CAMH. Table of Changes CAMH Update 2, September 2011

Transcription

1 Comprehensive Accreditation Manual for 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 requirements for accreditation, policies, procedures, and other information include the following: n Deleted the requirement for a Periodic Performance Review (PPR) in the year of the hospital s triennial survey in The Accreditation Process (ACC) chapter, effective January 1, 2012 n Revised accreditation decision rules for 2012 in the ACC chapter, effective January 1, 2012 n Added new National Patient Safety Goal NPSG regarding catheterassociated urinary tract infections (CAUTI), effective January 1, 2012 n Added information on performance expectations for ORYX accountability measures to the Performance Measurement and the ORYX Initiative (PM) chapter, effective January 1, 2012 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 q Previous title page q Updated title page Effective immediately Foreword (FW) q Previous Foreword q New Foreword for 2012 Effective immediately How to Use This Manual (HM) q Entire chapter q Included information Effective January 1, 2012 about access to The Joint Commission Connect extranet site q Expanded the description of how changes are made to the manual q Revised Table 1. Acronyms Used in This Manual q Edited descriptions of chapter overviews, standards, rationales, and elements of performance q Updated chapter descriptions q Added clarifying information to the descriptions of the icons used in the manual q Updated descriptions of the four levels of scoring criticality 2

3 Requirements for Accreditation q q Included new resources and updated existing resources available at The Joint Commission listed in Sidebar 2. Where Should I Go for More Information? Minor editorial changes Accreditation Participation Requirements (APR) q Entire chapter q Revised chapter outline Effective January 1, 2012 q Updated the timing for the Periodic Performance Review (PPR) in APR q Added APR Environment of Care (EC) q Entire chapter q Added Note 2 for Effective January 1, 2012 EC , EP 3 Emergency Management (EM) Human Resources (HR) q Entire chapter q Revised chapter outline Effective January 1, 2012 q Added standards link to HR , EP 1 3

4 Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) q Entire chapter q Revised LD , Effective January 1, 2012 EP 17 q Revised introduction to LD q Revised Note 3 for EP 4, deleted Note for EP 9, and added EP 23 for LD Life Safety (LS) Medication Management (MM) q Entire chapter q Added Note 1 and Effective January 1, 2012 Note 2 for MM , EP 1 4

5 Medical Staff (MS) q Entire chapter q Revisions to Introduc- Effective January 1, 2012 tion for MS q Revised EP text, deleted Note 3, and revised standards link for MS , EP 1 National Patient Safety Goals (NPSG) q Entire chapter q Revised chapter outline Effective January 1, 2012 q Changed scoring and deleted measure of success for NPSG , EP 2 q Added NPSG for CAUTIs q Added documentation icon to NPSG Nursing (NR) Provision of Care, Treatment, and Services (PC) q Entire chapter q Revised chapter outline Effective January 1,

6 Performance Improvement (PI) q Entire chapter q Revised chapter outline Effective January 1, 2012 q Deleted EP 6 for PI q Added EP 1 for PI Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) q Entire chapter q Revised chapter outline Effective January 1, 2012 q Added Notes to EPs 1 and 2 for RI Transplant Safety (TS) Waived Testing (WT) 6

7 Policies, Procedures, and Other Information The Accreditation Process (ACC) q Entire chapter q Added program descrip- Effective January 1, 2012 tions for critical access hospital and officebased surgery practices to the Joint Commission Accreditation Programs section q Clarified Centers for Medicare & Medicaid Services text in the Release of Data to Government Agencies and Accrediting Bodies" section q Added Second Generation Tracers section with description q Added information about accessing the Accreditation Publicity Kit online in the Accreditation Award Display and Use section q Deleted the requirement for a PPR in the year of the hospital s triennial survey q Updated accreditation decision rules for 2012 q Revised Review and Appeal Procedures for adverse decisions 7

8 Standards Applicability Grid (SAG) q q Updated Figure 9. Process Flow for the Appeal of a Preliminary Denial of Accreditation Decision Minor editorial changes q Entire chapter q Added long term acute Effective January 1, 2012 care category q Added APR , EP 1 q Added EP 23 for LD q Added NPSG , EPs 1 4 q Deleted EP 6 for PI q Added PI , EP 1 Sentinel Events (SE) and policy clarifications q Updated the Hospital- Specific Definition of Sentinel Event section q Updated footnotes in the Definition of Occurrences That Are Subject to Review by The Joint Commission Under the Sentinel Event Policy section 8

9 q Clarified time period for loss of function applicability in Table 2. Examples of Sentinel Events That Are Not Reviewable Under The Joint Commission s Sentinel Event Policy The Joint Commission Quality Report (QR) Performance Measurement and the ORYX Initiative (PM) q Entire chapter q Revised the Overview Effective January 1, 2012 q Revised The Continued Role of ORYX section q Revised Web address for vendors listed in Current Requirements for section q Added discussion heading Requirements for Small q Made minor revision to Requirements for Small q Relocated Use of Performance Measure Data section later in chapter 9

10 q Added information on performance expectations for ORYX Accountability Measures (effective January 1, 2012) q Replaced Figures 1 through 4 Simplifying Compliance Activities (SCA) q Reordered sections in alphabetical order q Updated Web site references Required Written Documentation (RWD) q Entire chapter q Added EP 23 for Effective January 1, 2012 LD q Added EP 1 for NPSG Early Survey Policy Option (ESP) q Entire chapter q Added EPs 4 and 9 for Effective January 1, 2012 LD Appendix A: Medicare Requirements for (AXA) q Entire chapter q Added information Effective January 1, 2012 about Conditions of Participation: Governing Body q Added information about Condition of Participation: Medical Staff 10

11 Glossary (GL) q Entire chapter q Revised the term appeal Effective January 1, 2012 process to include change from Review Hearing Panel to First Level Review & Appeal q Revised the term complex organization to simplify the definition q Clarified the definition of Early Survey Policy q Added new terms e-soc and home care q Added new term First Level Review & Appeal and deleted the term Review Hearing Panel to reflect updated review and appeal process Index (IX) q Entire chapter q Updated index Effective immediately 11

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