2016 ComprehensiveComprehensive Accreditation ... ComprehensiveComprehensive Accreditation...

2016 ComprehensiveComprehensive AccreditationAccreditationCAMH ManualManual forfor HospitalsHospitals

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What's NewJanuary 2016 Release

“What’s New” is intended to help you understand the substantive changes in the mostrecent E-dition® release. Please refer to the following table and to E-dition screens formore details about changes included in this release. Standards revisions can be foundeasily by clicking on “Filters” in the blue navigation bar across the top of the screen andchecking the “New/Changed EPs as of selected effective date” box. Major changes torequirements for accreditation policies, procedures, and other important information inthis update include the following:n Removed “selected direct and indirect impact requirements” as a risk category in the

Focused Standards Assessment (FSA) to reflect that these requirements were eitherreallocated to another risk category or are no longer recognized as a risk area. Thischange is reflected in the “How to Use This Manual” (HM) chapter and “TheAccreditation Process” (ACC) chapter, as well as through the removal of the iconfrom several elements of performance (EPs) throughout the standards chapters.

n Updated section formerly titled “Second Generation Tracers” (renamed “RiskAreas”) in the ACC chapter to more aptly reflect that this process involvessurveyors’ focused evaluation of risk areas

n Added sections to the ACC chapter about Immediate Threat to Health or Safetyfindings during survey, withdrawing from survey, and decision rules for organiza-tions seeking initial accreditation

CAMH , January 2016

E-dition January 1, 2016, Release

2016 ComprehensiveComprehensive AccreditationAccreditation ManualManual forforCAMH HospitalsHospitals

CAMH , January 2016

TypeType ofof ChangeChange EffectiveEffectiveDateDate

HowHow toto UseUse ThisThis ManualManual (HM)(HM)q Table 1. Acronyms Used in This Manual: Added entry for MOS Effective

(Measure of Success) immediatelyq Identifying Applicable Standards: Clarified standards applicability in

the print and E-dition® versions of the manualq Understanding the Icons Used in the Manual: Updated the

description of the risk iconq Keys to Successfully Achieving Standards Compliance: Added bullet

about educating staff on how to access standards through the E-dition and expanded bullet on compiling 12 months of performancemeasurement data

q Minor editorial revisionsPatientPatient SafetySafety SystemsSystems (PS)(PS)q Sidebar 1. Key Terms to Understand: Revised the term close call to Effective

include “no harm” events and clarified that event analyses are January 1,necessary to determine if practical prevention and mitigation 2016countermeasures are available

q Sidebar 2. Assessing Staff Accountability: Revised by clarifying thatthe Decision Tree is one of several sources that help organizationscreate decision processes and by adding a reference to the NationalPatient Safety Foundation’s RCA² report

q Appendix. Key Patient Safety Requirements: Revised by moving tothe end of the chapter (following the References) and adding the fulltext of each requirement

AccreditationAccreditation RequirementsRequirementsAccreditationAccreditation ParticipationParticipation RequirementsRequirements (APR)(APR)q Minor editorial revision Effective

immediatelyEnvironmentEnvironment ofof CareCare (EC)(EC)q Removed risk area icons from the following: Effective

January 1,n EC.01.01.01, EPs 3, 5, 7, 82016

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n EC.02.02.01, EPs 4, 10, 19n EC.02.04.01, EPs 1, 2, 8n EC.02.04.03, EPs 3, 4

q Added risk area icons to the following:n EC.02.01.01, EP 1n EC.02.02.01, EPs 1, 3, 5, 11, 12n EC.02.03.03, EPs 1, 5n EC.02.03.05, EPs 3, 18n EC.02.05.01, EPs 2, 4, 9, 14n EC.02.06.01, EPs 1, 13n EC.03.01.01, EP 2n EC.04.01.01, EP 14n EC.04.01.05, EP 1

q EC.02.01.01, EP 17: Changed to EC.02.02.01, EP 17 (effectiveimmediately)

q EC.02.01.03, EP 1: Added note to clarify that requirement appliesto all smoking types

q EC.02.05.05, EP 5: Changed to Category A and removed Measureof Success icon

EmergencyEmergency ManagementManagement (EM)(EM)q Added risk area icons to the following: Effective

January 1,n EM.01.01.01, EPs 1, 2, 82016

n EM.02.01.01, EPs 1, 2n EM.03.01.01, EPs 1–3n EM.03.01.03, EPs 1, 14

HumanHuman ResourcesResources (HR)(HR)q Removed risk area icons from the following: Effective

January 1,n HR.01.02.01, EP 12016

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n HR.01.02.05, EPs 1–7, 10–16, 18n HR.01.04.01, EPs 1–3, 5n HR.01.05.03, EPs 1, 4, 5, 13n HR.01.06.01, EPs 1, 2, 5, 6, 15n HR.01.07.01, EPs 2, 5

q Added risk area icon to HR.01.02.07, EPs 1, 2InfectionInfection PreventionPrevention andand ControlControl (IC)(IC)q Removed risk area icons from the following: Effective

January 1,n IC.01.05.01, EPs 2, 3, 5–82016

n IC.02.01.01, EPs 3, 10, 11n IC.02.02.01, EP 5

InformationInformation ManagementManagement (IM)(IM)q Removed risk area icons from the following: Effective

January 1,n IM.01.01.01, EPs 1–42016

n IM.01.01.03, EPs 1–6n IM.02.01.01, EPs 1–5n IM.02.01.03, EPs 1–8n IM.02.02.01, EPs 1–3n IM.02.02.03, EPs 1–3n IM.04.01.01, EP 1

LeadershipLeadership (LD)(LD)q Removed risk area icons from the following: Effective

January 1,n LD.03.01.01, EP 52016

n LD.03.02.01, EPs 1, 3–7n LD.03.06.01, EPs 1, 3–6n LD.04.01.05, EPs 1–4, 6, 8n LD.04.01.07, EPs 1, 2n LD.04.02.03, EP 5

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n LD.04.03.01, EP 1n LD.04.03.07, EP 2n LD.04.03.09, EPs 1–10, 23n LD.04.03.11, EPs 1–8n LD.04.04.03, EP 1n LD.04.04.05, EPs 1–14

LifeLife SafetySafety (LS)(LS)q Added risk area icons to the following: Effective

January 1,n LS.01.01.01, EP 42016

n LS.02.01.20, EP 1n LS.02.01.30, EP 2n LS.02.01.34, EP 2n LS.02.01.35, EP 9n LS.03.01.10, EP 3n LS.03.01.30, EP 5n LS.03.01.34, EP 2

q Minor editorial revisionsMedicationMedication ManagementManagement (MM)(MM)q Removed risk area icons from the following: Effective

January 1,n MM.06.01.03, EPs 6, 72016

n MM.06.01.05, EP 2q Added risk area icons to the following:

n MM.01.01.03, EP 5n MM.02.01.01, EP 15n MM.05.01.01, EP 7n MM.05.01.11, EP 4n MM.06.01.01, EP 2

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MedicalMedical StaffStaff (MS)(MS)q Removed risk area icons from the following: Effective

January 1,n MS.03.01.01, EPs 2, 16, 172016

n MS.03.01.03, EPs 1, 3–6, 12n MS.06.01.03, EP 6n MS.06.01.05, EPs 2, 3n MS.08.01.01, EPs 1–9n MS.08.01.03, EPs 1–3n MS.09.01.01, EPs 1, 2n MS.13.01.01, EP 1

q Added risk area icons to the following:n MS.04.01.01, EPs 1, 2n MS.06.01.01, EPs 1, 2n MS.06.01.03, EP 5n MS.06.01.05, EPs 1, 10n MS.06.01.09, EP 1n MS.06.01.13, EPs 1, 3

NationalNational PatientPatient SafetySafety GoalsGoals (NPSG)(NPSG)q NPSG.06.01.01, EPs 3, 4: Removed “January 1, 2016” effective Effective

date as this is the effective date for the entire update January 1,2016

NursingNursing (NR)(NR)q Removed risk area icons from the following: Effective

January 1,n NR.02.02.01, EPs 1–52016

n NR.02.03.01, EPs 1–4, 6, 7ProvisionProvision ofof Care,Care, Treatment,Treatment, andand ServicesServices (PC)(PC)q Removed risk area icons from the following: Effective

January 1,n PC.01.01.01, EP 72016

n PC.01.02.01, EPs 3, 4

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n PC.01.02.03, EPs 1, 6–8n PC.01.02.07, EP 4n PC.01.02.09, EP 2n PC.01.02.11, EPs 1–7n PC.01.02.13, EPs 1–7n PC.01.02.15, EPs 1–3n PC.01.03.03, EP 4n PC.02.01.03, EPs 1, 7n PC.02.01.05, EP 1n PC.02.03.01, EP 1n PC.03.01.09, EP 2n PC.03.02.07, EPs 2, 3n PC.03.03.07, EP 4n PC.03.03.19, EPs 2, 3n PC.03.03.23, EP 1n PC.03.03.25, EP 1n PC.04.01.01, EPs 1–4, 22–26n PC.04.01.03, EPs 1–4, 10, 11n PC.04.01.05, EPs 1, 3, 5, 7, 8n PC.04.02.01, EP 1n PC.05.01.09, EP 1

q PC.02.01.03, EP 1: Added language to Note (second bullet) toinclude licensing in accordance with Veterans Administration andDepartment of Defense requirements

PerformancePerformance ImprovementImprovement (PI)(PI)q About This Chapter: Added cross-reference to Standard PI.01.01.01 Effective

January 1,q Removed risk area icons from PI.02.01.01, EPs 1–5, 7, 8, 12–142016

q PI.02.01.03: Updated to reflect that standard and EP 1 are not ineffect in 2016

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CAMH , January 2016


RecordRecord ofof Care,Care, Treatment,Treatment, andand ServicesServices (RC)(RC)q Removed risk area icons from the following: Effective

January 1,n RC.01.01.01, EP 82016

n RC.02.01.01, EP 2n RC.02.04.01, EP 3

RightsRights andand ResponsibilitiesResponsibilities ofof thethe IndividualIndividual (RI)(RI)q Removed risk area icons from the following: Effective

January 1,n RI.01.01.01, EPs 2, 4, 10, 282016

n RI.01.02.01, EP 2n RI.01.03.01, EPs 1–7, 9, 11–13n RI.01.05.01, EPs 1, 4–6, 8–13, 15–17, 19, 20n RI.01.06.03, EPs 2–5

TransplantTransplant SafetySafety (TS)(TS)q Removed risk area icons from all chapter requirements Effective

January 1,2016

WaivedWaived TestingTesting (WT)(WT)q Removed risk area icons from the following: Effective

January 1,n WT.01.01.01, EP 62016

n WT.03.01.01, EP 5n WT.04.01.01, EPs 3, 4

AccreditationAccreditation ProcessProcess InformationInformationTheThe AccreditationAccreditation ProcessProcess (ACC)(ACC)q Primary Care Medical Home Certification Option: Added potential Effective

benefit of using the Provider Information Tool January 1,2016q Eligibility for Preliminary Accreditation: Streamlined information

about when organizations surveyed under the Early Survey Policyreceive a Preliminary Accreditation decision

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q During the Survey: Updated to reflect that off-shift activitiesconducted (as necessary) by surveyors are no longer restricted to fullsurveys of three or more days

q ISO Certification Option: Deleted section as this option is nolonger being evaluated for integration in the accreditation process

q Risk Areas: Revised section formerly titled “Second GenerationTracers” to more aptly reflect that this process involves surveyors’focused evaluation of risk areas

q Immediate Threat to Health or Safety During Initial Survey: Addedsection providing information about what happens when anImmediate Threat to Health or Safety is found at an organizationundergoing its first Joint Commission survey

q Figure 2: Qualified that figure showing process flow for ImmediateThreat to Health or Safety situations applies only to organizationsseeking reaccreditation

q The Summary of Survey Findings Report: Clarified that singleCategory C observations appear in the Opportunities forImprovement section of the report

q Decision Categories for Organizations Seeking Initial Accreditation:Clarified that Condition-level deficiencies during initial survey resultin a second initial Medicare survey

q Withdrawing from Initial Survey: Added section addressing whenorganizations may withdraw from initial survey without receivingDenial of Accreditation

q Measure of Success (MOS) Report: Added note explaining when anon-site follow-up survey replaces an MOS submission

q Intracycle Monitoring: Removed “selected direct and indirectimpact requirements” as a Focused Standards Assessment riskcategory to reflect that these requirements were either reallocated toanother risk area or are no longer recognized as a risk area

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q Extension Surveys: Revised extension survey time frame from“within 6 to 12 months” to “within 6 months” of when anorganization acquires a new entity for which The Joint Commissionhas standards or significantly alters its delivery of care, treatment, orservices

q Decision Rules for Organizations Seeking Reaccreditation:n Updated section title to emphasize the listed rules are for

organizations seeking renewal of accreditation (a separate sectionwas created for initial organizations)

n Revised Contingent Accreditation (CONT) decision ruleCONT02 and Accreditation with Follow-up Survey (AFS)decision rule AFS03 to reflect that organizations have twoopportunities to resolve issues

n Revised AFS08 regarding failure of Medicare follow-up surveyn Added Medicare Survey category and decision rule CLD01

addressing a Condition-level deficiency for organizations that useaccreditation for deemed status purposes

n Expanded Evidence of Standards Compliance (ESC) category byadding new decision rule ESC02 regarding submission of asecond ESC and renumbering former ESC02 to ESC03 (andremoved On-site ESC Survey decision rule category)

n Added Measure of Success (MOS) decision rule MOS02regarding submission of a second MOS

q Decision Rules for Organizations Seeking Initial Accreditation:n Added new section to isolate the specific rules that apply to

organizations undergoing their first Joint Commission surveyn Removed the categories Preliminary Denial of Accreditation

(PDA), CONT, and AFS that appear in the Decision Rules forOrganizations Seeking Reaccreditation, but included some of theconcepts from these categories in additional rules in the Denialof Accreditation (DA) category

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n Eliminated decision rule DA02 regarding resolving a CONT orAFS status, neither of which is applicable to organizationsseeking initial accreditation

StandardsStandards ApplicabilityApplicability GridGrid (SAG)(SAG)q EC.02.01.01, EP 17: Changed to EC.02.02.01, EP 17 (with Effective

applicability to Acute, Long Term Acute Care, Psychiatric, and immediatelySurgical Specialty services)

SentinelSentinel EventsEvents (SE)(SE)q Throughout chapter: The term “Sentinel Event Unit” has been Effective

changed to Office of Quality and Patient Safety January 1,2016q Sentinel Events: Revised opening paragraph to improve clarity

q Definition of Sentinel Event: Added detail to bulleted list describingappropriate response to a sentinel event

q Action plan: Revised bulleted list of what action plan must addressq Review of Comprehensive Systematic Analyses and Action Plans:

Added text to opening paragraph indicating that analyses should notfocus on individual performance, updated footnote reference, revisedcriteria for acceptable action plan

q Minor editorial revisionsPerformancePerformance MeasurementMeasurement andand thethe ORYXORYX®® InitiativeInitiative (PM)(PM)q Current Requirements for Hospitals: Deleted data collection date, Effective

revised births-per-year requirement necessary to initiate inclusion of January 1,Perinatal Care measure set with its selected core measures sets, and 2016deleted “quarterly” from the second and third measure reportingoptions

q Analyzing ORYX Data: Deleted online navigation informationq Use of Performance Measure Data: Updated contact information for

the ORYX Information Lineq Figures 1 through 4: Updated imagesq Minor editorial revisions

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EarlyEarly SurveySurvey PolicyPolicy OptionOption (ESP)(ESP)q EC.02.01.01, EP 17: Changed to EC.02.02.01, EP 17 Effective

January 1,2016

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