CAMH. Table of Changes CAMH Update 1, March 2011

Transcription

1 Comprehensive Accreditation Manual for Hospitals: The Official Handbook Table of Changes To update your manual, please remove and recycle the pages listed in this table of changes and insert the replacement pages provided in this packet. Check boxes have been provided in the table of changes for your convenience to track the removal and addition of pages. Major changes that appear in this update to reuirements for accreditation, policies, procedures, and other information include the following: n Updates to the National Patient Safety Goals (NPSGs) regarding medication reconciliation, effective July 1, 2011 n Revisions to standards in the Environment of Care (EC), Emergency Management (EM), Information Management (IM), Leadership (LD), and Provision of Care, Treatment, and Services (PC) chapters to align Joint Commission reuirements with Medicare Conditions of Participation n Revised time frame for unannounced surveys from between 18 and 39 months to between 18 and 36 months in The Accreditation Process (ACC) chapter, effective immediately n Revised Public Information Policy in The Accreditation Process (ACC) chapter, effective immediately n A major reorganization and edit of the How to Use This Manual (HM) chapter to improve navigation of the chapter, understanding of its subject matter, and ease of reading,effectiveeffective immediately Refer to the table beginning on page 2 and the actual update pages for more details about revisions included in this update. Revisions to content within this update are highlighted in shaded text within your replacement pages. 1

2 Title Page and Contents Page Title page and Contents Updated title page and Effective immediately page contents page How to Use This Manual (HM) Entire chapter Reorganized, edited, Effective immediately and updated to make the chapter more useful to readers (Note: Many of these changes will not show up in shaded text.) Deleted description of post-survey process and sample sizes Added new Table 1. Acronyms Used in This Manual Updated chapter descriptions Included new information for Identifying Applicable Accreditation Reuirements Expanded descriptions of the icons used in the manual 2

3 Reuirements for Accreditation Augmented Keys to Successfully Using This Manual section, providing tips on how to use the manual to maintain continuous compliance and prepare for a survey Revised the comprehensive list of resources in Sidebar 2. Where Should I Go for More Information? Accreditation Participation Reuirements (APR) APR-5 APR-6 Deleted reference to Effective July 1, 2011 legal counsel for APR , EP 3 Environment of Care (EC) Remove EC-9 through Added standards link to Effective July 1, 2011 EC-22 and replace with EC , EP 9 EC-9 EC-22b Added standards link and NFPA reference to EC , EP 10 Revised EP 2 and added new EP 25 to EC Revised Note for EC , EP 6 Revised NFPA reference for EC , EP 1 3

4 Emergency Management (EM) Added Note to EC , EPs 2 6 Added standards link to EC , EP 2 EM-17 EM-24 Added standards link to Effective July 1, 2011 EM , EP 2 Added Note 4 to EM , EP 1 Human Resources (HR) HR-7 HR-8 Added standards link to Effective July 1, 2011 HR , EP 2 Infection Prevention and Control (IC) IC-11 IC-12 Deleted part of Note Effective July 1, 2011 and revised footnote for IC , EP 2 Information Management (IM) IM-7 IM-10 Added Note to Effective July 1, 2011 IM , EP 2 Leadership (LD) LD-23 LD-38 Added EP 10 and Note Effective July 1, 2011 to LD Life Safety (LS) LS-1 LS-2 Added text to the Appli- Effective July 1, 2011 LS-17 LS-18 cability of the Standards LS-21 LS-22 section of the chapter LS-25 LS-28 overview and revised its LS-33 LS-34 Note Deleted Note 1 for LS , EP 6 4

5 Medication Management (MM) Revised Note for LS , EP 25 Added standards link to LS , EP 4 Revised text for LS , EP 3 Revised Note for LS , EP 20 MM-7 MM-8 Deleted standards link Effective July 1, 2011 MM-13 MM-14 for MM , EP 2 MM-21 MM-24 Deleted EP 10 for MM Added Note and standards link to MM

6 Medical Staff (MS) MS-3 MS-6 Deleted Note 2 for the Effective July 1, 2011 MS-9 MS-10 Introduction to Stan MS-27 MS-28 dard MS MS-33 MS-38 Added standards links Remove MS-43 MS-50 to MS , EP 14 and replace with MS- Editorial change to 43 MS-46 MS Added text to rationale for MS Added standards link to MS , EP 1 Added documentation icon to MS , EP 3 and EP 5 Revised footnote for Introduction to MS Deleted 2010 version of Standard MS National Patient Safety Goals (NPSG) Entire chapter Added NPSG Effective July 1, 2011 to the chapter outline Added Note to NPSG , EP 3 Inserted new NPSG (was NPSG NPSG ) and Introduction Deleted NPSG to NPSG (revised and renumbered as NPSG ) 6

7 Provision of Care, Treatment, and Services (PC) PC-11 PC-14 Revised bulleted list for Effective July 1, 2011 PC-17 PC-18 PC , EP 2 Added bullet to list for PC , EP 6 Added Note to PC , EP 5 Added EP 43 to PC Editorial change to PC , EP 4 Record of Care, Treatment, and Services (RC) RC-5 RC-10 Revised Note to Effective July 1, 2011 RC , EP 4 Revised Note to RC , EP 4 Rights and Responsibilities of the Individual (RI) RI-5 RI-6 Deleted Note 2 for Effective July 1, 2011 RI , EP 28 Deleted Note for RI , EP 29 Transplant Safety (TS) TS-5 TS-6 Added text to Effective July 1, 2011 TS , EP 2 7

8 Policies, Procedures, and Other Information The Accreditation Process (ACC) Entire chapter Made editorial revisions Effective immediately to Joint Commission Accreditation Programs descriptions Clarified medical record review reuirements for specialty hospitals Revised Public Information Policy Made minor edits to Sidebar 1. Early Survey Policy Made minor editorial revisions to the descriptions under Priority Focus Process (PFP) and Priority Focus Areas (PFAs) 8

9 Revised the time frame for unannounced survey from between 18 and 39 months to between 18 and 36 months Updated Figure 4. Continuum of survey activity outcomes Revised Evidence of Standards Compliance (ESC) Process section Added new Sample Sizes section with a description of how to respond to a Reuirement for Improvement with a mandatory Measure of Success Updated Duration of Accreditation Award with the 36-month survey window Added new section for Accreditation Status of Organizations That Cease Provision of Services for a Period of Time Refined description of Clarification Validation Survey (CVS) Minor editorial changes 9

10 Standards Applicability Grid (SAG) Add new tab and entire Added standards appli- Effective July 1, 2011 chapter cability grid for acute, psychiatric, and surgical specialty services Sentinel Events (SE) Entire chapter Minor editorial changes Effective July 1, 2011 Replaced the phrase surgical and nonsurgical invasive procedures with invasive procedures, including surgery Refined the term rape to encompass sexual abuse/assault (including rape) Revised Table 1 s list of reviewable sentinel events Replaced the category Transfusion Death in Table 3 with Transfusion Reaction Clarified the notification process for Reviewable Sentinel Events That Are Not Reported by the Hospital Updated the section Submission of Root Cause Analysis and Action Plan 10

11 The Joint Commission Quality Report (QR) Entire chapter Minor editorial changes Effective immediately Deletion of Ernest A. Codman Award under Special uality awards/ merit badges Modified description of National Patient Safety Goals in the Quality Indicators section Deleted Quality Report User Guide section Updated description of features under What Is Quality Check? Deleted What Are the Accreditation Decision Categories? section Updated description of the criteria and process for submitting a commentary Revised description of marketing and communication guidelines for using Quality Reports 11

12 Performance Measurement and the ORYX Initiative (PM) Entire chapter Updated Web site Effective July 1, 2011 references Replaced Figure 1 and Figure 2 Replaced Figure 3 Replaced Figure 4 Minor editorial changes Simplifying Compliance Activities (SCA) Entire chapter Reordered sections in Effective immediately alphabetical order Updated Web site references Reuired Written Documentation (RWD) Entire chapter Added EC , Effective July 1, 2011 EP 25 Added EC , EP 2 Added MS , EPs 3, 5, 7 Added NPSG , EPs 1, 4 Deleted NPSG , EP 1 Deleted NPSG , EP 1 Deleted NPSG , EP 2 Early Survey Policy Option (ESP) Entire chapter Added LD , Effective July 1, 2011 EP 10 Added PC , EP 43 12

13 Glossary (GL) Index (IX) Entire chapter Added definitions for Effective July 1, 2011 the terms close call, prohibited abbreviations, and Quality Report Updated cross references to new terms Revised several terms to better align with their definitions: mitigation, emergency office-based surgery practice preparedness, emergency recovery, emergency response, emergency security, information Deleted the term nursing home Minor editorial changes Entire chapter Updated index Effective immediately 13

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