JCR CAMAC 2022

$178.21

Comprehensive Accreditation Manual for Ambulatory Care (CAMAC)

Published By	Publication Date	Number of Pages
Joint Commission	2022

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Description

Continuous compliance starts with staff who know what The Joint Commission requires. The 2022 Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) provides all 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, including standards and elements of performance for the optional Primary Care Medical Home certification. The hard-copy CAMAC includes color-coded tabs that allow you to find exactly what you need for standards compliance or survey readiness when you need it. Get ready to power performance improvement and excellence in your organization! Please note: Beginning in 2022, this hard-copy manual will no longer have an Update Service. The CAMAC is now delivered annually. For the most up-to-date standards throughout 2022, access E-dition® on your Joint Commission Connect® extranet site or consider purchasing the E-dition® Ambulatory Care version here. Understanding Which Standards Apply. The Joint Commission surveys many types of organizations under the ambulatory health care standards, including ambulatory surgery centers, community health centers, imaging centers, rehabilitation centers, and urgent care clinics. (See the section on Settings below for a longer list of settings.) Eligibility requirements will differ based on the services provided and survey option you select; more information is available on the Joint Commission’s website. Standards for all these settings appear in the 2022 CAMAC. The goal of this manual’s “Standards Applicability Process” chapter is to help each organization determine which specific standards and EPs in the manual apply to its setting(s), service(s), and program(s). The applicability grid allow you to quickly identify the services, as you identified them in your E-App, and find related standards that apply to your organization. In contrast, the E-dition on an accredited organization’s Joint Commission Connect® extranet site provides a customized manual based on the settings and services checked on your E-App. (That is, the E-dition only displays an organization-specific compliment of standards and EPs). Key Topics: “Gold tab” standards requirements including the standards, National Patient Safety Goals, and Accreditation Participation Requirements effective January 1, 2022 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: Icons to help navigate documentation requirements as well as risk areas “What’s New” summary of changes made since the previous edition Integrated regulatory requirements for ambulatory surgery center deemed status Color-coded blue and gold tabs allow you to find exactly what you need when you need it Standards: All ambulatory care standards Setting: Organizations accredited under the Ambulatory Care Accreditation Program, including surgery centers, community health centers, group practices, imaging centers, telehealth providers, sleep labs, rehabilitation centers, student health centers, urgent care clinics, and other ambulatory providers Key Audience: Staff working on accreditation, compliance, patient safety, or quality improvement

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2022 CAMAC
13	Cover
14	Copyright
15	Contents
17	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
18	I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation
20	The Joint Commission’s Ambulatory Care Accreditation Program
21	Addressing Complex Issues in Ambulatory Care
22	Table 1. Standards That Address Complex Care Issues in Ambulatory Care Organizations
23	II. About the
24	How Is This Manual Organized? Table 2. Acronyms Used in This Manual
25	Table 2.
27	Accreditation Requirements
28	Accreditation Process Information
30	Identifying Applicable Standards
33	Understanding the Organization of the Standards Chapters
35	Understanding the Icons Used in the Manual
36	III. Steps to Achieving and Maintaining Compliance Become Familiar with the Standards Assess Compliance with the Standards
38	Stimulate Improvement
40	Accelerate PI™
41	Keep Current with Standards Changes via Perspectives
43	IV. Get Extra Help Getting Started with Accreditation Account Executive
44	Contacting The Joint Commission Standards Questions Requesting Permission to Share Content from the Manual
45	Patient Safety Systems (PS) Quality and Safety in Health Care Sidebar 1. Key Terms
46	Sidebar 1.
47	Goals of This Chapter
48	Becoming a Learning Organization
49	The Role of Leaders in Patient Safety Safety Culture
53	Sidebar 2. Assessing Staff Accountability
54	Sidebar 2 Data Use and Reporting Systems
55	Effective Use of Data
56	Table 1. Defining and Comparing Analytical Tools
57	A Proactive Approach to Preventing Harm
60	Sidebar 3. Strategies for an Effective Risk Assessment Encouraging Patient Activation
62	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
64	References
67	Accreditation Participation Requirements (APR) Overview
68	Chapter Outline
69	Requirements, Rationales, and Elements of Performance APR.01.01.01 Elements of Performance for APR.01.01.01 APR.01.02.01
70	Rationale for APR.01.02.01 Elements of Performance for APR.01.02.01 APR.01.03.01 Elements of Performance for APR.01.03.01
71	APR.02.01.01 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
72	APR.06.01.01 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
73	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
74	APR.09.03.01 Elements of Performance for APR.09.03.01 APR.09.04.01 Elements of Performance for APR.09.04.01
75	Environment of Care (EC) Overview About This Chapter
76	Other Issues for Consideration
78	Chapter Outline
79	Standards, Rationales, and Elements of Performance Standard EC.01.01.01 Rationale for EC.01.01.01
80	Elements of Performance for EC.01.01.01 Standard EC.02.01.01 Rationale for EC.02.01.01
81	Elements of Performance for EC.02.01.01
82	Standard EC.02.01.03 Elements of Performance for EC.02.01.03 Standard EC.02.02.01 Rationale for EC.02.02.01
83	Elements of Performance for EC.02.02.01
84	Standard EC.02.03.01
85	Elements of Performance for EC.02.03.01 Standard EC.02.03.03
86	Rationale for EC.02.03.03 Elements of Performance for EC.02.03.03
87	Standard EC.02.03.05 Elements of Performance for EC.02.03.05
91	Standard EC.02.04.01 Elements of Performance for EC.02.04.01
92	Standard EC.02.04.03 Elements of Performance for EC.02.04.03
98	This page is blank due to revisions through the update.
99	Standard EC.02.05.01
100	Elements of Performance for EC.02.05.01
104	Standard EC.02.05.03 Elements of Performance for EC.02.05.03
106	This page is blank due to revisions through the update.
108	Standard EC.02.05.05 Elements of Performance for EC.02.05.05
109	Standard EC.02.05.07 Rationale for EC.02.05.07 Elements of Performance for EC.02.05.07
112	Standard EC.02.05.09 Rationale for EC.02.05.09 Elements of Performance for EC.02.05.09
115	Introduction to Standard EC.02.06.01
116	Standard EC.02.06.01 Elements of Performance for EC.02.06.01 Standard EC.02.06.05 Rationale for EC.02.06.05
117	Elements of Performance for EC.02.06.05
118	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
120	This page is blank due to revisions through the update.
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
123	Emergency Management (EM) Overview About This Chapter
125	Chapter Outline
126	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
127	Standard EM.02.01.01
128	Rationale for EM.02.01.01 Elements of Performance for EM.02.01.01
131	Standard EM.02.02.01 Rationale for EM.02.02.01 Elements of Performance for EM.02.02.01
134	Standard EM.02.02.03 Rationale for EM.02.02.03
135	Elements of Performance for EM.02.02.03 Standard EM.02.02.05
136	Rationale for EM.02.02.05 Elements of Performance for EM.02.02.05 Standard EM.02.02.07 Rationale for EM.02.02.07 Elements of Performance for EM.02.02.07
138	Standard EM.02.02.09
139	Rationale for EM.02.02.09 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
141	Introduction to Standards EM.02.02.13 and EM.02.02.15
142	Standard EM.02.02.13 Elements of Performance for EM.02.02.13
144	Standard EM.02.02.15 Elements of Performance for EM.02.02.15
146	Standard EM.03.01.03 Rationale for EM.03.01.03 Elements of Performance for EM.03.01.03
148	This page is blank due to revisions through the update.
149	Introduction to Standard EM.04.01.01
150	This page is blank due to revisions through the update.
151	Standard EM.04.01.01 Elements of Performance for EM.04.01.01
155	Human Resources (HR) Overview About This Chapter
156	Chapter Outline
157	Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01
159	Standard HR.01.02.05 Elements of Performance for HR.01.02.05
160	Standard HR.01.02.07 Elements of Performance for HR.01.02.07 Introduction to Standard HR.01.04.01 Standard HR.01.04.01
161	Elements of Performance for HR.01.04.01 Introduction to Standard HR.01.05.03
162	Standard HR.01.05.03 Elements of Performance for HR.01.05.03
163	Introduction to Standards HR.01.06.01 and HR.01.07.01
164	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
165	Introduction to Standard HR.02.01.03
166	Standard HR.02.01.03
167	Elements of Performance for HR.02.01.03
171	Standard HR.02.01.05 Elements of Performance for HR.02.01.05
172	Standard HR.02.02.01 Elements of Performance for HR.02.02.01 Standard HR.02.03.01
173	Elements of Performance for HR.02.03.01 Standard HR.02.04.01 Elements of Performance for HR.02.04.01
174	Standard HR.02.04.03 Elements of Performance for HR.02.04.03
175	Standard HR.03.01.01
176	Elements of Performance for HR.03.01.01
177	Infection Prevention and Control (IC) Overview
178	About This Chapter
179	Chapter Outline
180	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
181	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 Standard IC.01.04.01
182	Elements of Performance for IC.01.04.01 Standard IC.01.05.01 Elements of Performance for IC.01.05.01
183	Standard 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 Standard IC.02.01.01
184	Elements of Performance for IC.02.01.01
185	Standard IC.02.02.01 Rationale for IC.02.02.01
186	Elements of Performance for IC.02.02.01
187	Standard IC.02.03.01 Elements of Performance for IC.02.03.01 Introduction to Standard IC.02.04.01
188	Standard IC.02.04.01 Elements of Performance for IC.02.04.01
189	Standard IC.02.05.01 Elements of Performance for IC.02.05.01
190	Introduction to Standard IC.03.01.01— Evaluation and Improvement Standard IC.03.01.01 Elements of Performance for IC.03.01.01
191	Information Management (IM) Overview About This Chapter
192	Chapter Outline
193	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
194	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
195	Introduction to Standard IM.02.01.01 Standard IM.02.01.01
196	Elements of Performance for IM.02.01.01
197	Introduction to Standard IM.02.01.03 Standard IM.02.01.03 Elements of Performance for IM.02.01.03
198	Standard IM.02.02.01 Rationale for IM.02.02.01 Elements of Performance for IM.02.02.01
199	Introduction to Standard IM.02.02.03 Standard IM.02.02.03
200	Rationale for IM.02.02.03 Elements of Performance for IM.02.02.03 Standard IM.03.01.01 Elements of Performance for IM.03.01.01
201	Leadership (LD) Overview
202	Proactive Risk Assessment
203	About This Chapter
204	Chapter Outline
205	Standards, Rationales, and Elements of Performance Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.07.01 Standard LD.01.01.01 Rationale for LD.01.01.01
206	Elements of Performance for LD.01.01.01 Standard LD.01.03.01 Rationale for LD.01.03.01 Elements of Performance for LD.01.03.01
207	Standard LD.01.04.01 Elements of Performance for LD.01.04.01 Standard LD.01.07.01 Elements of Performance for LD.01.07.01
208	Introduction to Leadership Relationships, Standards LD.02.01.01 and LD.02.03.01 Standard LD.02.01.01 Rationale for LD.02.01.01 Elements of Performance for LD.02.01.01 Standard LD.02.03.01 Rationale for LD.02.03.01
209	Elements of Performance for LD.02.03.01 Introduction to Organization Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
211	Standard LD.03.01.01 Rationale for LD.03.01.01 Elements of Performance for LD.03.01.01
212	Standard LD.03.02.01 Rationale for LD.03.02.01 Elements of Performance for LD.03.02.01 Standard LD.03.03.01 Rationale for LD.03.03.01
213	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
214	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
215	Introduction to Operations, Standards LD.03.07.01 Through LD.04.03.09 Standard LD.03.07.01 Elements of Performance for LD.03.07.01
217	Standard LD.03.08.01 Elements of Performance for LD.03.08.01 Introduction to Standard LD.03.09.01
218	Standard LD.03.09.01 Elements of Performance for LD.03.09.01
220	Standard LD.03.10.01 Rationale for LD.03.10.01 Elements of Performance for LD.03.10.01
221	Standard LD.04.01.01 Elements of Performance for LD.04.01.01
222	Standard LD.04.01.03 Elements of Performance for LD.04.01.03 Standard LD.04.01.05 Rationale for LD.04.01.05 Elements of Performance for LD.04.01.05
223	Standard LD.04.01.07 Elements of Performance for LD.04.01.07
224	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
225	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
226	Standard LD.04.03.07 Rationale for LD.04.03.07 Elements of Performance for LD.04.03.07 Introduction to Oversight of Care, Treatment, or Services Provided Through Contractual Agreement, Standard LD.04.03.09
227	Monitoring Contracted Services
228	Standard LD.04.03.09 Elements of Performance for LD.04.03.09
229	Introduction to Standard LD.04.03.13 Standard LD.04.03.13
230	Elements of Performance for LD.04.03.13
231	Life Safety (LS) Overview About This Chapter
233	Chapter Outline
234	Standards, Rationales, and Elements of Performance Introduction to Standard LS.01.01.01 Standard LS.01.01.01
235	Elements of Performance for LS.01.01.01
236	Standard LS.01.02.01 Elements of Performance for LS.01.02.01
238	Standard LS.03.01.10 Rationale for LS.03.01.10
240	This page is blank due to revisions through the update.
241	Elements of Performance for LS.03.01.10
243	Standard LS.03.01.20 Rationale for LS.03.01.20 Elements of Performance for LS.03.01.20
246	Standard LS.03.01.30 Rationale for LS.03.01.30 Elements of Performance for LS.03.01.30
250	Standard LS.03.01.34 Elements of Performance for LS.03.01.34
251	Standard LS.03.01.35
252	Elements of Performance for LS.03.01.35
253	Standard LS.03.01.40 Elements of Performance for LS.03.01.40
254	Standard LS.03.01.50 Elements of Performance for LS.03.01.50
256	This page is blank due to revisions through the update.
258	Standard LS.03.01.70 Elements of Performance for LS.03.01.70
261	Medication Management (MM) Overview
262	About This Chapter
264	Chapter Outline
265	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
266	Standard MM.01.01.03 Rationale for MM.01.01.03 Elements of Performance for MM.01.01.03
267	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
268	Standard MM.03.01.01 Rationale for MM.03.01.01
269	Elements of Performance for MM.03.01.01 Standard MM.03.01.03
270	Rationale for MM.03.01.03 Elements of Performance for MM.03.01.03 Standard MM.03.01.05 Rationale for MM.03.01.05 Elements of Performance for MM.03.01.05
271	Introduction to Standard MM.04.01.01 Standard MM.04.01.01 Elements of Performance for MM.04.01.01
273	Standard MM.05.01.01 Elements of Performance for MM.05.01.01 Standard MM.05.01.07 Elements of Performance for MM.05.01.07
274	Standard MM.05.01.09 Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09
275	Standard MM.05.01.11 Elements of Performance for MM.05.01.11 Standard MM.05.01.15 Elements of Performance for MM.05.01.15 Standard MM.05.01.17
276	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
277	Standard MM.06.01.01 Elements of Performance for MM.06.01.01
278	Standard MM.06.01.05 Rationale for MM.06.01.05 Elements of Performance for MM.06.01.05
279	Standard MM.07.01.01 Elements of Performance for MM.07.01.01 Standard MM.07.01.03 Rationale for MM.07.01.03
280	Elements of Performance for MM.07.01.03 Standard MM.08.01.01 Elements of Performance for MM.08.01.01
281	Standard MM.09.01.03 Elements of Performance for MM.09.01.03
283	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
284	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 3 NPSG.03.04.01
285	Rationale for NPSG.03.04.01 Elements of Performance for NPSG.03.04.01
286	NPSG.03.05.01 Rationale for NPSG.03.05.01
287	Elements of Performance for NPSG.03.05.01
288	Introduction to Reconciling Medication Information NPSG.03.06.01
289	Rationale for NPSG.03.06.01 Elements of Performance for NPSG.03.06.01
290	Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01
291	Elements of Performance for NPSG.07.01.01 Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
292	UP.01.01.01 Rationale for UP.01.01.01
293	Elements of Performance for UP.01.01.01 Introduction to UP.01.02.01
294	UP.01.02.01 Elements of Performance for UP.01.02.01
295	UP.01.03.01
296	Rationale for UP.01.03.01 Elements of Performance for UP.01.03.01
299	Provision of Care, Treatment, and Services (PC) Overview
300	About This Chapter
301	Chapter Outline
302	Standards, Rationales, and Elements of Performance Standard PC.01.01.01 Elements of Performance for PC.01.01.01 Introduction to Standard PC.01.02.01
303	Standard PC.01.02.01 Elements of Performance for PC.01.02.01 Standard PC.01.02.03 Elements of Performance for PC.01.02.03
304	Introduction to Standard PC.01.02.07 Standard PC.01.02.07 Elements of Performance for PC.01.02.07
306	Introduction to Standard PC.01.02.09 Standard PC.01.02.09 Elements of Performance for PC.01.02.09 Standard PC.01.02.15 Elements of Performance for PC.01.02.15
308	Introduction to Standard PC.01.03.01 Standard PC.01.03.01 Elements of Performance for PC.01.03.01
309	Standard PC.02.01.01
310	Elements of Performance for PC.02.01.01 Standard PC.02.01.03
311	Elements of Performance for PC.02.01.03 Standard PC.02.01.05 Elements of Performance for PC.02.01.05 Standard PC.02.01.07 Elements of Performance for PC.02.01.07 Standard PC.02.01.09 Elements of Performance for PC.02.01.09
312	Standard PC.02.01.21 Elements of Performance for PC.02.01.21
313	Introduction to Standard PC.02.02.01 Standard PC.02.02.01 Elements of Performance for PC.02.02.01
314	Standard PC.02.02.03 Elements of Performance for PC.02.02.03 Introduction to Standard PC.02.03.01 Standard PC.02.03.01 Elements of Performance for PC.02.03.01
315	Standard PC.02.04.01
316	Elements of Performance for PC.02.04.01 Standard PC.02.04.03 Elements of Performance for PC.02.04.03
318	Standard PC.02.04.05 Elements of Performance for PC.02.04.05
319	Introduction to Standards PC.03.01.01 Through PC.03.01.07 Standard PC.03.01.01
320	Elements of Performance for PC.03.01.01 Standard PC.03.01.03 Elements of Performance for PC.03.01.03
322	Standard PC.03.01.05 Elements of Performance for PC.03.01.05
323	Standard PC.03.01.07 Elements of Performance for PC.03.01.07 Standard PC.03.02.03
324	Elements of Performance for PC.03.02.03 Standard PC.03.02.07 Rationale for PC.03.02.07 Elements of Performance for PC.03.02.07
325	Standard PC.04.01.01 Elements of Performance for PC.04.01.01 Standard PC.04.01.03 Elements of Performance for PC.04.01.03
326	Standard PC.04.01.05 Elements of Performance for PC.04.01.05
327	Standard PC.04.02.01 Elements of Performance for PC.04.02.01
329	Performance Improvement (PI) Overview About This Chapter
331	Chapter Outline
332	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
334	Standard PI.02.01.01 Rationale for PI.02.01.01 Elements of Performance for PI.02.01.01
335	Introduction to Standard PI.03.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
336	Standard PI.04.01.01
337	Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
339	Record of Care, Treatment, and Services (RC) Overview About This Chapter
340	Chapter Outline
341	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
342	Standard RC.01.03.01 Elements of Performance for RC.01.03.01 Standard RC.01.04.01 Elements of Performance for RC.01.04.01 Standard RC.01.05.01 Elements of Performance for RC.01.05.01
343	Standard RC.02.01.01 Elements of Performance for RC.02.01.01
345	Standard RC.02.01.03 Elements of Performance for RC.02.01.03
347	Standard RC.02.01.05 Elements of Performance for RC.02.01.05 Standard RC.02.03.07 Elements of Performance for RC.02.03.07
349	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
351	Chapter Outline
352	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
353	Introduction to Standard RI.01.01.03
354	Standard RI.01.01.03 Elements of Performance for RI.01.01.03
355	Standard RI.01.02.01 Elements of Performance for RI.01.02.01
356	Standard RI.01.03.01 Rationale for RI.01.03.01 Elements of Performance for RI.01.03.01
357	Standard RI.01.03.05 Elements of Performance for RI.01.03.05
358	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
359	Standard RI.01.05.01 Elements of Performance for RI.01.05.01
360	Standard RI.01.06.03 Elements of Performance for RI.01.06.03 Standard RI.01.07.01 Elements of Performance for RI.01.07.01
362	Introduction to Standard RI.02.01.01 Standard RI.02.01.01 Elements of Performance for RI.02.01.01
363	Transplant Safety (TS) Overview About This Chapter
364	Chapter Outline
365	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
367	Standard TS.03.01.01 Elements of Performance for TS.03.01.01
368	Standard TS.03.02.01
369	Elements of Performance for TS.03.02.01
370	Standard TS.03.03.01 Elements of Performance for TS.03.03.01
371	Waived Testing (WT) Overview
372	About This Chapter
374	Chapter Outline
375	Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01
376	Standard WT.02.01.01 Elements of Performance for WT.02.01.01
377	Standard WT.03.01.01 Elements of Performance for WT.03.01.01
378	Standard WT.04.01.01 Elements of Performance for WT.04.01.01
379	Standard WT.05.01.01 Elements of Performance for WT.05.01.01
381	The Accreditation Process (ACC) Notices ACC Chapter Contents
383	Overview General Eligibility Requirements
384	Scope of Accreditation Surveys
385	Accreditation Policies Tailored Survey Policy
387	Organizational and Functional Integration
390	System Accreditation Option
391	Contracted Services Integrated Care Certification Option
392	Deemed Status Option
393	Advanced Diagnostic Imaging Accreditation Option Primary Care Medical Home Certification Option
395	Initial Surveys
396	Information Accuracy and Truthfulness Policy
398	Good Faith Participation in Accreditation/ Certification
399	Public Information Policy# Process for Responding to a Complaint
400	Early Survey Policy Sidebar 1. Early Survey Policy
401	Sidebar 1.
403	Before the Survey
404	An Organization’s Secure Joint Commission Connect Extranet Site
405	Role of the Account Executive Electronic Application for Accreditation (E-App)
407	Accreditation/Certification Contract and Business Associate Agreement Annual and Survey Fees
409	During the Survey Survey Notification
410	Table 3. Exceptions to Unannounced Surveys††
412	Initial and Full Survey Team Composition
413	Survey Agenda
418	Tracer Methodology
419	Table 4. Ambulatory Care–Specific Tracer Applicability and Objectives
423	Immediate Threat to Health or Safety
427	Summary of the Accreditation Reports
428	After the Survey The Scoring Process
434	Evidence of Standards Compliance (ESC) Process
437	Accreditation Award Display and Use
439	Recommendation Letter for Organizations That Elect to Use The Joint Commission Deemed Status Option Advanced Diagnostic Imaging Letter Primary Care Medical Home Certification Letter Between Accreditation Surveys
440	Duration of Accreditation Award Continuous Compliance Intracycle Monitoring (ICM)
441	Focused Standards Assessment (FSA)
442	Sidebar 2. Focused Standards Assessment (FSA) Options
443	Sidebar 2. Sentinel Event Follow-up
444	Notifying The Joint Commission About Organization Changes
446	Accreditation Status of Organizations That Cease Services After a Disaster‡
448	Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time Reentering the Accreditation Process
449	Additional Surveys
451	Decision Rules for Organizations Seeking Initial Accreditation Accredited
452	Primary Care Medical Home Certification Limited, Temporary Accreditation
453	Evidence of Standards Compliance (ESC) One-Month Survey Medicare Deficiency Follow-up Survey
454	Denial of Accreditation
455	Decision Rules for Organizations Seeking Reaccreditation Accredited Primary Care Medical Home Certification
456	Evidence of Standards Compliance (ESC) One-Month Survey Medicare Deficiency Follow-up Survey
457	Accreditation with Follow-up Survey
458	Preliminary Denial of Accreditation
459	Denial of Accreditation
460	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
462	Process for Organizations That Meet Decision Rule PDA04
463	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
464	II. Accreditation with Follow-up Survey
465	III. Review Hearings
466	IV. Following a Review Hearing
467	V. Final Review &Appeal Request
469	Standards Applicability Process (SAP)
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500	This page is blank due to revisions through the update.
505	Sentinel Event Policy (SE)
506	Goals of the Sentinel Event Policy
507	Identifying Sentinel Events
509	Sidebar 1. Key Terms
510	Sidebar 1.
511	Determining That a Sentinel Event Is Subject to Review
512	Relationship to the Survey Process
513	Required Organization Response to a Sentinel Event
514	Reporting a Sentinel Event to The Joint Commission
516	Conducting a Comprehensive Systematic Analysis
517	Developing a Corrective Action Plan
518	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
519	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
520	Table 1.
521	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
522	Follow-up Activities
524	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
525	Overseeing the Sentinel Event Policy
527	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
528	What Will My Quality Report Contain? What Is Quality Check?
529	Is a Quality Report Available for My Accredited Ambulatory Care Organization? Can My Ambulatory Care Organization Comment on Its Quality Report?
530	How Does My Ambulatory Care Organization 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?
531	Guidelines for Publicizing Compliance with the National Patient Safety Goals
533	Required Written Documentation (RWD)
535	List of EPs Requiring Written Documentation for Ambulatory Care by Service Ambulatory Surgical Centers Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
536	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM)
537	National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) 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)
538	Waived Testing (WT) Endoscopy Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
539	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM)
540	National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT)
541	Medical Centers Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC)
542	Information Management (IM) Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) Provision of Care, Treatment, and Services (PC)
543	Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Transplant Safety (TS) Waived Testing (WT) Dental Centers Accreditation Participation Requirements (APR) Environment of Care (EC)
544	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
545	Medication Management (MM) National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
546	Transplant Safety (TS) Waived Testing (WT) Diagnostic/Therapeutic Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
547	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
548	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Diagnostic Imaging Services Accreditation Participation Requirements (APR) Environment of Care (EC)
549	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
550	Medication Management (MM) National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT)
551	Diagnostic Sleep Centers Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC)
552	Information Management (IM) Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC)
553	Rights and Responsibilities of the Individual (RI) Kidney Care/Dialysis Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
554	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) Provision of Care, Treatment, and Services (PC)
555	Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Telehealth/Nonsurgical Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
556	Human Resources (HR) Information Management (IM) Leadership (LD) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
557	Telehealth/Surgical Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Information Management (IM) Leadership (LD)
558	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Episodic Care Accreditation Participation Requirements (APR) Environment of Care (EC)
559	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM)
560	National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performanc Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Transplant Safety (TS) Waived Testing (WT)
561	Occupational/Worksite Health Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC)
562	Information Management (IM) Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
563	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Urgent/Immediate Care Accreditation Participation Requirements (APR) Environment of Care (EC)
564	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM)
565	National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Convenient Care Accreditation Participation Requirements (APR)
566	Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
567	Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
568	Waived Testing (WT)
569	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Environment of Care (EC)
570	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
571	LD Life Safety (LS) Medication Management (MM) National Patient Safety Goals (NPSG)
572	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)
573	Primary Care Medical Home Certification Option (PCMH) Overview Primary Care Medical Home Model
574	I. Patient-Centered Care II. Comprehensive Care
576	This page is blank due to revisions through the update.
577	III. Coordinated Care
578	IV. Superb Access to Care V. Systems-Based Approach to Quality and Safety
579	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
580	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
581	Standard LD.04.01.11 Elements of Performance for LD.04.01.11 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 Standard PC.02.01.21
582	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
584	Standard PC.02.04.01 Elements of Performance for PC.02.04.01 Standard PC.02.04.05 Elements of Performance for PC.02.04.05
585	Record of Care, Treatment, and Services (RC) Standard RC.02.01.01 Elements of Performance for RC.02.01.01 Rights and Responsibilities of the Individual (RI) Standard RI.01.01.01
586	Elements of Performance for RI.01.01.01 Standard RI.01.01.03 Elements of Performance for RI.01.01.03
587	Standard RI.01.02.01 Elements of Performance for RI.01.02.01
588	Standard RI.01.03.01 Elements of Performance for RI.01.03.01
589	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
590	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
591	II. Comprehensive Care Human Resources (HR) Standard HR.03.01.01 Elements of Performance for HR.03.01.01 Provision of Care, Treatment, and Services (PC) Standard PC.02.01.05 Elements of Performance for PC.02.01.05
592	Standard PC.02.04.03 Elements of Performance for PC.02.04.03 Standard PC.02.04.05
593	Elements of Performance for PC.02.04.05 Rights and Responsibilities of the Individual (RI) Standard RI.01.04.03
594	Elements of Performance for RI.01.04.03 III. Coordinated Care Human Resources (HR) Standard HR.01.02.07 Elements of Performance for HR.01.02.07 Provision of Care, Treatment, and Services (PC) Standard PC.01.03.01 Elements of Performance for PC.01.03.01
595	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 Standard PC.02.04.03
596	Elements of Performance for PC.02.04.03 Standard PC.02.04.05 Elements of Performance for PC.02.04.05
597	Standard PC.04.01.01 Elements of Performance for PC.04.01.01 Standard PC.04.01.03 Elements of Performance for PC.04.01.03
598	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
599	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 Elements of Performance for PC.02.04.01
600	V. Systems-Based Approach to Quality and Safety Leadership (LD) Standard LD.03.04.01 Elements of Performance for LD.03.04.01
601	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
602	Standard LD.03.09.01 Elements of Performance for LD.03.09.01
604	Standard LD.03.10.01 Elements of Performance for LD.03.10.01 Standard LD.04.01.05 Elements of Performance for LD.04.01.05
605	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
606	Elements of Performance for PI.01.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
607	Standard PI.04.01.01 Elements of Performance for PI.04.01.01
609	Glossary (GL)
645	Index (IX)