JCR CAMCAH 2023

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Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH)

Published By	Publication Date	Number of Pages
Joint Commission	2023

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Description

The 2023 Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH) provides all the information your organization needs to understand and maintain continuous standards compliance. It features the official Joint Commission standards, elements of performance, National Patient Safety Goals®, and other accreditation requirements, including those for the optional Primary Care Medical Home certification. The CAMCAH is spiral bound with color-coded tabs that allow you to find exactly what you need. Please note: The CAMCAH is published annually. It is not updated throughout the year. The most up-to-date standards throughout 2023 are available electronically through E-dition®, found on your Joint Commission Connect® extranet site, or are available for purchase. Not sure if your organization is a critical access hospital? A critical access hospital is defined by the Centers for Medicare & Medicaid Services as a hospital that offers limited services and is located more than 35 miles from a hospital or another critical access hospital or is certified by the state as being a necessary provider of health care services to residents in the area. It maintains no more than 25 beds that could be used for inpatient care. This manual won’t apply unless you meet those criteria. Key Topics: “Gold tab” standards requirements including the standards, National Patient Safety Goals®, and Accreditation Participation Requirements effective January 1, 2023 “Blue tab” accreditation process information about Joint Commission policies and procedures and practical survey preparation information on the Early Survey Policy, documentation requirements, and more Keys to successfully using the manual for survey preparedness Standards: All critical access hospital standards Setting: Critical access hospitals Key Audience: Staff responsible for accreditation, patient safety, or quality improvement in critical access hospitals or the distinct part psychiatric and/or rehabilitation distinct part units within a critical access hospital.

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2023 CAMCAH
15	Cover
16	Copyright
17	Contents
19	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
20	I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation
22	The Joint Commission’s Critical Access Hospital Accreditation Program
23	II. About the
24	How Is This Manual Organized? Table 1. Acronyms Used in This Manual
25	Table 1.
27	Accreditation Requirements
29	Accreditation Process Information
31	Identifying Applicable Standards
33	Understanding the Organization of the Standards Chapters
36	Understanding the Icons Used in the Manual
37	III. Steps to Achieving and Maintaining Compliance Become Familiar with the Standards Use the Standards to Improve Care, Treatment, and Services
38	Assess Compliance with the Standards
40	Stimulate Improvement
43	Keep Current with Standards Changes via Perspectives
44	IV. Get Extra Help Getting Started with Accreditation Account Executive
45	Contacting The Joint Commission Standards Questions Requesting Permission to Share Content from the Manual
47	Patient Safety Systems (PS) Quality and Safety in Health Care Sidebar 1. Key Terms
48	Sidebar 1.
49	Goals of This Chapter
50	Becoming a Learning Organization
51	The Role of Leaders in Patient Safety Safety Culture
55	Sidebar 2. Assessing Staff Accountability
56	Sidebar 2. Data Use and Reporting Systems
57	Effective Use of Data
59	Table 1. Defining and Comparing Analytical Tools
60	A Proactive Approach to Preventing Harm
62	Sidebar 3. Strategies for an Effective Risk Assessment
63	Sidebar 3. Encouraging Patient Activation
64	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
66	References
69	Accreditation Participation Requirements (APR) Overview
70	Chapter Outline
71	Requirements, Rationales, and Elements of Performance APR.01.01.01 Elements of Performance for APR.01.01.01 APR.01.02.01
72	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
73	APR.02.01.01 Elements of Performance for APR.02.01.01 APR.04.01.01 Elements of Performance for APR.04.01.01
74	APR.05.01.01
75	Rationale for APR.05.01.01 Elements of Performance for APR.05.01.01 APR.06.01.01 Elements of Performance for APR.06.01.01 APR.07.01.01 Elements of Performance for APR.07.01.01
76	APR.08.01.01 Elements of Performance for APR.08.01.01 APR.09.01.01 Elements of Performance for APR.09.01.01 APR.09.02.01
77	Rationale for APR.09.02.01 Elements of Performance for APR.09.02.01 APR.09.03.01 Elements of Performance for APR.09.03.01 APR.09.04.01
78	Elements of Performance for APR.09.04.01
79	Environment of Care (EC) Overview About This Chapter
80	Other Issues for Consideration
82	Chapter Outline
83	Standards, Rationales, and Elements of Performance Standard EC.01.01.01 Rationale for EC.01.01.01
84	Elements of Performance for EC.01.01.01 Standard EC.02.01.01 Rationale for EC.02.01.01
85	Elements of Performance for EC.02.01.01
86	Standard EC.02.01.03 Elements of Performance for EC.02.01.03
87	Standard EC.02.02.01 Elements of Performance for EC.02.02.01
89	Standard EC.02.03.01 Elements of Performance for EC.02.03.01
90	Standard EC.02.03.03 Elements of Performance for EC.02.03.03
92	Standard EC.02.03.05 Elements of Performance for EC.02.03.05
96	Standard EC.02.04.01 Elements of Performance for EC.02.04.01
98	Standard EC.02.04.03
99	Elements of Performance for EC.02.04.03
105	Standard EC.02.05.01 Elements of Performance for EC.02.05.01
110	Standard EC.02.05.02
111	Elements of Performance for EC.02.05.02
112	Standard EC.02.05.03 Elements of Performance for EC.02.05.03
115	Standard EC.02.05.05 Elements of Performance for EC.02.05.05
116	Standard EC.02.05.07
117	Rationale for EC.02.05.07 Elements of Performance for EC.02.05.07
119	Standard EC.02.05.09 Elements of Performance for EC.02.05.09
123	Introduction to Standard EC.02.06.01 Standard EC.02.06.01 Elements of Performance for EC.02.06.01
124	Standard EC.02.06.05 Elements of Performance for EC.02.06.05
125	Standard EC.03.01.01 Rationale for EC.03.01.01
126	Elements of Performance for EC.03.01.01 Standard EC.04.01.01 Elements of Performance for EC.04.01.01
127	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
129	Emergency Management (EM) Overview About This Chapter
131	Chapter Outline
132	Standards, Rationales, and Elements of Performance Introduction to the Emergency Management Program, Standard EM.09.01.01 Standard EM.09.01.01
133	Rationale for EM.09.01.01 Elements of Performance for EM.09.01.01
134	Introduction to Leadership, Standard EM.10.01.01 Standard EM.10.01.01 Rationale for EM.10.01.01
135	Elements of Performance for EM.10.01.01
137	Introduction to Hazard Vulnerability Analysis (HVA), Standard EM.11.01.01 Standard EM.11.01.01 Rationale for EM.11.01.01
138	Elements of Performance for EM.11.01.01
139	Introduction to the Emergency Operations Plan, Standard EM.12.01.01
140	Standard EM.12.01.01 Rationale for EM.12.01.01 Elements of Performance for EM.12.01.01
143	Introduction to Communications, Standard EM.12.02.01 Standard EM.12.02.01 Rationale for EM.12.02.01
144	Elements of Performance for EM.12.02.01
146	Introduction to Staffing, Standard EM.12.02.03 Standard EM.12.02.03
147	Rationale for EM.12.02.03 Elements of Performance for EM.12.02.03
148	Introduction to Patient Care and Clinical Support, Standard EM.12.02.05
149	Standard EM.12.02.05 Rationale for EM.12.02.05 Elements of Performance for EM.12.02.05 Introduction to Safety and Security, Standard EM.12.02.07
150	Standard EM.12.02.07 Rationale for EM.12.02.07 Elements of Performance for EM.12.02.07
151	Introduction to Resources and Assets, Standard EM.12.02.09
152	Standard EM.12.02.09 Rationale for EM.12.02.09 Elements of Performance for EM.12.02.09
153	Introduction to Utilities, Standard EM.12.02.11
154	Standard EM.12.02.11 Rationale for EM.12.02.11 Elements of Performance for EM.12.02.11
155	Introduction to the Continuity of Operations Plan (COOP), Standard EM.13.01.01
156	Standard EM.13.01.01 Rationale for EM.13.01.01 Elements of Performance for EM.13.01.01
157	Introduction to Disaster Recovery, Standard EM.14.01.01
158	Standard EM.14.01.01 Rationale for EM.14.01.01 Elements of Performance for EM.14.01.01
159	Introduction to Education and Training, Standard EM.15.01.01 Standard EM.15.01.01
160	Rationale for EM.15.01.01 Elements of Performance for EM.15.01.01
161	Introduction to Exercises and Testing, Standard EM.16.01.01
162	Standard EM.16.01.01 Rationale for EM.16.01.01 Elements of Performance for EM.16.01.01
164	Introduction to Evaluation, Standard EM.17.01.01 Standard EM.17.01.01 Rationale for EM.17.01.01 Elements of Performance for EM.17.01.01
167	Human Resources (HR) Overview About This Chapter
168	Chapter Outline
169	Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01
172	Standard HR.01.02.01 Elements of Performance for HR.01.02.01 Standard HR.01.02.05
173	Elements of Performance for HR.01.02.05
175	Standard HR.01.02.07 Elements of Performance for HR.01.02.07 Standard HR.01.03.01 Elements of Performance for HR.01.03.01 Standard HR.01.04.01
176	Elements of Performance for HR.01.04.01 Standard HR.01.05.03 Elements of Performance for HR.01.05.03
178	Introduction to Standards HR.01.06.01 and HR.01.07.01 Standard HR.01.06.01
179	Elements of Performance for HR.01.06.01 Standard HR.01.07.01 Elements of Performance for HR.01.07.01
181	Infection Prevention and Control (IC) Overview
182	About This Chapter
183	Chapter Outline
184	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
185	Standard IC.01.02.01
186	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
187	Elements of Performance for IC.01.04.01 Standard IC.01.05.01 Elements of Performance for IC.01.05.01 Standard IC.01.06.01 Elements of Performance for IC.01.06.01
188	Introduction to Standards IC.02.01.01 Through IC.02.04.01 – Implementation Standard IC.02.01.01 Elements of Performance for IC.02.01.01
190	Standard IC.02.02.01 Rationale for IC.02.02.01
191	Elements of Performance for IC.02.02.01 Standard IC.02.03.01
192	Elements of Performance for IC.02.03.01 Introduction to Standard IC.02.04.01
193	Standard IC.02.04.01 Elements of Performance for IC.02.04.01
194	Standard IC.02.04.02 Rationale for IC.02.04.02 Elements of Performance for IC.02.04.02
196	Standard IC.02.05.01
197	Elements of Performance for IC.02.05.01
198	Introduction to Standard IC.03.01.01— Evaluation and Improvement Standard IC.03.01.01 Elements of Performance for IC.03.01.01
199	Information Management (IM) Overview About This Chapter
200	Chapter Outline
201	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
202	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
203	Introduction to Standard IM.02.01.01 Standard IM.02.01.01
204	Elements of Performance for IM.02.01.01 Introduction to Standard IM.02.01.03
205	Standard IM.02.01.03 Elements of Performance for IM.02.01.03 Standard IM.02.02.01 Elements of Performance for IM.02.02.01
206	Introduction to Standard IM.02.02.03 Standard IM.02.02.03
207	Elements of Performance for IM.02.02.03 Standard IM.02.02.07 Rationale for IM.02.02.07
208	Elements of Performance for IM.02.02.07
209	Standard IM.03.01.01 Elements of Performance for IM.03.01.01
211	Leadership (LD) Overview
212	Proactive Risk Assessment
213	About This Chapter
215	Chapter Outline
216	Standards, Rationales, and Elements of Performance Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01
217	Standard LD.01.01.01 Rationale for LD.01.01.01 Elements of Performance for LD.01.01.01 Standard LD.01.02.01 Rationale for LD.01.02.01 Elements of Performance for LD.01.02.01
218	Standard LD.01.03.01 Rationale for LD.01.03.01 Elements of Performance for LD.01.03.01
219	Standard LD.01.04.01 Elements of Performance for LD.01.04.01 Standard LD.01.05.01 Elements of Performance for LD.01.05.01
220	Introduction to Leadership Relationships, Standards LD.02.01.01 Through LD.02.04.01 Standard LD.02.01.01 Rationale for LD.02.01.01 Elements of Performance for LD.02.01.01
221	Standard LD.02.02.01 Rationale for LD.02.02.01 Elements of Performance for LD.02.02.01 Introduction to Standard LD.02.04.01
222	Standard LD.02.04.01 Elements of Performance for LD.02.04.01
223	Introduction to Critical Access Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
225	Standard LD.03.01.01 Rationale for LD.03.01.01 Elements of Performance for LD.03.01.01
226	Standard LD.03.02.01 Rationale for LD.03.02.01 Elements of Performance for LD.03.02.01
227	Standard LD.03.03.01 Rationale for LD.03.03.01 Elements of Performance for LD.03.03.01 Standard LD.03.04.01
228	Rationale for LD.03.04.01 Elements of Performance for LD.03.04.01 Standard LD.03.05.01 Rationale for LD.03.05.01 Elements of Performance for LD.03.05.01
229	Standard LD.03.06.01 Rationale for LD.03.06.01 Elements of Performance for LD.03.06.01 Introduction to Operations, Standards LD.03.07.01 Through LD.04.03.11
230	Standard LD.03.07.01 Elements of Performance for LD.03.07.01 Standard LD.03.08.01
231	Elements of Performance for LD.03.08.01 Introduction to Standard LD.03.09.01 Standard LD.03.09.01
232	Elements of Performance for LD.03.09.01
234	Standard LD.03.10.01 Rationale for LD.03.10.01 Elements of Performance for LD.03.10.01 Standard LD.04.01.01 Elements of Performance for LD.04.01.01
237	Standard LD.04.01.03 Elements of Performance for LD.04.01.03 Standard LD.04.01.05 Rationale for LD.04.01.05
238	Elements of Performance for LD.04.01.05
239	Standard LD.04.01.06 Elements of Performance for LD.04.01.06 Standard LD.04.01.07 Elements of Performance for LD.04.01.07
240	Standard LD.04.01.10 Elements of Performance for LD.04.01.10 Standard LD.04.01.11
241	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
242	Standard LD.04.02.03 Elements of Performance for LD.04.02.03
243	Standard LD.04.02.05 Rationale for LD.04.02.05 Elements of Performance for LD.04.02.05 Standard LD.04.03.01 Elements of Performance for LD.04.03.01
246	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
247	Standard LD.04.03.08 Rationale for LD.04.03.08
248	Elements of Performance for LD.04.03.08
249	Introduction to Oversight of Care, Treatment, and Services Provided Through Contractual Agreement, Standard LD.04.03.09
250	Monitoring Contracted Services
251	Standard LD.04.03.09 Elements of Performance for LD.04.03.09
254	Standard LD.04.03.11 Rationale for LD.04.03.11 Elements of Performance for LD.04.03.11 Introduction to Standard LD.04.03.13
255	Standard LD.04.03.13 Elements of Performance for LD.04.03.13
257	Life Safety (LS) Overview About This Chapter
260	Chapter Outline
261	Standards, Rationales, and Elements of Performance Introduction to Standard LS.01.01.01 Standard LS.01.01.01 Elements of Performance for LS.01.01.01
263	Standard LS.01.02.01 Elements of Performance for LS.01.02.01
265	Standard LS.02.01.10 Rationale for LS.02.01.10
266	Elements of Performance for LS.02.01.10
268	Standard LS.02.01.20 Rationale for LS.02.01.20
269	Elements of Performance for LS.02.01.20
275	Standard LS.02.01.30
276	Rationale for LS.02.01.30 Elements of Performance for LS.02.01.30
282	Standard LS.02.01.34 Elements of Performance for LS.02.01.34
283	Standard LS.02.01.35 Elements of Performance for LS.02.01.35
285	Standard LS.02.01.40 Elements of Performance for LS.02.01.40
286	Standard LS.02.01.50 Elements of Performance for LS.02.01.50
288	Standard LS.02.01.70 Elements of Performance for LS.02.01.70
290	Standard LS.03.01.10 Elements of Performance for LS.03.01.10
292	Standard LS.03.01.20
293	Rationale for LS.03.01.20 Elements of Performance for LS.03.01.20
295	Standard LS.03.01.30
296	Elements of Performance for LS.03.01.30
299	Standard LS.03.01.34 Elements of Performance for LS.03.01.34
301	Standard LS.03.01.35 Elements of Performance for LS.03.01.35
302	Standard LS.03.01.40
303	Elements of Performance for LS.03.01.40 Standard LS.03.01.50
304	Elements of Performance for LS.03.01.50
305	Standard LS.03.01.70
306	Elements of Performance for LS.03.01.70
307	Standard LS.05.01.10 Elements of Performance for LS.05.01.10
308	Standard LS.05.01.20 Elements of Performance for LS.05.01.20
309	Standard LS.05.01.30 Elements of Performance for LS.05.01.30
310	Standard LS.05.01.34 Elements of Performance for LS.05.01.34
311	Standard LS.05.01.35 Elements of Performance for LS.05.01.35
313	Medication Management (MM) Overview
314	About This Chapter
316	Chapter Outline
317	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 Standard MM.01.01.03
318	Rationale for MM.01.01.03 Elements of Performance for MM.01.01.03
319	Standard MM.01.02.01 Elements of Performance for MM.01.02.01 Standard MM.02.01.01
320	Elements of Performance for MM.02.01.01
321	Standard MM.03.01.01 Rationale for MM.03.01.01 Elements of Performance for MM.03.01.01
322	Standard MM.03.01.03 Rationale for MM.03.01.03
323	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
324	Introduction to Standard MM.04.01.01 Standard MM.04.01.01 Elements of Performance for MM.04.01.01
326	Standard MM.05.01.01 Elements of Performance for MM.05.01.01
327	Standard MM.05.01.07
328	Elements of Performance for MM.05.01.07 Standard MM.05.01.09 Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09
329	Standard MM.05.01.11 Elements of Performance for MM.05.01.11 Standard MM.05.01.13
330	Rationale for MM.05.01.13 Elements of Performance for MM.05.01.13 Standard MM.05.01.15 Elements of Performance for MM.05.01.15
331	Standard MM.05.01.17 Elements of Performance for MM.05.01.17 Standard MM.05.01.19
332	Rationale for MM.05.01.19 Elements of Performance for MM.05.01.19 Standard MM.06.01.01 Elements of Performance for MM.06.01.01
333	Standard MM.06.01.03 Elements of Performance for MM.06.01.03
334	Standard MM.06.01.05 Rationale for MM.06.01.05 Elements of Performance for MM.06.01.05
335	Standard MM.07.01.01 Elements of Performance for MM.07.01.01 Standard MM.07.01.03 Rationale for MM.07.01.03 Elements of Performance for MM.07.01.03
336	Standard MM.08.01.01 Elements of Performance for MM.08.01.01
337	Standard MM.09.01.01 Elements of Performance for MM.09.01.01
341	Medical Staff (MS) Overview
342	Medical Staff Structure
343	Chapter Outline
344	Standards, Rationales, and Elements of Performance Introduction to Standard MS.01.01.01
345	Standard MS.01.01.01 Elements of Performance for MS.01.01.01
349	Standard MS.02.01.01 Elements of Performance for MS.02.01.01
350	Introduction to Standard MS.03.01.01 Management of Patient Care, Treatment, and Services Standard MS.03.01.01 Rationale for MS.03.01.01 Elements of Performance for MS.03.01.01
352	Standard MS.03.01.03 Rationale for MS.03.01.03
353	Elements of Performance for MS.03.01.03
354	Standard MS.05.01.01 Rationale for MS.05.01.01 Elements of Performance for MS.05.01.01
356	Introduction to Standard MS.06.01.01 Credentialing and Privileging
357	Standard MS.06.01.01 Rationale for MS.06.01.01 Elements of Performance for MS.06.01.01
358	Introduction to Standard MS.06.01.03 Credentialing
360	Standard MS.06.01.03 Rationale for MS.06.01.03 Elements of Performance for MS.06.01.03
362	Introduction to Standard MS.06.01.05 Privileging Standard MS.06.01.05 Elements of Performance for MS.06.01.05
365	Standard MS.06.01.07 Elements of Performance for MS.06.01.07
366	Standard MS.06.01.09 Elements of Performance for MS.06.01.09 Standard MS.06.01.13 Rationale for MS.06.01.13
367	Elements of Performance for MS.06.01.13 Standard MS.07.01.01
368	Elements of Performance for MS.07.01.01 Introduction to Standard MS.08.01.01 Focused Professional Practice Evaluation
369	Standard MS.08.01.01 Rationale for MS.08.01.01 Elements of Performance for MS.08.01.01
370	Introduction to Standard MS.08.01.03
371	Standard MS.08.01.03 Elements of Performance for MS.08.01.03 Standard MS.09.01.01
372	Rationale for MS.09.01.01 Elements of Performance for MS.09.01.01 Introduction to Standard MS.13.01.01 Telemedicine
373	Standard MS.13.01.01 Rationale for MS.13.01.01 Elements of Performance for MS.13.01.01
377	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals® Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
378	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
379	Goal 2 NPSG.02.03.01 Rationale for NPSG.02.03.01 Elements of Performance for NPSG.02.03.01
380	Goal 3 NPSG.03.04.01 Rationale for NPSG.03.04.01 Elements of Performance for NPSG.03.04.01
381	NPSG.03.05.01
382	Rationale for NPSG.03.05.01 Elements of Performance for NPSG.03.05.01
383	Introduction to Reconciling Medication Information
384	NPSG.03.06.01 Rationale for NPSG.03.06.01
385	Elements of Performance for NPSG.03.06.01
386	Goal 6 NPSG.06.01.01 Rationale for NPSG.06.01.01 Elements of Performance for NPSG.06.01.01
387	Goal 7 NPSG.07.01.01
388	Rationale for NPSG.07.01.01 Elements of Performance for NPSG.07.01.01 Goal 15 NPSG.15.01.01
389	Elements of Performance for NPSG.15.01.01
390	Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
391	UP.01.01.01 Rationale for UP.01.01.01
392	Elements of Performance for UP.01.01.01 Introduction to UP.01.02.01
393	UP.01.02.01 Elements of Performance for UP.01.02.01
394	UP.01.03.01
395	Rationale for UP.01.03.01 Elements of Performance for UP.01.03.01
397	Nursing (NR) Overview
398	Chapter Outline
399	Standards, Rationales, and Elements of Performance Standard NR.01.01.01 Rationale for NR.01.01.01 Elements of Performance for NR.01.01.01
400	Standard NR.01.02.01 Elements of Performance for NR.01.02.01 Standard NR.02.01.01 Elements of Performance for NR.02.01.01
401	Standard NR.02.02.01 Elements of Performance for NR.02.02.01 Standard NR.02.03.01 Elements of Performance for NR.02.03.01
403	Provision of Care, Treatment, and Services (PC) Overview
404	About This Chapter
405	Chapter Outline
406	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
407	Standard PC.01.02.01 Elements of Performance for PC.01.02.01
409	Standard PC.01.02.03 Elements of Performance for PC.01.02.03
411	Standard PC.01.02.05 Elements of Performance for PC.01.02.05 Introduction to Standard PC.01.02.07
412	Standard PC.01.02.07 Elements of Performance for PC.01.02.07
414	Standard PC.01.02.08 Elements of Performance for PC.01.02.08 Introduction to Standard PC.01.02.09 Standard PC.01.02.09 Elements of Performance for PC.01.02.09
415	Introduction to Standard PC.01.02.13 Standard PC.01.02.13 Elements of Performance for PC.01.02.13
417	Standard PC.01.02.15 Elements of Performance for PC.01.02.15
419	Introduction to Standard PC.01.03.01 Standard PC.01.03.01 Elements of Performance for PC.01.03.01
421	Standard PC.02.01.01 Elements of Performance for PC.02.01.01
422	Standard PC.02.01.03 Elements of Performance for PC.02.01.03
423	Standard PC.02.01.05 Elements of Performance for PC.02.01.05 Standard PC.02.01.09 Elements of Performance for PC.02.01.09 Standard PC.02.01.11
424	Elements of Performance for PC.02.01.11
425	Standard PC.02.01.19 Rationale for PC.02.01.19 Elements of Performance for PC.02.01.19 Standard PC.02.01.20 Elements of Performance for PC.02.01.20
426	Standard PC.02.01.21 Elements of Performance for PC.02.01.21
427	Introduction to Standard PC.02.02.01 Standard PC.02.02.01 Elements of Performance for PC.02.02.01
428	Standard PC.02.02.03 Elements of Performance for PC.02.02.03
429	Introduction to Standard PC.02.03.01 Standard PC.02.03.01 Elements of Performance for PC.02.03.01
430	Standard PC.02.04.01
431	Elements of Performance for PC.02.04.01 Standard PC.02.04.03 Elements of Performance for PC.02.04.03
432	Standard PC.02.04.05 Elements of Performance for PC.02.04.05
434	Standard PC.02.04.06 Elements of Performance for PC.02.04.06 Introduction to Standards PC.03.01.01 Through PC.03.01.07
435	Standard PC.03.01.01 Elements of Performance for PC.03.01.01
437	Standard PC.03.01.03 Elements of Performance for PC.03.01.03
438	Standard PC.03.01.05 Elements of Performance for PC.03.01.05 Standard PC.03.01.07 Elements of Performance for PC.03.01.07
439	Standard PC.03.01.08 Elements of Performance for PC.03.01.08 Standard PC.03.05.01 Elements of Performance for PC.03.05.01
440	Standard PC.03.05.03 Elements of Performance for PC.03.05.03 Standard PC.03.05.05 Elements of Performance for PC.03.05.05
441	Standard PC.03.05.07 Elements of Performance for PC.03.05.07
442	Standard PC.03.05.09 Elements of Performance for PC.03.05.09
443	Standard PC.03.05.11 Elements of Performance for PC.03.05.11
444	Standard PC.03.05.13 Elements of Performance for PC.03.05.13 Standard PC.03.05.15 Elements of Performance for PC.03.05.15
445	Standard PC.03.05.17 Elements of Performance for PC.03.05.17
446	Standard PC.03.05.19 Elements of Performance for PC.03.05.19
447	Standard PC.04.01.01
448	Elements of Performance for PC.04.01.01
449	Standard PC.04.01.03 Elements of Performance for PC.04.01.03
451	Standard PC.04.01.05 Elements of Performance for PC.04.01.05
452	Standard PC.04.01.07 Elements of Performance for PC.04.01.07
453	Standard PC.04.02.01 Elements of Performance for PC.04.02.01 Standard PC.05.01.09
454	Elements of Performance for PC.05.01.09
455	Performance Improvement (PI) Overview About This Chapter
457	Chapter Outline
458	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
460	Standard PI.02.01.01 Rationale for PI.02.01.01
461	Elements of Performance for PI.02.01.01 Introduction to Standard PI.03.01.01
462	Standard PI.03.01.01 Elements of Performance for PI.03.01.01
463	Standard PI.04.01.01
464	Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
465	Record of Care, Treatment, and Services (RC) Overview About This Chapter
466	Chapter Outline
467	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
468	Standard RC.01.03.01 Elements of Performance for RC.01.03.01
469	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 Standard RC.02.01.01 Elements of Performance for RC.02.01.01
472	Standard RC.02.01.03 Elements of Performance for RC.02.01.03
474	Standard RC.02.03.07 Elements of Performance for RC.02.03.07 Standard RC.02.04.01
475	Elements of Performance for RC.02.04.01
477	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
479	Chapter Outline
480	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
482	Introduction to Standard RI.01.01.03
483	Standard RI.01.01.03 Elements of Performance for RI.01.01.03 Standard RI.01.02.01
484	Elements of Performance for RI.01.02.01
485	Standard RI.01.03.01 Rationale for RI.01.03.01
486	Elements of Performance for RI.01.03.01 Standard RI.01.03.05 Elements of Performance for RI.01.03.05
487	Standard RI.01.04.01 Elements of Performance for RI.01.04.01 Standard RI.01.04.03
488	Elements of Performance for RI.01.04.03
489	Standard RI.01.05.01 Elements of Performance for RI.01.05.01
490	Standard RI.01.06.01 Elements of Performance for RI.01.06.01 Standard RI.01.06.03 Elements of Performance for RI.01.06.03
491	Standard RI.01.06.05 Elements of Performance for RI.01.06.05
492	Standard RI.01.06.09 Elements of Performance for RI.01.06.09 Standard RI.01.06.11
493	Elements of Performance for RI.01.06.11 Standard RI.01.07.01 Rationale for RI.01.07.01 Elements of Performance for RI.01.07.01
494	Standard RI.01.07.05 Rationale for RI.01.07.05 Elements of Performance for RI.01.07.05
495	Standard RI.01.07.13 Elements of Performance for RI.01.07.13
497	Transplant Safety (TS) Overview
498	About This Chapter
499	Chapter Outline
500	Standards, Rationales, and Elements of Performance Introduction to Standard TS.01.01.01 Standard TS.01.01.01 Elements of Performance for TS.01.01.01
502	Standard TS.02.01.01 Elements of Performance for TS.02.01.01
503	Introduction to Standards TS.03.01.01, TS.03.02.01, and TS.03.03.01 Examples of Tissue and Cell Products
505	Standard TS.03.01.01 Elements of Performance for TS.03.01.01
507	Standard TS.03.02.01 Elements of Performance for TS.03.02.01
508	Standard TS.03.03.01 Elements of Performance for TS.03.03.01
509	Waived Testing (WT) Overview
510	About This Chapter
512	Chapter Outline
513	Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01
514	Standard WT.02.01.01 Elements of Performance for WT.02.01.01
515	Standard WT.03.01.01 Elements of Performance for WT.03.01.01
516	Standard WT.04.01.01 Elements of Performance for WT.04.01.01
517	Standard WT.05.01.01 Elements of Performance for WT.05.01.01
519	The Accreditation Process (ACC) Notices ACC Chapter Contents
521	Overview General Eligibility Requirements
522	Initial Surveys
523	Scope of Accreditation Surveys Accreditation Policies Tailored Survey Policy
524	Organizational and Functional Integration
527	Inclusion of Physician Practices in Survey Multiorganization Option Concurrent Survey Option
528	Contracted Services Integrated Care Certification Option
529	Primary Care Medical Home Certification Option
530	Patient Blood Management Certification Option
531	Survey Postponement Policy Information Accuracy and Truthfulness Policy
533	Good Faith Participation in Accreditation/ Certification
534	Public Information Policy‡
535	Process for Responding to a Complaint
536	Early Survey Policy Sidebar 1. Early Survey Policy
539	Before the Survey An Organization’s Secure Joint Commission Connect Extranet Site
540	Role of the Account Executive Electronic Application for Accreditation (E-App)
541	Accreditation/Certification Contract and Business Associate Agreement
542	Annual and Survey Fees
543	During the Survey
544	Survey Notification Table 1. Exceptions to Unannounced Surveys\|\|
546	Initial and Full Survey Team Composition
547	Survey Agenda
552	Tracer Methodology
553	Table 2. Critical Access Hospital–Specific Tracer Applicability and Objectives
556	Immediate Threat to Health or Safety
560	Summary of the Accreditation Reports
561	After the Survey The Scoring Process
567	Evidence of Standards Compliance (ESC) Process
570	Accreditation Award Display and Use
572	Recommendation Letter for Critical Access Hospitals That Use Joint Commission Accreditation for Deemed Status Purposes Between Accreditation Surveys Duration of Accreditation Award
573	Continuous Compliance Intracycle Monitoring (ICM)
574	Focused Standards Assessment (FSA)
575	Sidebar 2. Focused Standards Assessment (FSA) Options
576	Sidebar 2. Sentinel Event Follow-up Notifying The Joint Commission About Organization Changes
578	Accreditation Status of Organizations That Cease Services After a Disaster
580	Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time
581	Reentering the Accreditation Process
582	Additional Surveys
584	Decision Rules for Organizations Seeking Initial Accreditation Accredited
585	Primary Care Medical Home Certification Limited, Temporary Accreditation
586	Evidence of Standards Compliance (ESC) One-Month Survey Medicare Deficiency Follow-up Survey
587	Denial of Accreditation
588	Decision Rules for Organizations Seeking Reaccreditation Accredited Primary Care Medical Home Certification
589	Evidence of Standards Compliance (ESC) One-Month Survey Medicare Deficiency Follow-up Survey
590	Accreditation with Follow-up Survey
591	Preliminary Denial of Accreditation
592	Denial of Accreditation
593	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
595	Process for Organizations That Meet Decision Rule PDA04
596	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
597	II. Accreditation with Follow-up Survey
598	III. Review Hearings
599	IV. Following a Review Hearing
600	V. Final Review &Appeal Request
603	Standards Applicability Grid (SAG)
639	Sentinel Event Policy (SE)
640	Goals of the Sentinel Event Policy
641	Identifying Sentinel Events
643	Sidebar 1. Key Terms
644	Sidebar 1.
646	Determining That a Sentinel Event Is Subject to Review Relationship to the Survey Process
647	Required Organization Response to a Sentinel Event
649	Reporting a Sentinel Event to The Joint Commission
651	Conducting a Comprehensive Systematic Analysis
652	Developing a Corrective Action Plan
653	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
654	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
655	Table 1.
656	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
657	Follow-up Activities
659	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
660	Overseeing the Sentinel Event Policy
661	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
662	What Will My Quality Report Contain?
663	What Is Quality Check?
664	Is a Quality Report Available for My Accredited Critical Access Hospital? Can My Critical Access Hospital Comment on Its Quality Report? How Does My Critical Access Hospital Submit a Commentary? Are There Any Criteria That Must Be Met in a Commentary?
665	What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
666	Guidelines for Publicizing Compliance with the National Patient Safety Goals
667	Information Released by The Joint Commission Guidelines for Publication
669	Performance Measurement and the ORYX Initiative (PM) Overview The Continued Role of ORYX
670	Accelerate PI™
671	Use of Performance Measure Data Current Requirements for Critical Access Hospitals
673	Required Written Documentation (RWD)
674	List of EPs Requiring Written Documentation for Critical Access Hospitals by Service Acute Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR)
675	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM)
676	Medical Staff (MS) National Patient Safety Goals (NPSG) (including the Universal Protocol [UP]) Nursing (NR) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC)
677	Rights and Responsibilities of the Individual (RI) Transplant Safety (TS) Waived Testing (WT) Inpatient Rehab Distinct Part Unit Environment of Care (EC) Leadership (LD) Medication Management (MM)
678	Medical Staff (MS) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Psychiatric Distinct Part Unit Environment of Care (EC)
679	Leadership (LD) Medication Management (MM) Medical Staff (MS) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
680	Swing Beds Environment of Care (EC) Human Resources (HR) Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Rights and Responsibilities of the Individual (RI)
681	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Environment of Care (EC)
682	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
683	Leadership (LD) Life Safety (LS) Medication Management (MM)
684	Medical Staff (MS) National Patient Safety Goals (NPSG) Nursing (NR) Provision of Care, Treatment, and Services (PC)
685	Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Transplant Safety (TS) Waived Testing (WT)
687	Primary Care Medical Home Certification Option (PCMH) Overview Primary Care Medical Home Model
688	I. Patient-Centered Care II. Comprehensive Care
689	III. Coordinated Care
690	IV. Superb Access to Care V. Systems-Based Approach to Quality and Safety
691	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
692	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
693	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
694	Standard PC.02.01.21 Elements of Performance for PC.02.01.21 Standard PC.02.02.01 Elements of Performance for PC.02.02.01
695	Standard PC.02.03.01 Elements of Performance for PC.02.03.01
696	Standard PC.02.04.05 Elements of Performance for PC.02.04.05 Record of Care, Treatment, and Services (RC) Standard RC.02.01.01 Elements of Performance for RC.02.01.01
697	Rights and Responsibilities of the Individual (RI) Standard RI.01.01.01 Elements of Performance for RI.01.01.01
699	Standard RI.01.01.03 Elements of Performance for RI.01.01.03 Standard RI.01.02.01 Elements of Performance for RI.01.02.01
701	Standard RI.01.03.01 Elements of Performance for RI.01.03.01
702	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
703	Standard RI.01.05.01 Elements of Performance for RI.01.05.01
704	Standard RI.01.07.01 Elements of Performance for RI.01.07.01
705	II. Comprehensive Care Leadership (LD) Standard LD.04.01.06 Elements of Performance for LD.04.01.06 Medical Staff (MS) Standard MS.03.01.01 Elements of Performance for MS.03.01.01
706	Provision of Care, Treatment, and Services (PC) Standard PC.02.01.05 Elements of Performance for PC.02.01.05 Standard PC.02.04.03 Elements of Performance for PC.02.04.03
707	Standard PC.02.04.05 Elements of Performance for PC.02.04.05
708	III. Coordinated Care Human Resources (HR) Standard HR.01.02.07 Elements of Performance for HR.01.02.07 Medical Staff (MS) Standard MS.03.01.01 Elements of Performance for MS.03.01.01 Provision of Care, Treatment, and Services (PC) Standard PC.01.03.01
709	Elements of Performance for PC.01.03.01 Standard PC.02.02.01 Elements of Performance for PC.02.02.01
710	Standard PC.02.04.03 Elements of Performance for PC.02.04.03 Standard PC.02.04.05 Elements of Performance for PC.02.04.05
711	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
712	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
713	Record of Care, Treatment, and Services (RC) Standard RC.01.01.01 Elements of Performance for RC.01.01.01
714	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
715	V. Systems-Based Approach to Quality and Safety Leadership (LD) Standard LD.01.03.01 Elements of Performance for LD.01.03.01 Standard LD.03.04.01 Elements of Performance for LD.03.04.01
716	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 Standard LD.03.09.01 Elements of Performance for LD.03.09.01
718	Standard LD.03.10.01
719	Elements of Performance for LD.03.10.01 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
720	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 Elements of Performance for PI.01.01.01
721	Standard PI.03.01.01 Elements of Performance for PI.03.01.01 Standard PI.04.01.01 Elements of Performance for PI.04.01.01
723	Appendix A: Medicare Requirements for Critical Access Hospitals (AXA) 485.610 Condition of Participation: Status and Location
724	485.616 Condition of Participation: Agreements
727	485.627 Condition of Participation: Organizational Structure 485.635 Condition of Participation: Provision of Services
728	485.641 Condition of Participation: Periodic Evaluation and Quality Assurance Review
729	Appendix B: Medicare Requirements for Critical Access Hospitals with DPUs (AXB) Part 409 Subpart B—Inpatient Hospital Services and Inpatient Critical Access Hospital Services
730	409.17: Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services
731	412.25 Excluded Hospital Units: Common Requirements
733	412.29 Excluded Rehabilitation Units: Additional Requirements
734	412.30 Exclusion of New Rehabilitation Units and Expansion of Units Already Excluded
736	482.12 Condition of Participation: Governing Body
737	482.22 Condition of Participation: Medical Staff
739	482.24 Condition of Participation: Medical Record Services
740	482.27 Condition of Participation: Laboratory Services
744	482.30 Condition of Participation: Utilization Review
747	482.51 Condition of Participation: Surgical Services
749	Glossary (GL)
791	Index (IX)