2013 Comprehensive Accreditation Manual for Table of Changes March 2013 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: Added a requirement to the Information Management (IM) chapter to address radiation event reporting requirements for hospitals in California that provide computed tomography (CT) services Added the Primary Care Medical Home Certification Option (PCMH) chapter, which lists all the current and new requirements that apply to hospitals pursuing optional Primary Care Medical Home Certification Added new requirements for hospitals pursuing optional Primary Care Medical Home Certification to the Leadership (LD) chapter, the Medication Management (MM) chapter, the Medical Staff (MS) chapter, the Provision of Care, Treatment, and Services (PC) chapter, the Performance Improvement (PI) chapter, the Record of Care, Treatment, and Services (RC) chapter, and the Rights and Responsibilities of the Individual (RI) chapter Clarified that all first and second surveys for hospitals are unannounced in The Accreditation Process (ACC) chapter Added Primary Care Medical Home Certification section and decision rules PCMH01 and PCMH02 to the ACC chapter Revised the Review and Appeal Procedures section in the ACC chapter 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
Title Page and Contents Page Title page and Updated title page and contents page Effective Contents page immediately How to Use This Manual (HM) Entire chapter Standardized use of the terms standard Effective and requirement July 1, 2013 Revised Table 1. Acronyms Used in This Manual Clarified the description of rationale Revised Figure 1. Components of a standards chapter Updated the descriptions of the accreditation programs Rearranged the order of the icon descriptions in the requirements chapters Revised Sidebar 1. Icons in This Manual 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? Made minor editorial changes 2
Requirements for Accreditation Accreditation Participation Requirements (APR) APR-3 APR-8 Revised fourth bullet point regarding Effective electronic submission of information July 1, 2013 to The Joint Commission in Note 1 and updated definition of falsification in Note 2 at APR.01.02.01 Clarified that the hospital uses measure data available through its ORYX vendor in Standard APR.04.01.01 and EPs 22 23 and 26 Made minor editorial changes Human Resources (HR) HR-1 HR-2 Deleted HR.02.01.01 from Chapter Effective Outline immediately Infection Prevention and Control (IC) IC-11 IC-14 Updated Introduction to IC.02.04.01 Effective (including the website also noted in EP immediately 5) and deleted Rationale Information Management (IM) Insert IM-8a Added IM.02.02.03, EP 13, on Effective IM-8b radiation event reporting requirements July 1, 2013 for hospitals in California that provide CT services 3
Leadership (LD) LD-3 LD-4 Updated Chapter Outline Effective LD-7 LD-16 For hospitals that elect the Primary July 1, 2013 with LD-7 Care Medical Home option: LD-16b Added LD.01.03.01, EP 20 LD-23 LD-24 Added LD.04.01.06 and EP 1 with LD-23 Added LD.04.04.01, EPs 5 and 24 LD-24b Revised LD.04.03.09, EP 23, to reflect LD-31 LD-32 telemedicine services furnished to a LD-35 LD-38 hospital s patients with LD-35 LD-38b Made minor editorial changes Medication Management (MM) MM-3 MM-4 Clarified that MM.05.01.15 is not Effective applicable to hospitals in Chapter immediately Outline MM-13 MM- Added MM.04.01.01, EP 21, for Effective 16 with MM- hospitals that elect the Primary Care July 1, 2013 13 MM-16b Medical Home option MM-23 Revised MM.07.01.03, EP 6, on the Effective MM-24 reporting of medication errors December 5, 2012 Medical Staff (MS) Insert MS-8a Added note about other categories of Effective MS-8b nonphysician practitioners to December 5, 2012 MS.01.01.01, EP 13 MS-17 MS-18 Added MS.03.01.01, EP 18, for Effective with MS-17 hospitals that elect the Primary Care July 1, 2013 MS-18b Medical Home option Made minor editorial changes Nursing (NR) NR-5 NR-6 Made minor editorial change Effective July 1, 2013 4
Provision of Care, Treatment, and Services (PC) PC-3 PC-6 Deleted PC.05.01.01, PC.05.01.03, Effective PC.05.01.05, and PC.05.01.07 from immediately Chapter Outline PC-15 PC-22 Deleted cross reference from Effective with PC-15 PC- PC.01.01.01, EP 4 July 1, 2013 22b Added cross reference to PC.01.02.01, PC-25 PC-26 EP 23 with PC-25-PC- For hospitals that elect the Primary 26d Care Medical Home option: PC-65 PC-66 Added PC.01.03.01, EPs 44 45 with PC-65 PC- Added PC.02.01.01, EPs 16 17 66b Added PC.02.02.01, EPs 24 25 Added PC.02.03.01, EP 28 Added PC.02.04.01 and EPs 1 3 Added PC.02.04.03 and EPs 1 5 Added PC.02.04.05 and EPs 1 2, 4 13 Made minor editorial changes Clarified third bullet in PC.03.05.19, Effective EP 1, regarding the exception of soft January 3, 2013 wrist restraints Performance Improvement (PI) PI-5 PI-8 with For hospitals that elect the Primary Effective PI-5 PI-8b Care Medical Home option: July 1, 2013 Added PI.01.01.01, EPs 40 42 Added PI.03.01.01, EP 11 Made minor editorial changes 5
Record of Care, Treatment, and Services (RC) RC-3 RC-4 For hospitals that elect the Primary Effective with RC-3 RC- Care Medical Home option: July 1, 2013 4b Added Note to RC.01.01.01, EP 8 RC-7 RC-8 Added RC.02.01.01, EP 29 with RC-7 RC- 8b Rights and Responsibilities of the Individual (RI) RI-3 RI-4 Updated Chapter Outline Effective RI-7 RI-8 with For hospitals that elect the Primary July 1, 2013 RI-7 RI-8b Care Medical Home option: RI-11 RI-12 Added RI.01.02.01, EPs 31 32 with RI-11 RI- Added RI.01.04.03 and EPs 1 6 12b Transplant Safety (TS) TS-11 TS-12 Corrected cross reference in second Effective bullet of footnote to TS.03.02.01, July 1, 2013 EP 7 Policies, Procedures, and Other Information The Accreditation Process (ACC) Entire chapter Made minor editorial changes and Effective policy clarifications July 1, 2013 Updated descriptions in Joint Commission Accreditation Programs section Changed 10 patients must be present to 10 inpatients must be served in Eligibility Requirements for Initial Surveys section 6
Moved and updated Tailored Survey Policy section, including adding language for entities seeking separate accreditation Added Primary Care Medical Home Certification Option section Changed percentage of organizations that undergo a random unannounced on-site validation survey from 5% to 2% in Initial Surveys section Changed 10 patients to 10 inpatients and added language about hospitals not using Joint Commission accreditation for deemed status to last bullet of Initial Surveys section Made minor editorial changes to Public Information Policy section Updated Early Survey Policy section by revising Sidebar 1. Early Survey Policy and Eligibility for Preliminary Accreditation section to reflect that all first and second surveys are unannounced, by clarifying that CMS recognition comes after the second full survey and an Accredited decision, and by deleting the statement that organizations may stay in Preliminary Accreditation for one year Updated Table 1. Exceptions to Unannounced Surveys 7
Clarified in the Unannounced Surveys section that avoid dates can be identified in the E-App and that the survey eligibility range is after the last full (rather than last full unannounced) survey Revised Survey Agenda section by deleting statement that surveyors can review MOS during the planning session, adding a separate Competence Assessment section, revising the Leadership section, and making minor editorial changes Deleted bullet stating corrective action is considered when an organization demonstrates that it prepared a root cause analysis from Immediate Threat to Health or Safety section Clarified that Evidence of Standards Compliance (ESCs) are required at 45 (direct impact) and 60 (indirect impact) calendar days in How Accreditation Decisions Are Made section Added cross reference to Random Validation of Evidence of Standards Compliance to Measure of Success (MOS) Report 8
Added statement that organizations have 5 days to submit post-survey corrections in Figure 7. Process Flow for a Preliminary Denial of Accreditation (PDA) Decision and Figure 8. Process Flow for a Contingent Accreditation (CONT) Decision Clarified the options for and timing of Focused Standards Assessment (FSA) submission in the Focused Standards Assessment (FSA) section Updated Sidebar 3. Focused Standards Assessment Options by deleting the bullets stating that surveyors may review any required MOS at full survey and by making minor editorial changes Changed percentage of organizations that undergo a random unannounced on-site validation survey from 5% to 2% in Random Validation of Evidence of Standards of Compliance section Updated 2013 Accreditation Decision Rules section, including Clarifying that the initial survey is for deemed status in Contingent (CONT) Accreditation decision rule CONT04 Updating Note in Accreditation with Follow-up Survey (AFS) decision rule AFS08 to specify organizations that are already Medicare certified 9
10 Adding reference to CONT06 in AFS09 Deleting reference to deemed status from the Note to Preliminary Accreditation (PA) decision rule PA01 and changing announced survey to unannounced survey Adding Primary Care Medical Home Certification section and decision rules PCMH01 and PCMH02 Updated Review and Appeal Procedures section, including Changing First Level Review & Appeal Committee to Review Hearing Panel throughout Changing time frame from six to four months in III. Contingent Accreditation section and stating that follow-up electronic survey will replace MOS submission Adding IV. Accreditation with Follow-up Survey section Replacing IV. First Level Review & Appeal section with V. Review Hearings Replacing V. Second Consideration by the Accreditation Committee section with VI. Accreditation Committee Review Following Review Hearing Revising VI. Final Review & Appeal Request and renumbering it as section VII.
Renumbering sections VII. X. as VIII. XI. Standards Applicability Grid (SAG) SAG-1 SAG-2 Added IM.02.02.03, EP 13 (with Effective SAG-11 SAG- applicability to Acute and Surgical July 1, 2013 16 with SAG- Specialty services) 11 SAG-16b Added LD.01.03.01, EP 20 (with SAG-21 SAG- 24 with SAG- Added LD.04.01.06, EP 1 (with 21 SAG-24b SAG-31 SAG- Added LD.04.04.01, EPs 5 and 24 42 with SAG- (with 31 SAG-44 Added MM.04.01.01, EP 21 (with Added MS.03.01.01, EP 18 (with Added PC.01.03.01, EPs 44 45 (with Added PC.02.01.01, EPs 16 17 (with Added PC.02.02.01, EPs 24 25 (with Added PC.02.03.01, EP 28 (with Added PC.02.04.01, EPs 1 3 (with Added PC.02.04.03, EPs 1 5 (with Added PC.02.04.05, EPs 1 2, 4 13 (with Added PI.01.01.01, EPs 40 42 (with 11
Sentinel Events (SE) Added PI.03.01.01, EP 11 (with Added RC.02.01.01, EP 29 (with Added RI.01.02.01, EPs 31 32 (with Added RI.01.04.03, EPs 1 6 (with SE-5 SE-8 Revised Definition of Occurrences Effective That Are Subject to Review by The July 1, 2013 Joint Commission Under the Sentinel Event Policy section Revised Table 1. Examples of Sentinel Events That Are Reviewable Under The Joint Commission s Sentinel Event Policy The Joint Commission Quality Report (QR) QR-3 QR-4 Made minor editorial changes Effective July 1, 2013 Performance Measurement and the ORYX Initiative (PM) PM-5 PM-6 Added section describing requirements Effective with PM-5 PM- for long term acute care hospitals and July 1, 2013 6b inpatient rehabilitation facilities PM-9 PM-12 d Figures 1 through 5 Required Written Documentation (RWD) RWD-5 RWD- Added PI.02.01.01, EP 14 Effective 6 immediately 12
Primary Care Medical Home Certification Option (PCMH) Insert new Added chapter that lists all standards Effective chapter and EPs that apply to hospitals July 1, 2013 pursuing optional Primary Care Medical Home Certification Glossary Entire chapter Revised definitions for the following Effective terms: July 1, 2013 accreditation decisions accreditation process anesthesia and sedation appeal process behavioral health care child Early Survey Policy Focused Standards Assessment (FSA) Intracycle Monitoring (ICM) read-back surveyor tabletop exercise The Joint Commission Updated definitions for the terms accreditation manual, medical record, medication error, and record to reflect revisions resulting from the Long Term Care Reinvention Project 13
Index Added new terms chronic care, clinical decision support, electronic prescribing, functional exercise, health literacy, health risk behaviors, population-based care, preventive care, primary care clinician, self-management, and urgent care, all related to the new Primary Care Medical Home Certification program Changed the term First Level Review & Appeal to Review Hearing Panel;no change in definition Deleted the definition for the term long term care and in its place created a cross reference to the new term nursing and rehabilitation center care Deleted the definition for the term medical record and in its place created a cross reference to the term record Made minor editorial changes Entire chapter Updated index Effective immediately 14