JCR CAMAC 2023

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Comprehensive Accreditation Manual for Ambulatory Care (CAMAC)

Published By	Publication Date	Number of Pages
Joint Commission	2023	700

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Category: Joint Commission

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Description

Our best-selling ambulatory care accreditation resource is available as a PDF. The CAMAC PDF manual provides you with all ambulatory care standards, elements of performance (EPs), National Patient Safety Goals®, and Accreditation Participation Requirements (APRs) effective January 1, 2023. Please note: This PDF manual is a digital version of the print Comprehensive Accreditation Manual for Ambulatory Care effective January 1, 2023. It will not be updated throughout 2023. Please refer to your E-dition® for any updates. Key Topics: Standards requirements including the standards, National Patient Safety Goals, and APRs effective January 1, 2023 Standards and EPs for optional Primary Care Medical Home certification 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: Regulatory requirements for deemed status Icons to help navigate documentation requirements as well as risk areas “What’s New” summary of changes Integrated regulatory requirements for ambulatory surgery center deemed status 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 2023 CAMAC
9	Cover
10	Copyright
11	Contents
13	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
14	I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation
16	The Joint Commission’s Ambulatory Care Accreditation Program
17	Addressing Complex Issues in Ambulatory Care
18	Table 1. Standards That Address Complex Care Issues in Ambulatory Care Organizations
19	II. About the
20	How Is This Manual Organized? Table 2. Acronyms Used in This Manual
21	Table 2.
23	Accreditation Requirements
24	Accreditation Process Information
26	Identifying Applicable Standards
29	Understanding the Organization of the Standards Chapters
31	Understanding the Icons Used in the Manual
32	III. Steps to Achieving and Maintaining Compliance Become Familiar with the Standards Assess Compliance with the Standards
34	Stimulate Improvement
36	Accelerate PI™
37	Keep Current with Standards Changes via Perspectives
39	IV. Get Extra Help Getting Started with Accreditation Account Executive
40	Contacting The Joint Commission Standards Questions Requesting Permission to Share Content from the Manual
41	Patient Safety Systems (PS) Quality and Safety in Health Care Sidebar 1. Key Terms
42	Sidebar 1.
43	Goals of This Chapter
44	Becoming a Learning Organization
45	The Role of Leaders in Patient Safety Safety Culture
49	Sidebar 2. Assessing Staff Accountability
50	Sidebar 2 Data Use and Reporting Systems
51	Effective Use of Data
52	Table 1. Defining and Comparing Analytical Tools
53	A Proactive Approach to Preventing Harm
56	Sidebar 3. Strategies for an Effective Risk Assessment Encouraging Patient Activation
58	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
59	References
63	Accreditation Participation Requirements (APR) Overview
64	Chapter Outline
65	Requirements, Rationales, and Elements of Performance APR.01.01.01 Elements of Performance for APR.01.01.01 APR.01.02.01
66	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
67	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
68	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
69	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
70	APR.09.03.01 Elements of Performance for APR.09.03.01 APR.09.04.01 Elements of Performance for APR.09.04.01
71	Environment of Care (EC) Overview About This Chapter
72	Other Issues for Consideration
74	Chapter Outline
75	Standards, Rationales, and Elements of Performance Standard EC.01.01.01 Rationale for EC.01.01.01
76	Elements of Performance for EC.01.01.01 Standard EC.02.01.01 Rationale for EC.02.01.01
77	Elements of Performance for EC.02.01.01
78	Standard EC.02.01.03 Elements of Performance for EC.02.01.03 Standard EC.02.02.01 Rationale for EC.02.02.01
79	Elements of Performance for EC.02.02.01
80	Standard EC.02.03.01
81	Elements of Performance for EC.02.03.01 Standard EC.02.03.03
82	Rationale for EC.02.03.03 Elements of Performance for EC.02.03.03
83	Standard EC.02.03.05 Elements of Performance for EC.02.03.05
88	Standard EC.02.04.01 Elements of Performance for EC.02.04.01
89	Standard EC.02.04.03 Elements of Performance for EC.02.04.03
95	Standard EC.02.05.01 Elements of Performance for EC.02.05.01
99	Standard EC.02.05.03
100	Elements of Performance for EC.02.05.03
102	Standard EC.02.05.05 Elements of Performance for EC.02.05.05
103	Standard EC.02.05.07 Rationale for EC.02.05.07 Elements of Performance for EC.02.05.07
105	Standard EC.02.05.09 Rationale for EC.02.05.09 Elements of Performance for EC.02.05.09
109	Introduction to Standard EC.02.06.01 Standard EC.02.06.01
110	Elements of Performance for EC.02.06.01 Standard EC.02.06.05 Rationale for EC.02.06.05 Elements of Performance for EC.02.06.05
111	Standard EC.03.01.01
112	Rationale for EC.03.01.01 Elements of Performance for EC.03.01.01 Introduction to Standard EC.04.01.01 Standard EC.04.01.01
113	Elements of Performance for EC.04.01.01 Standard EC.04.01.03 Elements of Performance for EC.04.01.03 Standard EC.04.01.05
114	Elements of Performance for EC.04.01.05
115	Emergency Management (EM) Overview About This Chapter
117	Chapter Outline
118	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
119	Standard EM.02.01.01
120	Rationale for EM.02.01.01 Elements of Performance for EM.02.01.01
123	Standard EM.02.02.01 Rationale for EM.02.02.01 Elements of Performance for EM.02.02.01
126	Standard EM.02.02.03 Rationale for EM.02.02.03
127	Elements of Performance for EM.02.02.03 Standard EM.02.02.05
128	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
130	Standard EM.02.02.09
131	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
133	Introduction to Standards EM.02.02.13 and EM.02.02.15
134	Standard EM.02.02.13 Elements of Performance for EM.02.02.13
136	Standard EM.02.02.15 Elements of Performance for EM.02.02.15
138	Standard EM.03.01.03 Rationale for EM.03.01.03 Elements of Performance for EM.03.01.03
139	Introduction to Standard EM.04.01.01
140	Standard EM.04.01.01 Elements of Performance for EM.04.01.01
143	Human Resources (HR) Overview About This Chapter
144	Chapter Outline
145	Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01
147	Standard HR.01.02.05 Elements of Performance for HR.01.02.05
148	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
149	Elements of Performance for HR.01.04.01 Introduction to Standard HR.01.05.03
150	Standard HR.01.05.03 Elements of Performance for HR.01.05.03
151	Introduction to Standards HR.01.06.01 and HR.01.07.01
152	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
153	Introduction to Standard HR.02.01.03
154	Standard HR.02.01.03 Elements of Performance for HR.02.01.03
158	Standard HR.02.01.05
159	Elements of Performance for HR.02.01.05 Standard HR.02.02.01
160	Elements of Performance for HR.02.02.01 Standard HR.02.03.01 Elements of Performance for HR.02.03.01 Standard HR.02.04.01
161	Elements of Performance for HR.02.04.01
162	Standard HR.02.04.03 Elements of Performance for HR.02.04.03
163	Standard HR.03.01.01 Elements of Performance for HR.03.01.01
165	Infection Prevention and Control (IC) Overview
166	About This Chapter
167	Chapter Outline
168	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
169	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
170	Elements of Performance for IC.01.04.01 Standard IC.01.05.01 Elements of Performance for IC.01.05.01
171	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
172	Elements of Performance for IC.02.01.01
173	Standard IC.02.02.01 Rationale for IC.02.02.01
174	Elements of Performance for IC.02.02.01
175	Standard IC.02.03.01 Elements of Performance for IC.02.03.01 Introduction to Standard IC.02.04.01
176	Standard IC.02.04.01 Elements of Performance for IC.02.04.01
177	Standard IC.02.04.02 Rationale for IC.02.04.02 Elements of Performance for IC.02.04.02
180	Standard IC.02.05.01 Elements of Performance for IC.02.05.01
181	Introduction to Standard IC.03.01.01— Evaluation and Improvement Standard IC.03.01.01 Elements of Performance for IC.03.01.01
183	Information Management (IM) Overview About This Chapter
184	Chapter Outline
185	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
186	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
187	Introduction to Standard IM.02.01.01 Standard IM.02.01.01
188	Elements of Performance for IM.02.01.01
189	Introduction to Standard IM.02.01.03 Standard IM.02.01.03 Elements of Performance for IM.02.01.03
190	Standard IM.02.02.01 Rationale for IM.02.02.01 Elements of Performance for IM.02.02.01
191	Introduction to Standard IM.02.02.03 Standard IM.02.02.03
192	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
193	Leadership (LD) Overview
194	Proactive Risk Assessment
195	About This Chapter
196	Chapter Outline
197	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
198	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
199	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
200	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
201	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
203	Standard LD.03.01.01 Rationale for LD.03.01.01 Elements of Performance for LD.03.01.01
204	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
205	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
206	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
207	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
209	Standard LD.03.08.01 Elements of Performance for LD.03.08.01 Introduction to Standard LD.03.09.01
210	Standard LD.03.09.01 Elements of Performance for LD.03.09.01
212	Standard LD.03.10.01 Rationale for LD.03.10.01 Elements of Performance for LD.03.10.01
213	Standard LD.04.01.01 Elements of Performance for LD.04.01.01
214	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
215	Standard LD.04.01.07 Elements of Performance for LD.04.01.07
216	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
217	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
218	Standard LD.04.03.07 Rationale for LD.04.03.07 Elements of Performance for LD.04.03.07 Introduction to Standard LD.04.03.08
219	Standard LD.04.03.08 Rationale for LD.04.03.08
220	Elements of Performance for LD.04.03.08
221	Introduction to Oversight of Care, Treatment, or Services Provided Through Contractual Agreement, Standard LD.04.03.09
222	Monitoring Contracted Services
223	Standard LD.04.03.09 Elements of Performance for LD.04.03.09
224	Introduction to Standard LD.04.03.13
225	Standard LD.04.03.13 Elements of Performance for LD.04.03.13
227	Life Safety (LS) Overview About This Chapter
229	Chapter Outline
230	Standards, Rationales, and Elements of Performance Introduction to Standard LS.01.01.01 Standard LS.01.01.01
231	Elements of Performance for LS.01.01.01
232	Standard LS.01.02.01 Elements of Performance for LS.01.02.01
234	Standard LS.03.01.10
235	Rationale for LS.03.01.10 Elements of Performance for LS.03.01.10
237	Standard LS.03.01.20 Rationale for LS.03.01.20
238	Elements of Performance for LS.03.01.20
240	Standard LS.03.01.30 Rationale for LS.03.01.30
241	Elements of Performance for LS.03.01.30
244	Standard LS.03.01.34 Elements of Performance for LS.03.01.34
246	Standard LS.03.01.35 Elements of Performance for LS.03.01.35
247	Standard LS.03.01.40
248	Elements of Performance for LS.03.01.40 Standard LS.03.01.50 Elements of Performance for LS.03.01.50
250	Standard LS.03.01.70
251	Elements of Performance for LS.03.01.70
253	Medication Management (MM) Overview
254	About This Chapter
256	Chapter Outline
257	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
258	Standard MM.01.01.03 Rationale for MM.01.01.03 Elements of Performance for MM.01.01.03
259	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
260	Standard MM.03.01.01 Rationale for MM.03.01.01
261	Elements of Performance for MM.03.01.01 Standard MM.03.01.03
262	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
263	Introduction to Standard MM.04.01.01 Standard MM.04.01.01 Elements of Performance for MM.04.01.01
265	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
266	Standard MM.05.01.09 Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09
267	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
268	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
269	Standard MM.06.01.01 Elements of Performance for MM.06.01.01
270	Standard MM.06.01.05 Rationale for MM.06.01.05 Elements of Performance for MM.06.01.05
271	Standard MM.07.01.01 Elements of Performance for MM.07.01.01 Standard MM.07.01.03 Rationale for MM.07.01.03
272	Elements of Performance for MM.07.01.03 Standard MM.08.01.01 Elements of Performance for MM.08.01.01
273	Standard MM.09.01.03 Elements of Performance for MM.09.01.03
275	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals® Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
276	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
277	Rationale for NPSG.03.04.01 Elements of Performance for NPSG.03.04.01
278	NPSG.03.05.01 Rationale for NPSG.03.05.01
279	Elements of Performance for NPSG.03.05.01
280	Introduction to Reconciling Medication Information NPSG.03.06.01
281	Rationale for NPSG.03.06.01 Elements of Performance for NPSG.03.06.01
282	Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01
283	Elements of Performance for NPSG.07.01.01 Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
284	UP.01.01.01 Rationale for UP.01.01.01
285	Elements of Performance for UP.01.01.01 Introduction to UP.01.02.01
286	UP.01.02.01 Elements of Performance for UP.01.02.01
287	UP.01.03.01
288	Rationale for UP.01.03.01 Elements of Performance for UP.01.03.01
291	Provision of Care, Treatment, and Services (PC) Overview
292	About This Chapter
293	Chapter Outline
294	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
295	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
296	Introduction to Standard PC.01.02.07 Standard PC.01.02.07 Elements of Performance for PC.01.02.07
298	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
300	Introduction to Standard PC.01.03.01 Standard PC.01.03.01 Elements of Performance for PC.01.03.01
301	Standard PC.02.01.01
302	Elements of Performance for PC.02.01.01 Standard PC.02.01.03
303	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
304	Standard PC.02.01.21 Elements of Performance for PC.02.01.21
305	Introduction to Standard PC.02.02.01 Standard PC.02.02.01 Elements of Performance for PC.02.02.01
306	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
307	Standard PC.02.04.01
308	Elements of Performance for PC.02.04.01 Standard PC.02.04.03 Elements of Performance for PC.02.04.03
310	Standard PC.02.04.05 Elements of Performance for PC.02.04.05
311	Introduction to Standards PC.03.01.01 Through PC.03.01.07 Standard PC.03.01.01
312	Elements of Performance for PC.03.01.01 Standard PC.03.01.03 Elements of Performance for PC.03.01.03
314	Standard PC.03.01.05 Elements of Performance for PC.03.01.05
315	Standard PC.03.01.07 Elements of Performance for PC.03.01.07 Standard PC.03.02.03
316	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
317	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
318	Standard PC.04.01.05 Elements of Performance for PC.04.01.05
319	Standard PC.04.02.01 Elements of Performance for PC.04.02.01
321	Performance Improvement (PI) Overview About This Chapter
323	Chapter Outline
324	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
326	Standard PI.02.01.01 Rationale for PI.02.01.01 Elements of Performance for PI.02.01.01
327	Introduction to Standard PI.03.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
328	Standard PI.04.01.01
329	Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
331	Record of Care, Treatment, and Services (RC) Overview About This Chapter
332	Chapter Outline
333	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
334	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
335	Standard RC.02.01.01 Elements of Performance for RC.02.01.01
337	Standard RC.02.01.03 Elements of Performance for RC.02.01.03
339	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
341	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
343	Chapter Outline
344	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
345	Introduction to Standard RI.01.01.03
346	Standard RI.01.01.03 Elements of Performance for RI.01.01.03
347	Standard RI.01.02.01 Elements of Performance for RI.01.02.01
348	Standard RI.01.03.01 Rationale for RI.01.03.01 Elements of Performance for RI.01.03.01
349	Standard RI.01.03.05 Elements of Performance for RI.01.03.05
350	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
351	Standard RI.01.05.01 Elements of Performance for RI.01.05.01
352	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
354	Introduction to Standard RI.02.01.01 Standard RI.02.01.01
355	Elements of Performance for RI.02.01.01
357	Transplant Safety (TS) Overview About This Chapter
358	Chapter Outline
359	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
361	Standard TS.03.01.01 Elements of Performance for TS.03.01.01
362	Standard TS.03.02.01
363	Elements of Performance for TS.03.02.01
364	Standard TS.03.03.01 Elements of Performance for TS.03.03.01
365	Waived Testing (WT) Overview
366	About This Chapter
368	Chapter Outline
369	Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01
370	Standard WT.02.01.01 Elements of Performance for WT.02.01.01
371	Standard WT.03.01.01 Elements of Performance for WT.03.01.01
372	Standard WT.04.01.01 Elements of Performance for WT.04.01.01
373	Standard WT.05.01.01 Elements of Performance for WT.05.01.01
375	The Accreditation Process (ACC) Notices ACC Chapter Contents
377	Overview General Eligibility Requirements
378	Scope of Accreditation Surveys
379	Accreditation Policies Tailored Survey Policy
380	Organizational and Functional Integration
383	System Accreditation Option
384	Contracted Services Integrated Care Certification Option
385	Deemed Status Option
386	Advanced Diagnostic Imaging Accreditation Option Primary Care Medical Home Certification Option
388	Initial Surveys
389	Information Accuracy and Truthfulness Policy
391	Good Faith Participation in Accreditation/ Certification
392	Public Information Policy\|\| Process for Responding to a Complaint
393	Early Survey Policy Sidebar 1. Early Survey Policy
394	Sidebar 1.
396	Before the Survey
397	An Organization’s Secure Joint Commission Connect Extranet Site
398	Role of the Account Executive Electronic Application for Accreditation (E-App)
399	Accreditation/Certification Contract and Business Associate Agreement
400	Annual and Survey Fees
401	During the Survey
402	Survey Notification Table 3. Exceptions to Unannounced Surveys**
403	Table 3.
405	Initial and Full Survey Team Composition
406	Survey Agenda
411	Tracer Methodology
412	Table 4. Ambulatory Care–Specific Tracer Applicability and Objectives
416	Immediate Threat to Health or Safety
420	Summary of the Accreditation Reports
421	After the Survey The Scoring Process
427	Evidence of Standards Compliance (ESC) Process
430	Accreditation Award Display and Use
432	Recommendation Letter for Organizations That Elect to Use The Joint Commission Deemed Status Option Advanced Diagnostic Imaging Letter Primary Care Medical Home Certification Letter
433	Between Accreditation Surveys Duration of Accreditation Award Continuous Compliance
434	Intracycle Monitoring (ICM) Focused Standards Assessment (FSA)
435	Sidebar 2. Focused Standards Assessment (FSA) Options
436	Sidebar 2.
437	Sentinel Event Follow-up Notifying The Joint Commission About Organization Changes
439	Accreditation Status of Organizations That Cease Services After a Disaster†
441	Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time
442	Reentering the Accreditation Process Additional Surveys
445	Decision Rules for Organizations Seeking Initial Accreditation Accredited Primary Care Medical Home Certification
446	Limited, Temporary Accreditation Evidence of Standards Compliance (ESC) One-Month Survey
447	Medicare Deficiency Follow-up Survey Denial of Accreditation
448	Decision Rules for Organizations Seeking Reaccreditation Accredited
449	Primary Care Medical Home Certification Evidence of Standards Compliance (ESC)
450	One-Month Survey Medicare Deficiency Follow-up Survey Accreditation with Follow-up Survey
452	Preliminary Denial of Accreditation
453	Denial of Accreditation Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
456	Process for Organizations That Meet Decision Rule PDA04 Review and Appeal Procedures
457	I. Evaluation by Joint Commission Staff
458	II. Accreditation with Follow-up Survey III. Review Hearings
460	IV. Following a Review Hearing V. Final Review &Appeal Request
463	Standards Applicability Process (SAP)
495	Sentinel Event Policy (SE)
496	Goals of the Sentinel Event Policy
497	Identifying Sentinel Events
499	Sidebar 1. Key Terms
500	Sidebar 1.
502	Determining That a Sentinel Event Is Subject to Review Relationship to the Survey Process
503	Required Organization Response to a Sentinel Event
505	Reporting a Sentinel Event to The Joint Commission
507	Conducting a Comprehensive Systematic Analysis
508	Developing a Corrective Action Plan
509	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
510	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
511	Table 1.
512	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
513	Follow-up Activities
515	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
516	Overseeing the Sentinel Event Policy
517	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
518	What Will My Quality Report Contain? What Is Quality Check?
519	Is a Quality Report Available for My Accredited Ambulatory Care Organization? Can My Ambulatory Care Organization Comment on Its Quality Report?
520	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?
521	Guidelines for Publicizing Compliance with the National Patient Safety Goals
523	Required Written Documentation (RWD)
525	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)
526	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM)
527	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)
528	Waived Testing (WT) Endoscopy Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
529	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM)
530	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)
531	Medical Centers Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC)
532	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)
533	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)
534	Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
535	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)
536	Rights and Responsibilities of the Individual (RI) Transplant Safety (TS) Waived Testing (WT) Diagnostic/Therapeutic Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
537	Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM)
538	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)
539	Diagnostic Imaging Services Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
540	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)
541	Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Diagnostic Sleep Centers Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
542	Human Resources (HR) 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)
543	Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Kidney Care/Dialysis Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
544	Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM)
545	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) Telehealth/Nonsurgical Accreditation Participation Requirements (APR)
546	Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Information Management (IM) Leadership (LD) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
547	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Telehealth/Surgical Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Information Management (IM)
548	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) Episodic Care Accreditation Participation Requirements (APR)
549	Environment of Care (EC) 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) Provision of Care, Treatment, and Services (PC) Performanc Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
551	Transplant Safety (TS) Waived Testing (WT) Occupational/Worksite Health Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
552	Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG)
553	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) Urgent/Immediate Care Accreditation Participation Requirements (APR) Environment of Care (EC)
554	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
555	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)
556	Waived Testing (WT) Convenient Care Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
557	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
558	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT)
559	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Environment of Care (EC)
560	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
561	Life Safety (LS) Medication Management (MM) National Patient Safety Goals (NPSG)
562	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)
563	Primary Care Medical Home Certification Option (PCMH) Overview Primary Care Medical Home Model
564	I. Patient-Centered Care II. Comprehensive Care
565	III. Coordinated Care
566	IV. Superb Access to Care V. Systems-Based Approach to Quality and Safety
567	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
568	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
569	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
570	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
572	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
573	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
574	Elements of Performance for RI.01.01.01 Standard RI.01.01.03 Elements of Performance for RI.01.01.03
575	Standard RI.01.02.01 Elements of Performance for RI.01.02.01
576	Standard RI.01.03.01 Elements of Performance for RI.01.03.01
577	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
578	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
579	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
580	Standard PC.02.04.03 Elements of Performance for PC.02.04.03 Standard PC.02.04.05
581	Elements of Performance for PC.02.04.05 Rights and Responsibilities of the Individual (RI) Standard RI.01.04.03
582	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
583	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
584	Elements of Performance for PC.02.04.03 Standard PC.02.04.05 Elements of Performance for PC.02.04.05
585	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
586	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
587	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
588	V. Systems-Based Approach to Quality and Safety Leadership (LD) Standard LD.03.04.01 Elements of Performance for LD.03.04.01
589	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
590	Standard LD.03.09.01 Elements of Performance for LD.03.09.01
592	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
593	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
594	Elements of Performance for PI.01.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
595	Standard PI.04.01.01 Elements of Performance for PI.04.01.01
597	Glossary (GL)
633	Index (IX)