX)