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JC EBAPG 2020

$111.04

Hospital Compliance Assessment Workbook

Published By Publication Date Number of Pages
Joint Commission 2020 562
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This title was completely reimagined for 2020! A straightforward, hands-on resource, the 2020 Hospital Compliance Assessment Workbook engages staff and leadership in accreditation activities with questions, templates, and tracer tools to identify areas of noncompliance. This self-assessment workbook is designed to help your hospital maintain continuous standards compliance and survey readiness to assess standards compliance and survey readiness. The simplified workbook includes ALL hospital standards and EPs, including those used for deemed status purposes and primary care medical home certification in the hospital setting. Buy one for each member of your accreditation team, or a site license for all to share! Key Topics • Assessment of standards compliance • Application of the SAFERTM Matrix • Tracer methodology • Risk assessment Key Features • Questions to assess each element of performance in the E-dition®/Comprehensive Accreditation Manual for Hospitals as of January 1, 2020 • Downloadable, adaptable tools and templates for standards compliance • Tracer questions and worksheets to help with mock tracers and promote survey readiness Standards: All hospital standards effective January 1, 2020 Setting: Organizations accredited under the Hospital Accreditation Program, including general, acute psychiatric, pediatric, medical/surgical specialty, long term acute care, and rehabilitation hospitals Key Audience • Accreditation managers • Quality improvement managers • Physician and nurse leaders • Chapter leaders and department heads

PDF Catalog

PDF Pages PDF Title
1 Cover/title page
2 Copyright
3 Contents
5 Introduction
13 Part 1: Compliance Assessment Checklist
15 Accreditation Participation Requirements (APR)
31 Environment of Care® (EC)
87 Emergency Management (EM)
123 Human Resources (HR)
137 Infection Prevention and Control (IC)
153 Information Management (IM)
163 Leadership (LD)
203 Life Safety (LS)
267 Medication Management (MM)
299 Medical Staff (MS)
351 National Patient Safety Goals® (NPSG)
379 Nursing (NR)
387 Provision of Care, Treatment, and Services (PC)
453 Performance Improvement (PI)
465 Record of Care, Treatment, and Services (RC)
481 Rights and Responsibilities of the Individual (RI)
505 Transplant Safety (TS)
519 Waived Testing (WT)
529 Part 2: Compliance Assessment Tools and Templates
531 Mock Tracers
533 Sidebar 2-1. How to Choose the Topic of a Mock Tracer
535 Sidebar 2-2. Tips for Formulating Mock Tracer Questions
538 Figure 2-1. Example Mock Tracer Form—Tracing a Hospital Fire
541 The SAFER Approach
Risk Assessment
542 Figure 2-2. Determining Where to Place an Element of Performance (EP) on the SAFER Matrix
543 Figure 2-3. Example of EP Placement on the SAFER Matrix
544 Figure 2-4. The Seven Basic Steps of the Risk-Assessment Process
546 Tool 2-1. Mock Tracer Planning Task List
547 Tool 2-2. Sample Mock Tracer Questions
552 Tool 2-3. Required Documents Checklist
554 Tool 2-4. Mock Tracer Form
555 Tool 2-5. Mock Tracer Evaluation Checklist
558 Tool 2-6. Corrective Action Plan Worksheet
559 Tool 2-7. Survey Analysis for Evaluating Risk® (SAFER™) Matrix
560 Tool 2-8. Proactive Risk-Assessment Worksheet
JC EBAPG 2020
$111.04