JCR CAMLAB 2021

$178.21

Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing (CAMLAB)

Published By	Publication Date	Number of Pages
Joint Commission	2021

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Category: Joint Commission

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Description

Continuous compliance starts with staff who know what The Joint Commission requires. The 2021 Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing (CAMLAB) provides the key information your organization needs to power performance improvement and maintain continuous standards compliance. It features the official Joint Commission standards, National Patient Safety Goals, and other accreditation requirements. The portable CAMLAB is spiral bound with color-coded tabs that allow you to find exactly what you need for standards compliance or survey readiness when you need it. Inside you’ll find descriptions of the survey and decision process, questions to prompt discussion in your organization about compliance with the standards, checklists of the elements of performance that require written documentation, and action planning worksheets to address any issues of noncompliance. It’s lean and light, making it a perfect on-the-go reference. Keep it handy in meetings, during orientation and training, and as a practical overview of the Joint Commission’s accreditation requirements for everyone in your organization, from staff to leaders. Then, get ready to power performance improvement and excellence in your laboratory services! Please note: The CAMLAB is delivered annually. For the most up-to-date standards throughout 2021, access your E-dition on your Joint Commission ConnectTM extranet site or consider purchasing the E-dition Laboratory version. Key Topics: • “Gold tab” standards requirements including the standards, National Patient Safety Goals, and Accreditation Participation Requirements effective January 1, 2021 • “Blue tab” accreditation process information about Joint Commission policies and procedures and practical survey preparation information on the Early Survey Policy, documentation requirements, patient safety systems and more • Several appendixes, including one on standards related to Individualized Quality Control Plans (IQCP) and a new one on duplicated standards between the laboratory and hospital accreditation programs • Keys to successfully using the manual for survey preparedness Key Features: • Survey readiness tools including compliance prompts, documentation checklists, and action planning worksheets in every standards chapter • Icons to help navigate documentation requirements as well as risk areas • “What’s New” summary of changes made since the previous print edition Standards: All laboratory standards Setting: Organizations accredited under the Laboratory Accreditation Program, including • Laboratories in hospitals, clinics, nursing care facilities, home care organizations, behavioral health care organizations, ambulatory sites and physician offices • Reference laboratories • Freestanding laboratories, such as assisted reproductive technology laboratories • Blood transfusion and donor center laboratories • Public health laboratories, including Indian Health Service laboratories • Laboratories in federal health care facilities, such as the Department of Veterans Affairs • Point-of-care test sites in patient care areas, which may include blood gas laboratories providing services to patients in emergency rooms, surgical suites, and cardiac catheterization laboratories Key Audience: Staff responsible for accreditation, compliance, patient safety,

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2021 CAMLAB
13	Cover
14	The Joint Commission Mission
15	Contents
17	Introduction: How The Joint Commission Can Help You Move Toward High Reliability (INTRO)
18	I. Introduction to Joint Commission Accreditation
22	II. About the
34	III. Steps to Achieving and Maintaining Compliance
41	IV. Get Extra Help
43	Patient Safety Systems (PS) Introduction
44	What Does This Chapter Contain?
46	Becoming a Learning Organization
47	The Role of Laboratory Leaders in Patient Safety
52	Data Use and Reporting Systems
56	A Proactive Approach to Preventing Harm
59	Encouraging Patient Activation
60	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
62	References
64	Appendix. Key Patient Safety Requirements
73	Accreditation Participation Requirements (APR) Overview
74	Chapter Outline
75	Requirements, Rationales, and Elements of Performance
89	Document and Process Control (DC) Overview
90	Chapter Outline
91	Standards, Rationales, and Elements of Performance
113	Environment of Care (EC) Overview
116	Chapter Outline
117	Standards, Rationales, and Elements of Performance
149	Emergency Management (EM) Overview
152	Chapter Outline
153	Standards, Rationales, and Elements of Performance
175	Human Resources (HR) Overview
177	Chapter Outline
178	Standards, Rationales, and Elements of Performance
199	Infection Prevention and Control (IC) Overview
201	Chapter Outline
202	Standards, Rationales, and Elements of Performance
219	Information Management (IM) Overview
220	Chapter Outline
221	Standards, Rationales, and Elements of Performance
235	Leadership (LD) Overview
238	Chapter Outline
239	Standards, Rationales, and Elements of Performance
271	National Patient Safety Goals (NPSG) Chapter Outline
272	Requirements, Rationales, and Elements of Performance
279	Performance Improvement (PI) Overview
281	Chapter Outline
282	Standards, Rationales, and Elements of Performance
289	Quality System Assessment for Nonwaived Testing (QSA) Overview
290	Chapter Outline
295	Standards, Rationales, and Elements of Performance
479	Transplant Safety (TS) Overview
480	Chapter Outline
481	Standards, Rationales, and Elements of Performance
493	Waived Testing (WT) Overview
496	Chapter Outline
497	Standards, Rationales, and Elements of Performance
511	The Accreditation Process (ACC) Notices ACC Chapter Contents
513	Overview
514	Accreditation Policies
536	Before the Survey
541	During the Survey
554	After the Survey
564	Between Accreditation Surveys
576	Decision Rules for Organizations Seeking Initial Accreditation
579	Decision Rules for Organizations Seeking Reaccreditation
583	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
585	Process for Organizations That Meet Decision Rule PDA04
586	Review and Appeal Procedures
593	Standards Applicability Grid (SAG)
659	Sentinel Events (SE) I. Sentinel Events
663	II. Goals of the Sentinel Event Policy
664	III. Responding to Sentinel Events
671	IV. The Sentinel Event Database V. Determination That a Sentinel Event Is Subject to Review
672	VI. Optional On-Site Review of a Sentinel Event VII. Disclosable Information VIII. The Joint Commission’s Response
673	IX. Sentinel Event Measures of Success (SE MOS) X. Handling Sentinel Event–Related Documents
674	XI. Oversight of the Sentinel Event Policy XII. Survey Process
675	Appendix. Accreditation Requirements Related to Sentinel Events
677	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
678	What Will My Quality Report Contain? What Is Quality Check?
679	Can My Laboratory Comment on Its Quality Report?
680	What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
683	Required Written Documentation (RWD)
684	List of EPs Requiring Written Documentation for Laboratories and Pointof Care Testing
689	Early Survey Policy (ESP)
695	Appendix A: Retention Times for Records, Reports, and Specimens (AXA) Retention Times for Records, Reports, and Specimens
699	Appendix B: Laboratory Developed Tests (AXB) Laboratory Developed Tests
701	Appendix C: Individualized Quality Control Plan–Eligible Requirements (AXC)
703	Appendix D: Duplicate Laboratory and Hospital/ Critical Access Hospital Requirements (AXD)
705	Glossary (GL)
729	Index (IX)