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eLibrary > Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH) >

Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH), 2022

What’s New 2022 CAMCAH [Go to Page]
Introduction: How Joint Commission Accreditation Can Help on the Road toHigh Reliability (INTRO)
Patient Safety Systems (PS)
Accreditation Requirements
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM)
Medical Staff (MS)
National Patient Safety Goals (NPSG)
Nursing (NR)
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)
Waived Testing (WT)
Accreditation Process Information
The Accreditation Process (ACC)
Standards Applicability Grid (SAG)
Sentinel Event Policy (SE)
The Joint Commission Quality Report (QR)
Performance Measurement and the ORYX® Initiative (PM)
Required Written Documentation (RWD
Early Survey Policy (ESP)
Primary Care Medical Home (PCMH)
Appendix A: Medicare Requirements for Critical Access Hospitals (AXA)
Appendix B: Medicare Requirements for Critical Access Hospitals withDPUs (AXB)
Glossary
Index (IX)
Cover
Copyright
Contents
Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO) [Go to Page]
I. Introduction to Joint Commission Accreditation [Go to Page]
The Value of Joint Commission Accreditation
The Joint Commission’s Critical Access Hospital Accreditation Program
II. About the [Go to Page]
How Is This Manual Organized?
Accreditation Requirements
Accreditation Process Information
Identifying Applicable Standards
Understanding the Organization of the Standards Chapters
Understanding the Icons Used in the Manual
III. Steps to Achieving and Maintaining Compliance [Go to Page]
Become Familiar with the Standards
Use the Standards to Improve Care, Treatment, and Services
Assess Compliance with the Standards
Stimulate Improvement
Keep Current with Standards Changes via Perspectives
IV. Get Extra Help [Go to Page]
Getting Started with Accreditation
Account Executive
Contacting The Joint Commission
Standards Questions
Requesting Permission to Share Content from the Manual
Patient Safety Systems (PS) [Go to Page]
Quality and Safety in Health Care
Goals of This Chapter
Becoming a Learning Organization
The Role of Leaders in Patient Safety [Go to Page]
Safety Culture [Go to Page]
A Fair and Just Safety Culture
Data Use and Reporting Systems [Go to Page]
Effective Use of Data [Go to Page]
Collecting Data
Analyzing Data
Using Data to Drive Improvement
A Proactive Approach to Preventing Harm [Go to Page]
Unknown [Go to Page]
Tools for Conducting a Proactive Risk Assessment
Encouraging Patient Activation
Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
References
Accreditation Participation Requirements (APR) [Go to Page]
Overview
Chapter Outline
Requirements, Rationales, and Elements of Performance
Environment of Care (EC) [Go to Page]
Overview [Go to Page]
About This Chapter
Other Issues for Consideration
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard EC.02.06.01
Emergency Management (EM) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard EM.02.02.05
Introduction to Standards EM.02.02.13 and EM.02.02.15
Introduction to Standard EM.04.01.01
Human Resources (HR) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standards HR.01.06.01 and HR.01.07.01
Infection Prevention and Control (IC) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standards IC.01.01.01 Through IC.01.06.01 – Planning
Introduction to Standards IC.02.01.01 Through IC.02.04.01 – Implementation
Introduction to Standard IC.02.04.01
Introduction to Standard IC.03.01.01— Evaluation and Improvement
Information Management (IM) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard IM.01.01.01
Introduction to Standard IM.01.01.03
Introduction to Standard IM.02.01.01
Introduction to Standard IM.02.01.03
Introduction to Standard IM.02.02.03
Leadership (LD) [Go to Page]
Overview [Go to Page]
Proactive Risk Assessment
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01
Introduction to Leadership Relationships, Standards LD.02.01.01 Through LD.02.04.01
Introduction to Standard LD.02.04.01
Introduction to Critical Access Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
Introduction to Operations, Standards LD.03.07.01 Through LD.04.03.11
Introduction to Standard LD.03.09.01
Introduction to Oversight of Care, Treatment, and Services Provided Through Contractual Agreement, Standard LD.04.03.09
Introduction to Standard LD.04.03.13
Life Safety (LS) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard LS.01.01.01
Medication Management (MM) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard MM.04.01.01
Medical Staff (MS) [Go to Page]
Overview [Go to Page]
Medical Staff Structure
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard MS.01.01.01
Introduction to Standard MS.03.01.01
Introduction to Standard MS.06.01.01
Introduction to Standard MS.06.01.03
Introduction to Standard MS.06.01.05
Introduction to Standard MS.08.01.01
Introduction to Standard MS.08.01.03
Introduction to Standard MS.13.01.01
National Patient Safety Goals (NPSG) [Go to Page]
Chapter Outline
Requirements, Rationales, and Elements of Performance [Go to Page]
Goal 1
Goal 2
Goal 3
Introduction to Reconciling Medication Information
Goal 6
Goal 7
Goal 15
Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
Introduction to UP.01.02.01
Nursing (NR) [Go to Page]
Overview
Chapter Outline
Standards, Rationales, and Elements of Performance
Provision of Care, Treatment, and Services (PC) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard PC.01.02.01
Introduction to Standard PC.01.02.07
Introduction to Standard PC.01.02.09
Introduction to Standard PC.01.02.13
Introduction to Standard PC.01.03.01
Introduction to Standard PC.02.02.01
Introduction to Standard PC.02.03.01
Introduction to Standards PC.03.01.01 Through PC.03.01.07
Performance Improvement (PI) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard PI.01.01.01
Introduction to Standard PI.03.01.01
Record of Care, Treatment, and Services (RC) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance
Rights and Responsibilities of the Individual (RI) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard RI.01.01.01
Introduction to Standard RI.01.01.03
Transplant Safety (TS) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance [Go to Page]
Introduction to Standard TS.01.01.01
Introduction to Standards TS.03.01.01, TS.03.02.01, and TS.03.03.01
Waived Testing (WT) [Go to Page]
Overview [Go to Page]
About This Chapter
Chapter Outline
Standards, Rationales, and Elements of Performance
The Accreditation Process (ACC) [Go to Page]
Notices
ACC Chapter Contents
Overview [Go to Page]
General Eligibility Requirements
Initial Surveys
Scope of Accreditation Surveys
Accreditation Policies [Go to Page]
Tailored Survey Policy [Go to Page]
Complex Organization Survey Process
Organizational and Functional Integration
Inclusion of Physician Practices in Survey
Multiorganization Option
Concurrent Survey Option
Contracted Services
Integrated Care Certification Option
Primary Care Medical Home Certification Option
Patient Blood Management Certification Option
Survey Postponement Policy
Information Accuracy and Truthfulness Policy [Go to Page]
Policy Requirements
Good Faith Participation in Accreditation/ Certification
Public Information Policy
Process for Responding to a Complaint
Early Survey Policy [Go to Page]
Eligibility for Limited, Temporary Accreditation
Before the Survey [Go to Page]
An Organization’s Secure Joint Commission Connect Extranet Site [Go to Page]
EnsuringJoint Commission Connect Security
Role of Consultants
Role of the Account Executive
Electronic Application for Accreditation (E-App) [Go to Page]
Accuracy of the Application Information
Forfeiture of Survey Deposit
Accreditation/Certification Contract and Business Associate Agreement
Annual and Survey Fees
During the Survey [Go to Page]
Survey Notification
Initial and Full Survey Team Composition [Go to Page]
Life Safety Code
Surveyor Scope of Survey
Survey Agenda
Tracer Methodology [Go to Page]
Accreditation Program–Specific Tracer
Individual Tracer Activity
Risk Areas
System Tracer Activity
The Role of Staff in Tracer Methodology
Immediate Threat to Health or Safety [Go to Page]
Immediate Threat to Health or Safety During Initial Survey
Summary of the Accreditation Reports
After the Survey [Go to Page]
The Scoring Process [Go to Page]
How Accreditation Decisions Are Made
Accreditation Decisions for Organizations Seeking Renewal
Decision Outcomes for Organizations Seeking Initial Accreditation
Accreditation Effective Dates
Withdrawing or Closing After Undergoing a Resurvey
Evidence of Standards Compliance (ESC) Process [Go to Page]
Clarifying ESC
Corrective ESC
Accreditation Award Display and Use
Recommendation Letter for Critical Access Hospitals That Use Joint Commission Accreditation for Deemed Status Purposes
Between Accreditation Surveys [Go to Page]
Duration of Accreditation Award
Continuous Compliance
Intracycle Monitoring (ICM)
Focused Standards Assessment (FSA) [Go to Page]
Plan of Action (POA)
Sentinel Event Follow-up
Notifying The Joint Commission About Organization Changes [Go to Page]
Changes Affecting E-App Information
Changes to the Site of Care, Treatment, or Services
Mergers, Consolidations, and Acquisitions
Accreditation Status of Organizations That Cease Services After a Disaster||||||||||||
Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time
Reentering the Accreditation Process
Additional Surveys [Go to Page]
Extension Surveys
For-Cause Surveys
Random Validation of Evidence of Standards Compliance
Follow-up Survey for a Condition-level Deficiency
Decision Rules for Organizations Seeking Initial Accreditation [Go to Page]
Accredited
Primary Care Medical Home Certification
Limited, Temporary Accreditation
Evidence of Standards Compliance (ESC)
One-Month Survey
Medicare Deficiency Follow-up Survey
Denial of Accreditation
Decision Rules for Organizations Seeking Reaccreditation [Go to Page]
Accredited
Primary Care Medical Home Certification
Evidence of Standards Compliance (ESC)
One-Month Survey
Medicare Deficiency Follow-up Survey
Accreditation with Follow-up Survey
Preliminary Denial of Accreditation
Denial of Accreditation
Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
Process for Organizations That Meet Decision Rule PDA04
Review and Appeal Procedures [Go to Page]
I. Evaluation by Joint Commission Staff
II. Accreditation with Follow-up Survey
III. Review Hearings
IV. Following a Review Hearing
V. Final Review &Appeal Request
Standards Applicability Grid (SAG)
Sentinel Event Policy (SE) [Go to Page]
Goals of the Sentinel Event Policy
Identifying Sentinel Events [Go to Page]
Determining That a Sentinel Event Is Subject to Review
Relationship to the Survey Process
Required Organization Response to a Sentinel Event [Go to Page]
Reporting a Sentinel Event to The Joint Commission
Conducting a Comprehensive Systematic Analysis
Developing a Corrective Action Plan
Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
The Joint Commission’s Response [Go to Page]
Review of Comprehensive Systematic Analyses and Corrective Action Plans
Follow-up Activities [Go to Page]
Sentinel Event Measures of Success
Optional On-Site Review of a Sentinel Event
Disclosable Information
Handling Sentinel Event–Related Documents
The Sentinel Event Database
Overseeing the Sentinel Event Policy
The Joint Commission Quality Report (QR) [Go to Page]
Introduction
What Is The Joint Commission Quality Report?
What Will My Quality Report Contain?
What Is Quality Check? [Go to Page]
Is a Quality Report Available for My Accredited Critical Access Hospital?
Can My Critical Access Hospital Comment on Its Quality Report? [Go to Page]
How Does My Critical Access Hospital 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? [Go to Page]
Guidelines for Publicizing Compliance with the National Patient Safety Goals
Information Released by The Joint Commission
Guidelines for Publication
Performance Measurement and the ORYX Initiative (PM) [Go to Page]
Overview
The Continued Role of ORYX
Accelerate PI™
Use of Performance Measure Data
Current Requirements for Critical Access Hospitals
Required Written Documentation (RWD) [Go to Page]
List of EPs Requiring Written Documentation for Critical Access Hospitals by Service [Go to Page]
Acute
Inpatient Rehab Distinct Part Unit
Psychiatric Distinct Part Unit
Swing Beds
Early Survey Policy (ESP)
Primary Care Medical Home Certification Option (PCMH) [Go to Page]
Overview
Primary Care Medical Home Model [Go to Page]
I. Patient-Centered Care
II. Comprehensive Care
III. Coordinated Care
IV. Superb Access to Care
V. Systems-Based Approach to Quality and Safety
Standards, Rationales, Elements of Performance, and Scoring Specific to the Primary Care Medical Home Certification Option
I. Patient-Centered Care [Go to Page]
Leadership (LD)
Provision of Care, Treatment, and Services (PC)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
II. Comprehensive Care [Go to Page]
Leadership (LD)
Medical Staff (MS)
Provision of Care, Treatment, and Services (PC)
III. Coordinated Care [Go to Page]
Human Resources (HR)
Medical Staff (MS)
Provision of Care, Treatment, and Services (PC)
Record of Care, Treatment, and Services (RC)
IV. Superb Access to Care [Go to Page]
Provision of Care, Treatment, and Services (PC)
V. Systems-Based Approach to Quality and Safety [Go to Page]
Leadership (LD)
Medication Management (MM)
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Appendix A: Medicare Requirements for Critical Access Hospitals (AXA) [Go to Page]
Unknown [Go to Page]
485.610 Condition of Participation: Status and Location
485.616 Condition of Participation: Agreements
485.627 Condition of Participation: Organizational Structure
485.635 Condition of Participation: Provision of Services
485.641 Condition of Participation: Periodic Evaluation and Quality Assurance Review
Appendix B: Medicare Requirements for Critical Access Hospitals with DPUs (AXB) [Go to Page]
Unknown [Go to Page]
Part 409 Subpart B—Inpatient Hospital Services and Inpatient Critical Access Hospital Services
409.17: Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services
412.25 Excluded Hospital Units: Common Requirements
412.29 Excluded Rehabilitation Units: Additional Requirements
412.30 Exclusion of New Rehabilitation Units and Expansion of Units Already Excluded
482.12 Condition of Participation: Governing Body
482.22 Condition of Participation: Medical Staff
482.24 Condition of Participation: Medical Record Services
482.27 Condition of Participation: Laboratory Services
482.30 Condition of Participation: Utilization Review
482.51 Condition of Participation: Surgical Services
Glossary (GL)
Index (IX) [Go to Page]

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