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2013
CAMH
Comprehensive Accreditation
Manual for Hospitals
Summary of Changes
2013 Comprehensive Accreditation Manual
for Hospitals
Effective January 1, 2013
Standards and elements of performance (EPs) published in this manual are effective
January 1, 2013.
Note: Your organization is responsible for meeting all applicable changes to accreditation
requirements for hospitals published in The Joint Commission Perspectives®, the official
monthly newsletter of The Joint Commission.
Major changes reflected in the 2013 CAMH include the following:
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Discontinuance and removal of the “Foreword” (FW) from the manual
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New risk icon throughout the requirements for accreditation to denote elements
of performance (EPs) that must be assessed through the new Focused Standards
Assessment (FSA) process
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Revised and additional EPs applicable to hospitals that use Joint Commission
accreditation for deemed status purposes; these changes were made to maintain
alignment with requirements from the Centers for Medicare & Medicaid Services
(CMS) following the release of a final rule in 2012. Among other issues, the changes
address qualifications of staff, use of pre-printed or standing medication orders,
authentication of verbal and written orders, and death of a patient in restraints.
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Revised requirements for hospitals in California that provide computed tomography
(CT) services
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Revised and additional requirements to address the issue of emergency department
overcrowding
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Revised requirement for daily quality control checks of instruments used for waived
testing
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Increase in the number of days that an organization can identify as avoid dates for
an unannounced survey from 10 to 15 in “The Accreditation Process” (ACC)
chapter
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Addition of a description about the “ISO Certification Option” to the ACC chapter
A description of the new Intracycle Monitoring (ICM) process and the FSA in the
ACC chapter
Update to the ACC chapter indicating an organization must notify The Joint
Commission if it offers at least 50% (previously 25%) of its services at a new
location or in an altered physical plant
Accreditation decision rules for 2013 in the ACC chapter
Discontinuance and removal of the “Simplifying Compliance Activities” (SCA)
chapter from the manual
A summary of all revisions to requirements for accreditation, policies, procedures, and
other information in the 2013 CAMH follows.
How to Use This Manual (HM)
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Revised Table 1. Acronyms Used in This Manual
Changed references from “Periodic Performance Review (PPR)” to “Focused
Standards Assessment (FSA)” and the Intracycle Monitoring (ICM) process
throughout chapter as applicable
Revised Figure 1. Components of a requirements chapter
Deleted description for the “Simplifying Compliance Activities” (SCA) chapter
Added description of Appendix B: Special Conditions of Participation for
Psychiatric Hospitals
Updated descriptions of the four levels of scoring criticality and added the risk
icon in the “Understanding the Icons Used in the Manual” section
Added and revised tips for organizations in the “Keys to Successfully Using This
Manual” section
Included new resources and updated existing resources listed in Sidebar 2. Where
Should I Go for More Information?
Accreditation Participation Requirements (APR)
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Updated chapter outline
Revised APR.03.01.01 to reflect change from “Periodic Performance Review
(PPR)” to “Focused Standards Assessment (FSA)”; for EP 1, clarified timing of the
submission of the tool and added a second note
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Environment of Care (EC)
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Changed “accreditation” to “Joint Commission accreditation” in the first note for
EC.02.03.05, EP 2
Added EC.02.04.03, EP 17, for hospitals in California that provide computed
tomography (CT) services
Added risk icon to the following:
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EC.01.01.01, EPs 1–3, 5, 7–8
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EC.02.01.01, EPs 3, 8
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EC.02.02.01, EPs 4, 7, 10
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EC.02.03.01, EP 1
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EC.02.03.05, EPs 4, 11, 19
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EC.02.04.01, EPs 1–6
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EC.02.04.03, EPs 1–5
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EC.02.05.01, EP 6
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EC.02.05.03, EP 6
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EC.02.05.05, EPs 3–4
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EC.02.05.07, EPs 4–8
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EC.02.05.09, EP 1
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EC.02.06.01, EP 20
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EC.02.06.05, EP 3
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EC.04.01.01, EPs 1, 15
Emergency Management (EM)
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Added risk icon to the following:
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EM.02.01.01, EP 8
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EM.02.02.13, EP 5
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EM.02.02.15, EP 5
Human Resources (HR)
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Deleted last sentence of HR.01.02.01, EP 1, Note 4, which indicated that inclusion
of qualifications would not affect the accreditation decision
Deleted HR.01.02.01, EP 19, on administration of blood transfusions and
intravenous medications
Added risk icon to the following:
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HR.01.02.01, EP 1
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HR.01.02.05, EPs 1–7, 10–16, 18
HR.01.04.01, EPs 1–5
HR.01.05.03, EPs 1, 4–5, 13
HR.01.06.01, EPs 1–3, 5–6, 15
HR.01.07.01, EPs 2, 5
Infection Prevention and Control (IC)
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Updated website reference in the footnote to Standards IC.02.01.01, EPs 2 and 3,
and IC.02.02.01, EP 1
Added “Introduction to Standard IC.02.04.01” section
Added note clarifying applicability to IC.02.04.01
Added “Rationale for IC.02.04.01”
Revised IC.02.04.01, EP 3, to include accessible times
Revised IC.02.04.01, EP 4, and added documentation requirement
Revised IC.02.04.01, EP 5, and added documentation requirement
Added IC.02.04.01, EPs 6–9
Added risk icon to the following:
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IC.01.05.01, EPs 1–3, 5–8
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IC.02.01.01, EPs 3, 10–11
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IC.02.02.01, EPs 1–5
Information Management (IM)
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Added risk icon to the following:
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IM.01.01.01, EPs 1–4
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IM.01.01.03, EPs 1–6
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IM.02.01.01, EPs 1–5
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IM.02.01.03, EPs 1–8
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IM.02.02.01, EPs 1–3
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IM.02.02.03, EPs 1–3
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IM.04.01.01, EP 1
Leadership (LD)
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Updated LD.01.02.01, EP 4
Revised LD.01.05.01, EP 7, to include doctors of podiatric medicine
Revised Rationale for LD.03.01.01, as well as EPs 4 and 5, to reflect change from
disruptive behavior to behavior that undermines a culture of safety
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Revised LD.04.01.05, EP 8, regarding supervision of outpatient services
Revised LD.04.03.09, EP 23, to reflect changes to Medicare Conditions of
Participation related to the credentialing and privileging of telemedicine
practitioners
Revised LD.04.03.11 by adding Introduction; adding documentation requirement
to EPs 4, 5, and 7; revising EP 5, EP 6 (effective January 1, 2014), and EPs 7–8;
and adding EP 9 (effective January 1, 2014)
Added risk icon to the following:
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LD.03.01.01, EP 5
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LD.03.02.01, EPs 1, 3–7
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LD.03.06.01, EPs 1, 3–6
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LD.04.01.05, EPs 1–6, 8
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LD.04.01.07, EPs 1–2
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LD.04.02.03, EP 5
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LD.04.03.01, EP 1
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LD.04.03.07, EPs 1–2
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LD.04.03.09, EPs 1–10, 23
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LD.04.03.11, EPs 1–8
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LD.04.04.03, EP 1
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LD.04.04.05, EPs 1–14
Life Safety (LS)
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Added risk icon to the following:
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LS.01.01.01, EP 2
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LS.01.02.01, EPs 1, 3–5
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LS.02.01.20, EP 22
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LS.02.01.34, EP 1
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LS.02.01.35, EPs 1–2
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LS.03.01.20, EP 15
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LS.03.01.34, EP 1
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LS.03.01.35, EP 1
Medication Management (MM)
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Expanded criteria for selecting medications to include the population(s) served in
MM.02.01.01, EP 2
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Added MM.04.01.01, EP 15, regarding pre-printed and standing orders
Updated MM.05.01.07, EP 5, on preparing and administering medication
Updated MM.07.01.03, EP 6
Added risk icon to the following:
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o MM.01.01.03, EP 3
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o MM.01.02.01, EP 2
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o MM.02.01.01, EP 6
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o MM.03.01.01, EPs 7, 10
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o MM.03.01.03, EP 2
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o MM.03.01.05, EP 2
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o MM.04.01.01, EPs 8, 13
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o MM.05.01.01, EP 11
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o MM.05.01.07, EPs 1, 5
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o MM.05.01.09, EP 1
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o MM.05.01.13, EP 7
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o MM.05.01.17, EP 2
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o MM.06.01.03, EPs 6–7
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o MM.06.01.05, EPs 2, 4
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o MM.07.01.03, EPs 5–6
Medical Staff (MS)
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Revised MS.13.01.01, EP 1, to reflect changes to Medicare Conditions of
Participation related to the credentialing and privileging of telemedicine
practitioners
Added risk icon to the following:
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MS.03.01.01, EPs 2, 16–17
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MS.03.01.03, EPs 1–6, 12
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MS.06.01.03, EP 6
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MS.06.01.05, EPs 2–3
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MS.08.01.01, EPs 1–9
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MS.08.01.03, EPs 1–3
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MS.09.01.01, EPs 1–2
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MS.13.01.01, EP 1
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National Patient Safety Goals (NPSG)
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Added risk icon to all EPs in the chapter
Deleted NPSG.07.06.01, EP 1, and renumbered EPs 2–4 as EPs 1–3 on catheterassociated urinary tract infections (CAUTIs)
Nursing (NR)
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Added risk icon to the following:
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NR.02.02.01, EPs 1–5
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NR.02.03.01, EPs 1–4, 6–7
Provision of Care, Treatment, and Services (PC)
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Revised PC.01.01.01 by adding cross-reference to EP 4 and adding EP 24 on the
boarding of patients with behavioral health issues
Added PC.01.02.15, EPs 5–7, for hospitals in California that provide CT services
Updated PC.02.01.03, EP 1, on orders obtained or renewed from practitioners
Deleted Note to PC.02.01.21 indicating standard would not affect accreditation
decision
Changed PC.02.01.21, EP 1, from a Category A to a Category C requirement and
added Measure of Success (MOS) icon; deleted Note indicating EP would not affect
accreditation decision
Changed PC.02.01.21, EP 2, from a Category A to a Category C requirement and
deleted Note indicating EP would not affect accreditation decision
Clarified PC.03.05.19, EPs 1–2, on deaths related to restraint or seclusion, and
added documentation requirement to EP 2
Added PC.03.05.19, EP 3, on situations that include soft restraints but not
seclusion
Changed “accreditation” to “Joint Commission accreditation” in several requirements
Added risk icon to the following:
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PC.01.01.01, EP 7
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PC.01.02.01, EPs 1–4, 23
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PC.01.02.03, EPs 1–8
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PC.01.02.05, EP 1
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PC.01.02.07, EPs 1–4
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PC.01.02.08, EPs 1–2
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PC.01.02.09, EPs 1–7
PC.01.02.11, EPs 1–7
PC.01.02.13, EPs 1–7
PC.01.02.15, EPs 1–3
PC.01.03.01, EPs 1, 5, 23
PC.01.03.03, EP 4
PC.01.03.05, EP 6
PC.02.01.01, EP 1
PC.02.01.03, EPs 1, 7
PC.02.01.05, EP 1
PC.02.01.21, EPs 1–2
PC.02.02.01, EPs 1–3, 10, 17
PC.02.03.01, EP 1
PC.03.01.01, EPs 1–2, 5–8, 10
PC.03.01.03, EPs 1–2, 7–8, 18
PC.03.01.07, EPs 1–2, 4, 6–8
PC.03.01.09, EP 2
PC.03.02.07, EPs 2–3
PC.03.03.15, EP 1
PC.03.03.19, EPs 2–3
PC.03.03.23, EP 1
PC.03.03.25, EP 1
PC.03.05.01, EP 1
PC.03.05.03, EP 1
PC.03.05.05, EPs 5–6
PC.03.05.07, EP 1
PC.03.05.11, EPs 1–3
PC.04.01.01, EPs 1–4, 22–26
PC.04.01.03, EPs 1–4, 10–11
PC.04.01.05, EPs 1–3, 5, 7–8
PC.04.02.01, EP 1
PC.05.01.09, EP 1
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Performance Improvement (PI)
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Added risk icon to the following:
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PI.02.01.01, EPs 1–5, 7–8, 12–14
Record of Care, Treatment, and Services (RC)
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Updated RC.01.02.01, EP 4, Note 3, on dating and authenticating orders, and
added documentation requirement
Added documentation requirement to RC.02.01.01, EP 1
Changed RC.02.01.01, EP 28, from a Category A to a Category C requirement and
added MOS icon; deleted Note indicating EP would not affect accreditation
decision
Changed RC.02.01.05, EP 2, from a Category C to a Category A requirement and
deleted MOS icon
Changed “accreditation” to “Joint Commission accreditation” in RC.02.01.05,
EPs 1–4
Deleted RC.02.03.07, EP 4, Notes 1 and 2, on authenticating verbal orders
Added risk icon to the following:
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RC.01.01.01, EP 8
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RC.01.02.01, EPs 1–5
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RC.02.01.01, EPs 1–2, 4, 10, 21, 28
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RC.02.01.03, EPs 1–3, 5–11
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RC.02.04.01, EP 3
Rights and Responsibilities of the Individual (RI)
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Added risk icon to the following:
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RI.01.01.01, EPs 2, 4–6, 9–10, 28–29
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RI.01.01.03, EPs 1–3
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RI.01.02.01, EPs 1–3, 6–8, 20–22
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RI.01.03.01, EPs 1–7, 9, 11–13
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RI.01.05.01, EPs 1, 4–6, 8–13, 15–17, 19–20
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RI.01.06.03, EPs 2–3
Transplant Safety (TS)
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Added risk icon to the following:
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TS.01.01.01, EPs 1–12
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TS.02.01.01, EPs 1–2
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TS.03.01.01, EPs 1–11
TS.03.02.01, EPs 1–7
TS.03.03.01, EPs 1–5
Waived Testing (WT)
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Added risk icon to the following:
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WT.01.01.01, EP 6
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WT.03.01.01, EP 5
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WT.04.01.01, EPs 3–4
Revised WT.04.01.01, EP 4, on quality control checks of instruments
The Accreditation Process (ACC)
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Changed references from “Periodic Performance Review (PPR)” to “Focused
Standards Assessment (FSA)” throughout chapter as applicable
Added note about new Appendix B in “General Eligibility Requirements” section
Updated “Eligibility Requirements for Initial Surveys” section to address hospitals
that do not use The Joint Commission for deemed status purposes
Added footnote addressing laboratories to “Tailored Survey Policy” section
Added footnote defining complex organization to “Complex Organization Survey
Process” section
Reformatted and made minor editorial changes to “Public Information Policy”
section
Updated Sidebar 1. Early Survey Policy and “Eligibility for Preliminary Accreditation” section to reflect that an organization’s Preliminary Accreditation decision will
change to Unaccredited if it is not ready for a second survey at six months
Added Note addressing Medicare certification to Sidebar 1. Early Survey Policy
Identified length of time organizations may stay in Preliminary Accreditation in
“Eligibility for Preliminary Accreditation” section
Updated “Forfeiture of Survey Deposit” section
Added new or revised subprocesses to “Priority Focus Areas” (PFAs) categories
Communication, Infection Control, Orientation & Training, and Physical
Environment
Revised Table 1. Exceptions to Unannounced Surveys
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Changed number of days that organizations can identify as those on which an
unannounced survey should be avoided from 10 to 15 in “Unannounced Surveys”
section
Added “ISO Certification Option” to “Survey Team Composition” section
Revised “Survey Agenda” section
Moved “Second Generation Tracers” section and added high-risk topics “Therapeutic radiation” and “Clinical/health information”
Added “Accreditation with Follow-up Survey” to Figure 3. Scoring Criticality
Method
Revised definitions of Contingent Accreditation and Preliminary Denial of Accreditation in “Accreditation Decision Categories” section
Added “Top Performers on Key Quality Measures” section
Added new “Intracycle Monitoring” section to the “Between Accreditation Surveys”
section
Replaced “Periodic Performance Review (PPR)” section with new “Focused
Standards Assessment (FSA)” section
Updated the “Changes to the Site of Care, Treatment, or Services” section to
indicate an organization must notify The Joint Commission if it offers at least 50%
(previously 25%) of services at a new location or in an altered physical plant
Updated “Accreditation Status of Organizations That Cease Provision of Services
for a Period of Time” regarding the need to notify The Joint Commission if an
organization ceases to provide services
In the “Extension Surveys” section, increased the condition regarding service
capacity from “25%” to “50%”
Updated “On-site Follow-up Survey for a Condition-level Deficiency” section
Updated “2013 Accreditation Decision Rules” section, including
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adding Contingent (CONT) Accreditation decision rules CONT03,
CONT04, CONT05, CONT06, and CONT07
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adding Accreditation with Follow-up Survey (AFS) decision rule AFS02
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deleting “On-site MOS Survey” section and decision rule MOS02
Standards Applicability Grid (SAG)
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Deleted applicability to Long Term Acute Care services for APR.04.01.01,
EPs 11–12, 17–24, 26
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Added applicability to Psychiatric and Surgical Specialty services for EC.02.03.05,
EP 25
Added EC.02.04.03, EP 17 (with applicability to Acute, Long Term Acute Care,
and Surgical Specialty services)
Deleted HR.01.02.01, EP 19
Added IC.02.04.01, EPs 6–9 (with applicability to all four services)
Added LD.04.03.11, EP 9 (with applicability to Acute and Psychiatric services)
Added MM.04.01.01, EP 15 (with applicability to all four services)
Added applicability to Psychiatric services for NPSG.02.03.01, EP 2
Deleted NPSG.07.06.01, EP 4
Added applicability to Psychiatric services for UP.01.01.01, EPs 1–3; UP.01.02.01,
EPs 1–5; and UP.01.03.01, EPs 1–5
Added PC.01.01.01, EP 24 (with applicability to Acute and Psychiatric services)
Added PC.01.02.15, EPs 5–7 (with applicability to Acute, Long Term Acute Care,
and Surgical Specialty services)
Added PC.03.05.19, EP 3 (with applicability to all four services)
Sentinel Events (SE)
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Made minor editorial changes
The Joint Commission Quality Report (QR)
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Revised list of common conditions reported for the National Quality Improvement
Goals requirements and made minor editorial changes
Performance Measurement and the ORYX ® Initiative (PM)
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Made minor revision to “The Continued Role of ORYX” section
Replaced “Future Scope” section with discussion of accountability measures
Defined the frequency for submitting aggregate monthly data in “Requirements for
Psychiatric Hospitals”
Clarified information about compliance with Standard PI.02.01.03 and accountability measures in the “ORYX Performance Measure Report” section
Revised subhead under “Use of Performance Measure Data”
Added new Figure 1. Accountability Measure Composite Rate and replaced Figures
2 through 5
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Staffing Effectiveness Indicators (SEI)
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No changes
Required Written Documentation (RWD)
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Added the following:
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EC.02.04.03, EP 17
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IC.02.04.01, EPs 4–6, 8
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LD.04.03.11, EPs 4, 5, 7
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MM.04.01.01, EP 15
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PC.01.02.15, EP 5
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PC.03.05.19, EPs 2–3
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RC.01.02.01, EP 4
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RC.02.01.01, EP 1
Early Survey Policy Option (ESP)
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Added the following:
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APR.09.04.01, EP 1
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IC.02.04.01, EP 6
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LD.04.03.09, EP 23
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LS.02.01.30, EP 24
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PC.01.02.15, EPs 5–7
Appendix A: Medicare Requirements for Hospitals (AXA)
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Revised standard 482.22(a) regarding eligibility and appointment to the medical
staff and reformatted chapter
Appendix B: Special Conditions of Participation for Psychiatric Hospitals
(AXB)
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Added chapter to manual
Glossary (GL)
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Added “Option 1” after “Early Survey Policy” to definition for Preliminary
Accreditation (see entry for accreditation decisions)
Revised the terms Accredited, Contingent Accreditation, and Preliminary Denial of
Accreditation to parallel updated accreditation decision rules (see entry for
accreditation decisions)
Revised the term accreditation survey
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Expanded behavioral health care definition to include developmental disabilities and
community-based settings
Deleted the definition for the term disruptive and inappropriate behavior and in its
place added a cross-reference to the new term behaviors that undermine a culture of
safety
Added new terms Focused Standards Assessment (FSA) and Intracycle Monitoring
(ICM)
Changed term Immediate Threat to Health and Safety to Immediate Threat to Health
or Safety
Deleted the definition for the term Periodic Performance Review (PPR) and in its
place created a cross-reference to the new term Focused Standards Assessment (FSA)
Deleted the term ratio
Revised surveyor definition to include additional information that the type of
surveyor assigned is determined by the program and its services
CAMH, January 2013
Comprehensive
AccreditationManual
CAMH
for Hospitals
Effective January 2013
Standards
Elements of Performance
Scoring
Accreditation Policies
The Joint Commission
Accreditation
Hospital
The Joint Commission Mission
The mission of The Joint Commission is to continuously improve health care for the
public, in collaboration with other stakeholders, by evaluating health care organizations
and inspiring them to excel in providing safe and effective care of the highest quality and
value.
© 2013 The Joint Commission
Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint
Commission, has been designated by The Joint Commission to publish publications and
multimedia products. JCR reproduces and distributes these materials under license from
The Joint Commission.
JCR educational programs and publications support, but are separate from, the
accreditation activities of The Joint Commission. Attendees at JCR educational
programs and purchasers of JCR publications receive no special consideration or
treatment in, or confidential information about, the accreditation process.
All rights reserved. No part of this publication may be reproduced in any form or by any
means without written permission from the publisher.
Printed in the U.S.A. 5 4 3 2 1
Requests for permission to make copies of any part of this work should be mailed to the
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[email protected]
ISBN: 978-1-59940-635-0
ISSN: 1076-5638
For more information about The Joint Commission, please visit
http://www.jointcommission.org.
Contents
How to Use This Manual (HM)...........................................................HM-1
Requirements for Accreditation
Accreditation Participation Requirements (APR)..................................APR-1
Environment of Care (EC) .....................................................................EC-1
Emergency Management (EM) ..............................................................EM-1
Human Resources (HR).........................................................................HR-1
Infection Prevention and Control (IC) ....................................................IC-1
Information Management (IM) ..............................................................IM-1
Leadership (LD) .....................................................................................LD-1
Life Safety (LS) ........................................................................................LS-1
Medication Management (MM)...........................................................MM-1
Medical Staff (MS).................................................................................MS-1
National Patient Safety Goals (NPSG) ..............................................NPSG-1
Nursing (NR) ........................................................................................NR-1
Provision of Care, Treatment, and Services (PC) ....................................PC-1
Performance Improvement (PI)................................................................PI-1
Record of Care, Treatment, and Services (RC) .......................................RC-1
Rights and Responsibilities of the Individual (RI) ....................................RI-1
Transplant Safety (TS) ............................................................................TS-1
Waived Testing (WT) ...........................................................................WT-1
Policies, Procedures, and Other Information
The Accreditation Process (ACC) ..................................................ACC-1
Standards Applicability Grid (SAG) ...............................................SAG-1
Sentinel Events (SE) ..........................................................................SE-1
The Joint Commission Quality Report (QR) ....................................QR-1
Performance Measurement and the ORYX® Initiative (PM).............PM-1
Staffing Effectiveness Indicators (SEI)............................................SEI-1
CAMH, January 2013
3
◤Comprehensive Accreditation Manual for Hospitals
Required Written Documentation (RWD)......................................RWD-1
Early Survey Policy Option (ESP)...................................................ESP-1
Appendix A: Medicare Requirements for Hospitals (AXA) ..........AXA-1
Appendix B: Special Conditions of Participation for
Psychiatric Hospitals (AXB) ...........................................................AXB-1
Glossary (GL) ..................................................................................... GL-1
Index (IX)............................................................................................... IX-1
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CAMH, January 2013