JCR CAMH 2023

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Comprehensive Accreditation Manual for Hospitals (CAMH)

Published By	Publication Date	Number of Pages
Joint Commission	2023

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Category: Joint Commission

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Description

Get the official Joint Commission standards and accreditation policies in the 2023 Comprehensive Accreditation Manual for Hospitals (CAMH). A portable, updatable three-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” accreditation requirements, including the standards, National Patient Safety Goals®, and Accreditation Participation Requirements effective January 1, 2023 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 updated 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 2023 CAMH
15	Cover
16	Copyright
17	Contents
19	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
20	I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation
22	The Joint Commission’s Hospital Accreditation Program
23	II. About the
24	How Is This Manual Organized? Table 1. Acronyms Used in This Manual
25	Table 1.
27	Accreditation Requirements
29	Accreditation Process Information
31	Identifying Applicable Standards
33	Understanding the Organization of the Standards Chapters
34	Understanding the Icons Used in the Manual
37	III. Steps to Achieving and Maintaining Compliance Become Familiar with the Standards Use the Standards to Improve Care, Treatment, and Services
38	Assess Compliance with the Standards
40	Stimulate Improvement
43	Keep Current with Standards Changes via Perspectives
44	IV. Get Extra Help Getting Started with Accreditation Account Executive
45	Contacting The Joint Commission Standards Questions Requesting Permission to Share Content from the Manual
47	Patient Safety Systems (PS) Quality and Safety in Health Care Sidebar 1. Key Terms
48	Sidebar 1.
49	Goals of This Chapter
50	Becoming a Learning Organization
51	The Role of Leaders in Patient Safety Safety Culture
55	Sidebar 2. Assessing Staff Accountability
56	Sidebar 2. Data Use and Reporting Systems
57	Effective Use of Data
58	Table 1. Defining and Comparing Analytical Tools
59	A Proactive Approach to Preventing Harm
62	Sidebar 3. Strategies for an Effective Risk Assessment Encouraging Patient Activation
64	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
65	References
69	Accreditation Participation Requirements (APR) Overview
70	Chapter Outline
71	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
72	Elements of Performance for APR.01.02.01 APR.01.03.01 Elements of Performance for APR.01.03.01
73	APR.02.01.01 Elements of Performance for APR.02.01.01 APR.04.01.01 Elements of Performance for APR.04.01.01
74	APR.05.01.01 Rationale for APR.05.01.01 Elements of Performance for APR.05.01.01 APR.06.01.01
75	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
76	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
77	Elements of Performance for APR.09.03.01 APR.09.04.01 Elements of Performance for APR.09.04.01
79	Environment of Care (EC) Overview About This Chapter
80	Other Issues for Consideration
82	Chapter Outline
83	Standards, Rationales, and Elements of Performance Standard EC.01.01.01 Rationale for EC.01.01.01
84	Elements of Performance for EC.01.01.01 Standard EC.02.01.01 Rationale for EC.02.01.01
86	This page is blank due to revisions through the update.
87	Elements of Performance for EC.02.01.01
88	Standard EC.02.01.03 Elements of Performance for EC.02.01.03
89	Standard EC.02.02.01 Elements of Performance for EC.02.02.01
91	Standard EC.02.03.01 Elements of Performance for EC.02.03.01
92	Standard EC.02.03.03 Elements of Performance for EC.02.03.03
93	Standard EC.02.03.05
94	Elements of Performance for EC.02.03.05
98	Standard EC.02.04.01 Elements of Performance for EC.02.04.01
100	Standard EC.02.04.03 Elements of Performance for EC.02.04.03
106	Standard EC.02.05.01
107	Elements of Performance for EC.02.05.01
113	Standard EC.02.05.02 Elements of Performance for EC.02.05.02
115	Standard EC.02.05.03 Elements of Performance for EC.02.05.03
117	Standard EC.02.05.05 Elements of Performance for EC.02.05.05
119	Standard EC.02.05.07 Rationale for EC.02.05.07 Elements of Performance for EC.02.05.07
122	Standard EC.02.05.09 Elements of Performance for EC.02.05.09
125	Introduction to Standard EC.02.06.01
126	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
128	Standard EC.03.01.01 Rationale for EC.03.01.01 Elements of Performance for EC.03.01.01 Standard EC.04.01.01 Elements of Performance for EC.04.01.01
129	Standard EC.04.01.03
130	Elements of Performance for EC.04.01.03 Standard EC.04.01.05 Elements of Performance for EC.04.01.05
131	Emergency Management (EM) Overview About This Chapter
133	Chapter Outline
134	Standards, Rationales, and Elements of Performance Introduction to the Emergency Management Program, Standard EM.09.01.01 Standard EM.09.01.01
135	Rationale for EM.09.01.01 Elements of Performance for EM.09.01.01
136	Introduction to Leadership, Standard EM.10.01.01
137	Standard EM.10.01.01 Rationale for EM.10.01.01 Elements of Performance for EM.10.01.01
139	Introduction to Hazard Vulnerability Analysis (HVA), Standard EM.11.01.01 Standard EM.11.01.01
140	Rationale for EM.11.01.01 Elements of Performance for EM.11.01.01
141	Introduction to the Emergency Operations Plan, Standard EM.12.01.01
142	Standard EM.12.01.01 Rationale for EM.12.01.01 Elements of Performance for EM.12.01.01
145	Introduction to Communications, Standard EM.12.02.01 Standard EM.12.02.01 Rationale for EM.12.02.01
146	Elements of Performance for EM.12.02.01
148	Introduction to Staffing, Standard EM.12.02.03 Standard EM.12.02.03
149	Rationale for EM.12.02.03 Elements of Performance for EM.12.02.03
150	Introduction to Patient Care and Clinical Support, Standard EM.12.02.05 Standard EM.12.02.05
151	Rationale for EM.12.02.05 Elements of Performance for EM.12.02.05 Introduction to Safety and Security, Standard EM.12.02.07
152	Standard EM.12.02.07 Rationale for EM.12.02.07 Elements of Performance for EM.12.02.07
153	Introduction to Resources and Assets, Standard EM.12.02.09 Standard EM.12.02.09
154	Rationale for EM.12.02.09 Elements of Performance for EM.12.02.09
155	Introduction to Utilities, Standard EM.12.02.11
156	Standard EM.12.02.11 Rationale for EM.12.02.11 Elements of Performance for EM.12.02.11
157	Introduction to the Continuity of Operations Plan (COOP), Standard EM.13.01.01 Standard EM.13.01.01
158	Rationale for EM.13.01.01 Elements of Performance for EM.13.01.01
159	Introduction to Disaster Recovery, Standard EM.14.01.01
160	Standard EM.14.01.01 Rationale for EM.14.01.01 Elements of Performance for EM.14.01.01 Introduction to Education and Training, Standard EM.15.01.01
161	Standard EM.15.01.01 Rationale for EM.15.01.01 Elements of Performance for EM.15.01.01
163	Introduction to Exercises and Testing, Standard EM.16.01.01 Standard EM.16.01.01 Rationale for EM.16.01.01
164	Elements of Performance for EM.16.01.01
165	Introduction to Evaluation, Standard EM.17.01.01 Standard EM.17.01.01
166	Rationale for EM.17.01.01 Elements of Performance for EM.17.01.01
169	Human Resources (HR) Overview About This Chapter
170	Chapter Outline
171	Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01
174	Standard HR.01.02.01
175	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
176	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
178	Introduction to Standards HR.01.06.01 and HR.01.07.01
179	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
181	Infection Prevention and Control (IC) Overview
182	About This Chapter
183	Chapter Outline
184	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
185	Standard IC.01.02.01 Elements of Performance for IC.01.02.01
186	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
187	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
188	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
189	Standard IC.02.02.01
190	Rationale for IC.02.02.01 Elements of Performance for IC.02.02.01
191	Standard IC.02.03.01 Elements of Performance for IC.02.03.01
192	Introduction to Standard IC.02.04.01 Standard IC.02.04.01
193	Elements of Performance for IC.02.04.01
194	Standard IC.02.04.02 Rationale for IC.02.04.02 Elements of Performance for IC.02.04.02
196	Standard IC.02.05.01
197	Elements of Performance for IC.02.05.01 Introduction to Standard IC.03.01.01 – Evaluation and Improvement
198	Standard IC.03.01.01 Elements of Performance for IC.03.01.01
199	Information Management (IM) Overview About This Chapter
200	Chapter Outline
201	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
202	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
203	Introduction to Standard IM.02.01.01 Standard IM.02.01.01 Elements of Performance for IM.02.01.01
204	Introduction to Standard IM.02.01.03 Standard IM.02.01.03 Elements of Performance for IM.02.01.03
205	Standard IM.02.02.01 Elements of Performance for IM.02.02.01
206	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
207	Rationale for IM.02.02.07 Elements of Performance for IM.02.02.07
208	Standard IM.03.01.01 Elements of Performance for IM.03.01.01
209	Leadership (LD) Overview
210	Proactive Risk Assessment
211	About This Chapter
212	Chapter Outline
213	Standards, Rationales, and Elements of Performance Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01
214	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
215	Standard LD.01.03.01 Rationale for LD.01.03.01 Elements of Performance for LD.01.03.01
218	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
219	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
220	Rationale for LD.02.02.01 Elements of Performance for LD.02.02.01 Introduction to Standard LD.02.04.01
221	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
223	Standard LD.03.01.01 Rationale for LD.03.01.01
224	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
225	Standard LD.03.03.01 Rationale for LD.03.03.01 Elements of Performance for LD.03.03.01
226	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
227	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
228	Standard LD.03.07.01 Elements of Performance for LD.03.07.01 Standard LD.03.08.01
229	Elements of Performance for LD.03.08.01 Introduction to Standard LD.03.09.01 Standard LD.03.09.01
230	Elements of Performance for LD.03.09.01
232	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
234	Standard LD.04.01.03 Elements of Performance for LD.04.01.03
235	Standard LD.04.01.05 Rationale for LD.04.01.05 Elements of Performance for LD.04.01.05
236	Standard LD.04.01.06
237	Elements of Performance for LD.04.01.06 Standard LD.04.01.07 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
238	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
239	Standard LD.04.02.03 Elements of Performance for LD.04.02.03 Standard LD.04.02.05
240	Rationale for LD.04.02.05 Elements of Performance for LD.04.02.05 Standard LD.04.03.01 Elements of Performance for LD.04.03.01
241	Standard LD.04.03.07
242	Rationale for LD.04.03.07 Elements of Performance for LD.04.03.07 Introduction to Standard LD.04.03.08
243	Standard LD.04.03.08 Rationale for LD.04.03.08
244	Elements of Performance for LD.04.03.08
245	Introduction to Oversight of Care, Treatment, and Services Provided Through Contractual Agreement, Standard LD.04.03.09 Monitoring Contracted Services
247	Standard LD.04.03.09 Elements of Performance for LD.04.03.09
249	Introduction to Standard LD.04.03.11
251	Standard LD.04.03.11 Rationale for LD.04.03.11 Elements of Performance for LD.04.03.11
252	Introduction to Standard LD.04.03.13 Standard LD.04.03.13
253	Elements of Performance for LD.04.03.13
255	Life Safety (LS) Overview About This Chapter
258	Chapter Outline
259	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
261	Standard LS.01.02.01 Elements of Performance for LS.01.02.01
263	Standard LS.02.01.10 Rationale for LS.02.01.10 Elements of Performance for LS.02.01.10
266	Standard LS.02.01.20 Rationale for LS.02.01.20
268	This page is blank due to revisions through the update.
269	Elements of Performance for LS.02.01.20
275	Standard LS.02.01.30
276	Rationale for LS.02.01.30 Elements of Performance for LS.02.01.30
278	This page is blank due to revisions through the update.
282	This page is blank due to revisions through the update.
285	Standard LS.02.01.34 Elements of Performance for LS.02.01.34
287	Standard LS.02.01.35 Elements of Performance for LS.02.01.35
289	Standard LS.02.01.40
290	This page is blank due to revisions through the update.
291	Elements of Performance for LS.02.01.40 Standard LS.02.01.50 Elements of Performance for LS.02.01.50
293	Standard LS.02.01.70 Elements of Performance for LS.02.01.70
295	Standard LS.03.01.10 Elements of Performance for LS.03.01.10
298	Standard LS.03.01.20 Rationale for LS.03.01.20 Elements of Performance for LS.03.01.20
301	Standard LS.03.01.30
302	This page is blank due to revisions through the update.
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
314	Standard LS.05.01.10 Elements of Performance for LS.05.01.10
315	Standard LS.05.01.20 Elements of Performance for LS.05.01.20
316	Standard LS.05.01.30 Elements of Performance for LS.05.01.30
317	Standard LS.05.01.34 Elements of Performance for LS.05.01.34
318	Standard LS.05.01.35 Elements of Performance for LS.05.01.35
319	Medication Management (MM) Overview
320	About This Chapter
322	Chapter Outline
323	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
324	Elements of Performance for MM.01.01.03
325	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
327	Standard MM.03.01.01 Rationale for MM.03.01.01 Elements of Performance for MM.03.01.01
328	Standard MM.03.01.03 Rationale for MM.03.01.03 Elements of Performance for MM.03.01.03
329	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
330	Standard MM.04.01.01 Elements of Performance for MM.04.01.01
332	Standard MM.05.01.01 Elements of Performance for MM.05.01.01
333	Standard MM.05.01.07 Elements of Performance for MM.05.01.07
334	Standard MM.05.01.09 Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09
335	Standard MM.05.01.11 Elements of Performance for MM.05.01.11
336	Standard MM.05.01.13 Rationale for MM.05.01.13 Elements of Performance for MM.05.01.13 Standard MM.05.01.17
337	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
338	Standard MM.06.01.01 Elements of Performance for MM.06.01.01
339	Standard MM.06.01.03 Elements of Performance for MM.06.01.03 Standard MM.06.01.05
340	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
341	Standard MM.08.01.01 Elements of Performance for MM.08.01.01
342	Standard MM.09.01.01 Elements of Performance for MM.09.01.01
345	Medical Staff (MS) Overview
346	Organized Medical Staff Structure
348	Chapter Outline
349	Standards, Rationales, and Elements of Performance Introduction to Standard MS.01.01.01
350	Standard MS.01.01.01 Elements of Performance for MS.01.01.01
357	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
358	Standard MS.02.01.01 Rationale for MS.02.01.01 Elements of Performance for MS.02.01.01
359	Introduction to Standard MS.03.01.01 Management of Patient Care, Treatment, and Services Standard MS.03.01.01
360	Rationale for MS.03.01.01 Elements of Performance for MS.03.01.01
362	Standard MS.03.01.03 Rationale for MS.03.01.03 Elements of Performance for MS.03.01.03
363	Standard MS.04.01.01 Rationale for MS.04.01.01
364	Elements of Performance for MS.04.01.01
365	Standard MS.05.01.01 Rationale for MS.05.01.01 Elements of Performance for MS.05.01.01
367	Standard MS.05.01.03 Elements of Performance for MS.05.01.03 Introduction to Standard MS.06.01.01 Credentialing and Privileging
370	This page is blank due to revisions through the update.
371	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
373	Standard MS.06.01.03 Rationale for MS.06.01.03 Elements of Performance for MS.06.01.03
374	Introduction to Standard MS.06.01.05 Privileging
375	Standard MS.06.01.05 Elements of Performance for MS.06.01.05
377	Standard MS.06.01.07 Elements of Performance for MS.06.01.07
378	Standard MS.06.01.09 Elements of Performance for MS.06.01.09
379	Standard MS.06.01.11 Elements of Performance for MS.06.01.11
380	Standard MS.06.01.13 Rationale for MS.06.01.13 Elements of Performance for MS.06.01.13
382	This page is blank due to revisions through the update.
383	Standard MS.07.01.01 Elements of Performance for MS.07.01.01
384	Standard MS.07.01.03 Rationale for MS.07.01.03 Elements of Performance for MS.07.01.03
385	Introduction to Standard MS.08.01.01 Focused Professional Practice Evaluation Standard MS.08.01.01 Rationale for MS.08.01.01
386	Elements of Performance for MS.08.01.01
387	Introduction to Standard MS.08.01.03 Ongoing Professional Practice Evaluation
388	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
389	Standard MS.10.01.01 Rationale for MS.10.01.01 Elements of Performance for MS.10.01.01
390	Standard MS.11.01.01 Rationale for MS.11.01.01 Elements of Performance for MS.11.01.01
391	Standard MS.12.01.01 Rationale for MS.12.01.01 Elements of Performance for MS.12.01.01
392	Introduction to Standard MS.13.01.01 Telemedicine
393	Standard MS.13.01.01 Rationale for MS.13.01.01 Elements of Performance for MS.13.01.01
394	Standard MS.13.01.03
395	Rationale for MS.13.01.03 Elements of Performance for MS.13.01.03
397	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals® Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
398	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
399	Goal 2 NPSG.02.03.01 Rationale for NPSG.02.03.01 Elements of Performance for NPSG.02.03.01
400	Goal 3 NPSG.03.04.01 Rationale for NPSG.03.04.01 Elements of Performance for NPSG.03.04.01
401	NPSG.03.05.01
402	Rationale for NPSG.03.05.01 Elements of Performance for NPSG.03.05.01
403	Introduction to Reconciling Medication Information
404	NPSG.03.06.01 Rationale for NPSG.03.06.01
405	Elements of Performance for NPSG.03.06.01
406	Goal 6 NPSG.06.01.01 Rationale for NPSG.06.01.01 Elements of Performance for NPSG.06.01.01
407	Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01
408	Elements of Performance for NPSG.07.01.01 Goal 15 NPSG.15.01.01 Rationale for NPSG.15.01.01
409	Elements of Performance for NPSG.15.01.01
410	Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
411	UP.01.01.01 Rationale for UP.01.01.01
412	Elements of Performance for UP.01.01.01 Introduction to UP.01.02.01
413	UP.01.02.01 Elements of Performance for UP.01.02.01
414	UP.01.03.01
415	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
420	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
421	Elements of Performance for NR.02.02.01 Standard NR.02.03.01 Elements of Performance for NR.02.03.01
423	Provision of Care, Treatment, and Services (PC) Overview
424	About This Chapter
425	Chapter Outline
426	Standards, Rationales, and Elements of Performance Standard PC.01.01.01 Elements of Performance for PC.01.01.01
427	Introduction to Standard PC.01.02.01 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
431	Standard PC.01.02.05 Elements of Performance for PC.01.02.05 Introduction to Standard PC.01.02.07
432	Standard PC.01.02.07 Elements of Performance for PC.01.02.07
433	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
434	Elements of Performance for PC.01.02.09 Introduction to Standard PC.01.02.11
435	Standard PC.01.02.11 Elements of Performance for PC.01.02.11
436	Introduction to Standard PC.01.02.13 Standard PC.01.02.13 Elements of Performance for PC.01.02.13
438	Standard PC.01.02.15 Elements of Performance for PC.01.02.15
440	Introduction to Standard PC.01.03.01 Standard PC.01.03.01 Elements of Performance for PC.01.03.01
442	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
443	Standard PC.01.03.05 Elements of Performance for PC.01.03.05
444	Standard PC.02.01.01 Elements of Performance for PC.02.01.01
445	Standard PC.02.01.03 Elements of Performance for PC.02.01.03
446	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
447	Standard PC.02.01.19 Rationale for PC.02.01.19
448	Elements of Performance for PC.02.01.19 Standard PC.02.01.20 Elements of Performance for PC.02.01.20
449	Standard PC.02.01.21 Rationale for PC.02.01.21 Elements of Performance for PC.02.01.21
450	Introduction to Standard PC.02.02.01 Standard PC.02.02.01 Elements of Performance for PC.02.02.01
451	Standard PC.02.02.03
452	Elements of Performance for PC.02.02.03 Introduction to Standard PC.02.02.13 Standard PC.02.02.13 Elements of Performance for PC.02.02.13
453	Introduction to Standard PC.02.03.01 Standard PC.02.03.01 Elements of Performance for PC.02.03.01
454	Standard PC.02.04.01 Elements of Performance for PC.02.04.01
456	This page is blank due to revisions through the update.
457	Standard PC.02.04.03 Elements of Performance for PC.02.04.03
458	Standard PC.02.04.05 Elements of Performance for PC.02.04.05
459	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
461	Standard PC.03.01.03 Elements of Performance for PC.03.01.03 Standard PC.03.01.05
462	Elements of Performance for PC.03.01.05 Standard PC.03.01.07 Elements of Performance for PC.03.01.07
463	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
464	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
465	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
467	Standard PC.03.05.11 Elements of Performance for PC.03.05.11 Standard PC.03.05.13
468	Elements of Performance for PC.03.05.13 Standard PC.03.05.15 Elements of Performance for PC.03.05.15
469	Standard PC.03.05.17 Elements of Performance for PC.03.05.17
470	Standard PC.03.05.19 Elements of Performance for PC.03.05.19
471	Standard PC.04.01.01 Elements of Performance for PC.04.01.01
473	Standard PC.04.01.03 Elements of Performance for PC.04.01.03
475	Standard PC.04.01.05 Elements of Performance for PC.04.01.05
476	Standard PC.04.01.07 Elements of Performance for PC.04.01.07 Standard PC.04.02.01
477	Elements of Performance for PC.04.02.01 Standard PC.05.01.09 Elements of Performance for PC.05.01.09
478	Standard PC.06.01.01 Elements of Performance for PC.06.01.01
479	Standard PC.06.03.01 Elements of Performance for PC.06.03.01
481	Performance Improvement (PI) Overview About This Chapter
483	Chapter Outline
484	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
486	Standard PI.02.01.01 Rationale for PI.02.01.01 Elements of Performance for PI.02.01.01
487	Introduction to Standard PI.03.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
490	Standard PI.04.01.01 Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
491	Record of Care, Treatment, and Services (RC) Overview About This Chapter
492	Chapter Outline
493	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
494	Standard RC.01.03.01 Elements of Performance for RC.01.03.01 Standard RC.01.04.01
495	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
498	Standard RC.02.01.03 Elements of Performance for RC.02.01.03
500	Standard RC.02.03.07 Elements of Performance for RC.02.03.07
501	Standard RC.02.04.01 Elements of Performance for RC.02.04.01
503	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
505	Chapter Outline
506	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
508	Introduction to Standard RI.01.01.03
509	Standard RI.01.01.03 Elements of Performance for RI.01.01.03 Standard RI.01.02.01
510	Elements of Performance for RI.01.02.01
511	Standard RI.01.03.01 Rationale for RI.01.03.01
512	Elements of Performance for RI.01.03.01 Standard RI.01.03.05 Elements of Performance for RI.01.03.05
513	Standard RI.01.04.01 Elements of Performance for RI.01.04.01
514	Standard RI.01.04.03 Elements of Performance for RI.01.04.03
515	Standard RI.01.05.01 Elements of Performance for RI.01.05.01
516	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
517	Standard RI.01.06.05 Elements of Performance for RI.01.06.05
518	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
519	Standard RI.01.07.01 Rationale for RI.01.07.01 Elements of Performance for RI.01.07.01
520	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
521	Standard RI.01.07.07 Elements of Performance for RI.01.07.07 Standard RI.01.07.13
522	Elements of Performance for RI.01.07.13 Standard RI.02.01.01 Rationale for RI.02.01.01 Elements of Performance for RI.02.01.01
525	Transplant Safety (TS) Overview
526	About This Chapter
527	Chapter Outline
528	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
530	Standard TS.02.01.01 Elements of Performance for TS.02.01.01
531	Introduction to Standards TS.03.01.01, TS.03.02.01, and TS.03.03.01 Examples of Tissue and Cell Products
532	Standard TS.03.01.01
533	Elements of Performance for TS.03.01.01
534	Standard TS.03.02.01 Elements of Performance for TS.03.02.01
535	Standard TS.03.03.01
536	Elements of Performance for TS.03.03.01
537	Waived Testing (WT) Overview
538	About This Chapter
540	This page is blank due to revisions through the update.
542	Chapter Outline
543	Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01
544	Standard WT.02.01.01 Elements of Performance for WT.02.01.01 Standard WT.03.01.01
545	Elements of Performance for WT.03.01.01
546	Standard WT.04.01.01 Elements of Performance for WT.04.01.01 Standard WT.05.01.01 Elements of Performance for WT.05.01.01
549	The Accreditation Process (ACC) Notices ACC Chapter Contents
551	Overview General Eligibility Requirements
553	Eligibility Requirements for Initial Surveys
554	Scope of Accreditation Surveys Accreditation Policies Tailored Survey Policy
555	Organizational and Functional Integration
559	Inclusion of Physician Practices in Survey Multiorganization Option Concurrent Survey Option
560	Contracted Services Integrated Care Certification Option
561	Primary Care Medical Home Certification Option
562	Patient Blood Management Certification Option
563	Accrediting in Accordance with CMS Certification Numbers Survey Postponement Policy
564	Information Accuracy and Truthfulness Policy
566	Good Faith Participation in Accreditation/ Certification
567	Public Information Policy Process for Responding to a Complaint
568	Early Survey Policy Sidebar 1. Early Survey Policy
571	Before the Survey An Organization’s Secure Joint Commission Connect Extranet Site
572	Role of the Account Executive
573	Electronic Application for Accreditation (E-App)
574	Accreditation/Certification Contract and Business Associate Agreement
575	Annual and Survey Fees
576	During the Survey
577	Survey Notification Table 1. Exceptions to Unannounced Surveys\|\|
579	Initial and Full Survey Team Composition
580	Survey Agenda
585	Tracer Methodology
586	Table 2. Hospital-Specific Tracer Applicability and Objectives
589	Immediate Threat to Health or Safety
593	Summary of the Accreditation Reports
594	After the Survey The Scoring Process
600	Evidence of Standards Compliance (ESC) Process
603	Accreditation Award Display and Use
605	Recommendation Letter for Hospitals That Use Joint Commission Accreditation for Deemed Status Purposes Between Accreditation Surveys Duration of Accreditation Award
606	Continuous Compliance Intracycle Monitoring (ICM)
607	Focused Standards Assessment (FSA)
608	Sidebar 2. Focused Standards Assessment (FSA) Options
609	Sidebar 2. Sentinel Event Follow-up Notifying The Joint Commission About Organization Changes
611	Accreditation Status of Organizations That Cease Services After a Disaster
613	Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time
614	Reentering the Accreditation Process Additional Surveys
617	Decision Rules for Organizations Seeking Initial Accreditation Accredited Primary Care Medical Home Certification
618	Limited, Temporary Accreditation Evidence of Standards Compliance (ESC) One-Month Survey
619	Medicare Deficiency Follow-up Survey Denial of Accreditation
620	Decision Rules for Organizations Seeking Reaccreditation Accredited
621	Primary Care Medical Home Certification Evidence of Standards Compliance (ESC) One-Month Survey Medicare Deficiency Follow-up Survey
622	Accreditation with Follow-up Survey
623	Preliminary Denial of Accreditation
624	Denial of Accreditation
625	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
627	Process for Organizations That Meet Decision Rule PDA04
628	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
629	II. Accreditation with Follow-up Survey
630	III. Review Hearings
631	IV. Following a Review Hearing
632	V. Final Review &Appeal Request
635	Standards Applicability Grid (SAG)
670	This page is blank due to revisions through the update.
675	Sentinel Event Policy (SE)
676	Goals of the Sentinel Event Policy
677	Identifying Sentinel Events
679	Sidebar 1. Key Terms
680	Sidebar 1.
682	Determining That a Sentinel Event Is Subject to Review Relationship to the Survey Process
683	Required Organization Response to a Sentinel Event
685	Reporting a Sentinel Event to The Joint Commission
687	Conducting a Comprehensive Systematic Analysis
688	Developing a Corrective Action Plan
689	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
690	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
691	Table 1.
692	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
693	Follow-up Activities
695	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
696	Overseeing the Sentinel Event Policy
697	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
698	What Will My Quality Report Contain?
699	What Is Quality Check?
700	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?
701	What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
702	Guidelines for Publicizing Compliance with the National Patient Safety Goals Information Released by The Joint Commission
703	Guidelines for Publication
705	Performance Measurement and the ORYX Initiative (PM) Overview The Continued Role of ORYX
706	Accelerate PI™
707	Use of Performance Measure Data Current Requirements for Hospitals
709	Required Written Documentation (RWD)
710	List of EPs Requiring Written Documentation for Hospitals Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
711	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM) Medical Staff (MS)
712	National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) Nursing (NR) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
713	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Transplant Safety (TS) Waived Testing (WT)
715	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Environment of Care (EC)
716	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
717	Leadership (LD) Life Safety (LS) Medication Management (MM)
718	Medical Staff (MS) National Patient Safety Goals (NPSG) Nursing (NR)
719	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)
720	Waived Testing (WT)
721	Primary Care Medical Home Certification Option (PCMH) Overview Primary Care Medical Home Model
722	I. Patient-Centered Care II. Comprehensive Care
723	III. Coordinated Care
724	IV. Superb Access to Care V. Systems-Based Approach to Quality and Safety
725	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
726	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
727	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
728	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
730	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
731	Rights and Responsibilities of the Individual (RI) Standard RI.01.01.01 Elements of Performance for RI.01.01.01
733	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
735	Standard RI.01.03.01 Elements of Performance for RI.01.03.01
736	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
738	Standard RI.01.05.01 Elements of Performance for RI.01.05.01 Standard RI.01.07.01 Elements of Performance for RI.01.07.01
740	This page is blank due to revisions through the update.
741	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
742	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
743	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
744	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
745	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
746	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
747	Standard PC.04.01.03 Elements of Performance for PC.04.01.03
748	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
749	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
750	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
751	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
752	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
754	Standard LD.03.10.01 Elements of Performance for LD.03.10.01
755	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
756	Elements of Performance for PI.01.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
757	Standard PI.04.01.01 Elements of Performance for PI.04.01.01
759	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
760	482.12 Condition of Participation: Governing Body
762	482.22 Condition of Participation: Medical staff
766	482.24 Condition of Participation: Medical Record Services
767	482.27 Condition of Participation: Laboratory Services
771	482.30 Condition of Participation: Utilization Review
774	482.51 Condition of Participation: Surgical Services
775	CoP Requirements Assessed by CMS or the Fiscal Intermediary
779	Appendix B: Special Conditions of Participation for Psychiatric Hospitals (AXB) Subpart E—Requirements for Specialty Hospitals 482.60 Special Provisions Applying to Psychiatric Hospitals
780	482.61 Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals
782	482.62 Condition of Participation: Special Staff Requirements for Psychiatric Hospitals
785	Glossary (GL)
827	Index (IX)