Comprehensive Accreditation Manual for Hospitals

Transcription

1 Comprehensive Accreditation Manual Table of Changes CAMH, June 2010 Standard, element of performance, and scoring changes in this update include the following: Clarifications to IM , EPs 2 and 3 regarding standardized terminology, effective immediately New note to UP , EP 3 regarding defining the limited circumstances to delegate site marking in the National Patient Safety Goals (NPSG) chapter, effective immediately Additional changes include the following: New information on the required Business Associate agreement in The Accreditation Process (ACC) chapter, effective immediately New text on Preliminary Denial of Accreditation for organizations without proper license, certificate, or permit in the ACC chapter, effective immediately Refer to the following table (pages 2 12) and the actual updated pages for more information on these and other revisions. To update your manual, please remove and recycle the pages listed in the Remove Pages column from your CAMH, and insert the new pages listed in the Insert Pages column. Check boxes have been provided for your convenience to track the removal and addition of pages. Major revisions to the accreditation policies and standards-related information are highlighted on your replacement pages. Minor editorial changes are not highlighted. CAMH, June

2 Title page and Copyright page Previous title page and copyright page (i ii) Environment of Care (EC) EC-7 EC-18 EC-21 EC-22 Updated title page and copyright page (i ii) EC-7 EC-18 EC-21 EC-22 Updated month and year for 2010 release for EC , EPs 7 and 11 for EC , EP 6 Changed scoring category to an A and deleted Measure of Success icon for EC , EP 7* for EC , EP 8 for EC , EP 1 for EC , EPs 3, 4, and 18 Changed scoring category to an A and deleted Measure of Success icon for EC , EPs 7, 9, 12, 16, 17, 19, and 20* for EC , EP 3 for EC , EP 1 2 CAMH, June 2010

3 EC (continued) for EC , EP 3 for EC , EP 1 for EC , EP 2 Deleted EPs 4, 5, 6, and 18 for EC Added tier 3 icon to EC , EP 20* Emergency Management (EM) EM-17 EM-18 EM-17 EM-18 Changed scoring category to a C for EM , EPs 7 and 8* Infection Prevention and Control (IC) IC-7 IC-14 IC-7 IC-14 Added standards reference link to IC , EP 8* Changed standards reference link to IC , EP 9* Changed text for IC , EP 1* Changed text to Note for IC , EP 2* Deleted standards reference link to IC , EP 6 CAMH, June

4 Information Management (IM) IM-7 IM-8 IM-7 IM-8b Changed scoring category to a C for IM , EP 6* Changed scoring category to an A and deleted Measure of Success icon for IM , EP 1* Changed text for IM , EP 2* Changed text and added Note 2 to IM , EP 3* Changed scoring category to an A and deleted Measure of Success icon for IM , EP 2* Leadership (LD) LD-9 LD-10 LD-13 LD-14 LD-17 LD-20 LD-23 LD-24 LD-27 LD-36 LD-9 LD-10 LD-13 LD-14 LD-17 LD-20 LD-23 LD-24 LD-27 LD-36 Added EP 8 for LD , effective July 15, 2010 Deleted LD , EP 3 Deleted LD , EP 2 Deleted LD , EP 2 Deleted LD , EP 2 Deleted LD , EP 2 Added standards reference link to LD , EP 7* Deleted LD , EP 2 Added missing scoring category A to LD , EP 26* Added missing scoring category A to LD , EPs 1 and 2* 4 CAMH, June 2010

5 LD (continued) Medication Management (MM) MM-3 MM-4 MM-3 MM-4 MM-7 MM-8 MM-7 MM-8 MM-17 MM-18 MM-17 MM-18 MM-21 MM-22 MM-21 MM-22 Added explanation to credentialing and privileging section of introduction for LD * Added Note 1 and Note 3 to LD , EP 4, effective July 15, 2010 Added lead-in text and note to LD , EP 9, effective July 15, 2010 Changed text for LD , EPs 1, 5, 7, 9, 12, and 14* Changed text and added bullet to LD , EP 13* MM listed in chapter outline as no longer applicable to hospitals* Deleted standards reference link from MM , EP 3 Changed scoring category to an A, added tier 3 icon, and deleted Measure of Success for MM , EP 2* Deleted Standard MM CAMH, June

6 Medical Staff (MS) MS-7 MS-10 MS-25 MS-30 MS-37 MS-40 MS-7 MS-10 MS-25 MS-30 MS-37 MS-40 Changed standards reference link for MS , EP 17* Changed scoring category to an A and deleted Measure of Success icon for MS , EP 5* Added new text for EP 3 and renumbered the remaining EPs for MS * Added note to Rationale for MS * Reworded text for MS , EPs 3 and 6* Added new EP 4 and renumbered the remaining EP for MS * Added lead-in lines to paragraphs and one bullet to the list in Introduction for MS , effective July 15, 2010 Added text to EP 1 for MS , effective July 15, 2010 Added EP 4 number to standards reference link for MS , EP 3, effective July 15, CAMH, June 2010

7 National Patient Safety Goals (NPSG) NPSG-7 NSPG-14 NPSG-23 NSPG-24 Nursing (NR) NPSG-7 NSPG-14b NPSG-23 NSPG-24 Deleted bullet from list for NPSG , EP 3 Added prescribers to text for NPSG , EP 7* Added text to NPSG , EP 3* Added text to NPSG , EP 7* Added note to UP , EP 3* Deleted bullet in note for UP , EP 5 NR-5 NR-6 NR-5 NR-6 Deleted standards reference link for NR , EP 4 CAMH, June

8 Provision of Care, Treatment, and Services (PC) PC-5 PC-6 PC-15 PC-20 PC-23 PC-26 PC-59 PC-60 PC-63 PC-64 PC-5 PC-6 PC-15 PC-20 PC-23 PC-26 PC-59 PC-60 PC-63 PC-64 Added Note 2 to PC , EP 1* Added Note 2 and Note 3 to PC , EP 4* Changed text for PC , EP 20* for PC , EPs 6, 9, and 11 Deleted EP 1 and 2 for PC Added text to standard PC * for PC , EP 3 Deleted Note 2 for PC , EP 3 Performance Improvement (PI) PI-5 PI-8 PI-5 PI-8 Changed scoring category to an A and deleted Measure of Success icon for PI , EPs 3 and 16* Added EPs 12, 13, and 14 to PI * 8 CAMH, June 2010

9 Record of Care (RC) RC-3 RC-6 RC-11 RC-12 RC-3 RC-6 RC-11 RC-12 for RC , EPs 11 and 19 Added standards reference link to RC , EP 4* for RC , EPs 3 and 4 Rights and Responsibilities of the Individual (RI) RI-13 RI-18 RI-13 RI-18 Deleted RI , EP 1 Added standards reference link to RI , EP 6* Added psychiatric to lead-in text for RI * Added Rationale for RI * Revised text for RI , EP 1* Transplant Safety (TS) TS-9 TS-10 TS-9 TS-10 Editorial change* CAMH, June

10 The Accreditation Process (ACC) ACC-1 ACC-92 ACC-105 ACC-106 ACC-1 ACC-92 ACC-105 ACC-106 Added new information on the required Business Associate agreement* Updates to the payment policy* Updated information on generating a survey agenda* Added new text on Preliminary Denial of Accreditation for organizations without proper license, certificate, or permit* Added information about the Medicare certification recommendation letter for hospitals that use Joint Commission accreditation for deemed status purposes* Updated the process flowchart for Immediate Threat to Health or Safety situations* Updated the figure about the Measure of Success Submission Time Line* Deleted decision rule PDA04 and renumbered the remaining rules* Made editorial changes and updates* 10 CAMH, June 2010

11 Sentinel Events (SE) SE-1 SE-6 SE-15 SE-18 SE-1 SE-6 SE-15 SE-18 Clarified information about how surveyors handle sentinel events during the survey process* Clarified information about The Joint Commission s response if a hospital has not undertaken serious improvement efforts regarding sentinel events* Editorial changes* The Joint Commission Quality Report (QR) QR-1 QR-2 QR-5 QR-8 QR-1 QR-2 QR-5 QR-8 Editorial changes* Performance Measurement and the ORYX Initiative (PM) PM-1 PM-6 PM-9 PM-12 PM-1 PM-6 PM-9 PM-12 Updated explanation regarding requirements for psychiatric hospitals* Updated the sample quality reports* Simplifying Compliance Activities (SCA) Remove entire chapter SCA-1 SCA-8 Insert entire chapter SCA-1 SCA-8 Updated Web sites* Editorial revisions* Required Written Documentation (RWD) RWD-7 RWD-8 RWD-7 RWD-8 Added PI , EP 14 to the tables of standards with required written documentation requirements* CAMH, June

12 Early Survey Policy Option (ESP) ESP-1 ESP-6 ESP-1 ESP-6 Deleted EC , EPs 4 6 and 18 from the EC table Added LD , EP 8 to the LD table* Added MS , EP 9 to the MS table* Added MS , EP 5 to the MS table* Deleted RI , EP 1 from the RI table Glossary (GL) GL-3 GL-6 GL-3 GL-6 Deleted anesthesia definition Added biologicals definition* Index (IX) Remove entire chapter IX-1 IX-34 Insert entire chapter IX-1 IX-34 Revised Index 12 CAMH, June 2010