2012 Comprehensive Accreditation Manual for Table of Changes March 2012 Effective July 1, 2012, or as noted 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 The number of days that an organization can identify as avoid dates for an unannounced survey has been increased from 10 to 15 in The Accreditation Process (ACC) chapter. n A description about the ISO Certification Option has been added to the ACC chapter. n The ACC chapter was updated to indicate 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. n Accreditation decision rules for 2012 in the ACC chapter have been updated and are effective immediately. n The Simplifying Compliance Activities (SCA) chapter has been discontinued and should be removed from the manual. 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 q Title page and contents Updated title page and Effective immediately page contents page How to Use This Manual (HM) q Entire chapter Revised Figure 1. Effective immediately Components of a standards or requirements chapter Deleted description for the Simplifying Compliance Activities (SCA) chapter Added description of Appendix B: Special Conditions of Participation for Psychiatric Updated descriptions of the four levels of scoring criticality in the Understanding the Icons Used in the Manual section Added new tips for organizations in the Keys to Successfully Using This Manual section 2
Requirements for Accreditation 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 APR-3 APR-6 with Revised language re- Effective July 1, 2012 APR-3 APR-6b garding timing of submission of Periodic Performance Review (PPR) and added second note to APR.03.01.01, EP 1 Minor editorial changes Environment of Care (EC) q EC-9 EC-12 Changed accredita- Effective July 1, 2012 q EC-15 EC-16 with tion to Joint Com- EC-15 EC-16b mission 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 computerized tomography (CT) scans 3
Human Resources (HR) q HR-3 HR-4 Deleted last sentence of Effective July 1, 2012 HR.01.02.01, EP 1, Note 4, which indicated that inclusion of qualifications would not affect the accreditation decision Infection Prevention and Control (IC) q IC-7 IC-12 with Updated website refer- Effective July 1, 2012 IC-7 IC-12b ence 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 4
Leadership (LD) q LD-15 LD-16 Revised Rationale for Effective July 1, 2012 q LD-31 LD-32 with LD.03.01.01, as well as LD-31 LD-32b EPs 4 and 5, to reflect change from disruptive behavior to behavior that undermines a culture of safety Medication Management (MM) Revised LD.04.03.09, Effective immediately EP 23, to reflect changes to Medicare Conditions of Participation related to the credentialing and privileging of telemedicine practitioners q MM-7 MM-8 with Expanded criteria for Effective July 1, 2012 MM-7 MM-8b selecting medications to include the population(s) served in MM.02.01.01, EP 2 Medical Staff (MS) q MS-43 MS-46 Revised MS.13.01.01, Effective immediately EP 1, to reflect changes to Medicare Conditions of Participation related to the credentialing and privileging of telemedicine practitioners 5
Provision of Care, Treatment, and Services (PC) q PC-7 PC-8 Added PC.01.02.15, Effective July 1, 2012 q PC-11 PC-16 with EPs 5 7, for hospitals in PC-11 PC-16b California that provide q PC-19 PC-20 computerized tomograq PC-31 PC-54 with phy (CT) scans PC-31 PC-54b 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 Changed accreditation to Joint Commission accreditation in several requirements 6
Record of Care, Treatment, and Services (RC) q RC-7 RC-12 Changed RC.02.01.01, Effective July 1, 2012 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 Policies, Procedures, and Other Information The Accreditation Process (ACC) q Entire chapter Added note about new Effective July 1, 2012 Appendix B in General Eligibility Requirements section Identified length of time organizations may stay in Preliminary Accreditation in Eligibility for Preliminary Accreditation section Made minor updates to Priority Focus Areas (PFAs) section 7
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 Added Assessment and Staffing to list of high-risk topics in Second Generation Tracers section Added Accreditation with Follow-up Survey to Figure 3. Scoring Criticality Method Added Top Performers on Key Quality Measures section Deleted references to PPR as annual 8
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 In the Extension Surveys section, increased the condition regarding service capacity from 25% to 50% Added information to the On-site Follow-up Survey for a Conditionlevel Deficiency section Minor editorial changes and policy clarifications Revised definitions of Effective immediately Contingent Accreditation and Preliminary Denial of Accreditation in Accreditation Decision Categories section 9
Standards Applicability Grid (SAG) Updated 2012 Accre- Effective immediately ditation Decision Rules section, including adding Contingent (CONT) Accreditation decision rules CONT03, CONT04, and CONT05 and Accreditation with Followup Survey (AFS) decision rule AFS02 q Entire chapter Added applicability to Effective July 1, 2012 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) Added IC.02.04.01, EPs 6 9 (with applicability to all four services) Added applicability to Psychiatric services for NPSG.02.03.01, EP 2 Added PC.01.02.15, EPs 5 7 (with applicability to Acute, Long Term Acute Care, and Surgical Specialty services) 10
Sentinel Events (SE) q Entire chapter Minor editorial changes Effective immediately The Joint Commission Quality Report (QR) q QR-7 QR-10 Revised list of common Effective July 1, 2012 conditions reported for the National Quality Improvement Goals requirements Performance Measurement and the ORYX Initiative (PM) q Entire chapter Made minor revision to Effective July 1, 2012 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 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 11
Added new Figure 1. Accountability Measure Composite Rate and replaced Figures 2 through 4 Simplifying Compliance Activities (SCA) q Entire chapter and tab Discontinued chapter Effective immediately and do not replace Required Written Documentation (RWD) q Entire chapter Added EC.02.04.03, Effective July 1, 2012 EP 17 Added IC.02.04.01, EPs 4 6, 8 Added PC.01.02.15, EP 5 Early Survey Policy Option (ESP) q Entire chapter Added APR.09.04.01, Effective July 1, 2012 EP 1 Added IC.02.04.01, EP 6 Added LD.04.03.09, EP 23 Added PC.01.02.15, EPs 5 7 Appendix B: Special Conditions of Participation for Psychiatric (AXB) q Entire chapter and tab Added new chapter to Effective July 1, 2012 manual 12
Glossary q Entire chapter Added Option 1 after Effective immediately Early Survey Policy to definition for Preliminary Accreditation (see entry for accreditation decisions) Revised the terms Contingent Accreditation and Preliminary Denial of Accreditation to parallel updated accreditation decision rules (see entry for accreditation decisions) 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 Changed term Immediate Threat to Health and Safety to Immediate Threat to Health or Safety Index q Entire chapter Updated index Effective immediately 13
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