JCR CAMH 2020
$210.71
Comprehensive Accreditation Manual for Hospitals (CAMH)
| Published By | Publication Date | Number of Pages |
| JCR | 2020 | 848 |
The CAMH manual provides you with direct digital access to the hospital elements of performance for hospital standards, National Patient Safety Goals, and Accreditation Participation Requirements (APRs) effective January 1, 2020.
Key Topics:
Standards requirements including the standards, National Patient Safety Goals, and Accreditation Participation Requirements effective January 1, 2020
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 2019
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 2020 CAMH |
| 9 | Cover |
| 10 | Copyright |
| 11 | Contents |
| 13 | Introduction: How The Joint Commission Can Help You Move Toward High Reliability (INTRO) |
| 14 | I. Introduction to Joint Commission Accreditation |
| 16 | II. About the Comprehensive Accreditation Manual for Hospitals |
| 18 | Table 1. Acronyms Used in This Manual |
| 19 | Table 1. |
| 30 | III. Steps to Achieving and Maintaining Compliance |
| 37 | IV. Get Extra Help |
| 41 | Patient Safety Systems (PS) Introduction |
| 42 | What Does This Chapter Contain? |
| 43 | Sidebar 1. Key Terms to Understand |
| 44 | Sidebar 1. Becoming a Learning Organization |
| 46 | The Role of Hospital Leaders in Patient Safety |
| 50 | Sidebar 2. Assessing Staff Accountability |
| 51 | Sidebar 2. Data Use and Reporting Systems |
| 54 | Table 1. Defining and Comparing Analytical Tools |
| 55 | A Proactive Approach to Preventing Harm |
| 56 | Sidebar 3. Strategies for an Effective Risk Assessment |
| 57 | Sidebar 3. |
| 59 | Encouraging Patient Activation |
| 60 | Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner |
| 62 | References |
| 65 | Appendix. Key Patient Safety Requirements Standard APR.09.01.01 Elements of Performance for APR.09.01.01 Standard APR.09.02.01 |
| 66 | Elements of Performance for APR.09.02.01 Standard EC.04.01.01 Elements of Performance for EC.04.01.01 |
| 67 | Standard IC.01.03.01 Elements of Performance for IC.01.03.01 |
| 68 | Standard LD.02.01.01 Elements of Performance for LD.02.01.01 Standard LD.02.04.01 Elements of Performance for LD.02.04.01 |
| 69 | Standard LD.03.01.01 Elements of Performance for LD.03.01.01 Standard LD.03.02.01 Elements of Performance for LD.03.02.01 Standard LD.03.03.01 Elements of Performance for LD.03.03.01 |
| 70 | Standard LD.03.04.01 Elements of Performance for LD.03.04.01 Standard LD.03.05.01 Elements of Performance for LD.03.05.01 Standard LD.03.06.01 Elements of Performance for LD.03.06.01 |
| 71 | Standard LD.03.07.01 Elements of Performance for LD.03.07.01 |
| 72 | Standard LD.03.09.01 Elements of Performance for LD.03.09.01 |
| 74 | Standard LD.04.01.01 Elements of Performance for LD.04.01.01 |
| 76 | Standard LD.04.01.05 Elements of Performance for LD.04.01.05 Standard LD.04.01.10 Elements of Performance for LD.04.01.10 Standard MM.07.01.03 Elements of Performance for MM.07.01.03 |
| 77 | Standard MM.08.01.01 Elements of Performance for MM.08.01.01 Standard MS.08.01.01 |
| 78 | Elements of Performance for MS.08.01.01 Standard MS.09.01.01 |
| 79 | Elements of Performance for MS.09.01.01 Standard NR.02.01.01 Elements of Performance for NR.02.01.01 |
| 80 | Standard PC.03.05.19 Elements of Performance for PC.03.05.19 |
| 81 | Standard PI.01.01.01 Elements of Performance for PI.01.01.01 |
| 83 | Standard PI.02.01.01 Elements of Performance for PI.02.01.01 |
| 84 | Standard PI.03.01.01 Elements of Performance for PI.03.01.01 |
| 85 | Standard RI.01.01.01 Elements of Performance for RI.01.01.01 |
| 86 | Standard RI.01.01.03 Elements of Performance for RI.01.01.03 |
| 87 | Standard RI.01.02.01 Elements of Performance for RI.01.02.01 |
| 88 | Standard RI.01.03.01 Elements of Performance for RI.01.03.01 |
| 89 | Standard RI.01.05.01 Elements of Performance for RI.01.05.01 |
| 90 | Standard RI.02.01.01 Elements of Performance for RI.02.01.01 |
| 93 | Accreditation Participation Requirements (APR) Overview |
| 94 | Chapter Outline |
| 95 | 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 |
| 96 | Elements of Performance for APR.01.02.01 APR.01.03.01 Elements of Performance for APR.01.03.01 APR.02.01.01 |
| 97 | Elements of Performance for APR.02.01.01 APR.03.01.01 Rationale for APR.03.01.01 Elements of Performance for APR.03.01.01 |
| 98 | APR.04.01.01 Elements of Performance for APR.04.01.01 |
| 99 | APR.05.01.01 Rationale for APR.05.01.01 Elements of Performance for APR.05.01.01 APR.06.01.01 Elements of Performance for APR.06.01.01 |
| 100 | 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 |
| 101 | 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 |
| 102 | Elements of Performance for APR.09.03.01 APR.09.04.01 Elements of Performance for APR.09.04.01 |
| 103 | Environment of Care (EC) Overview |
| 106 | Chapter Outline |
| 107 | Standards, Rationales, and Elements of Performance Standard EC.01.01.01 Rationale for EC.01.01.01 |
| 108 | Elements of Performance for EC.01.01.01 Standard EC.02.01.01 Rationale for EC.02.01.01 |
| 109 | Elements of Performance for EC.02.01.01 |
| 110 | Standard EC.02.01.03 Elements of Performance for EC.02.01.03 Standard EC.02.02.01 |
| 111 | Elements of Performance for EC.02.02.01 |
| 112 | Standard EC.02.03.01 Elements of Performance for EC.02.03.01 |
| 113 | Standard EC.02.03.03 |
| 114 | Elements of Performance for EC.02.03.03 Standard EC.02.03.05 |
| 115 | Elements of Performance for EC.02.03.05 |
| 119 | Standard EC.02.04.01 Elements of Performance for EC.02.04.01 |
| 121 | Standard EC.02.04.03 Elements of Performance for EC.02.04.03 |
| 129 | Standard EC.02.05.01 Elements of Performance for EC.02.05.01 |
| 135 | Standard EC.02.05.03 Elements of Performance for EC.02.05.03 |
| 137 | Standard EC.02.05.05 Elements of Performance for EC.02.05.05 |
| 139 | Standard EC.02.05.07 Rationale for EC.02.05.07 Elements of Performance for EC.02.05.07 |
| 142 | Standard EC.02.05.09 Elements of Performance for EC.02.05.09 |
| 146 | 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 |
| 147 | Standard EC.03.01.01 Rationale for EC.03.01.01 |
| 148 | Elements of Performance for EC.03.01.01 Standard EC.04.01.01 Elements of Performance for EC.04.01.01 |
| 149 | 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 |
| 151 | Emergency Management (EM) Overview |
| 153 | Chapter Outline |
| 154 | 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 |
| 156 | Standard EM.02.01.01 Rationale for EM.02.01.01 Elements of Performance for EM.02.01.01 |
| 161 | Standard EM.02.02.01 Rationale for EM.02.02.01 Elements of Performance for EM.02.02.01 |
| 163 | Standard EM.02.02.03 |
| 164 | Rationale for EM.02.02.03 Elements of Performance for EM.02.02.03 |
| 166 | Standard EM.02.02.05 Elements of Performance for EM.02.02.05 Standard EM.02.02.07 |
| 167 | Rationale for EM.02.02.07 Elements of Performance for EM.02.02.07 |
| 168 | Standard EM.02.02.09 Rationale for EM.02.02.09 |
| 169 | Elements of Performance for EM.02.02.09 Standard EM.02.02.11 Rationale for EM.02.02.11 |
| 170 | Elements of Performance for EM.02.02.11 |
| 172 | Standard EM.02.02.13 Elements of Performance for EM.02.02.13 |
| 174 | Standard EM.02.02.15 Elements of Performance for EM.02.02.15 |
| 176 | Standard EM.03.01.01 Rationale for EM.03.01.01 Elements of Performance for EM.03.01.01 Standard EM.03.01.03 |
| 177 | Rationale for EM.03.01.03 Elements of Performance for EM.03.01.03 |
| 180 | Standard EM.04.01.01 Elements of Performance for EM.04.01.01 |
| 183 | Human Resources (HR) Overview |
| 184 | Chapter Outline |
| 185 | Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01 |
| 191 | Standard HR.01.02.01 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 |
| 192 | Elements of Performance for HR.01.02.07 Standard HR.01.04.01 Elements of Performance for HR.01.04.01 Standard HR.01.05.03 |
| 193 | Elements of Performance for HR.01.05.03 |
| 194 | Standard HR.01.06.01 |
| 195 | Elements of Performance for HR.01.06.01 Standard HR.01.07.01 Elements of Performance for HR.01.07.01 |
| 197 | Infection Prevention and Control (IC) Overview |
| 199 | Chapter Outline |
| 200 | Standards, Rationales, and Elements of Performance Standard IC.01.01.01 Elements of Performance for IC.01.01.01 |
| 201 | Standard IC.01.02.01 Elements of Performance for IC.01.02.01 Standard IC.01.03.01 Elements of Performance for IC.01.03.01 |
| 202 | Standard IC.01.04.01 Elements of Performance for IC.01.04.01 Standard IC.01.05.01 Elements of Performance for IC.01.05.01 |
| 203 | Standard IC.01.06.01 Elements of Performance for IC.01.06.01 Standard IC.02.01.01 Elements of Performance for IC.02.01.01 |
| 205 | Standard IC.02.02.01 Rationale for IC.02.02.01 |
| 206 | Elements of Performance for IC.02.02.01 Standard IC.02.03.01 |
| 207 | Elements of Performance for IC.02.03.01 |
| 208 | Standard IC.02.04.01 Elements of Performance for IC.02.04.01 |
| 209 | Standard IC.03.01.01 Elements of Performance for IC.03.01.01 |
| 211 | Information Management (IM) Overview |
| 212 | Chapter Outline |
| 213 | Standards, Rationales, and Elements of Performance Standard IM.01.01.01 Elements of Performance for IM.01.01.01 |
| 214 | Standard IM.01.01.03 Elements of Performance for IM.01.01.03 |
| 215 | Standard IM.02.01.01 Elements of Performance for IM.02.01.01 |
| 216 | Standard IM.02.01.03 Elements of Performance for IM.02.01.03 Standard IM.02.02.01 Elements of Performance for IM.02.02.01 |
| 217 | Standard IM.02.02.03 |
| 218 | Elements of Performance for IM.02.02.03 Standard IM.03.01.01 Elements of Performance for IM.03.01.01 |
| 219 | Leadership (LD) Overview |
| 222 | Chapter Outline |
| 223 | Standards, Rationales, and Elements of Performance |
| 224 | 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 |
| 225 | Standard LD.01.03.01 Rationale for LD.01.03.01 Elements of Performance for LD.01.03.01 |
| 226 | Standard LD.01.04.01 Elements of Performance for LD.01.04.01 |
| 227 | Standard LD.01.05.01 Elements of Performance for LD.01.05.01 |
| 228 | Standard LD.02.01.01 Rationale for LD.02.01.01 Elements of Performance for LD.02.01.01 Standard LD.02.02.01 Rationale for LD.02.02.01 Elements of Performance for LD.02.02.01 |
| 229 | Standard LD.02.04.01 |
| 230 | Elements of Performance for LD.02.04.01 |
| 232 | Standard LD.03.01.01 Rationale for LD.03.01.01 Elements of Performance for LD.03.01.01 |
| 233 | Standard LD.03.02.01 Rationale for LD.03.02.01 Elements of Performance for LD.03.02.01 Standard LD.03.03.01 Rationale for LD.03.03.01 |
| 234 | Elements of Performance for LD.03.03.01 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 |
| 235 | Elements of Performance for LD.03.05.01 Standard LD.03.06.01 Rationale for LD.03.06.01 Elements of Performance for LD.03.06.01 |
| 236 | Standard LD.03.07.01 Elements of Performance for LD.03.07.01 Standard LD.03.08.01 |
| 237 | Elements of Performance for LD.03.08.01 Standard LD.03.09.01 |
| 238 | Elements of Performance for LD.03.09.01 |
| 240 | 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 |
| 242 | Standard LD.04.01.03 Elements of Performance for LD.04.01.03 Standard LD.04.01.05 |
| 243 | Rationale for LD.04.01.05 Elements of Performance for LD.04.01.05 |
| 244 | Standard LD.04.01.06 Elements of Performance for LD.04.01.06 Standard LD.04.01.07 |
| 245 | 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 |
| 246 | 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 |
| 247 | Elements of Performance for LD.04.02.03 Standard LD.04.02.05 Rationale for LD.04.02.05 |
| 248 | Elements of Performance for LD.04.02.05 Standard LD.04.03.01 Elements of Performance for LD.04.03.01 |
| 249 | Standard LD.04.03.07 Rationale for LD.04.03.07 |
| 250 | Elements of Performance for LD.04.03.07 Monitoring Contracted Services |
| 252 | Standard LD.04.03.09 Elements of Performance for LD.04.03.09 |
| 256 | Standard LD.04.03.11 Rationale for LD.04.03.11 Elements of Performance for LD.04.03.11 |
| 259 | Standard LD.04.03.13 Elements of Performance for LD.04.03.13 |
| 261 | Life Safety (LS) Overview |
| 264 | Chapter Outline |
| 265 | Standards, Rationales, and Elements of Performance Standard LS.01.01.01 Elements of Performance for LS.01.01.01 |
| 267 | Standard LS.01.02.01 Elements of Performance for LS.01.02.01 |
| 269 | Standard LS.02.01.10 Rationale for LS.02.01.10 Elements of Performance for LS.02.01.10 |
| 272 | Standard LS.02.01.20 Rationale for LS.02.01.20 |
| 273 | Elements of Performance for LS.02.01.20 |
| 281 | Standard LS.02.01.30 Rationale for LS.02.01.30 |
| 282 | Elements of Performance for LS.02.01.30 |
| 289 | Standard LS.02.01.34 Elements of Performance for LS.02.01.34 |
| 291 | Standard LS.02.01.35 Elements of Performance for LS.02.01.35 |
| 292 | Standard LS.02.01.40 |
| 293 | Elements of Performance for LS.02.01.40 Standard LS.02.01.50 Elements of Performance for LS.02.01.50 |
| 295 | Standard LS.02.01.70 Elements of Performance for LS.02.01.70 |
| 297 | Standard LS.03.01.10 Elements of Performance for LS.03.01.10 |
| 299 | Standard LS.03.01.20 |
| 300 | Rationale for LS.03.01.20 Elements of Performance for LS.03.01.20 |
| 302 | Standard LS.03.01.30 |
| 303 | Elements of Performance for LS.03.01.30 |
| 306 | Standard LS.03.01.34 Elements of Performance for LS.03.01.34 |
| 308 | Standard LS.03.01.35 Elements of Performance for LS.03.01.35 |
| 309 | Standard LS.03.01.40 |
| 310 | Elements of Performance for LS.03.01.40 Standard LS.03.01.50 |
| 311 | Elements of Performance for LS.03.01.50 |
| 312 | Standard LS.03.01.70 |
| 313 | Elements of Performance for LS.03.01.70 |
| 315 | Medication Management (MM) Overview |
| 318 | Chapter Outline |
| 319 | 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 |
| 320 | Elements of Performance for MM.01.01.03 |
| 321 | 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 |
| 323 | Standard MM.03.01.01 Rationale for MM.03.01.01 Elements of Performance for MM.03.01.01 |
| 324 | Standard MM.03.01.03 Rationale for MM.03.01.03 Elements of Performance for MM.03.01.03 |
| 325 | Standard MM.03.01.05 Rationale for MM.03.01.05 Elements of Performance for MM.03.01.05 Standard MM.04.01.01 |
| 326 | Elements of Performance for MM.04.01.01 |
| 327 | Standard MM.05.01.01 |
| 328 | Elements of Performance for MM.05.01.01 |
| 329 | Standard MM.05.01.07 Elements of Performance for MM.05.01.07 |
| 330 | Standard MM.05.01.09 Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09 |
| 331 | Standard MM.05.01.11 Elements of Performance for MM.05.01.11 Standard MM.05.01.13 Rationale for MM.05.01.13 Elements of Performance for MM.05.01.13 |
| 332 | Standard MM.05.01.17 Elements of Performance for MM.05.01.17 |
| 333 | Standard MM.05.01.19 Rationale for MM.05.01.19 Elements of Performance for MM.05.01.19 Standard MM.06.01.01 Elements of Performance for MM.06.01.01 |
| 334 | Standard MM.06.01.03 Elements of Performance for MM.06.01.03 |
| 335 | Standard MM.06.01.05 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 |
| 336 | Elements of Performance for MM.07.01.03 Standard MM.08.01.01 Elements of Performance for MM.08.01.01 |
| 337 | Standard MM.09.01.01 Elements of Performance for MM.09.01.01 |
| 341 | Medical Staff (MS) Overview |
| 344 | Chapter Outline |
| 345 | Standards, Rationales, and Elements of Performance |
| 346 | Standard MS.01.01.01 Elements of Performance for MS.01.01.01 |
| 353 | Standard MS.01.01.03 Rationale for MS.01.01.03 Elements of Performance for MS.01.01.03 Standard MS.01.01.05 |
| 354 | Elements of Performance for MS.01.01.05 Standard MS.02.01.01 Rationale for MS.02.01.01 |
| 355 | Elements of Performance for MS.02.01.01 |
| 356 | Management of Patient Care, Treatment, and Services Standard MS.03.01.01 Rationale for MS.03.01.01 Elements of Performance for MS.03.01.01 |
| 358 | Standard MS.03.01.03 Rationale for MS.03.01.03 Elements of Performance for MS.03.01.03 |
| 359 | Standard MS.04.01.01 Rationale for MS.04.01.01 Elements of Performance for MS.04.01.01 |
| 361 | Standard MS.05.01.01 Rationale for MS.05.01.01 Elements of Performance for MS.05.01.01 |
| 362 | Standard MS.05.01.03 Elements of Performance for MS.05.01.03 |
| 365 | Credentialing and Privileging |
| 367 | Standard MS.06.01.01 Rationale for MS.06.01.01 Elements of Performance for MS.06.01.01 Credentialing |
| 369 | Standard MS.06.01.03 Rationale for MS.06.01.03 Elements of Performance for MS.06.01.03 |
| 370 | Privileging |
| 371 | Standard MS.06.01.05 Elements of Performance for MS.06.01.05 |
| 373 | Standard MS.06.01.07 Elements of Performance for MS.06.01.07 |
| 374 | Standard MS.06.01.09 Elements of Performance for MS.06.01.09 |
| 375 | Standard MS.06.01.11 Elements of Performance for MS.06.01.11 |
| 376 | Standard MS.06.01.13 Rationale for MS.06.01.13 Elements of Performance for MS.06.01.13 |
| 377 | Standard MS.07.01.01 Elements of Performance for MS.07.01.01 |
| 378 | Standard MS.07.01.03 Rationale for MS.07.01.03 Elements of Performance for MS.07.01.03 |
| 379 | Focused Professional Practice Evaluation Standard MS.08.01.01 Rationale for MS.08.01.01 |
| 380 | Elements of Performance for MS.08.01.01 |
| 381 | Ongoing Professional Practice Evaluation |
| 382 | 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 |
| 383 | Standard MS.10.01.01 Rationale for MS.10.01.01 Elements of Performance for MS.10.01.01 Standard MS.11.01.01 |
| 384 | Rationale for MS.11.01.01 Elements of Performance for MS.11.01.01 |
| 385 | Standard MS.12.01.01 Rationale for MS.12.01.01 Elements of Performance for MS.12.01.01 |
| 386 | Telemedicine |
| 387 | Standard MS.13.01.01 Rationale for MS.13.01.01 Elements of Performance for MS.13.01.01 |
| 388 | Standard MS.13.01.03 Rationale for MS.13.01.03 |
| 389 | Elements of Performance for MS.13.01.03 |
| 391 | National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ |
| 392 | Requirements, Rationales, and Elements of Performance NPSG.01.01.01 Rationale for NPSG.01.01.01 Elements of Performance for NPSG.01.01.01 |
| 393 | NPSG.01.03.01 Elements of Performance for NPSG.01.03.01 NPSG.02.03.01 Rationale for NPSG.02.03.01 |
| 394 | Elements of Performance for NPSG.02.03.01 NPSG.03.04.01 Rationale for NPSG.03.04.01 |
| 395 | Elements of Performance for NPSG.03.04.01 |
| 396 | NPSG.03.05.01 Rationale for NPSG.03.05.01 Elements of Performance for NPSG.03.05.01 |
| 398 | NPSG.03.06.01 |
| 399 | Rationale for NPSG.03.06.01 Elements of Performance for NPSG.03.06.01 |
| 400 | NPSG.06.01.01 Rationale for NPSG.06.01.01 |
| 401 | Elements of Performance for NPSG.06.01.01 |
| 402 | NPSG.07.01.01 Rationale for NPSG.07.01.01 Elements of Performance for NPSG.07.01.01 NPSG.07.03.01 |
| 403 | Rationale for NPSG.07.03.01 Elements of Performance for NPSG.07.03.01 |
| 404 | NPSG.07.04.01 |
| 405 | Elements of Performance for NPSG.07.04.01 |
| 406 | NPSG.07.05.01 Elements of Performance for NPSG.07.05.01 |
| 407 | NPSG.07.06.01 |
| 408 | Elements of Performance for NPSG.07.06.01 |
| 409 | NPSG.15.01.01 Rationale for NPSG.15.01.01 |
| 410 | Elements of Performance for NPSG.15.01.01 |
| 412 | UP.01.01.01 Rationale for UP.01.01.01 |
| 413 | Elements of Performance for UP.01.01.01 |
| 414 | UP.01.02.01 Elements of Performance for UP.01.02.01 |
| 415 | UP.01.03.01 |
| 416 | Rationale for UP.01.03.01 Elements of Performance for UP.01.03.01 |
| 417 | Nursing (NR) Overview |
| 418 | Chapter Outline |
| 419 | 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 Elements of Performance for NR.01.02.01 |
| 420 | Standard NR.02.01.01 Elements of Performance for NR.02.01.01 Standard NR.02.02.01 Elements of Performance for NR.02.02.01 |
| 421 | Standard NR.02.03.01 Elements of Performance for NR.02.03.01 |
| 423 | Provision of Care, Treatment, and Services (PC) Overview |
| 425 | Chapter Outline |
| 426 | Standards, Rationales, and Elements of Performance Standard PC.01.01.01 Elements of Performance for PC.01.01.01 |
| 427 | Standard PC.01.02.01 Elements of Performance for PC.01.02.01 |
| 429 | Standard PC.01.02.03 Elements of Performance for PC.01.02.03 Standard PC.01.02.05 |
| 430 | Elements of Performance for PC.01.02.05 |
| 431 | Standard PC.01.02.07 Elements of Performance for PC.01.02.07 |
| 432 | Standard PC.01.02.08 Elements of Performance for PC.01.02.08 Standard PC.01.02.09 Rationale for PC.01.02.09 |
| 433 | Elements of Performance for PC.01.02.09 |
| 434 | Standard PC.01.02.11 Elements of Performance for PC.01.02.11 |
| 435 | Standard PC.01.02.13 |
| 436 | Elements of Performance for PC.01.02.13 |
| 437 | Standard PC.01.02.15 Elements of Performance for PC.01.02.15 |
| 439 | Standard PC.01.03.01 Elements of Performance for PC.01.03.01 |
| 441 | Standard PC.01.03.03 |
| 442 | Elements of Performance for PC.01.03.03 |
| 443 | Standard PC.01.03.05 Elements of Performance for PC.01.03.05 Standard PC.02.01.01 Elements of Performance for PC.02.01.01 |
| 444 | Standard PC.02.01.03 Elements of Performance for PC.02.01.03 |
| 445 | 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 |
| 446 | Standard PC.02.01.19 Rationale for PC.02.01.19 Elements of Performance for PC.02.01.19 Standard PC.02.01.21 Rationale for PC.02.01.21 |
| 447 | Elements of Performance for PC.02.01.21 |
| 448 | Standard PC.02.02.01 Elements of Performance for PC.02.02.01 |
| 449 | Standard PC.02.02.03 Elements of Performance for PC.02.02.03 |
| 450 | Standard PC.02.02.09 Elements of Performance for PC.02.02.09 Standard PC.02.02.13 |
| 451 | Elements of Performance for PC.02.02.13 Standard PC.02.03.01 Elements of Performance for PC.02.03.01 |
| 452 | Standard PC.02.04.01 |
| 453 | Elements of Performance for PC.02.04.01 Standard PC.02.04.03 Elements of Performance for PC.02.04.03 |
| 454 | Standard PC.02.04.05 Elements of Performance for PC.02.04.05 |
| 456 | Standard PC.03.01.01 Elements of Performance for PC.03.01.01 |
| 457 | Standard PC.03.01.03 Elements of Performance for PC.03.01.03 |
| 458 | Standard PC.03.01.05 Elements of Performance for PC.03.01.05 Standard PC.03.01.07 Elements of Performance for PC.03.01.07 |
| 459 | 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 |
| 460 | Standard PC.03.05.01 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 |
| 461 | Elements of Performance for PC.03.05.05 |
| 462 | 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 |
| 463 | Standard PC.03.05.11 Elements of Performance for PC.03.05.11 |
| 464 | Standard PC.03.05.13 Elements of Performance for PC.03.05.13 |
| 465 | Standard PC.03.05.15 Elements of Performance for PC.03.05.15 Standard PC.03.05.17 Elements of Performance for PC.03.05.17 |
| 466 | Standard PC.03.05.19 |
| 467 | Elements of Performance for PC.03.05.19 |
| 468 | Standard PC.04.01.01 Elements of Performance for PC.04.01.01 |
| 469 | Standard PC.04.01.03 Elements of Performance for PC.04.01.03 |
| 471 | Standard PC.04.01.05 Elements of Performance for PC.04.01.05 Standard PC.04.01.07 |
| 472 | Elements of Performance for PC.04.01.07 Standard PC.04.02.01 Elements of Performance for PC.04.02.01 |
| 473 | Standard PC.05.01.09 Elements of Performance for PC.05.01.09 |
| 475 | Performance Improvement (PI) Overview |
| 477 | Chapter Outline |
| 478 | Standards, Rationales, and Elements of Performance Standard PI.01.01.01 Elements of Performance for PI.01.01.01 |
| 480 | Standard PI.02.01.01 Elements of Performance for PI.02.01.01 |
| 482 | Standard PI.03.01.01 Elements of Performance for PI.03.01.01 |
| 483 | Record of Care, Treatment, and Services (RC) Overview |
| 484 | Chapter Outline |
| 485 | 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 |
| 486 | Standard RC.01.03.01 Elements of Performance for RC.01.03.01 Standard RC.01.04.01 |
| 487 | 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 |
| 490 | Standard RC.02.01.03 Elements of Performance for RC.02.01.03 |
| 492 | Standard RC.02.03.07 Elements of Performance for RC.02.03.07 Standard RC.02.04.01 Elements of Performance for RC.02.04.01 |
| 495 | Rights and Responsibilities of the Individual (RI) Overview |
| 497 | Chapter Outline |
| 498 | Standards, Rationales, and Elements of Performance Standard RI.01.01.01 Elements of Performance for RI.01.01.01 |
| 500 | Standard RI.01.01.03 Elements of Performance for RI.01.01.03 |
| 501 | Standard RI.01.02.01 Elements of Performance for RI.01.02.01 |
| 502 | Standard RI.01.03.01 Rationale for RI.01.03.01 |
| 503 | Elements of Performance for RI.01.03.01 |
| 504 | Standard RI.01.03.05 Elements of Performance for RI.01.03.05 Standard RI.01.04.01 Elements of Performance for RI.01.04.01 |
| 505 | Standard RI.01.04.03 Elements of Performance for RI.01.04.03 |
| 506 | Standard RI.01.05.01 Elements of Performance for RI.01.05.01 |
| 507 | 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 |
| 509 | Standard RI.01.06.05 Elements of Performance for RI.01.06.05 Standard RI.01.06.09 Elements of Performance for RI.01.06.09 |
| 510 | Standard RI.01.06.11 Elements of Performance for RI.01.06.11 Standard RI.01.07.01 Rationale for RI.01.07.01 Elements of Performance for RI.01.07.01 |
| 513 | 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 |
| 514 | Standard RI.01.07.07 Elements of Performance for RI.01.07.07 |
| 515 | Standard RI.01.07.13 Elements of Performance for RI.01.07.13 Standard RI.02.01.01 Rationale for RI.02.01.01 |
| 516 | Elements of Performance for RI.02.01.01 |
| 517 | Transplant Safety (TS) Overview |
| 519 | Chapter Outline |
| 520 | Standards, Rationales, and Elements of Performance Standard TS.01.01.01 Elements of Performance for TS.01.01.01 |
| 522 | Standard TS.02.01.01 Elements of Performance for TS.02.01.01 |
| 523 | Examples of Tissue and Cell Products |
| 524 | Standard TS.03.01.01 |
| 525 | Elements of Performance for TS.03.01.01 |
| 526 | Standard TS.03.02.01 Elements of Performance for TS.03.02.01 |
| 527 | Standard TS.03.03.01 Elements of Performance for TS.03.03.01 |
| 529 | Waived Testing (WT) Overview |
| 532 | Chapter Outline |
| 533 | Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01 |
| 534 | Standard WT.02.01.01 Elements of Performance for WT.02.01.01 |
| 535 | Standard WT.03.01.01 Elements of Performance for WT.03.01.01 |
| 536 | Standard WT.04.01.01 Elements of Performance for WT.04.01.01 Standard WT.05.01.01 |
| 537 | Elements of Performance for WT.05.01.01 |
| 539 | The Accreditation Process (ACC) Notices ACC Chapter Contents |
| 541 | Overview |
| 544 | Accreditation Policies |
| 564 | Sidebar 1. Early Survey Policy |
| 567 | Before the Survey |
| 572 | During the Survey |
| 573 | Table 1. Exceptions to Unannounced Surveys |
| 581 | Table 2. Hospital-Specific Tracer Applicability and Objectives |
| 582 | Table 2. |
| 590 | After the Survey |
| 602 | Between Accreditation Surveys |
| 605 | Sidebar 2. Focused Standards Assessment (FSA) Options |
| 606 | Sidebar 2. |
| 614 | Decision Rules for Organizations Seeking Initial Accreditation |
| 618 | Decision Rules for Organizations Seeking Reaccreditation |
| 622 | Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific |
| 625 | Process for Organizations That Meet Decision Rule PDA04 Review and Appeal Procedures |
| 631 | Standards Applicability Grid (SAG) |
| 671 | Sentinel Events (SE) I. Sentinel Events |
| 677 | II. Goals of the Sentinel Event Policy III. Responding to Sentinel Events |
| 685 | IV. The Sentinel Event Database V. Determination That a Sentinel Event Is Subject to Review VI. Optional On-Site Review of a Sentinel Event |
| 686 | VII. Disclosable Information VIII. The Joint Commission’s Response |
| 687 | IX. Sentinel Event Measures of Success (SE MOS) X. Handling Sentinel Event–Related Documents |
| 688 | XI. Oversight of the Sentinel Event Policy XII. Survey Process |
| 689 | Appendix. Accreditation Requirements Related to Sentinel Events Standard LD.03.09.01 Elements of Performance for LD.03.09.01 |
| 691 | Standard MS.05.01.01 |
| 692 | Elements of Performance for MS.05.01.01 |
| 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 | Can My Hospital Comment on Its Quality Report? |
| 697 | What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality? |
| 701 | Performance Measurement and the ORYX Initiative (PM) Overview The Continued Role of ORYX |
| 702 | Current Requirements for Hospitals* ORYX Performance Measure Report |
| 703 | Analyzing ORYX Data |
| 704 | Use of Performance Measure Data |
| 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) Infection Prevention and Control (IC) |
| 707 | 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) Medical Staff (MS) |
| 714 | 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 |
| 721 | Standards, Rationales, Elements of Performance, and Scoring Specific to the Primary Care Medical Home Certification Option 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 Standard PC.01.03.01 |
| 723 | Elements of Performance for PC.01.03.01 Standard PC.02.01.01 Elements of Performance for PC.02.01.01 Standard PC.02.01.21 Elements of Performance for PC.02.01.21 |
| 724 | 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 |
| 725 | Standard PC.02.04.05 Elements of Performance for PC.02.04.05 |
| 726 | Standard RC.02.01.01 Elements of Performance for RC.02.01.01 Standard RI.01.01.01 |
| 727 | Elements of Performance for RI.01.01.01 |
| 728 | Standard RI.01.01.03 Elements of Performance for RI.01.01.03 Standard RI.01.02.01 |
| 729 | Elements of Performance for RI.01.02.01 |
| 730 | Standard RI.01.03.01 Elements of Performance for RI.01.03.01 |
| 731 | Standard RI.01.04.01 Elements of Performance for RI.01.04.01 |
| 733 | Standard RI.01.04.03 Elements of Performance for RI.01.04.03 |
| 734 | Standard RI.01.05.01 Elements of Performance for RI.01.05.01 |
| 735 | Standard RI.01.07.01 Elements of Performance for RI.01.07.01 Standard LD.04.01.06 Element of Performance for LD.04.01.06 |
| 736 | Standard MS.03.01.01 Elements of Performance for MS.03.01.01 Standard PC.02.01.05 Element of Performance for PC.02.01.05 Standard PC.02.04.03 Elements of Performance for PC.02.04.03 |
| 737 | Standard PC.02.04.05 Elements of Performance for PC.02.04.05 |
| 738 | Standard HR.01.02.07 Elements of Performance for HR.01.02.07 Standard MS.03.01.01 Elements of Performance for MS.03.01.01 |
| 739 | Standard PC.01.03.01 Elements of Performance for PC.01.03.01 Standard PC.02.02.01 Elements of Performance for PC.02.02.01 Standard PC.02.04.03 |
| 740 | Elements of Performance for PC.02.04.03 Standard PC.02.04.05 Elements of Performance for PC.02.04.05 |
| 741 | Standard PC.04.01.01 Elements of Performance for PC.04.01.01 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 | Standard RC.01.01.01 Elements of Performance for RC.01.01.01 Standard PC.02.04.01 |
| 744 | Elements of Performance for PC.02.04.01 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 Standard MM.04.01.01 Elements of Performance for MM.04.01.01 Standard PC.01.03.01 Elements of Performance for PC.01.03.01 Standard PI.01.01.01 |
| 750 | Elements of Performance for PI.01.01.01 Standard PI.02.01.01 Elements of Performance for PI.02.01.01 |
| 751 | Standard PI.03.01.01 Elements of Performance for PI.03.01.01 |
| 753 | Appendix A: Medicare Requirements for Hospitals (AXA) |
| 766 | CoP Requirements Assessed by CMS or the Fiscal Intermediary |
| 769 | Appendix B: Special Conditions of Participation for Psychiatric Hospitals (AXB) Subpart E—Requirements for Specialty Hospitals |
| 775 | Glossary (GL) |
| 815 | Index (IX) |
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