JC EBAPG 2020
$111.04
Hospital Compliance Assessment Workbook
Published By | Publication Date | Number of Pages |
Joint Commission | 2020 | 562 |
This title was completely reimagined for 2020! A straightforward, hands-on resource, the 2020 Hospital Compliance Assessment Workbook engages staff and leadership in accreditation activities with questions, templates, and tracer tools to identify areas of noncompliance. This self-assessment workbook is designed to help your hospital maintain continuous standards compliance and survey readiness to assess standards compliance and survey readiness. The simplified workbook includes ALL hospital standards and EPs, including those used for deemed status purposes and primary care medical home certification in the hospital setting. Buy one for each member of your accreditation team, or a site license for all to share! Key Topics • Assessment of standards compliance • Application of the SAFERTM Matrix • Tracer methodology • Risk assessment Key Features • Questions to assess each element of performance in the E-dition®/Comprehensive Accreditation Manual for Hospitals as of January 1, 2020 • Downloadable, adaptable tools and templates for standards compliance • Tracer questions and worksheets to help with mock tracers and promote survey readiness Standards: All hospital standards effective January 1, 2020 Setting: Organizations accredited under the Hospital Accreditation Program, including general, acute psychiatric, pediatric, medical/surgical specialty, long term acute care, and rehabilitation hospitals Key Audience • Accreditation managers • Quality improvement managers • Physician and nurse leaders • Chapter leaders and department heads
PDF Catalog
PDF Pages | PDF Title |
---|---|
1 | Cover/title page |
2 | Copyright |
3 | Contents |
5 | Introduction |
13 | Part 1: Compliance Assessment Checklist |
15 | Accreditation Participation Requirements (APR) |
31 | Environment of Care® (EC) |
87 | Emergency Management (EM) |
123 | Human Resources (HR) |
137 | Infection Prevention and Control (IC) |
153 | Information Management (IM) |
163 | Leadership (LD) |
203 | Life Safety (LS) |
267 | Medication Management (MM) |
299 | Medical Staff (MS) |
351 | National Patient Safety Goals® (NPSG) |
379 | Nursing (NR) |
387 | Provision of Care, Treatment, and Services (PC) |
453 | Performance Improvement (PI) |
465 | Record of Care, Treatment, and Services (RC) |
481 | Rights and Responsibilities of the Individual (RI) |
505 | Transplant Safety (TS) |
519 | Waived Testing (WT) |
529 | Part 2: Compliance Assessment Tools and Templates |
531 | Mock Tracers |
533 | Sidebar 2-1. How to Choose the Topic of a Mock Tracer |
535 | Sidebar 2-2. Tips for Formulating Mock Tracer Questions |
538 | Figure 2-1. Example Mock Tracer Form—Tracing a Hospital Fire |
541 | The SAFER Approach Risk Assessment |
542 | Figure 2-2. Determining Where to Place an Element of Performance (EP) on the SAFER Matrix |
543 | Figure 2-3. Example of EP Placement on the SAFER Matrix |
544 | Figure 2-4. The Seven Basic Steps of the Risk-Assessment Process |
546 | Tool 2-1. Mock Tracer Planning Task List |
547 | Tool 2-2. Sample Mock Tracer Questions |
552 | Tool 2-3. Required Documents Checklist |
554 | Tool 2-4. Mock Tracer Form |
555 | Tool 2-5. Mock Tracer Evaluation Checklist |
558 | Tool 2-6. Corrective Action Plan Worksheet |
559 | Tool 2-7. Survey Analysis for Evaluating Risk® (SAFER™) Matrix |
560 | Tool 2-8. Proactive Risk-Assessment Worksheet |