JCR CAMLAB 2022
$178.21
Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing (CAMLAB)
| Published By | Publication Date | Number of Pages |
| Joint Commission | 2022 | 784 |
Continuous compliance starts with staff who know what The Joint Commission requires. The 2022 Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing (CAMLAB) provides the key information your organization needs to power performance improvement and maintain continuous standards compliance. It features the official Joint Commission standards, National Patient Safety Goals®, and other accreditation requirements. The portable CAMLAB is spiral bound with color-coded tabs that allow you to find exactly what you need for standards compliance or survey readiness when you need it. Inside you’ll find descriptions of the survey and decision process, questions to prompt discussion in your organization about compliance with the standards, checklists of the elements of performance that require written documentation, and action planning worksheets to address any issues of noncompliance. It’s lean and light, making it a perfect on-the-go reference. Keep it handy in meetings, during orientation and training, and as a practical overview of the Joint Commission’s accreditation requirements for everyone in your organization, from staff to leaders. Then, get ready to power performance improvement and excellence in your laboratory services! Please note: The CAMLAB is delivered annually. For the most up-to-date standards throughout 2022, access your E-dition® on your Joint Commission Connect® extranet site or consider purchasing the E-dition® Laboratory version. Key Topics: “Gold tab” standards requirements including the standards, National Patient Safety Goals, and Accreditation Participation Requirements effective January 1, 2022 “Blue tab” accreditation process information about Joint Commission policies and procedures and practical survey preparation information on the Early Survey Policy, documentation requirements, patient safety systems and more Several appendixes, including one on standards related to Individualized Quality Control Plans (IQCP) and a new one on duplicated standards between the laboratory and hospital accreditation programs Keys to successfully using the manual for survey preparedness Key Features: Survey readiness tools including compliance prompts, documentation checklists, and action planning worksheets in every standards chapter Icons to help navigate documentation requirements as well as risk areas “What’s New” summary of changes made since the previous print edition Color-coded blue and gold tabs allow you to find exactly what you need when you need it Softcover, spiral-bound book Standards: All laboratory standards Setting: Organizations accredited under the Laboratory Accreditation Program, including Laboratories in hospitals, clinics, nursing care facilities, home care organizations, behavioral health care organizations, ambulatory sites and physician offices Reference laboratories Freestanding laboratories, such as assisted reproductive technology laboratories Blood transfusion and donor center laboratories Public health laboratories, including Indian Health Service laboratories Laboratories in federal health care facilities, such as the Department of Veterans Affairs Point-of-care test sites in patient care areas, which may include blood gas laboratories providing services to patients in emergency rooms, surgical suites, and cardiac catheterization laboratories Key Audience: Staff responsible for accreditation, compliance, patient safety,
PDF Catalog
| PDF Pages | PDF Title |
|---|---|
| 1 | What’s New 2022 CAMLAB |
| 11 | Cover |
| 12 | Copyright |
| 13 | Contents |
| 15 | Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO) |
| 16 | I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation |
| 18 | The Joint Commission’s Laboratory Accreditation Program |
| 19 | Addressing Complex Issues in Laboratories Accredited by The Joint Commission |
| 20 | Table 1. Standards That Address Complex Issues in Laboratories |
| 21 | II. About the |
| 22 | How Is This Manual Organized? |
| 23 | Table 2. Acronyms Used in This Manual |
| 24 | Table 2. |
| 25 | Accreditation Requirements |
| 26 | Accreditation Process Information |
| 28 | Identifying Applicable Standards |
| 30 | Understanding the Organization of the Standards Chapters |
| 33 | Understanding the Icons Used in the Manual |
| 34 | III. Steps to Achieving and Maintaining Compliance Become Familiar with the Standards Use the Standards to Improve Quality |
| 35 | Assess Compliance with the Standards |
| 36 | Stimulate Improvement |
| 38 | Keep Current with Standards Changes via Perspectives |
| 40 | IV. Get Extra Help Getting Started with Accreditation Account Executive Contacting The Joint Commission |
| 41 | Standards Questions Requesting Permission to Share Content from the Manual |
| 43 | Patient Safety Systems (PS) Quality and Safety in Laboratories Sidebar 1. Key Terms |
| 44 | Sidebar 1. |
| 45 | Goals of This Chapter |
| 46 | Becoming a Learning Organization |
| 47 | The Role of Leaders in Patient Safety Safety Culture |
| 51 | Sidebar 2. Assessing Staff Accountability |
| 52 | Sidebar 2. Data Use and Reporting Systems |
| 53 | Effective Use of Data |
| 54 | Table 1. Defining and Comparing Analytical Tools |
| 55 | A Proactive Approach to Preventing Harm |
| 58 | Sidebar 3. Strategies for an Effective Risk Assessment Encouraging Patient Activation |
| 59 | Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner |
| 61 | References |
| 65 | Accreditation Participation Requirements (APR) Overview |
| 66 | Chapter Outline |
| 67 | Requirements, Rationales, and Elements of Performance APR.01.01.01 Elements of Performance for APR.01.01.01 APR.01.02.01 Rationale for APR.01.02.01 |
| 68 | Elements of Performance for APR.01.02.01 APR.01.03.01 Elements of Performance for APR.01.03.01 APR.02.01.01 |
| 69 | 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 APR.06.01.01 Elements of Performance for APR.06.01.01 APR.07.01.01 Elements of Performance for APR.07.01.01 |
| 70 | 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 |
| 71 | 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 Elements of Performance for APR.09.04.01 |
| 72 | APR.10.03.01 Elements of Performance for APR.10.03.01 |
| 76 | Written Documentation Checklist Accreditation Participation Requirements (APR) |
| 79 | Document and Process Control (DC) Overview About This Chapter |
| 80 | Chapter Outline |
| 81 | Standards, Rationales, and Elements of Performance Standard DC.01.01.01 Rationale for DC.01.01.01 Elements of Performance for DC.01.01.01 |
| 82 | Standard DC.01.02.01 Elements of Performance for DC.01.02.01 |
| 83 | Standard DC.01.02.03 Elements of Performance for DC.01.02.03 Standard DC.01.03.01 Elements of Performance for DC.01.03.01 |
| 84 | Standard DC.02.01.01 Rationale for DC.02.01.01 Elements of Performance for DC.02.01.01 |
| 85 | Standard DC.02.01.03 Elements of Performance for DC.02.01.03 Standard DC.02.01.05 |
| 86 | Elements of Performance for DC.02.01.05 Standard DC.02.01.07 Elements of Performance for DC.02.01.07 |
| 87 | Standard DC.02.02.01 Elements of Performance for DC.02.02.01 Standard DC.02.03.01 Elements of Performance for DC.02.03.01 |
| 88 | Standard DC.02.03.03 |
| 89 | Elements of Performance for DC.02.03.03 Standard DC.02.04.01 Elements of Performance for DC.02.04.01 |
| 91 | Standard DC.03.01.01 Elements of Performance for DC.03.01.01 |
| 96 | Written Documentation Checklist Document and Process Control (DC) |
| 103 | Environment of Care (EC) Overview About This Chapter |
| 104 | Other Issues for Consideration |
| 106 | Chapter Outline |
| 107 | Standards, Rationales, and Elements of Performance Standard EC.01.01.01 Rationale for EC.01.01.01 Elements of Performance for EC.01.01.01 |
| 108 | Standard EC.02.01.01 Rationale for EC.02.01.01 Elements of Performance for EC.02.01.01 |
| 109 | Standard EC.02.01.03 Elements of Performance for EC.02.01.03 Standard EC.02.02.01 Rationale for EC.02.02.01 |
| 110 | Elements of Performance for EC.02.02.01 |
| 111 | Standard EC.02.03.01 Rationale for EC.02.03.01 Elements of Performance for EC.02.03.01 |
| 112 | Standard EC.02.03.03 Elements of Performance for EC.02.03.03 Standard EC.02.03.05 |
| 113 | Elements of Performance for EC.02.03.05 Standard EC.02.04.01 |
| 114 | Elements of Performance for EC.02.04.01 Standard EC.02.04.03 Elements of Performance for EC.02.04.03 |
| 116 | Standard EC.02.04.05 Elements of Performance for EC.02.04.05 Standard EC.02.05.01 |
| 117 | Elements of Performance for EC.02.05.01 |
| 118 | Standard EC.02.05.03 Elements of Performance for EC.02.05.03 |
| 119 | Standard EC.02.05.05 Elements of Performance for EC.02.05.05 Standard EC.02.05.07 Rationale for EC.02.05.07 |
| 120 | Elements of Performance for EC.02.05.07 |
| 122 | Introduction to Standard EC.02.06.01 Standard EC.02.06.01 Elements of Performance for EC.02.06.01 |
| 123 | Standard EC.02.06.05 Rationale for EC.02.06.05 |
| 124 | Elements of Performance for EC.02.06.05 Standard EC.03.01.01 Rationale for EC.03.01.01 Elements of Performance for EC.03.01.01 Introduction to Standard EC.04.01.01 |
| 125 | Standard EC.04.01.01 Elements of Performance for EC.04.01.01 |
| 126 | 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 | Written Documentation Checklist Environment of Care (EC) |
| 139 | Emergency Management (EM) Overview |
| 140 | About This Chapter |
| 142 | Chapter Outline |
| 143 | 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 |
| 144 | Standard EM.02.01.01 |
| 145 | Rationale for EM.02.01.01 Elements of Performance for EM.02.01.01 |
| 146 | Standard EM.02.02.01 Rationale for EM.02.02.01 Elements of Performance for EM.02.02.01 |
| 147 | Standard EM.02.02.03 Rationale for EM.02.02.03 Elements of Performance for EM.02.02.03 |
| 148 | Introduction to Standard EM.02.02.05 Standard EM.02.02.05 Elements of Performance for EM.02.02.05 Standard EM.02.02.07 |
| 149 | Rationale for EM.02.02.07 Elements of Performance for EM.02.02.07 Standard EM.02.02.09 Rationale for EM.02.02.09 |
| 150 | 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 |
| 151 | Introduction to Standard EM.02.02.15 |
| 152 | Standard EM.02.02.15 Elements of Performance for EM.02.02.15 |
| 154 | Standard EM.03.01.03 Rationale for EM.03.01.03 Elements of Performance for EM.03.01.03 |
| 159 | Written Documentation Checklist Emergency Management (EM) |
| 165 | Human Resources (HR) Overview About This Chapter |
| 166 | Chapter Outline |
| 167 | Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01 |
| 168 | Standard HR.01.02.03 Elements of Performance for HR.01.02.03 |
| 170 | Introduction to Standard HR.01.02.05 Standard HR.01.02.05 Elements of Performance for HR.01.02.05 Standard HR.01.02.07 |
| 171 | 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 Elements of Performance for HR.01.04.01 |
| 173 | Standard HR.01.05.03 Elements of Performance for HR.01.05.03 Introduction to Standard HR.01.06.01 Standard HR.01.06.01 Elements of Performance for HR.01.06.01 |
| 175 | Standard HR.01.07.01 Elements of Performance for HR.01.07.01 |
| 182 | Written Documentation Checklist Human Resources (HR) |
| 189 | Infection Prevention and Control (IC) Overview |
| 190 | About This Chapter |
| 191 | Chapter Outline |
| 192 | Standards, Rationales, and Elements of Performance Introduction to Standards IC.01.01.01 Through IC.01.06.01 – Planning Standard IC.01.01.01 |
| 193 | Rationale for IC.01.01.01 Elements of Performance for IC.01.01.01 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 |
| 194 | Standard IC.01.04.01 Elements of Performance for IC.01.04.01 Standard IC.01.05.01 Elements of Performance for IC.01.05.01 |
| 195 | Standard IC.01.06.01 Rationale for 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 |
| 196 | Standard IC.02.01.01 Elements of Performance for IC.02.01.01 |
| 197 | Standard IC.02.02.01 Rationale for IC.02.02.01 Elements of Performance for IC.02.02.01 |
| 198 | Standard IC.02.03.01 Elements of Performance for IC.02.03.01 |
| 199 | Introduction to Standard IC.02.04.01 Standard IC.02.04.01 |
| 200 | Elements of Performance for IC.02.04.01 |
| 201 | Introduction to Standard IC.03.01.01 – Evaluation and Improvement Standard IC.03.01.01 Elements of Performance for IC.03.01.01 |
| 205 | Written Documentation Checklist Infection Control and Prevention (IC) |
| 209 | Information Management (IM) Overview About This Chapter |
| 210 | Chapter Outline |
| 211 | 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 |
| 212 | Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03 |
| 213 | Introduction to Standard IM.02.01.01 Standard IM.02.01.01 Elements of Performance for IM.02.01.01 |
| 214 | Introduction to Standard IM.02.01.03 Standard IM.02.01.03 Elements of Performance for IM.02.01.03 |
| 215 | Standard IM.02.02.01 Rationale for IM.02.02.01 Elements of Performance for IM.02.02.01 |
| 216 | Introduction to Standard IM.02.02.03 Standard IM.02.02.03 Rationale for IM.02.02.03 |
| 217 | Elements of Performance for IM.02.02.03 Standard IM.02.02.05 Elements of Performance for IM.02.02.05 Standard IM.03.01.01 |
| 218 | Elements of Performance for IM.03.01.01 Standard IM.04.01.01 Rationale for IM.04.01.01 Elements of Performance for IM.04.01.01 Standard IM.05.01.01 Elements of Performance for IM.05.01.01 |
| 221 | Written Documentation Checklist Information Management (IM) |
| 225 | Leadership (LD) Overview |
| 226 | Proactive Risk Assessment |
| 227 | About This Chapter |
| 228 | Chapter Outline |
| 229 | Standards, Rationales, and Elements of Performance Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.03.01 Standard LD.01.01.01 |
| 230 | Rationale for LD.01.01.01 Elements of Performance for LD.01.01.01 Standard LD.01.03.01 Rationale for LD.01.03.01 |
| 231 | Elements of Performance for LD.01.03.01 Introduction to Leadership Relationships, Standard LD.02.01.01 |
| 232 | Standard LD.02.01.01 Rationale for LD.02.01.01 Elements of Performance for LD.02.01.01 Introduction to Organization Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01 |
| 234 | Standard LD.03.01.01 Rationale for LD.03.01.01 |
| 235 | Elements of Performance for LD.03.01.01 Standard LD.03.02.01 Rationale for LD.03.02.01 Elements of Performance for LD.03.02.01 Standard LD.03.03.01 |
| 236 | Rationale for LD.03.03.01 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 |
| 237 | 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 |
| 238 | Introduction to Operations, Standards LD.03.07.01 Through LD.04.05.13 |
| 239 | 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 |
| 240 | Introduction to Standard LD.03.09.01 Standard LD.03.09.01 Elements of Performance for LD.03.09.01 Standard LD.04.01.01 Elements of Performance for LD.04.01.01 |
| 241 | Standard LD.04.01.03 Elements of Performance for LD.04.01.03 |
| 242 | Standard LD.04.01.05 Elements of Performance for LD.04.01.05 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 |
| 243 | 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 Introduction to Oversight of Laboratory Services Provided Through Contractual Agreement, Standard LD.04.03.09 |
| 244 | Monitoring Contracted Services |
| 245 | Standard LD.04.03.09 Elements of Performance for LD.04.03.09 |
| 246 | Standard LD.04.05.01 Rationale for LD.04.05.01 Elements of Performance for LD.04.05.01 |
| 247 | Standard LD.04.05.03 |
| 248 | Elements of Performance for LD.04.05.03 Standard LD.04.05.05 Elements of Performance for LD.04.05.05 Standard LD.04.05.07 |
| 249 | Elements of Performance for LD.04.05.07 Standard LD.04.05.09 Elements of Performance for LD.04.05.09 |
| 251 | Standard LD.04.05.11 Elements of Performance for LD.04.05.11 Standard LD.04.05.13 Elements of Performance for LD.04.05.13 |
| 256 | Written Documentation Checklist Leadership (LD) |
| 261 | National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals® |
| 262 | 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 2 NPSG.02.03.01 Rationale for NPSG.02.03.01 |
| 263 | Elements of Performance for NPSG.02.03.01 Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01 |
| 264 | Elements of Performance for NPSG.07.01.01 |
| 266 | Written Documentation Checklist National Patient Safety Goal (NPSG) |
| 269 | Performance Improvement (PI) Overview About This Chapter |
| 271 | Chapter Outline |
| 272 | 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 |
| 273 | Standard PI.02.01.01 Rationale for PI.02.01.01 |
| 274 | Elements of Performance for PI.02.01.01 Introduction to Standard PI.03.01.01 |
| 275 | Standard PI.03.01.01 Elements of Performance for PI.03.01.01 Standard PI.04.01.01 Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01 |
| 278 | Written Documentation Checklist Performance Improvement (PI) |
| 283 | Quality System Assessment for Nonwaived Testing (QSA) Overview About This Chapter |
| 284 | Chapter Outline |
| 289 | Standards, Rationales, and Elements of Performance Introduction to Standards QSA.01.01.01 Through QSA.01.03.01 Standard QSA.01.01.01 Rationale for QSA.01.01.01 |
| 290 | Elements of Performance for QSA.01.01.01 |
| 292 | Standard QSA.01.02.01 Rationale for QSA.01.02.01 Elements of Performance for QSA.01.02.01 |
| 294 | Standard QSA.01.03.01 Elements of Performance for QSA.01.03.01 Standard QSA.01.04.01 |
| 295 | Elements of Performance for QSA.01.04.01 Standard QSA.01.05.01 Elements of Performance for QSA.01.05.01 |
| 296 | Standard QSA.02.01.01 Elements of Performance for QSA.02.01.01 |
| 298 | Standard QSA.02.02.01 Rationale for QSA.02.02.01 Elements of Performance for QSA.02.02.01 |
| 299 | Standard QSA.02.03.01 Elements of Performance for QSA.02.03.01 |
| 300 | Introduction to Standard QSA.02.04.01 |
| 301 | Standard QSA.02.04.01 Elements of Performance for QSA.02.04.01 |
| 302 | Standard QSA.02.06.01 Elements of Performance for QSA.02.06.01 |
| 303 | Standard QSA.02.07.01 Elements of Performance for QSA.02.07.01 |
| 304 | Standard QSA.02.08.01 Elements of Performance for QSA.02.08.01 |
| 305 | Standard QSA.02.09.01 Elements of Performance for QSA.02.09.01 Standard QSA.02.10.01 |
| 306 | Elements of Performance for QSA.02.10.01 |
| 307 | Standard QSA.02.10.03 |
| 308 | Elements of Performance for QSA.02.10.03 |
| 309 | Standard QSA.02.11.01 Elements of Performance for QSA.02.11.01 |
| 310 | Standard QSA.02.12.01 Elements of Performance for QSA.02.12.01 |
| 312 | Standard QSA.02.13.01 Elements of Performance for QSA.02.13.01 |
| 313 | Standard QSA.02.14.01 Elements of Performance for QSA.02.14.01 |
| 314 | Standard QSA.03.01.01 Elements of Performance for QSA.03.01.01 Standard QSA.03.02.01 Rationale for QSA.03.02.01 Elements of Performance for QSA.03.02.01 Standard QSA.03.03.01 Elements of Performance for QSA.03.03.01 |
| 315 | Standard QSA.04.01.01 Elements of Performance for QSA.04.01.01 |
| 316 | Standard QSA.04.02.01 Elements of Performance for QSA.04.02.01 |
| 317 | Standard QSA.04.03.01 Elements of Performance for QSA.04.03.01 |
| 318 | Standard QSA.04.04.01 Elements of Performance for QSA.04.04.01 |
| 319 | Standard QSA.04.05.01 Elements of Performance for QSA.04.05.01 Standard QSA.04.06.01 Elements of Performance for QSA.04.06.01 |
| 320 | Standard QSA.04.07.01 Rationale for QSA.04.07.01 Elements of Performance for QSA.04.07.01 Standard QSA.05.01.01 Elements of Performance for QSA.05.01.01 |
| 321 | Standard QSA.05.02.01 Elements of Performance for QSA.05.02.01 |
| 322 | Standard QSA.05.02.03 Elements of Performance for QSA.05.02.03 |
| 323 | Standard QSA.05.02.05 Elements of Performance for QSA.05.02.05 Standard QSA.05.03.01 Elements of Performance for QSA.05.03.01 Standard QSA.05.03.03 Elements of Performance for QSA.05.03.03 |
| 324 | Standard QSA.05.04.01 Elements of Performance for QSA.05.04.01 |
| 325 | Standard QSA.05.04.03 Elements of Performance for QSA.05.04.03 Standard QSA.05.05.01 Elements of Performance for QSA.05.05.01 |
| 326 | Standard QSA.05.06.01 Elements of Performance for QSA.05.06.01 Standard QSA.05.07.01 |
| 327 | Elements of Performance for QSA.05.07.01 Standard QSA.05.08.01 Elements of Performance for QSA.05.08.01 |
| 328 | Standard QSA.05.09.01 Elements of Performance for QSA.05.09.01 |
| 329 | Standard QSA.05.09.03 |
| 330 | Elements of Performance for QSA.05.09.03 Standard QSA.05.10.01 Elements of Performance for QSA.05.10.01 |
| 331 | Standard QSA.05.11.01 Elements of Performance for QSA.05.11.01 Standard QSA.05.12.01 |
| 332 | Rationale for QSA.05.12.01 Elements of Performance for QSA.05.12.01 Standard QSA.05.13.01 Elements of Performance for QSA.05.13.01 Standard QSA.05.14.01 Elements of Performance for QSA.05.14.01 |
| 334 | Standard QSA.05.14.03 Elements of Performance for QSA.05.14.03 Standard QSA.05.14.05 Elements of Performance for QSA.05.14.05 |
| 335 | Standard QSA.05.14.07 Elements of Performance for QSA.05.14.07 Standard QSA.05.16.01 Elements of Performance for QSA.05.16.01 |
| 336 | Standard QSA.05.17.01 Elements of Performance for QSA.05.17.01 Standard QSA.05.18.01 Elements of Performance for QSA.05.18.01 |
| 337 | Standard QSA.05.19.01 Elements of Performance for QSA.05.19.01 |
| 338 | Standard QSA.05.19.03 Elements of Performance for QSA.05.19.03 |
| 339 | Standard QSA.05.19.05 Elements of Performance for QSA.05.19.05 Standard QSA.05.20.01 Elements of Performance for QSA.05.20.01 |
| 340 | Standard QSA.05.21.01 Elements of Performance for QSA.05.21.01 |
| 341 | Standard QSA.05.22.01 Elements of Performance for QSA.05.22.01 Standard QSA.05.23.01 Elements of Performance for QSA.05.23.01 |
| 342 | Standard QSA.05.24.01 Elements of Performance for QSA.05.24.01 |
| 343 | Standard QSA.05.24.03 Elements of Performance for QSA.05.24.03 Standard QSA.05.25.01 |
| 344 | Elements of Performance for QSA.05.25.01 |
| 345 | Standard QSA.06.01.01 Elements of Performance for QSA.06.01.01 Standard QSA.06.02.01 Elements of Performance for QSA.06.02.01 Standard QSA.06.03.01 |
| 346 | Elements of Performance for QSA.06.03.01 Standard QSA.06.03.03 Elements of Performance for QSA.06.03.03 |
| 347 | Standard QSA.06.04.01 Elements of Performance for QSA.06.04.01 Standard QSA.06.04.03 Elements of Performance for QSA.06.04.03 |
| 348 | Standard QSA.06.04.05 Elements of Performance for QSA.06.04.05 |
| 349 | Standard QSA.07.01.01 Rationale for QSA.07.01.01 Elements of Performance for QSA.07.01.01 Standard QSA.07.02.01 Elements of Performance for QSA.07.02.01 Standard QSA.08.01.01 |
| 350 | Elements of Performance for QSA.08.01.01 Standard QSA.08.02.01 Elements of Performance for QSA.08.02.01 |
| 351 | Standard QSA.08.03.01 Elements of Performance for QSA.08.03.01 |
| 353 | Standard QSA.08.04.01 Elements of Performance for QSA.08.04.01 |
| 356 | Standard QSA.08.05.01 Elements of Performance for QSA.08.05.01 Standard QSA.08.06.01 Elements of Performance for QSA.08.06.01 |
| 357 | Standard QSA.08.06.03 Elements of Performance for QSA.08.06.03 Standard QSA.08.07.01 |
| 358 | Elements of Performance for QSA.08.07.01 Standard QSA.08.08.01 Elements of Performance for QSA.08.08.01 |
| 359 | Standard QSA.08.09.01 Elements of Performance for QSA.08.09.01 |
| 360 | Standard QSA.09.01.01 Elements of Performance for QSA.09.01.01 Standard QSA.09.02.01 Elements of Performance for QSA.09.02.01 |
| 361 | Standard QSA.09.03.01 Elements of Performance for QSA.09.03.01 |
| 362 | Standard QSA.09.03.03 Elements of Performance for QSA.09.03.03 Standard QSA.09.03.05 |
| 363 | Elements of Performance for QSA.09.03.05 Standard QSA.09.03.07 Elements of Performance for QSA.09.03.07 |
| 364 | Standard QSA.09.04.01 Elements of Performance for QSA.09.04.01 Standard QSA.09.05.01 Elements of Performance for QSA.09.05.01 |
| 365 | Standard QSA.09.06.01 Elements of Performance for QSA.09.06.01 Standard QSA.09.07.01 Elements of Performance for QSA.09.07.01 |
| 366 | Standard QSA.09.07.03 Elements of Performance for QSA.09.07.03 Standard QSA.10.01.01 Elements of Performance for QSA.10.01.01 |
| 368 | Standard QSA.10.02.01 Elements of Performance for QSA.10.02.01 |
| 369 | Standard QSA.10.03.01 Rationale for QSA.10.03.01 Elements of Performance for QSA.10.03.01 |
| 370 | Standard QSA.10.04.01 Elements of Performance for QSA.10.04.01 |
| 371 | Standard QSA.10.05.01 Rationale for QSA.10.05.01 Elements of Performance for QSA.10.05.01 |
| 372 | Standard QSA.10.06.01 Elements of Performance for QSA.10.06.01 |
| 373 | Standard QSA.10.07.01 Elements of Performance for QSA.10.07.01 |
| 374 | Standard QSA.11.01.01 Elements of Performance for QSA.11.01.01 Standard QSA.11.02.01 Elements of Performance for QSA.11.02.01 |
| 376 | Standard QSA.12.01.01 Elements of Performance for QSA.12.01.01 |
| 378 | Standard QSA.12.02.01 Elements of Performance for QSA.12.02.01 |
| 379 | Standard QSA.12.03.01 Elements of Performance for QSA.12.03.01 Standard QSA.12.04.01 |
| 380 | Elements of Performance for QSA.12.04.01 Standard QSA.12.05.01 Elements of Performance for QSA.12.05.01 Standard QSA.12.06.01 Elements of Performance for QSA.12.06.01 |
| 381 | Standard QSA.12.07.01 Elements of Performance for QSA.12.07.01 Standard QSA.13.01.01 Elements of Performance for QSA.13.01.01 |
| 382 | Standard QSA.13.02.01 Elements of Performance for QSA.13.02.01 Standard QSA.13.03.01 Elements of Performance for QSA.13.03.01 |
| 383 | Standard QSA.13.03.03 Elements of Performance for QSA.13.03.03 Standard QSA.13.04.01 Elements of Performance for QSA.13.04.01 |
| 384 | Standard QSA.13.05.01 Elements of Performance for QSA.13.05.01 Standard QSA.13.06.01 Elements of Performance for QSA.13.06.01 |
| 385 | Standard QSA.13.07.01 Elements of Performance for QSA.13.07.01 |
| 386 | Standard QSA.13.08.01 Elements of Performance for QSA.13.08.01 |
| 387 | Standard QSA.14.01.01 Elements of Performance for QSA.14.01.01 Standard QSA.14.02.01 Elements of Performance for QSA.14.02.01 |
| 388 | Introduction to Standards QSA.15.01.01 Through QSA.16.02.01 Standard QSA.15.01.01 Elements of Performance for QSA.15.01.01 |
| 389 | Standard QSA.15.02.01 Elements of Performance for QSA.15.02.01 Standard QSA.15.03.01 Elements of Performance for QSA.15.03.01 |
| 390 | Standard QSA.15.03.03 Elements of Performance for QSA.15.03.03 Standard QSA.15.04.01 Elements of Performance for QSA.15.04.01 |
| 391 | Standard QSA.15.05.01 Elements of Performance for QSA.15.05.01 |
| 392 | Standard QSA.16.01.01 Elements of Performance for QSA.16.01.01 Standard QSA.16.02.01 |
| 393 | Elements of Performance for QSA.16.02.01 Standard QSA.17.01.01 Elements of Performance for QSA.17.01.01 Standard QSA.17.01.03 |
| 394 | Elements of Performance for QSA.17.01.03 Standard QSA.17.02.01 Elements of Performance for QSA.17.02.01 Standard QSA.18.01.01 Elements of Performance for QSA.18.01.01 Standard QSA.19.01.01 Elements of Performance for QSA.19.01.01 |
| 395 | Standard QSA.19.02.01 Elements of Performance for QSA.19.02.01 |
| 396 | Standard QSA.20.01.01 Elements of Performance for QSA.20.01.01 |
| 397 | Standard QSA.21.01.01 Elements of Performance for QSA.21.01.01 Standard QSA.21.02.01 Elements of Performance for QSA.21.02.01 |
| 398 | Standard QSA.21.03.01 Elements of Performance for QSA.21.03.01 Standard QSA.21.04.01 Elements of Performance for QSA.21.04.01 |
| 434 | Written Documentation Checklist Quality System Assessment (QSA) |
| 479 | Transplant Safety (TS) Overview About This Chapter |
| 480 | Chapter Outline |
| 481 | 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 |
| 483 | Standard TS.03.01.01 Elements of Performance for TS.03.01.01 |
| 485 | Standard TS.03.02.01 Elements of Performance for TS.03.02.01 |
| 486 | Standard TS.03.03.01 Elements of Performance for TS.03.03.01 |
| 490 | Written Documentation Checklist Transplant Safety (TS) |
| 495 | Waived Testing (WT) Overview |
| 496 | About This Chapter |
| 498 | Chapter Outline |
| 499 | Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01 |
| 500 | Standard WT.02.01.01 |
| 501 | Elements of Performance for WT.02.01.01 Standard WT.03.01.01 Elements of Performance for WT.03.01.01 |
| 502 | Standard WT.04.01.01 Elements of Performance for WT.04.01.01 |
| 503 | Standard WT.05.01.01 Elements of Performance for WT.05.01.01 |
| 508 | Written Documentation Checklist Waived Testing (WT) |
| 513 | The Accreditation Process (ACC) Notices ACC Chapter Contents |
| 515 | Overview General Eligibility Requirements |
| 516 | Scope of Accreditation Surveys Accreditation Policies Tailored Survey Policy |
| 518 | Organizational and Functional Integration |
| 521 | Multiorganization Option Concurrent Survey Option |
| 522 | Contracted Services Proficiency Testing Monitoring |
| 523 | Initial Surveys |
| 524 | Information Accuracy and Truthfulness Policy |
| 526 | Good Faith Participation in Accreditation/ Certification |
| 527 | Public Information Policy Process for Responding to a Complaint |
| 528 | Early Survey Policy |
| 529 | Sidebar 1. Early Survey Policy |
| 531 | Before the Survey |
| 532 | An Organization’s Secure Joint Commission Connect Extranet Site |
| 533 | Role of the Account Executive Electronic Application for Accreditation (E-App) |
| 535 | Accreditation/Certification Contract and Business Associate Agreement Annual and Survey Fees |
| 536 | During the Survey |
| 537 | Survey Notification Table 1. Exceptions to Unannounced Surveys# |
| 538 | Table 1. |
| 540 | Initial and Full Survey Team Composition Survey Agenda |
| 543 | Tracer Methodology |
| 545 | Immediate Threat to Health or Safety |
| 549 | Summary of the Accreditation Reports |
| 550 | After the Survey The Scoring Process |
| 555 | Evidence of Standards Compliance (ESC) Process |
| 559 | Accreditation Award Display and Use |
| 560 | Between Accreditation Surveys |
| 561 | Duration of Accreditation Award Continuous Compliance Intracycle Monitoring (ICM) |
| 562 | Focused Standards Assessment (FSA) |
| 563 | Sidebar 2. Focused Standards Assessment (FSA) Options |
| 564 | Sidebar 2. Sentinel Event Follow-up |
| 565 | Notifying The Joint Commission About Organization Changes |
| 567 | Accreditation Status of Organizations That Cease Services After a Disaster|||||||||||| |
| 568 | Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time |
| 569 | Reentering the Accreditation Process Additional Surveys |
| 572 | Decision Rules for Organizations Seeking Initial Accreditation Accredited Limited, Temporary Accreditation |
| 573 | Evidence of Standards Compliance (ESC) One-Month Survey Retrospective Cytology Survey Proficiency Testing Monitoring Survey |
| 574 | Denial of Accreditation |
| 575 | Decision Rules for Organizations Seeking Reaccreditation Accredited Evidence of Standards Compliance (ESC) |
| 576 | One-Month Survey Retrospective Cytology Survey Proficiency Testing Monitoring Survey Accreditation with Follow-up Survey |
| 577 | Preliminary Denial of Accreditation |
| 579 | Denial of Accreditation Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific |
| 581 | Process for Organizations That Meet Decision Rule PDA04 |
| 582 | Review and Appeal Procedures I. Evaluation by Joint Commission Staff |
| 584 | II. Accreditation with Follow-up Survey III. Review Hearings |
| 586 | IV. Following a Review Hearing V. Final Review &Appeal Request |
| 589 | Standards Applicability Grid (SAG) |
| 651 | Sentinel Event Policy (SE) |
| 652 | Goals of the Sentinel Event Policy |
| 653 | Identifying Sentinel Events |
| 655 | Sidebar 1. Key Terms |
| 656 | Sidebar 1. |
| 657 | Determining That a Sentinel Event Is Subject to Review |
| 658 | Relationship to the Survey Process |
| 659 | Required Organization Response to a Sentinel Event |
| 660 | Reporting a Sentinel Event to The Joint Commission |
| 662 | Conducting a Comprehensive Systematic Analysis |
| 663 | Developing a Corrective Action Plan |
| 664 | Submitting the Comprehensive Systematic Analysis and Corrective Action Plan |
| 665 | Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event |
| 666 | Table 1. |
| 667 | The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans |
| 668 | Follow-up Activities |
| 670 | Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database |
| 671 | Overseeing the Sentinel Event Policy |
| 673 | The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report? |
| 674 | What Will My Quality Report Contain? What Is Quality Check? |
| 675 | Is a Quality Report Available for My Accredited Laboratory? Can My Laboratory Comment on Its Quality Report? |
| 676 | How Does My Laboratory 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? |
| 677 | Guidelines for Publicizing Compliance with the National Patient Safety Goals |
| 679 | Required Written Documentation (RWD) |
| 680 | List of EPs Requiring Written Documentation for Laboratories and Pointof Care Testing Accreditation Participation Requirements (APR) Document and Process Control (DC) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) |
| 681 | Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) National Patient Safety Goals (NPSG) Performance Improvement (PI) |
| 682 | Quality System Assessment for Nonwaived Testing (QSA) |
| 683 | Transplant Safety (TS) Waived Testing (WT) |
| 685 | Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Document and Process Control (DC) |
| 686 | Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) |
| 687 | Information Management (IM) Leadership (LD) National Patient Safety Goals (NPSG) Performance Improvement (PI) |
| 688 | Quality System Assessment for Nonwaived Testing (QSA) |
| 689 | Transplant Safety (TS) Waived Testing (WT) |
| 691 | Appendix A: Retention Times for Records, Reports, and Specimens (AXA) Retention Times for Records, Reports, and Specimens |
| 695 | Appendix B: Laboratory Developed Tests (AXB) Laboratory Developed Tests |
| 697 | Appendix C: Individualized Quality Control Plan–Eligible Requirements (AXC) Quality System Assessment for Nonwaived Testing (QSA) |
| 699 | Appendix D: Duplicate Laboratory and Hospital/ Critical Access Hospital Requirements (AXD) Environment of Care (EC) |
| 700 | Infection Prevention and Control (IC) Transplant Safety (TS) |
| 701 | Glossary (GL) |
| 725 | Index (IX) |
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