JCR CAMLAB 2023

$190.67

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

Published By	Publication Date	Number of Pages
Joint Commission	2023

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Category: Joint Commission

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Description

The 2023 Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing (CAMLAB) provides the official Joint Commission standards, elements of performance (EPs), National Patient Safety Goals®, and other accreditation requirements for labs for 2023. 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 EPs that require written documentation, and action planning worksheets to address any issues of noncompliance. Please note: The CAMLAB is published annually. The most up-to-date standards throughout 2023 are available electronically through E-dition®, found on your Joint Commission Connect® extranet site, or are available for purchase. Key Topics: “Gold tab” standards requirements including the standards, elements of performance, National Patient Safety Goals®, and Accreditation Participation Requirements effective January 1, 2023 “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 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 Color-coded blue and gold tabs allow you to find exactly what you need when you need it

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2023 CAMLAB
7	Untitled
8	Copyright
9	Contents
11	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
12	I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation
14	The Joint Commission’s Laboratory Accreditation Program
15	Addressing Complex Issues in Laboratories Accredited by The Joint Commission
16	Table 1. Standards That Address Complex Issues in Laboratories
17	II. About the
18	How Is This Manual Organized?
19	Table 2. Acronyms Used in This Manual
20	Table 2.
21	Accreditation Requirements
22	Accreditation Process Information
24	Identifying Applicable Standards
26	Understanding the Organization of the Standards Chapters
29	Understanding the Icons Used in the Manual
30	III. Steps to Achieving and Maintaining Compliance Become Familiar with the Standards Use the Standards to Improve Quality
31	Assess Compliance with the Standards
32	Stimulate Improvement
34	Keep Current with Standards Changes via Perspectives
35	IV. Get Extra Help
36	Getting Started with Accreditation Account Executive Contacting The Joint Commission
37	Standards Questions Requesting Permission to Share Content from the Manual
39	Patient Safety Systems (PS) Quality and Safety in Laboratories Sidebar 1. Key Terms
40	Sidebar 1.
41	Goals of This Chapter
42	Becoming a Learning Organization
43	The Role of Leaders in Patient Safety Safety Culture
47	Sidebar 2. Assessing Staff Accountability
48	Sidebar 2. Data Use and Reporting Systems
49	Effective Use of Data
50	Table 1. Defining and Comparing Analytical Tools
51	A Proactive Approach to Preventing Harm
54	Sidebar 3. Strategies for an Effective Risk Assessment Encouraging Patient Activation
55	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
57	References
61	Accreditation Participation Requirements (APR) Overview
62	Chapter Outline
63	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
64	Elements of Performance for APR.01.02.01 APR.01.03.01 Elements of Performance for APR.01.03.01 APR.02.01.01
65	Elements of Performance for APR.02.01.01 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 APR.07.01.01 Elements of Performance for APR.07.01.01
66	APR.08.01.01 Elements of Performance for APR.08.01.01 APR.09.01.01 Elements of Performance for APR.09.01.01 APR.09.02.01
67	Rationale for APR.09.02.01 Elements of Performance for APR.09.02.01 APR.09.03.01 Elements of Performance for APR.09.03.01 APR.09.04.01 Elements of Performance for APR.09.04.01
68	APR.10.03.01 Elements of Performance for APR.10.03.01
72	Written Documentation Checklist Accreditation Participation Requirements (APR)
75	Document and Process Control (DC) Overview About This Chapter
76	Chapter Outline
77	Standards, Rationales, and Elements of Performance Standard DC.01.01.01 Rationale for DC.01.01.01 Elements of Performance for DC.01.01.01
78	Standard DC.01.02.01 Elements of Performance for DC.01.02.01
79	Standard DC.01.02.03 Elements of Performance for DC.01.02.03 Standard DC.01.03.01 Elements of Performance for DC.01.03.01
80	Standard DC.02.01.01 Rationale for DC.02.01.01 Elements of Performance for DC.02.01.01
81	Standard DC.02.01.03 Elements of Performance for DC.02.01.03 Standard DC.02.01.05
82	Elements of Performance for DC.02.01.05 Standard DC.02.01.07 Elements of Performance for DC.02.01.07
83	Standard DC.02.02.01 Elements of Performance for DC.02.02.01 Standard DC.02.03.01 Elements of Performance for DC.02.03.01
84	Standard DC.02.03.03
85	Elements of Performance for DC.02.03.03 Standard DC.02.04.01 Elements of Performance for DC.02.04.01
87	Standard DC.03.01.01 Elements of Performance for DC.03.01.01
92	Written Documentation Checklist Document and Process Control (DC)
99	Environment of Care (EC) Overview About This Chapter
100	Other Issues for Consideration
102	Chapter Outline
103	Standards, Rationales, and Elements of Performance Standard EC.01.01.01 Rationale for EC.01.01.01 Elements of Performance for EC.01.01.01
104	Standard EC.02.01.01 Rationale for EC.02.01.01
105	Elements of Performance for EC.02.01.01 Standard EC.02.01.03 Elements of Performance for EC.02.01.03 Standard EC.02.02.01
106	Rationale for EC.02.02.01 Elements of Performance for EC.02.02.01
107	Standard EC.02.03.01 Rationale for EC.02.03.01 Elements of Performance for EC.02.03.01
108	Standard EC.02.03.03 Elements of Performance for EC.02.03.03 Standard EC.02.03.05
109	Elements of Performance for EC.02.03.05 Standard EC.02.04.01
110	Elements of Performance for EC.02.04.01 Standard EC.02.04.03 Elements of Performance for EC.02.04.03
112	Standard EC.02.04.05 Elements of Performance for EC.02.04.05 Standard EC.02.05.01
113	Elements of Performance for EC.02.05.01
114	Standard EC.02.05.03 Elements of Performance for EC.02.05.03
115	Standard EC.02.05.05 Elements of Performance for EC.02.05.05 Standard EC.02.05.07 Rationale for EC.02.05.07
116	Elements of Performance for EC.02.05.07
118	Introduction to Standard EC.02.06.01 Standard EC.02.06.01 Elements of Performance for EC.02.06.01
119	Standard EC.02.06.05 Rationale for EC.02.06.05
120	Elements of Performance for EC.02.06.05 Standard EC.03.01.01 Rationale for EC.03.01.01 Elements of Performance for EC.03.01.01 Introduction to Standard EC.04.01.01
121	Standard EC.04.01.01 Elements of Performance for EC.04.01.01
122	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
125	Written Documentation Checklist Environment of Care (EC)
135	Emergency Management (EM) Overview
136	About This Chapter
138	Chapter Outline
139	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
140	Standard EM.02.01.01
141	Rationale for EM.02.01.01 Elements of Performance for EM.02.01.01
142	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 Elements of Performance for EM.02.02.03
144	Introduction to Standard EM.02.02.05 Standard EM.02.02.05 Elements of Performance for EM.02.02.05 Standard EM.02.02.07
145	Rationale for EM.02.02.07 Elements of Performance for EM.02.02.07 Standard EM.02.02.09 Rationale for EM.02.02.09
146	Elements of Performance for EM.02.02.09 Standard EM.02.02.11 Rationale for EM.02.02.11 Elements of Performance for EM.02.02.11
147	Introduction to Standard EM.02.02.15
148	Standard EM.02.02.15 Elements of Performance for EM.02.02.15
150	Standard EM.03.01.03 Rationale for EM.03.01.03 Elements of Performance for EM.03.01.03
155	Written Documentation Checklist Emergency Management (EM)
161	Human Resources (HR) Overview About This Chapter
162	Chapter Outline
163	Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01
164	Standard HR.01.02.03 Elements of Performance for HR.01.02.03
166	Introduction to Standard HR.01.02.05 Standard HR.01.02.05 Elements of Performance for HR.01.02.05 Standard HR.01.02.07
167	Elements of Performance for HR.01.02.07 Standard HR.01.03.01 Elements of Performance for HR.01.03.01 Standard HR.01.04.01 Elements of Performance for HR.01.04.01
169	Standard HR.01.05.03 Elements of Performance for HR.01.05.03 Introduction to Standard HR.01.06.01 Standard HR.01.06.01 Elements of Performance for HR.01.06.01
171	Standard HR.01.07.01 Elements of Performance for HR.01.07.01
178	Written Documentation Checklist Human Resources (HR)
185	Infection Prevention and Control (IC) Overview
186	About This Chapter
187	Chapter Outline
188	Standards, Rationales, and Elements of Performance Introduction to Standards IC.01.01.01 Through IC.01.06.01 – Planning Standard IC.01.01.01
189	Rationale for IC.01.01.01 Elements of Performance for IC.01.01.01 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
190	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
191	Standard IC.01.06.01 Rationale for IC.01.06.01 Elements of Performance for IC.01.06.01 Introduction to Standards IC.02.01.01 Through IC.02.03.01 – Implementation
192	Standard IC.02.01.01 Elements of Performance for IC.02.01.01
193	Standard IC.02.02.01 Rationale for IC.02.02.01 Elements of Performance for IC.02.02.01
194	Standard IC.02.03.01 Elements of Performance for IC.02.03.01
195	Introduction to Standard IC.02.04.01 Standard IC.02.04.01
196	Elements of Performance for IC.02.04.01
197	Introduction to Standard IC.03.01.01 – Evaluation and Improvement Standard IC.03.01.01 Elements of Performance for IC.03.01.01
201	Written Documentation Checklist Infection Control and Prevention (IC)
205	Information Management (IM) Overview About This Chapter
206	Chapter Outline
207	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
208	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
209	Introduction to Standard IM.02.01.01 Standard IM.02.01.01 Elements of Performance for IM.02.01.01
210	Introduction to Standard IM.02.01.03 Standard IM.02.01.03 Elements of Performance for IM.02.01.03
211	Standard IM.02.02.01 Rationale for IM.02.02.01 Elements of Performance for IM.02.02.01
212	Introduction to Standard IM.02.02.03 Standard IM.02.02.03 Rationale for IM.02.02.03
213	Elements of Performance for IM.02.02.03 Standard IM.02.02.05 Elements of Performance for IM.02.02.05 Standard IM.03.01.01
214	Elements of Performance for IM.03.01.01 Standard IM.04.01.01 Rationale for IM.04.01.01 Elements of Performance for IM.04.01.01 Standard IM.05.01.01 Elements of Performance for IM.05.01.01
217	Written Documentation Checklist Information Management (IM)
221	Leadership (LD) Overview
222	Proactive Risk Assessment
223	About This Chapter
224	Chapter Outline
225	Standards, Rationales, and Elements of Performance Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.03.01 Standard LD.01.01.01
226	Rationale for LD.01.01.01 Elements of Performance for LD.01.01.01 Standard LD.01.03.01 Rationale for LD.01.03.01
227	Elements of Performance for LD.01.03.01 Introduction to Leadership Relationships, Standard LD.02.01.01
228	Standard LD.02.01.01 Rationale for LD.02.01.01 Elements of Performance for LD.02.01.01 Introduction to Organization Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
230	Standard LD.03.01.01 Rationale for LD.03.01.01
231	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 Standard LD.03.03.01
232	Rationale for LD.03.03.01 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
233	Standard LD.03.05.01 Rationale for LD.03.05.01 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
234	Introduction to Operations, Standards LD.03.07.01 Through LD.04.05.13
235	Standard LD.03.07.01 Elements of Performance for LD.03.07.01 Standard LD.03.08.01 Elements of Performance for LD.03.08.01
236	Introduction to Standard LD.03.09.01 Standard LD.03.09.01 Elements of Performance for LD.03.09.01 Standard LD.04.01.01 Elements of Performance for LD.04.01.01
237	Standard LD.04.01.03 Elements of Performance for LD.04.01.03
238	Standard LD.04.01.05 Elements of Performance for LD.04.01.05 Standard LD.04.01.11 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.04.03.01 Elements of Performance for LD.04.03.01 Introduction to Oversight of Laboratory Services Provided Through Contractual Agreement, Standard LD.04.03.09
240	Monitoring Contracted Services
241	Standard LD.04.03.09 Elements of Performance for LD.04.03.09
242	Standard LD.04.05.01 Rationale for LD.04.05.01 Elements of Performance for LD.04.05.01
243	Standard LD.04.05.03
244	Elements of Performance for LD.04.05.03 Standard LD.04.05.05 Elements of Performance for LD.04.05.05 Standard LD.04.05.07
245	Elements of Performance for LD.04.05.07 Standard LD.04.05.09 Elements of Performance for LD.04.05.09
247	Standard LD.04.05.11 Elements of Performance for LD.04.05.11 Standard LD.04.05.13 Elements of Performance for LD.04.05.13
252	Written Documentation Checklist Leadership (LD)
257	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals®
258	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 Goal 2 NPSG.02.03.01 Rationale for NPSG.02.03.01
259	Elements of Performance for NPSG.02.03.01 Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01
260	Elements of Performance for NPSG.07.01.01
262	Written Documentation Checklist National Patient Safety Goal (NPSG)
265	Performance Improvement (PI) Overview About This Chapter
267	Chapter Outline
268	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
269	Standard PI.02.01.01 Rationale for PI.02.01.01
270	Elements of Performance for PI.02.01.01 Introduction to Standard PI.03.01.01
271	Standard PI.03.01.01 Elements of Performance for PI.03.01.01 Standard PI.04.01.01 Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
274	Written Documentation Checklist Performance Improvement (PI)
279	Quality System Assessment for Nonwaived Testing (QSA) Overview About This Chapter
280	Chapter Outline
285	Standards, Rationales, and Elements of Performance Introduction to Standards QSA.01.01.01 Through QSA.01.03.01 Standard QSA.01.01.01 Rationale for QSA.01.01.01
286	Elements of Performance for QSA.01.01.01
288	Standard QSA.01.02.01 Rationale for QSA.01.02.01 Elements of Performance for QSA.01.02.01
290	Standard QSA.01.03.01 Elements of Performance for QSA.01.03.01 Standard QSA.01.04.01
291	Elements of Performance for QSA.01.04.01 Standard QSA.01.05.01 Elements of Performance for QSA.01.05.01
292	Standard QSA.02.01.01 Elements of Performance for QSA.02.01.01
294	Standard QSA.02.02.01 Rationale for QSA.02.02.01 Elements of Performance for QSA.02.02.01
295	Standard QSA.02.03.01 Elements of Performance for QSA.02.03.01
296	Introduction to Standard QSA.02.04.01
297	Standard QSA.02.04.01 Elements of Performance for QSA.02.04.01
298	Standard QSA.02.06.01 Elements of Performance for QSA.02.06.01
299	Standard QSA.02.07.01 Elements of Performance for QSA.02.07.01
300	Standard QSA.02.08.01 Elements of Performance for QSA.02.08.01
301	Standard QSA.02.09.01 Elements of Performance for QSA.02.09.01 Standard QSA.02.10.01
302	Elements of Performance for QSA.02.10.01
303	Standard QSA.02.10.03
304	Elements of Performance for QSA.02.10.03
305	Standard QSA.02.11.01 Elements of Performance for QSA.02.11.01
306	Standard QSA.02.12.01 Elements of Performance for QSA.02.12.01
308	Standard QSA.02.13.01 Elements of Performance for QSA.02.13.01
309	Standard QSA.02.14.01 Elements of Performance for QSA.02.14.01
310	Standard QSA.03.01.01 Elements of Performance for QSA.03.01.01 Standard QSA.03.02.01 Rationale for QSA.03.02.01 Elements of Performance for QSA.03.02.01 Standard QSA.03.03.01 Elements of Performance for QSA.03.03.01
311	Standard QSA.04.01.01 Elements of Performance for QSA.04.01.01
312	Standard QSA.04.02.01 Elements of Performance for QSA.04.02.01
313	Standard QSA.04.03.01 Elements of Performance for QSA.04.03.01
314	Standard QSA.04.04.01 Elements of Performance for QSA.04.04.01
315	Standard QSA.04.05.01 Elements of Performance for QSA.04.05.01 Standard QSA.04.06.01 Elements of Performance for QSA.04.06.01
316	Standard QSA.04.07.01 Rationale for QSA.04.07.01 Elements of Performance for QSA.04.07.01 Standard QSA.05.01.01 Elements of Performance for QSA.05.01.01
317	Standard QSA.05.02.01 Elements of Performance for QSA.05.02.01
318	Standard QSA.05.02.03 Elements of Performance for QSA.05.02.03
319	Standard QSA.05.02.05 Elements of Performance for QSA.05.02.05 Standard QSA.05.03.01 Elements of Performance for QSA.05.03.01 Standard QSA.05.03.03 Elements of Performance for QSA.05.03.03
320	Standard QSA.05.04.01 Elements of Performance for QSA.05.04.01
321	Standard QSA.05.04.03 Elements of Performance for QSA.05.04.03 Standard QSA.05.05.01 Elements of Performance for QSA.05.05.01
322	Standard QSA.05.06.01 Elements of Performance for QSA.05.06.01 Standard QSA.05.07.01
323	Elements of Performance for QSA.05.07.01 Standard QSA.05.08.01 Elements of Performance for QSA.05.08.01
324	Standard QSA.05.09.01 Elements of Performance for QSA.05.09.01
325	Standard QSA.05.09.03
326	Elements of Performance for QSA.05.09.03 Standard QSA.05.10.01 Elements of Performance for QSA.05.10.01
327	Standard QSA.05.11.01 Elements of Performance for QSA.05.11.01 Standard QSA.05.12.01
328	Rationale for QSA.05.12.01 Elements of Performance for QSA.05.12.01 Standard QSA.05.13.01 Elements of Performance for QSA.05.13.01 Standard QSA.05.14.01 Elements of Performance for QSA.05.14.01
330	Standard QSA.05.14.03 Elements of Performance for QSA.05.14.03 Standard QSA.05.14.05 Elements of Performance for QSA.05.14.05
331	Standard QSA.05.14.07 Elements of Performance for QSA.05.14.07 Standard QSA.05.16.01 Elements of Performance for QSA.05.16.01
332	Standard QSA.05.17.01 Elements of Performance for QSA.05.17.01 Standard QSA.05.18.01 Elements of Performance for QSA.05.18.01
333	Standard QSA.05.19.01 Elements of Performance for QSA.05.19.01
334	Standard QSA.05.19.03 Elements of Performance for QSA.05.19.03
335	Standard QSA.05.19.05 Elements of Performance for QSA.05.19.05 Standard QSA.05.20.01 Elements of Performance for QSA.05.20.01
336	Standard QSA.05.21.01 Elements of Performance for QSA.05.21.01
337	Standard QSA.05.22.01 Elements of Performance for QSA.05.22.01 Standard QSA.05.23.01 Elements of Performance for QSA.05.23.01
338	Standard QSA.05.24.01 Elements of Performance for QSA.05.24.01
339	Standard QSA.05.24.03 Elements of Performance for QSA.05.24.03 Standard QSA.05.25.01
340	Elements of Performance for QSA.05.25.01
341	Standard QSA.06.01.01 Elements of Performance for QSA.06.01.01 Standard QSA.06.02.01 Elements of Performance for QSA.06.02.01 Standard QSA.06.03.01
342	Elements of Performance for QSA.06.03.01 Standard QSA.06.03.03 Elements of Performance for QSA.06.03.03
343	Standard QSA.06.04.01 Elements of Performance for QSA.06.04.01 Standard QSA.06.04.03 Elements of Performance for QSA.06.04.03
344	Standard QSA.06.04.05 Elements of Performance for QSA.06.04.05
345	Standard QSA.07.01.01 Rationale for QSA.07.01.01 Elements of Performance for QSA.07.01.01 Standard QSA.07.02.01 Elements of Performance for QSA.07.02.01 Standard QSA.08.01.01
346	Elements of Performance for QSA.08.01.01 Standard QSA.08.02.01 Elements of Performance for QSA.08.02.01
347	Standard QSA.08.03.01 Elements of Performance for QSA.08.03.01
349	Standard QSA.08.04.01 Elements of Performance for QSA.08.04.01
352	Standard QSA.08.05.01 Elements of Performance for QSA.08.05.01 Standard QSA.08.06.01 Elements of Performance for QSA.08.06.01
353	Standard QSA.08.06.03 Elements of Performance for QSA.08.06.03 Standard QSA.08.07.01
354	Elements of Performance for QSA.08.07.01 Standard QSA.08.08.01 Elements of Performance for QSA.08.08.01
355	Standard QSA.08.09.01 Elements of Performance for QSA.08.09.01
356	Standard QSA.09.01.01 Elements of Performance for QSA.09.01.01 Standard QSA.09.02.01 Elements of Performance for QSA.09.02.01
357	Standard QSA.09.03.01 Elements of Performance for QSA.09.03.01
358	Standard QSA.09.03.03 Elements of Performance for QSA.09.03.03 Standard QSA.09.03.05
359	Elements of Performance for QSA.09.03.05 Standard QSA.09.03.07 Elements of Performance for QSA.09.03.07
360	Standard QSA.09.04.01 Elements of Performance for QSA.09.04.01 Standard QSA.09.05.01 Elements of Performance for QSA.09.05.01
361	Standard QSA.09.06.01 Elements of Performance for QSA.09.06.01 Standard QSA.09.07.01 Elements of Performance for QSA.09.07.01
362	Standard QSA.09.07.03 Elements of Performance for QSA.09.07.03 Standard QSA.10.01.01 Elements of Performance for QSA.10.01.01
364	Standard QSA.10.02.01 Elements of Performance for QSA.10.02.01
365	Standard QSA.10.03.01 Rationale for QSA.10.03.01 Elements of Performance for QSA.10.03.01
366	Standard QSA.10.04.01 Elements of Performance for QSA.10.04.01
367	Standard QSA.10.05.01 Rationale for QSA.10.05.01 Elements of Performance for QSA.10.05.01
368	Standard QSA.10.06.01 Elements of Performance for QSA.10.06.01
369	Standard QSA.10.07.01 Elements of Performance for QSA.10.07.01
370	Standard QSA.11.01.01 Elements of Performance for QSA.11.01.01 Standard QSA.11.02.01 Elements of Performance for QSA.11.02.01
372	Standard QSA.12.01.01 Elements of Performance for QSA.12.01.01
374	Standard QSA.12.02.01 Elements of Performance for QSA.12.02.01
375	Standard QSA.12.03.01 Elements of Performance for QSA.12.03.01 Standard QSA.12.04.01
376	Elements of Performance for QSA.12.04.01 Standard QSA.12.05.01 Elements of Performance for QSA.12.05.01 Standard QSA.12.06.01 Elements of Performance for QSA.12.06.01
377	Standard QSA.12.07.01 Elements of Performance for QSA.12.07.01 Standard QSA.13.01.01 Elements of Performance for QSA.13.01.01
378	Standard QSA.13.02.01 Elements of Performance for QSA.13.02.01 Standard QSA.13.03.01 Elements of Performance for QSA.13.03.01
379	Standard QSA.13.03.03 Elements of Performance for QSA.13.03.03 Standard QSA.13.04.01 Elements of Performance for QSA.13.04.01
380	Standard QSA.13.05.01 Elements of Performance for QSA.13.05.01 Standard QSA.13.06.01 Elements of Performance for QSA.13.06.01
381	Standard QSA.13.07.01 Elements of Performance for QSA.13.07.01
382	Standard QSA.13.08.01 Elements of Performance for QSA.13.08.01
383	Standard QSA.14.01.01 Elements of Performance for QSA.14.01.01 Standard QSA.14.02.01 Elements of Performance for QSA.14.02.01
384	Introduction to Standards QSA.15.01.01 Through QSA.16.02.01 Standard QSA.15.01.01 Elements of Performance for QSA.15.01.01
385	Standard QSA.15.02.01 Elements of Performance for QSA.15.02.01 Standard QSA.15.03.01 Elements of Performance for QSA.15.03.01
386	Standard QSA.15.03.03 Elements of Performance for QSA.15.03.03 Standard QSA.15.04.01 Elements of Performance for QSA.15.04.01
387	Standard QSA.15.05.01 Elements of Performance for QSA.15.05.01
388	Standard QSA.16.01.01 Elements of Performance for QSA.16.01.01 Standard QSA.16.02.01
389	Elements of Performance for QSA.16.02.01 Standard QSA.17.01.01 Elements of Performance for QSA.17.01.01 Standard QSA.17.01.03
390	Elements of Performance for QSA.17.01.03 Standard QSA.17.02.01 Elements of Performance for QSA.17.02.01 Standard QSA.18.01.01 Elements of Performance for QSA.18.01.01 Standard QSA.19.01.01 Elements of Performance for QSA.19.01.01
391	Standard QSA.19.02.01 Elements of Performance for QSA.19.02.01
392	Standard QSA.20.01.01 Elements of Performance for QSA.20.01.01
393	Standard QSA.21.01.01 Elements of Performance for QSA.21.01.01 Standard QSA.21.02.01 Elements of Performance for QSA.21.02.01
394	Standard QSA.21.03.01 Elements of Performance for QSA.21.03.01 Standard QSA.21.04.01 Elements of Performance for QSA.21.04.01
430	Written Documentation Checklist Quality System Assessment (QSA)
475	Transplant Safety (TS) Overview About This Chapter
476	Chapter Outline
477	Standards, Rationales, and Elements of Performance Introduction to Standards TS.03.01.01, TS.03.02.01, and TS.03.03.01 Examples of Tissue and Cell Products
479	Standard TS.03.01.01 Elements of Performance for TS.03.01.01
481	Standard TS.03.02.01 Elements of Performance for TS.03.02.01
482	Standard TS.03.03.01 Elements of Performance for TS.03.03.01
486	Written Documentation Checklist Transplant Safety (TS)
491	Waived Testing (WT) Overview
492	About This Chapter
494	Chapter Outline
495	Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01
496	Standard WT.02.01.01
497	Elements of Performance for WT.02.01.01 Standard WT.03.01.01 Elements of Performance for WT.03.01.01
498	Standard WT.04.01.01 Elements of Performance for WT.04.01.01
499	Standard WT.05.01.01 Elements of Performance for WT.05.01.01
504	Written Documentation Checklist Waived Testing (WT)
509	The Accreditation Process (ACC) Notices ACC Chapter Contents
511	Overview General Eligibility Requirements
512	Scope of Accreditation Surveys Accreditation Policies Tailored Survey Policy
514	Organizational and Functional Integration
517	Multiorganization Option Concurrent Survey Option
518	Contracted Services Proficiency Testing Monitoring
519	Initial Surveys
520	Information Accuracy and Truthfulness Policy
522	Good Faith Participation in Accreditation/ Certification
523	Public Information Policy‡ Process for Responding to a Complaint
524	Early Survey Policy
525	Sidebar 1. Early Survey Policy
527	Before the Survey
528	An Organization’s Secure Joint Commission Connect Extranet Site
529	Role of the Account Executive Electronic Application for Accreditation (E-App)
530	Accreditation/Certification Contract and Business Associate Agreement
531	Annual and Survey Fees
532	During the Survey
533	Survey Notification Table 1. Exceptions to Unannounced Surveys\|\|
535	Initial and Full Survey Team Composition
536	Survey Agenda
539	Tracer Methodology
541	Immediate Threat to Health or Safety
544	Summary of the Accreditation Reports
545	After the Survey The Scoring Process
550	Evidence of Standards Compliance (ESC) Process
554	Accreditation Award Display and Use
555	Between Accreditation Surveys
556	Duration of Accreditation Award Continuous Compliance Intracycle Monitoring (ICM)
557	Focused Standards Assessment (FSA)
558	Sidebar 2. Focused Standards Assessment (FSA) Options
559	Sidebar 2. Sentinel Event Follow-up
560	Notifying The Joint Commission About Organization Changes
562	Accreditation Status of Organizations That Cease Services After a Disaster
563	Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time
564	Reentering the Accreditation Process Additional Surveys
567	Decision Rules for Organizations Seeking Initial Accreditation Accredited Limited, Temporary Accreditation
568	Evidence of Standards Compliance (ESC) One-Month Survey Retrospective Cytology Survey Proficiency Testing Monitoring Survey
569	Denial of Accreditation
570	Decision Rules for Organizations Seeking Reaccreditation Accredited Evidence of Standards Compliance (ESC)
571	One-Month Survey Retrospective Cytology Survey Proficiency Testing Monitoring Survey Accreditation with Follow-up Survey
572	Preliminary Denial of Accreditation
574	Denial of Accreditation Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
576	Process for Organizations That Meet Decision Rule PDA04
577	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
579	II. Accreditation with Follow-up Survey III. Review Hearings
581	IV. Following a Review Hearing V. Final Review &Appeal Request
583	Standards Applicability Grid (SAG)
645	Sentinel Event Policy (SE)
646	Goals of the Sentinel Event Policy
647	Identifying Sentinel Events
649	Sidebar 1. Key Terms
650	Sidebar 1.
652	Determining That a Sentinel Event Is Subject to Review Relationship to the Survey Process
653	Required Organization Response to a Sentinel Event
655	Reporting a Sentinel Event to The Joint Commission
657	Conducting a Comprehensive Systematic Analysis
658	Developing a Corrective Action Plan
659	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
660	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
661	Table 1.
662	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
663	Follow-up Activities
665	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
666	Overseeing the Sentinel Event Policy
667	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
668	What Will My Quality Report Contain? What Is Quality Check?
669	Is a Quality Report Available for My Accredited Laboratory? Can My Laboratory Comment on Its Quality Report?
670	How Does My Laboratory Submit a Commentary? Are There Any Criteria That Must Be Met in a Commentary? What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
671	Guidelines for Publicizing Compliance with the National Patient Safety Goals
673	Required Written Documentation (RWD)
674	List of EPs Requiring Written Documentation for Laboratories and Pointof Care Testing Accreditation Participation Requirements (APR) Document and Process Control (DC) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
675	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) National Patient Safety Goals (NPSG) Performance Improvement (PI)
676	Quality System Assessment for Nonwaived Testing (QSA)
677	Transplant Safety (TS) Waived Testing (WT)
679	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Document and Process Control (DC)
680	Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC)
681	Information Management (IM) Leadership (LD) National Patient Safety Goals (NPSG) Performance Improvement (PI)
682	Quality System Assessment for Nonwaived Testing (QSA)
683	Transplant Safety (TS) Waived Testing (WT)
685	Appendix A: Retention Times for Records, Reports, and Specimens (AXA) Retention Times for Records, Reports, and Specimens
689	Appendix B: Laboratory Developed Tests (AXB) Laboratory Developed Tests
691	Appendix C: Individualized Quality Control Plan–Eligible Requirements (AXC) Quality System Assessment for Nonwaived Testing (QSA)
693	Appendix D: Duplicate Laboratory and Hospital/ Critical Access Hospital Requirements (AXD) Environment of Care (EC)
694	Infection Prevention and Control (IC) Transplant Safety (TS)
695	Glossary (GL)
719	Index (IX)