{"id":411570,"date":"2024-10-20T05:45:49","date_gmt":"2024-10-20T05:45:49","guid":{"rendered":"https:\/\/pdfstandards.shop\/product\/uncategorized\/jcr-camac-2023\/"},"modified":"2024-10-26T10:40:03","modified_gmt":"2024-10-26T10:40:03","slug":"jcr-camac-2023","status":"publish","type":"product","link":"https:\/\/pdfstandards.shop\/product\/publishers\/joint-commission\/jcr-camac-2023\/","title":{"rendered":"JCR CAMAC 2023"},"content":{"rendered":"

Our best-selling ambulatory care accreditation resource is available as a PDF. The CAMAC PDF manual provides you with all ambulatory care standards, elements of performance (EPs), National Patient Safety Goals\u00ae, and Accreditation Participation Requirements (APRs) effective January 1, 2023. Please note: This PDF manual is a digital version of the print Comprehensive Accreditation Manual for Ambulatory Care effective January 1, 2023. It will not be updated throughout 2023. Please refer to your E-dition\u00ae for any updates. Key Topics: Standards requirements including the standards, National Patient Safety Goals, and APRs effective January 1, 2023 Standards and EPs for optional Primary Care Medical Home certification Accreditation process information about Joint Commission policies and procedures and practical survey preparation information on the Early Survey Policy, documentation requirements, standards applicability, and more Keys to successfully using the manual for survey preparedness Key Features: Regulatory requirements for deemed status Icons to help navigate documentation requirements as well as risk areas “What’s New” summary of changes Integrated regulatory requirements for ambulatory surgery center deemed status Standards: All ambulatory care standards Setting: Organizations accredited under the Ambulatory Care Accreditation Program, including surgery centers, community health centers, group practices, imaging centers, telehealth providers, sleep labs, rehabilitation centers, student health centers, urgent care clinics, and other ambulatory providers Key Audience: Staff working on accreditation, compliance, patient safety, or quality improvement<\/p>\n

PDF Catalog<\/h4>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
PDF Pages<\/th>\nPDF Title<\/th>\n<\/tr>\n
1<\/td>\nWhat\u2019s New 2023 CAMAC <\/td>\n<\/tr>\n
9<\/td>\nCover <\/td>\n<\/tr>\n
10<\/td>\nCopyright <\/td>\n<\/tr>\n
11<\/td>\nContents <\/td>\n<\/tr>\n
13<\/td>\nIntroduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO) <\/td>\n<\/tr>\n
14<\/td>\nI. Introduction to Joint Commission Accreditation
The Value of Joint Commission Accreditation <\/td>\n<\/tr>\n
16<\/td>\nThe Joint Commission\u2019s Ambulatory Care Accreditation Program <\/td>\n<\/tr>\n
17<\/td>\nAddressing Complex Issues in Ambulatory Care <\/td>\n<\/tr>\n
18<\/td>\nTable 1. Standards That Address Complex Care Issues in Ambulatory Care Organizations <\/td>\n<\/tr>\n
19<\/td>\nII. About the <\/td>\n<\/tr>\n
20<\/td>\nHow Is This Manual Organized?
Table 2. Acronyms Used in This Manual <\/td>\n<\/tr>\n
21<\/td>\nTable 2. <\/td>\n<\/tr>\n
23<\/td>\nAccreditation Requirements <\/td>\n<\/tr>\n
24<\/td>\nAccreditation Process Information <\/td>\n<\/tr>\n
26<\/td>\nIdentifying Applicable Standards <\/td>\n<\/tr>\n
29<\/td>\nUnderstanding the Organization of the Standards Chapters <\/td>\n<\/tr>\n
31<\/td>\nUnderstanding the Icons Used in the Manual <\/td>\n<\/tr>\n
32<\/td>\nIII. Steps to Achieving and Maintaining Compliance
Become Familiar with the Standards
Assess Compliance with the Standards <\/td>\n<\/tr>\n
34<\/td>\nStimulate Improvement <\/td>\n<\/tr>\n
36<\/td>\nAccelerate PI\u2122 <\/td>\n<\/tr>\n
37<\/td>\nKeep Current with Standards Changes via Perspectives <\/td>\n<\/tr>\n
39<\/td>\nIV. Get Extra Help
Getting Started with Accreditation
Account Executive <\/td>\n<\/tr>\n
40<\/td>\nContacting The Joint Commission
Standards Questions
Requesting Permission to Share Content from the Manual <\/td>\n<\/tr>\n
41<\/td>\nPatient Safety Systems (PS)
Quality and Safety in Health Care
Sidebar 1. Key Terms <\/td>\n<\/tr>\n
42<\/td>\nSidebar 1. <\/td>\n<\/tr>\n
43<\/td>\nGoals of This Chapter <\/td>\n<\/tr>\n
44<\/td>\nBecoming a Learning Organization <\/td>\n<\/tr>\n
45<\/td>\nThe Role of Leaders in Patient Safety
Safety Culture <\/td>\n<\/tr>\n
49<\/td>\nSidebar 2. Assessing Staff Accountability <\/td>\n<\/tr>\n
50<\/td>\nSidebar 2
Data Use and Reporting Systems <\/td>\n<\/tr>\n
51<\/td>\nEffective Use of Data <\/td>\n<\/tr>\n
52<\/td>\nTable 1. Defining and Comparing Analytical Tools <\/td>\n<\/tr>\n
53<\/td>\nA Proactive Approach to Preventing Harm <\/td>\n<\/tr>\n
56<\/td>\nSidebar 3. Strategies for an Effective Risk Assessment
Encouraging Patient Activation <\/td>\n<\/tr>\n
58<\/td>\nBeyond Accreditation: The Joint Commission Is Your Patient Safety Partner <\/td>\n<\/tr>\n
59<\/td>\nReferences <\/td>\n<\/tr>\n
63<\/td>\nAccreditation Participation Requirements (APR)
Overview <\/td>\n<\/tr>\n
64<\/td>\nChapter Outline <\/td>\n<\/tr>\n
65<\/td>\nRequirements, Rationales, and Elements of Performance
APR.01.01.01
Elements of Performance for APR.01.01.01
APR.01.02.01 <\/td>\n<\/tr>\n
66<\/td>\nRationale for APR.01.02.01
Elements of Performance for APR.01.02.01
APR.01.03.01
Elements of Performance for APR.01.03.01 <\/td>\n<\/tr>\n
67<\/td>\nAPR.02.01.01
Elements of Performance for APR.02.01.01
APR.05.01.01
Rationale for APR.05.01.01
Elements of Performance for APR.05.01.01 <\/td>\n<\/tr>\n
68<\/td>\nAPR.06.01.01
Elements of Performance for APR.06.01.01
APR.07.01.01
Elements of Performance for APR.07.01.01
APR.08.01.01
Elements of Performance for APR.08.01.01
APR.09.01.01 <\/td>\n<\/tr>\n
69<\/td>\nElements of Performance for APR.09.01.01
APR.09.02.01
Rationale for APR.09.02.01
Elements of Performance for APR.09.02.01 <\/td>\n<\/tr>\n
70<\/td>\nAPR.09.03.01
Elements of Performance for APR.09.03.01
APR.09.04.01
Elements of Performance for APR.09.04.01 <\/td>\n<\/tr>\n
71<\/td>\nEnvironment of Care (EC)
Overview
About This Chapter <\/td>\n<\/tr>\n
72<\/td>\nOther Issues for Consideration <\/td>\n<\/tr>\n
74<\/td>\nChapter Outline <\/td>\n<\/tr>\n
75<\/td>\nStandards, Rationales, and Elements of Performance
Standard EC.01.01.01
Rationale for EC.01.01.01 <\/td>\n<\/tr>\n
76<\/td>\nElements of Performance for EC.01.01.01
Standard EC.02.01.01
Rationale for EC.02.01.01 <\/td>\n<\/tr>\n
77<\/td>\nElements of Performance for EC.02.01.01 <\/td>\n<\/tr>\n
78<\/td>\nStandard EC.02.01.03
Elements of Performance for EC.02.01.03
Standard EC.02.02.01
Rationale for EC.02.02.01 <\/td>\n<\/tr>\n
79<\/td>\nElements of Performance for EC.02.02.01 <\/td>\n<\/tr>\n
80<\/td>\nStandard EC.02.03.01 <\/td>\n<\/tr>\n
81<\/td>\nElements of Performance for EC.02.03.01
Standard EC.02.03.03 <\/td>\n<\/tr>\n
82<\/td>\nRationale for EC.02.03.03
Elements of Performance for EC.02.03.03 <\/td>\n<\/tr>\n
83<\/td>\nStandard EC.02.03.05
Elements of Performance for EC.02.03.05 <\/td>\n<\/tr>\n
88<\/td>\nStandard EC.02.04.01
Elements of Performance for EC.02.04.01 <\/td>\n<\/tr>\n
89<\/td>\nStandard EC.02.04.03
Elements of Performance for EC.02.04.03 <\/td>\n<\/tr>\n
95<\/td>\nStandard EC.02.05.01
Elements of Performance for EC.02.05.01 <\/td>\n<\/tr>\n
99<\/td>\nStandard EC.02.05.03 <\/td>\n<\/tr>\n
100<\/td>\nElements of Performance for EC.02.05.03 <\/td>\n<\/tr>\n
102<\/td>\nStandard EC.02.05.05
Elements of Performance for EC.02.05.05 <\/td>\n<\/tr>\n
103<\/td>\nStandard EC.02.05.07
Rationale for EC.02.05.07
Elements of Performance for EC.02.05.07 <\/td>\n<\/tr>\n
105<\/td>\nStandard EC.02.05.09
Rationale for EC.02.05.09
Elements of Performance for EC.02.05.09 <\/td>\n<\/tr>\n
109<\/td>\nIntroduction to Standard EC.02.06.01
Standard EC.02.06.01 <\/td>\n<\/tr>\n
110<\/td>\nElements of Performance for EC.02.06.01
Standard EC.02.06.05
Rationale for EC.02.06.05
Elements of Performance for EC.02.06.05 <\/td>\n<\/tr>\n
111<\/td>\nStandard EC.03.01.01 <\/td>\n<\/tr>\n
112<\/td>\nRationale for EC.03.01.01
Elements of Performance for EC.03.01.01
Introduction to Standard EC.04.01.01
Standard EC.04.01.01 <\/td>\n<\/tr>\n
113<\/td>\nElements of Performance for EC.04.01.01
Standard EC.04.01.03
Elements of Performance for EC.04.01.03
Standard EC.04.01.05 <\/td>\n<\/tr>\n
114<\/td>\nElements of Performance for EC.04.01.05 <\/td>\n<\/tr>\n
115<\/td>\nEmergency Management (EM)
Overview
About This Chapter <\/td>\n<\/tr>\n
117<\/td>\nChapter Outline <\/td>\n<\/tr>\n
118<\/td>\nStandards, Rationales, and Elements of Performance
Standard EM.01.01.01
Rationale for EM.01.01.01
Elements of Performance for EM.01.01.01 <\/td>\n<\/tr>\n
119<\/td>\nStandard EM.02.01.01 <\/td>\n<\/tr>\n
120<\/td>\nRationale for EM.02.01.01
Elements of Performance for EM.02.01.01 <\/td>\n<\/tr>\n
123<\/td>\nStandard EM.02.02.01
Rationale for EM.02.02.01
Elements of Performance for EM.02.02.01 <\/td>\n<\/tr>\n
126<\/td>\nStandard EM.02.02.03
Rationale for EM.02.02.03 <\/td>\n<\/tr>\n
127<\/td>\nElements of Performance for EM.02.02.03
Standard EM.02.02.05 <\/td>\n<\/tr>\n
128<\/td>\nRationale for EM.02.02.05
Elements of Performance for EM.02.02.05
Standard EM.02.02.07
Rationale for EM.02.02.07
Elements of Performance for EM.02.02.07 <\/td>\n<\/tr>\n
130<\/td>\nStandard EM.02.02.09 <\/td>\n<\/tr>\n
131<\/td>\nRationale for EM.02.02.09
Elements of Performance for EM.02.02.09
Standard EM.02.02.11
Rationale for EM.02.02.11
Elements of Performance for EM.02.02.11 <\/td>\n<\/tr>\n
133<\/td>\nIntroduction to Standards EM.02.02.13 and EM.02.02.15 <\/td>\n<\/tr>\n
134<\/td>\nStandard EM.02.02.13
Elements of Performance for EM.02.02.13 <\/td>\n<\/tr>\n
136<\/td>\nStandard EM.02.02.15
Elements of Performance for EM.02.02.15 <\/td>\n<\/tr>\n
138<\/td>\nStandard EM.03.01.03
Rationale for EM.03.01.03
Elements of Performance for EM.03.01.03 <\/td>\n<\/tr>\n
139<\/td>\nIntroduction to Standard EM.04.01.01 <\/td>\n<\/tr>\n
140<\/td>\nStandard EM.04.01.01
Elements of Performance for EM.04.01.01 <\/td>\n<\/tr>\n
143<\/td>\nHuman Resources (HR)
Overview
About This Chapter <\/td>\n<\/tr>\n
144<\/td>\nChapter Outline <\/td>\n<\/tr>\n
145<\/td>\nStandards, Rationales, and Elements of Performance
Standard HR.01.01.01
Elements of Performance for HR.01.01.01 <\/td>\n<\/tr>\n
147<\/td>\nStandard HR.01.02.05
Elements of Performance for HR.01.02.05 <\/td>\n<\/tr>\n
148<\/td>\nStandard HR.01.02.07
Elements of Performance for HR.01.02.07
Introduction to Standard HR.01.04.01
Standard HR.01.04.01 <\/td>\n<\/tr>\n
149<\/td>\nElements of Performance for HR.01.04.01
Introduction to Standard HR.01.05.03 <\/td>\n<\/tr>\n
150<\/td>\nStandard HR.01.05.03
Elements of Performance for HR.01.05.03 <\/td>\n<\/tr>\n
151<\/td>\nIntroduction to Standards HR.01.06.01 and HR.01.07.01 <\/td>\n<\/tr>\n
152<\/td>\nStandard HR.01.06.01
Elements of Performance for HR.01.06.01
Standard HR.01.07.01
Elements of Performance for HR.01.07.01 <\/td>\n<\/tr>\n
153<\/td>\nIntroduction to Standard HR.02.01.03 <\/td>\n<\/tr>\n
154<\/td>\nStandard HR.02.01.03
Elements of Performance for HR.02.01.03 <\/td>\n<\/tr>\n
158<\/td>\nStandard HR.02.01.05 <\/td>\n<\/tr>\n
159<\/td>\nElements of Performance for HR.02.01.05
Standard HR.02.02.01 <\/td>\n<\/tr>\n
160<\/td>\nElements of Performance for HR.02.02.01
Standard HR.02.03.01
Elements of Performance for HR.02.03.01
Standard HR.02.04.01 <\/td>\n<\/tr>\n
161<\/td>\nElements of Performance for HR.02.04.01 <\/td>\n<\/tr>\n
162<\/td>\nStandard HR.02.04.03
Elements of Performance for HR.02.04.03 <\/td>\n<\/tr>\n
163<\/td>\nStandard HR.03.01.01
Elements of Performance for HR.03.01.01 <\/td>\n<\/tr>\n
165<\/td>\nInfection Prevention and Control (IC)
Overview <\/td>\n<\/tr>\n
166<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
167<\/td>\nChapter Outline <\/td>\n<\/tr>\n
168<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standards IC.01.01.01 Through IC.01.06.01 \u2013 Planning
Standard IC.01.01.01
Elements of Performance for IC.01.01.01 <\/td>\n<\/tr>\n
169<\/td>\nStandard IC.01.02.01
Elements of Performance for IC.01.02.01
Standard IC.01.03.01
Elements of Performance for IC.01.03.01
Standard IC.01.04.01 <\/td>\n<\/tr>\n
170<\/td>\nElements of Performance for IC.01.04.01
Standard IC.01.05.01
Elements of Performance for IC.01.05.01 <\/td>\n<\/tr>\n
171<\/td>\nStandard IC.01.06.01
Elements of Performance for IC.01.06.01
Introduction to Standards IC.02.01.01 Through IC.02.03.01 \u2013 Implementation
Standard IC.02.01.01 <\/td>\n<\/tr>\n
172<\/td>\nElements of Performance for IC.02.01.01 <\/td>\n<\/tr>\n
173<\/td>\nStandard IC.02.02.01
Rationale for IC.02.02.01 <\/td>\n<\/tr>\n
174<\/td>\nElements of Performance for IC.02.02.01 <\/td>\n<\/tr>\n
175<\/td>\nStandard IC.02.03.01
Elements of Performance for IC.02.03.01
Introduction to Standard IC.02.04.01 <\/td>\n<\/tr>\n
176<\/td>\nStandard IC.02.04.01
Elements of Performance for IC.02.04.01 <\/td>\n<\/tr>\n
177<\/td>\nStandard IC.02.04.02
Rationale for IC.02.04.02
Elements of Performance for IC.02.04.02 <\/td>\n<\/tr>\n
180<\/td>\nStandard IC.02.05.01
Elements of Performance for IC.02.05.01 <\/td>\n<\/tr>\n
181<\/td>\nIntroduction to Standard IC.03.01.01\u2014 Evaluation and Improvement
Standard IC.03.01.01
Elements of Performance for IC.03.01.01 <\/td>\n<\/tr>\n
183<\/td>\nInformation Management (IM)
Overview
About This Chapter <\/td>\n<\/tr>\n
184<\/td>\nChapter Outline <\/td>\n<\/tr>\n
185<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standard IM.01.01.01
Standard IM.01.01.01
Elements of Performance for IM.01.01.01 <\/td>\n<\/tr>\n
186<\/td>\nIntroduction to Standard IM.01.01.03
Standard IM.01.01.03
Elements of Performance for IM.01.01.03 <\/td>\n<\/tr>\n
187<\/td>\nIntroduction to Standard IM.02.01.01
Standard IM.02.01.01 <\/td>\n<\/tr>\n
188<\/td>\nElements of Performance for IM.02.01.01 <\/td>\n<\/tr>\n
189<\/td>\nIntroduction to Standard IM.02.01.03
Standard IM.02.01.03
Elements of Performance for IM.02.01.03 <\/td>\n<\/tr>\n
190<\/td>\nStandard IM.02.02.01
Rationale for IM.02.02.01
Elements of Performance for IM.02.02.01 <\/td>\n<\/tr>\n
191<\/td>\nIntroduction to Standard IM.02.02.03
Standard IM.02.02.03 <\/td>\n<\/tr>\n
192<\/td>\nRationale for IM.02.02.03
Elements of Performance for IM.02.02.03
Standard IM.03.01.01
Elements of Performance for IM.03.01.01 <\/td>\n<\/tr>\n
193<\/td>\nLeadership (LD)
Overview <\/td>\n<\/tr>\n
194<\/td>\nProactive Risk Assessment <\/td>\n<\/tr>\n
195<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
196<\/td>\nChapter Outline <\/td>\n<\/tr>\n
197<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.07.01
Standard LD.01.01.01
Rationale for LD.01.01.01 <\/td>\n<\/tr>\n
198<\/td>\nElements of Performance for LD.01.01.01
Standard LD.01.03.01
Rationale for LD.01.03.01
Elements of Performance for LD.01.03.01 <\/td>\n<\/tr>\n
199<\/td>\nStandard LD.01.04.01
Elements of Performance for LD.01.04.01
Standard LD.01.07.01
Elements of Performance for LD.01.07.01 <\/td>\n<\/tr>\n
200<\/td>\nIntroduction to Leadership Relationships, Standards LD.02.01.01 and LD.02.03.01
Standard LD.02.01.01
Rationale for LD.02.01.01
Elements of Performance for LD.02.01.01
Standard LD.02.03.01
Rationale for LD.02.03.01 <\/td>\n<\/tr>\n
201<\/td>\nElements of Performance for LD.02.03.01
Introduction to Organization Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01 <\/td>\n<\/tr>\n
203<\/td>\nStandard LD.03.01.01
Rationale for LD.03.01.01
Elements of Performance for LD.03.01.01 <\/td>\n<\/tr>\n
204<\/td>\nStandard LD.03.02.01
Rationale for LD.03.02.01
Elements of Performance for LD.03.02.01
Standard LD.03.03.01
Rationale for LD.03.03.01 <\/td>\n<\/tr>\n
205<\/td>\nElements of Performance for LD.03.03.01
Standard LD.03.04.01
Rationale for LD.03.04.01
Elements of Performance for LD.03.04.01 <\/td>\n<\/tr>\n
206<\/td>\nStandard LD.03.05.01
Rationale for LD.03.05.01
Elements of Performance for LD.03.05.01
Standard LD.03.06.01
Rationale for LD.03.06.01
Elements of Performance for LD.03.06.01 <\/td>\n<\/tr>\n
207<\/td>\nIntroduction to Operations, Standards LD.03.07.01 Through LD.04.03.09
Standard LD.03.07.01
Elements of Performance for LD.03.07.01 <\/td>\n<\/tr>\n
209<\/td>\nStandard LD.03.08.01
Elements of Performance for LD.03.08.01
Introduction to Standard LD.03.09.01 <\/td>\n<\/tr>\n
210<\/td>\nStandard LD.03.09.01
Elements of Performance for LD.03.09.01 <\/td>\n<\/tr>\n
212<\/td>\nStandard LD.03.10.01
Rationale for LD.03.10.01
Elements of Performance for LD.03.10.01 <\/td>\n<\/tr>\n
213<\/td>\nStandard LD.04.01.01
Elements of Performance for LD.04.01.01 <\/td>\n<\/tr>\n
214<\/td>\nStandard LD.04.01.03
Elements of Performance for LD.04.01.03
Standard LD.04.01.05
Rationale for LD.04.01.05
Elements of Performance for LD.04.01.05 <\/td>\n<\/tr>\n
215<\/td>\nStandard LD.04.01.07
Elements of Performance for LD.04.01.07 <\/td>\n<\/tr>\n
216<\/td>\nStandard LD.04.01.11
Rationale for LD.04.01.11
Elements of Performance for LD.04.01.11
Standard LD.04.02.01
Elements of Performance for LD.04.02.01 <\/td>\n<\/tr>\n
217<\/td>\nStandard LD.04.02.03
Elements of Performance for LD.04.02.03
Standard LD.04.03.01
Elements of Performance for LD.04.03.01 <\/td>\n<\/tr>\n
218<\/td>\nStandard LD.04.03.07
Rationale for LD.04.03.07
Elements of Performance for LD.04.03.07
Introduction to Standard LD.04.03.08 <\/td>\n<\/tr>\n
219<\/td>\nStandard LD.04.03.08
Rationale for LD.04.03.08 <\/td>\n<\/tr>\n
220<\/td>\nElements of Performance for LD.04.03.08 <\/td>\n<\/tr>\n
221<\/td>\nIntroduction to Oversight of Care, Treatment, or Services Provided Through Contractual Agreement, Standard LD.04.03.09 <\/td>\n<\/tr>\n
222<\/td>\nMonitoring Contracted Services <\/td>\n<\/tr>\n
223<\/td>\nStandard LD.04.03.09
Elements of Performance for LD.04.03.09 <\/td>\n<\/tr>\n
224<\/td>\nIntroduction to Standard LD.04.03.13 <\/td>\n<\/tr>\n
225<\/td>\nStandard LD.04.03.13
Elements of Performance for LD.04.03.13 <\/td>\n<\/tr>\n
227<\/td>\nLife Safety (LS)
Overview
About This Chapter <\/td>\n<\/tr>\n
229<\/td>\nChapter Outline <\/td>\n<\/tr>\n
230<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standard LS.01.01.01
Standard LS.01.01.01 <\/td>\n<\/tr>\n
231<\/td>\nElements of Performance for LS.01.01.01 <\/td>\n<\/tr>\n
232<\/td>\nStandard LS.01.02.01
Elements of Performance for LS.01.02.01 <\/td>\n<\/tr>\n
234<\/td>\nStandard LS.03.01.10 <\/td>\n<\/tr>\n
235<\/td>\nRationale for LS.03.01.10
Elements of Performance for LS.03.01.10 <\/td>\n<\/tr>\n
237<\/td>\nStandard LS.03.01.20
Rationale for LS.03.01.20 <\/td>\n<\/tr>\n
238<\/td>\nElements of Performance for LS.03.01.20 <\/td>\n<\/tr>\n
240<\/td>\nStandard LS.03.01.30
Rationale for LS.03.01.30 <\/td>\n<\/tr>\n
241<\/td>\nElements of Performance for LS.03.01.30 <\/td>\n<\/tr>\n
244<\/td>\nStandard LS.03.01.34
Elements of Performance for LS.03.01.34 <\/td>\n<\/tr>\n
246<\/td>\nStandard LS.03.01.35
Elements of Performance for LS.03.01.35 <\/td>\n<\/tr>\n
247<\/td>\nStandard LS.03.01.40 <\/td>\n<\/tr>\n
248<\/td>\nElements of Performance for LS.03.01.40
Standard LS.03.01.50
Elements of Performance for LS.03.01.50 <\/td>\n<\/tr>\n
250<\/td>\nStandard LS.03.01.70 <\/td>\n<\/tr>\n
251<\/td>\nElements of Performance for LS.03.01.70 <\/td>\n<\/tr>\n
253<\/td>\nMedication Management (MM)
Overview <\/td>\n<\/tr>\n
254<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
256<\/td>\nChapter Outline <\/td>\n<\/tr>\n
257<\/td>\nStandards, Rationales, and Elements of Performance
Standard MM.01.01.01
Rationale for MM.01.01.01
Elements of Performance for MM.01.01.01 <\/td>\n<\/tr>\n
258<\/td>\nStandard MM.01.01.03
Rationale for MM.01.01.03
Elements of Performance for MM.01.01.03 <\/td>\n<\/tr>\n
259<\/td>\nStandard MM.01.02.01
Elements of Performance for MM.01.02.01
Standard MM.02.01.01
Elements of Performance for MM.02.01.01 <\/td>\n<\/tr>\n
260<\/td>\nStandard MM.03.01.01
Rationale for MM.03.01.01 <\/td>\n<\/tr>\n
261<\/td>\nElements of Performance for MM.03.01.01
Standard MM.03.01.03 <\/td>\n<\/tr>\n
262<\/td>\nRationale for MM.03.01.03
Elements of Performance for MM.03.01.03
Standard MM.03.01.05
Rationale for MM.03.01.05
Elements of Performance for MM.03.01.05 <\/td>\n<\/tr>\n
263<\/td>\nIntroduction to Standard MM.04.01.01
Standard MM.04.01.01
Elements of Performance for MM.04.01.01 <\/td>\n<\/tr>\n
265<\/td>\nStandard MM.05.01.01
Elements of Performance for MM.05.01.01
Standard MM.05.01.07
Elements of Performance for MM.05.01.07 <\/td>\n<\/tr>\n
266<\/td>\nStandard MM.05.01.09
Rationale for MM.05.01.09
Elements of Performance for MM.05.01.09 <\/td>\n<\/tr>\n
267<\/td>\nStandard MM.05.01.11
Elements of Performance for MM.05.01.11
Standard MM.05.01.15
Elements of Performance for MM.05.01.15
Standard MM.05.01.17 <\/td>\n<\/tr>\n
268<\/td>\nElements of Performance for MM.05.01.17
Standard MM.05.01.19
Rationale for MM.05.01.19
Elements of Performance for MM.05.01.19 <\/td>\n<\/tr>\n
269<\/td>\nStandard MM.06.01.01
Elements of Performance for MM.06.01.01 <\/td>\n<\/tr>\n
270<\/td>\nStandard MM.06.01.05
Rationale for MM.06.01.05
Elements of Performance for MM.06.01.05 <\/td>\n<\/tr>\n
271<\/td>\nStandard MM.07.01.01
Elements of Performance for MM.07.01.01
Standard MM.07.01.03
Rationale for MM.07.01.03 <\/td>\n<\/tr>\n
272<\/td>\nElements of Performance for MM.07.01.03
Standard MM.08.01.01
Elements of Performance for MM.08.01.01 <\/td>\n<\/tr>\n
273<\/td>\nStandard MM.09.01.03
Elements of Performance for MM.09.01.03 <\/td>\n<\/tr>\n
275<\/td>\nNational Patient Safety Goals (NPSG)
Chapter Outline
National Patient Safety Goals\u00ae
Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery\u2122 <\/td>\n<\/tr>\n
276<\/td>\nRequirements, Rationales, and Elements of Performance
Goal 1
NPSG.01.01.01
Rationale for NPSG.01.01.01
Elements of Performance for NPSG.01.01.01
Goal 3
NPSG.03.04.01 <\/td>\n<\/tr>\n
277<\/td>\nRationale for NPSG.03.04.01
Elements of Performance for NPSG.03.04.01 <\/td>\n<\/tr>\n
278<\/td>\nNPSG.03.05.01
Rationale for NPSG.03.05.01 <\/td>\n<\/tr>\n
279<\/td>\nElements of Performance for NPSG.03.05.01 <\/td>\n<\/tr>\n
280<\/td>\nIntroduction to Reconciling Medication Information
NPSG.03.06.01 <\/td>\n<\/tr>\n
281<\/td>\nRationale for NPSG.03.06.01
Elements of Performance for NPSG.03.06.01 <\/td>\n<\/tr>\n
282<\/td>\nGoal 7
NPSG.07.01.01
Rationale for NPSG.07.01.01 <\/td>\n<\/tr>\n
283<\/td>\nElements of Performance for NPSG.07.01.01
Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery\u2122 <\/td>\n<\/tr>\n
284<\/td>\nUP.01.01.01
Rationale for UP.01.01.01 <\/td>\n<\/tr>\n
285<\/td>\nElements of Performance for UP.01.01.01
Introduction to UP.01.02.01 <\/td>\n<\/tr>\n
286<\/td>\nUP.01.02.01
Elements of Performance for UP.01.02.01 <\/td>\n<\/tr>\n
287<\/td>\nUP.01.03.01 <\/td>\n<\/tr>\n
288<\/td>\nRationale for UP.01.03.01
Elements of Performance for UP.01.03.01 <\/td>\n<\/tr>\n
291<\/td>\nProvision of Care, Treatment, and Services (PC)
Overview <\/td>\n<\/tr>\n
292<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
293<\/td>\nChapter Outline <\/td>\n<\/tr>\n
294<\/td>\nStandards, Rationales, and Elements of Performance
Standard PC.01.01.01
Elements of Performance for PC.01.01.01
Introduction to Standard PC.01.02.01 <\/td>\n<\/tr>\n
295<\/td>\nStandard PC.01.02.01
Elements of Performance for PC.01.02.01
Standard PC.01.02.03
Elements of Performance for PC.01.02.03 <\/td>\n<\/tr>\n
296<\/td>\nIntroduction to Standard PC.01.02.07
Standard PC.01.02.07
Elements of Performance for PC.01.02.07 <\/td>\n<\/tr>\n
298<\/td>\nIntroduction to Standard PC.01.02.09
Standard PC.01.02.09
Elements of Performance for PC.01.02.09
Standard PC.01.02.15
Elements of Performance for PC.01.02.15 <\/td>\n<\/tr>\n
300<\/td>\nIntroduction to Standard PC.01.03.01
Standard PC.01.03.01
Elements of Performance for PC.01.03.01 <\/td>\n<\/tr>\n
301<\/td>\nStandard PC.02.01.01 <\/td>\n<\/tr>\n
302<\/td>\nElements of Performance for PC.02.01.01
Standard PC.02.01.03 <\/td>\n<\/tr>\n
303<\/td>\nElements of Performance for PC.02.01.03
Standard PC.02.01.05
Elements of Performance for PC.02.01.05
Standard PC.02.01.07
Elements of Performance for PC.02.01.07
Standard PC.02.01.09
Elements of Performance for PC.02.01.09 <\/td>\n<\/tr>\n
304<\/td>\nStandard PC.02.01.21
Elements of Performance for PC.02.01.21 <\/td>\n<\/tr>\n
305<\/td>\nIntroduction to Standard PC.02.02.01
Standard PC.02.02.01
Elements of Performance for PC.02.02.01 <\/td>\n<\/tr>\n
306<\/td>\nStandard PC.02.02.03
Elements of Performance for PC.02.02.03
Introduction to Standard PC.02.03.01
Standard PC.02.03.01
Elements of Performance for PC.02.03.01 <\/td>\n<\/tr>\n
307<\/td>\nStandard PC.02.04.01 <\/td>\n<\/tr>\n
308<\/td>\nElements of Performance for PC.02.04.01
Standard PC.02.04.03
Elements of Performance for PC.02.04.03 <\/td>\n<\/tr>\n
310<\/td>\nStandard PC.02.04.05
Elements of Performance for PC.02.04.05 <\/td>\n<\/tr>\n
311<\/td>\nIntroduction to Standards PC.03.01.01 Through PC.03.01.07
Standard PC.03.01.01 <\/td>\n<\/tr>\n
312<\/td>\nElements of Performance for PC.03.01.01
Standard PC.03.01.03
Elements of Performance for PC.03.01.03 <\/td>\n<\/tr>\n
314<\/td>\nStandard PC.03.01.05
Elements of Performance for PC.03.01.05 <\/td>\n<\/tr>\n
315<\/td>\nStandard PC.03.01.07
Elements of Performance for PC.03.01.07
Standard PC.03.02.03 <\/td>\n<\/tr>\n
316<\/td>\nElements of Performance for PC.03.02.03
Standard PC.03.02.07
Rationale for PC.03.02.07
Elements of Performance for PC.03.02.07 <\/td>\n<\/tr>\n
317<\/td>\nStandard PC.04.01.01
Elements of Performance for PC.04.01.01
Standard PC.04.01.03
Elements of Performance for PC.04.01.03 <\/td>\n<\/tr>\n
318<\/td>\nStandard PC.04.01.05
Elements of Performance for PC.04.01.05 <\/td>\n<\/tr>\n
319<\/td>\nStandard PC.04.02.01
Elements of Performance for PC.04.02.01 <\/td>\n<\/tr>\n
321<\/td>\nPerformance Improvement (PI)
Overview
About This Chapter <\/td>\n<\/tr>\n
323<\/td>\nChapter Outline <\/td>\n<\/tr>\n
324<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standard PI.01.01.01
Standard PI.01.01.01
Elements of Performance for PI.01.01.01 <\/td>\n<\/tr>\n
326<\/td>\nStandard PI.02.01.01
Rationale for PI.02.01.01
Elements of Performance for PI.02.01.01 <\/td>\n<\/tr>\n
327<\/td>\nIntroduction to Standard PI.03.01.01
Standard PI.03.01.01
Elements of Performance for PI.03.01.01 <\/td>\n<\/tr>\n
328<\/td>\nStandard PI.04.01.01 <\/td>\n<\/tr>\n
329<\/td>\nRationale for PI.04.01.01
Elements of Performance for PI.04.01.01 <\/td>\n<\/tr>\n
331<\/td>\nRecord of Care, Treatment, and Services (RC)
Overview
About This Chapter <\/td>\n<\/tr>\n
332<\/td>\nChapter Outline <\/td>\n<\/tr>\n
333<\/td>\nStandards, Rationales, and Elements of Performance
Standard RC.01.01.01
Elements of Performance for RC.01.01.01
Standard RC.01.02.01
Elements of Performance for RC.01.02.01 <\/td>\n<\/tr>\n
334<\/td>\nStandard RC.01.03.01
Elements of Performance for RC.01.03.01
Standard RC.01.04.01
Elements of Performance for RC.01.04.01
Standard RC.01.05.01
Elements of Performance for RC.01.05.01 <\/td>\n<\/tr>\n
335<\/td>\nStandard RC.02.01.01
Elements of Performance for RC.02.01.01 <\/td>\n<\/tr>\n
337<\/td>\nStandard RC.02.01.03
Elements of Performance for RC.02.01.03 <\/td>\n<\/tr>\n
339<\/td>\nStandard RC.02.01.05
Elements of Performance for RC.02.01.05
Standard RC.02.03.07
Elements of Performance for RC.02.03.07 <\/td>\n<\/tr>\n
341<\/td>\nRights and Responsibilities of the Individual (RI)
Overview
About This Chapter <\/td>\n<\/tr>\n
343<\/td>\nChapter Outline <\/td>\n<\/tr>\n
344<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standard RI.01.01.01
Standard RI.01.01.01
Elements of Performance for RI.01.01.01 <\/td>\n<\/tr>\n
345<\/td>\nIntroduction to Standard RI.01.01.03 <\/td>\n<\/tr>\n
346<\/td>\nStandard RI.01.01.03
Elements of Performance for RI.01.01.03 <\/td>\n<\/tr>\n
347<\/td>\nStandard RI.01.02.01
Elements of Performance for RI.01.02.01 <\/td>\n<\/tr>\n
348<\/td>\nStandard RI.01.03.01
Rationale for RI.01.03.01
Elements of Performance for RI.01.03.01 <\/td>\n<\/tr>\n
349<\/td>\nStandard RI.01.03.05
Elements of Performance for RI.01.03.05 <\/td>\n<\/tr>\n
350<\/td>\nStandard RI.01.04.01
Elements of Performance for RI.01.04.01
Standard RI.01.04.03
Elements of Performance for RI.01.04.03 <\/td>\n<\/tr>\n
351<\/td>\nStandard RI.01.05.01
Elements of Performance for RI.01.05.01 <\/td>\n<\/tr>\n
352<\/td>\nStandard RI.01.06.03
Elements of Performance for RI.01.06.03
Standard RI.01.07.01
Elements of Performance for RI.01.07.01 <\/td>\n<\/tr>\n
354<\/td>\nIntroduction to Standard RI.02.01.01
Standard RI.02.01.01 <\/td>\n<\/tr>\n
355<\/td>\nElements of Performance for RI.02.01.01 <\/td>\n<\/tr>\n
357<\/td>\nTransplant Safety (TS)
Overview
About This Chapter <\/td>\n<\/tr>\n
358<\/td>\nChapter Outline <\/td>\n<\/tr>\n
359<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standards TS.03.01.01, TS.03.02.01, and TS.03.03.01
Examples of Tissue and Cell Products <\/td>\n<\/tr>\n
361<\/td>\nStandard TS.03.01.01
Elements of Performance for TS.03.01.01 <\/td>\n<\/tr>\n
362<\/td>\nStandard TS.03.02.01 <\/td>\n<\/tr>\n
363<\/td>\nElements of Performance for TS.03.02.01 <\/td>\n<\/tr>\n
364<\/td>\nStandard TS.03.03.01
Elements of Performance for TS.03.03.01 <\/td>\n<\/tr>\n
365<\/td>\nWaived Testing (WT)
Overview <\/td>\n<\/tr>\n
366<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
368<\/td>\nChapter Outline <\/td>\n<\/tr>\n
369<\/td>\nStandards, Rationales, and Elements of Performance
Standard WT.01.01.01
Elements of Performance for WT.01.01.01 <\/td>\n<\/tr>\n
370<\/td>\nStandard WT.02.01.01
Elements of Performance for WT.02.01.01 <\/td>\n<\/tr>\n
371<\/td>\nStandard WT.03.01.01
Elements of Performance for WT.03.01.01 <\/td>\n<\/tr>\n
372<\/td>\nStandard WT.04.01.01
Elements of Performance for WT.04.01.01 <\/td>\n<\/tr>\n
373<\/td>\nStandard WT.05.01.01
Elements of Performance for WT.05.01.01 <\/td>\n<\/tr>\n
375<\/td>\nThe Accreditation Process (ACC)
Notices
ACC Chapter Contents <\/td>\n<\/tr>\n
377<\/td>\nOverview
General Eligibility Requirements <\/td>\n<\/tr>\n
378<\/td>\nScope of Accreditation Surveys <\/td>\n<\/tr>\n
379<\/td>\nAccreditation Policies
Tailored Survey Policy <\/td>\n<\/tr>\n
380<\/td>\nOrganizational and Functional Integration <\/td>\n<\/tr>\n
383<\/td>\nSystem Accreditation Option <\/td>\n<\/tr>\n
384<\/td>\nContracted Services
Integrated Care Certification Option <\/td>\n<\/tr>\n
385<\/td>\nDeemed Status Option <\/td>\n<\/tr>\n
386<\/td>\nAdvanced Diagnostic Imaging Accreditation Option
Primary Care Medical Home Certification Option <\/td>\n<\/tr>\n
388<\/td>\nInitial Surveys <\/td>\n<\/tr>\n
389<\/td>\nInformation Accuracy and Truthfulness Policy <\/td>\n<\/tr>\n
391<\/td>\nGood Faith Participation in Accreditation\/ Certification <\/td>\n<\/tr>\n
392<\/td>\nPublic Information Policy||
Process for Responding to a Complaint <\/td>\n<\/tr>\n
393<\/td>\nEarly Survey Policy
Sidebar 1. Early Survey Policy <\/td>\n<\/tr>\n
394<\/td>\nSidebar 1. <\/td>\n<\/tr>\n
396<\/td>\nBefore the Survey <\/td>\n<\/tr>\n
397<\/td>\nAn Organization\u2019s Secure Joint Commission Connect Extranet Site <\/td>\n<\/tr>\n
398<\/td>\nRole of the Account Executive
Electronic Application for Accreditation (E-App) <\/td>\n<\/tr>\n
399<\/td>\nAccreditation\/Certification Contract and Business Associate Agreement <\/td>\n<\/tr>\n
400<\/td>\nAnnual and Survey Fees <\/td>\n<\/tr>\n
401<\/td>\nDuring the Survey <\/td>\n<\/tr>\n
402<\/td>\nSurvey Notification
Table 3. Exceptions to Unannounced Surveys** <\/td>\n<\/tr>\n
403<\/td>\nTable 3. <\/td>\n<\/tr>\n
405<\/td>\nInitial and Full Survey Team Composition <\/td>\n<\/tr>\n
406<\/td>\nSurvey Agenda <\/td>\n<\/tr>\n
411<\/td>\nTracer Methodology <\/td>\n<\/tr>\n
412<\/td>\nTable 4. Ambulatory Care\u2013Specific Tracer Applicability and Objectives <\/td>\n<\/tr>\n
416<\/td>\nImmediate Threat to Health or Safety <\/td>\n<\/tr>\n
420<\/td>\nSummary of the Accreditation Reports <\/td>\n<\/tr>\n
421<\/td>\nAfter the Survey
The Scoring Process <\/td>\n<\/tr>\n
427<\/td>\nEvidence of Standards Compliance (ESC) Process <\/td>\n<\/tr>\n
430<\/td>\nAccreditation Award Display and Use <\/td>\n<\/tr>\n
432<\/td>\nRecommendation Letter for Organizations That Elect to Use The Joint Commission Deemed Status Option
Advanced Diagnostic Imaging Letter
Primary Care Medical Home Certification Letter <\/td>\n<\/tr>\n
433<\/td>\nBetween Accreditation Surveys
Duration of Accreditation Award
Continuous Compliance <\/td>\n<\/tr>\n
434<\/td>\nIntracycle Monitoring (ICM)
Focused Standards Assessment (FSA) <\/td>\n<\/tr>\n
435<\/td>\nSidebar 2. Focused Standards Assessment (FSA) Options <\/td>\n<\/tr>\n
436<\/td>\nSidebar 2. <\/td>\n<\/tr>\n
437<\/td>\nSentinel Event Follow-up
Notifying The Joint Commission About Organization Changes <\/td>\n<\/tr>\n
439<\/td>\nAccreditation Status of Organizations That Cease Services After a Disaster\u2020 <\/td>\n<\/tr>\n
441<\/td>\nAccreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time <\/td>\n<\/tr>\n
442<\/td>\nReentering the Accreditation Process
Additional Surveys <\/td>\n<\/tr>\n
445<\/td>\nDecision Rules for Organizations Seeking Initial Accreditation
Accredited
Primary Care Medical Home Certification <\/td>\n<\/tr>\n
446<\/td>\nLimited, Temporary Accreditation
Evidence of Standards Compliance (ESC)
One-Month Survey <\/td>\n<\/tr>\n
447<\/td>\nMedicare Deficiency Follow-up Survey
Denial of Accreditation <\/td>\n<\/tr>\n
448<\/td>\nDecision Rules for Organizations Seeking Reaccreditation
Accredited <\/td>\n<\/tr>\n
449<\/td>\nPrimary Care Medical Home Certification
Evidence of Standards Compliance (ESC) <\/td>\n<\/tr>\n
450<\/td>\nOne-Month Survey
Medicare Deficiency Follow-up Survey
Accreditation with Follow-up Survey <\/td>\n<\/tr>\n
452<\/td>\nPreliminary Denial of Accreditation <\/td>\n<\/tr>\n
453<\/td>\nDenial of Accreditation
Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific <\/td>\n<\/tr>\n
456<\/td>\nProcess for Organizations That Meet Decision Rule PDA04
Review and Appeal Procedures <\/td>\n<\/tr>\n
457<\/td>\nI. Evaluation by Joint Commission Staff <\/td>\n<\/tr>\n
458<\/td>\nII. Accreditation with Follow-up Survey
III. Review Hearings <\/td>\n<\/tr>\n
460<\/td>\nIV. Following a Review Hearing
V. Final Review &Appeal Request <\/td>\n<\/tr>\n
463<\/td>\nStandards Applicability Process (SAP) <\/td>\n<\/tr>\n
495<\/td>\nSentinel Event Policy (SE) <\/td>\n<\/tr>\n
496<\/td>\nGoals of the Sentinel Event Policy <\/td>\n<\/tr>\n
497<\/td>\nIdentifying Sentinel Events <\/td>\n<\/tr>\n
499<\/td>\nSidebar 1. Key Terms <\/td>\n<\/tr>\n
500<\/td>\nSidebar 1. <\/td>\n<\/tr>\n
502<\/td>\nDetermining That a Sentinel Event Is Subject to Review
Relationship to the Survey Process <\/td>\n<\/tr>\n
503<\/td>\nRequired Organization Response to a Sentinel Event <\/td>\n<\/tr>\n
505<\/td>\nReporting a Sentinel Event to The Joint Commission <\/td>\n<\/tr>\n
507<\/td>\nConducting a Comprehensive Systematic Analysis <\/td>\n<\/tr>\n
508<\/td>\nDeveloping a Corrective Action Plan <\/td>\n<\/tr>\n
509<\/td>\nSubmitting the Comprehensive Systematic Analysis and Corrective Action Plan <\/td>\n<\/tr>\n
510<\/td>\nTable 1. Options for a Joint Commission Review of an Organization\u2019s Response to a Sentinel Event <\/td>\n<\/tr>\n
511<\/td>\nTable 1. <\/td>\n<\/tr>\n
512<\/td>\nThe Joint Commission\u2019s Response
Review of Comprehensive Systematic Analyses and Corrective Action Plans <\/td>\n<\/tr>\n
513<\/td>\nFollow-up Activities <\/td>\n<\/tr>\n
515<\/td>\nDisclosable Information
Handling Sentinel Event\u2013Related Documents
The Sentinel Event Database <\/td>\n<\/tr>\n
516<\/td>\nOverseeing the Sentinel Event Policy <\/td>\n<\/tr>\n
517<\/td>\nThe Joint Commission Quality Report (QR)
Introduction
What Is The Joint Commission Quality Report? <\/td>\n<\/tr>\n
518<\/td>\nWhat Will My Quality Report Contain?
What Is Quality Check? <\/td>\n<\/tr>\n
519<\/td>\nIs a Quality Report Available for My Accredited Ambulatory Care Organization?
Can My Ambulatory Care Organization Comment on Its Quality Report? <\/td>\n<\/tr>\n
520<\/td>\nHow Does My Ambulatory Care Organization Submit a Commentary?
Are There Any Criteria That Must Be Met in a Commentary?
What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality? <\/td>\n<\/tr>\n
521<\/td>\nGuidelines for Publicizing Compliance with the National Patient Safety Goals <\/td>\n<\/tr>\n
523<\/td>\nRequired Written Documentation (RWD) <\/td>\n<\/tr>\n
525<\/td>\nList of EPs Requiring Written Documentation for Ambulatory Care by Service
Ambulatory Surgical Centers
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR) <\/td>\n<\/tr>\n
526<\/td>\nInfection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM) <\/td>\n<\/tr>\n
527<\/td>\nNational Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Transplant Safety (TS) <\/td>\n<\/tr>\n
528<\/td>\nWaived Testing (WT)
Endoscopy
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR) <\/td>\n<\/tr>\n
529<\/td>\nInfection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM) <\/td>\n<\/tr>\n
530<\/td>\nNational Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Waived Testing (WT) <\/td>\n<\/tr>\n
531<\/td>\nMedical Centers
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC) <\/td>\n<\/tr>\n
532<\/td>\nInformation Management (IM)
Leadership (LD)
Medication Management (MM)
National Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
Provision of Care, Treatment, and Services (PC) <\/td>\n<\/tr>\n
533<\/td>\nPerformance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Transplant Safety (TS)
Waived Testing (WT)
Dental Centers
Accreditation Participation Requirements (APR) <\/td>\n<\/tr>\n
534<\/td>\nEnvironment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD) <\/td>\n<\/tr>\n
535<\/td>\nMedication Management (MM)
National Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC) <\/td>\n<\/tr>\n
536<\/td>\nRights and Responsibilities of the Individual (RI)
Transplant Safety (TS)
Waived Testing (WT)
Diagnostic\/Therapeutic
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM) <\/td>\n<\/tr>\n
537<\/td>\nHuman Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Medication Management (MM) <\/td>\n<\/tr>\n
538<\/td>\nNational Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Waived Testing (WT) <\/td>\n<\/tr>\n
539<\/td>\nDiagnostic Imaging Services
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM) <\/td>\n<\/tr>\n
540<\/td>\nLeadership (LD)
Medication Management (MM)
National Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC) <\/td>\n<\/tr>\n
541<\/td>\nRights and Responsibilities of the Individual (RI)
Waived Testing (WT)
Diagnostic Sleep Centers
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM) <\/td>\n<\/tr>\n
542<\/td>\nHuman Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Medication Management (MM)
National Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
Provision of Care, Treatment, and Services (PC) <\/td>\n<\/tr>\n
543<\/td>\nPerformance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Kidney Care\/Dialysis
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM) <\/td>\n<\/tr>\n
544<\/td>\nHuman Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Medication Management (MM) <\/td>\n<\/tr>\n
545<\/td>\nNational Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Waived Testing (WT)
Telehealth\/Nonsurgical
Accreditation Participation Requirements (APR) <\/td>\n<\/tr>\n
546<\/td>\nEnvironment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Information Management (IM)
Leadership (LD)
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI) <\/td>\n<\/tr>\n
547<\/td>\nRecord of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Telehealth\/Surgical
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Information Management (IM) <\/td>\n<\/tr>\n
548<\/td>\nLeadership (LD)
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Episodic Care
Accreditation Participation Requirements (APR) <\/td>\n<\/tr>\n
549<\/td>\nEnvironment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD) <\/td>\n<\/tr>\n
550<\/td>\nMedication Management (MM)
National Patient Safety Goals (NPSG)
Provision of Care, Treatment, and Services (PC)
Performanc Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI) <\/td>\n<\/tr>\n
551<\/td>\nTransplant Safety (TS)
Waived Testing (WT)
Occupational\/Worksite Health
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM) <\/td>\n<\/tr>\n
552<\/td>\nHuman Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Medication Management (MM)
National Patient Safety Goals (NPSG) <\/td>\n<\/tr>\n
553<\/td>\nProvision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Waived Testing (WT)
Urgent\/Immediate Care
Accreditation Participation Requirements (APR)
Environment of Care (EC) <\/td>\n<\/tr>\n
554<\/td>\nEmergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD) <\/td>\n<\/tr>\n
555<\/td>\nMedication Management (MM)
National Patient Safety Goals (NPSG)
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI) <\/td>\n<\/tr>\n
556<\/td>\nWaived Testing (WT)
Convenient Care
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR) <\/td>\n<\/tr>\n
557<\/td>\nInfection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Medication Management (MM)
National Patient Safety Goals (NPSG)
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI) <\/td>\n<\/tr>\n
558<\/td>\nRecord of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Waived Testing (WT) <\/td>\n<\/tr>\n
559<\/td>\nEarly Survey Policy (ESP)
Accreditation Participation Requirements (APR)
Environment of Care (EC) <\/td>\n<\/tr>\n
560<\/td>\nEmergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD) <\/td>\n<\/tr>\n
561<\/td>\nLife Safety (LS)
Medication Management (MM)
National Patient Safety Goals (NPSG) <\/td>\n<\/tr>\n
562<\/td>\nProvision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Transplant Safety (TS)
Waived Testing (WT) <\/td>\n<\/tr>\n
563<\/td>\nPrimary Care Medical Home Certification Option (PCMH)
Overview
Primary Care Medical Home Model <\/td>\n<\/tr>\n
564<\/td>\nI. Patient-Centered Care
II. Comprehensive Care <\/td>\n<\/tr>\n
565<\/td>\nIII. Coordinated Care <\/td>\n<\/tr>\n
566<\/td>\nIV. Superb Access to Care
V. Systems-Based Approach to Quality and Safety <\/td>\n<\/tr>\n
567<\/td>\nStandards, Rationales, Elements of Performance, and Scoring Specific to the Primary Care Medical Home Certification Option
I. Patient-Centered Care
Leadership (LD)
Standard LD.03.04.01
Elements of Performance for LD.03.04.01 <\/td>\n<\/tr>\n
568<\/td>\nStandard LD.03.07.01
Elements of Performance for LD.03.07.01
Standard LD.03.08.01
Elements of Performance for LD.03.08.01 <\/td>\n<\/tr>\n
569<\/td>\nStandard LD.04.01.11
Elements of Performance for LD.04.01.11
Provision of Care, Treatment, and Services (PC)
Standard PC.01.03.01
Elements of Performance for PC.01.03.01
Standard PC.02.01.01
Elements of Performance for PC.02.01.01
Standard PC.02.01.21 <\/td>\n<\/tr>\n
570<\/td>\nElements of Performance for PC.02.01.21
Standard PC.02.02.01
Elements of Performance for PC.02.02.01
Standard PC.02.03.01
Elements of Performance for PC.02.03.01 <\/td>\n<\/tr>\n
572<\/td>\nStandard PC.02.04.01
Elements of Performance for PC.02.04.01
Standard PC.02.04.05
Elements of Performance for PC.02.04.05 <\/td>\n<\/tr>\n
573<\/td>\nRecord of Care, Treatment, and Services (RC)
Standard RC.02.01.01
Elements of Performance for RC.02.01.01
Rights and Responsibilities of the Individual (RI)
Standard RI.01.01.01 <\/td>\n<\/tr>\n
574<\/td>\nElements of Performance for RI.01.01.01
Standard RI.01.01.03
Elements of Performance for RI.01.01.03 <\/td>\n<\/tr>\n
575<\/td>\nStandard RI.01.02.01
Elements of Performance for RI.01.02.01 <\/td>\n<\/tr>\n
576<\/td>\nStandard RI.01.03.01
Elements of Performance for RI.01.03.01 <\/td>\n<\/tr>\n
577<\/td>\nStandard RI.01.04.01
Elements of Performance for RI.01.04.01
Standard RI.01.04.03
Elements of Performance for RI.01.04.03 <\/td>\n<\/tr>\n
578<\/td>\nStandard RI.01.05.01
Elements of Performance for RI.01.05.01
Standard RI.01.07.01
Elements of Performance for RI.01.07.01 <\/td>\n<\/tr>\n
579<\/td>\nII. Comprehensive Care
Human Resources (HR)
Standard HR.03.01.01
Elements of Performance for HR.03.01.01
Provision of Care, Treatment, and Services (PC)
Standard PC.02.01.05
Elements of Performance for PC.02.01.05 <\/td>\n<\/tr>\n
580<\/td>\nStandard PC.02.04.03
Elements of Performance for PC.02.04.03
Standard PC.02.04.05 <\/td>\n<\/tr>\n
581<\/td>\nElements of Performance for PC.02.04.05
Rights and Responsibilities of the Individual (RI)
Standard RI.01.04.03 <\/td>\n<\/tr>\n
582<\/td>\nElements of Performance for RI.01.04.03
III. Coordinated Care
Human Resources (HR)
Standard HR.01.02.07
Elements of Performance for HR.01.02.07
Provision of Care, Treatment, and Services (PC)
Standard PC.01.03.01
Elements of Performance for PC.01.03.01 <\/td>\n<\/tr>\n
583<\/td>\nStandard PC.02.02.01
Elements of Performance for PC.02.02.01
Standard PC.02.03.01
Elements of Performance for PC.02.03.01
Standard PC.02.04.03 <\/td>\n<\/tr>\n
584<\/td>\nElements of Performance for PC.02.04.03
Standard PC.02.04.05
Elements of Performance for PC.02.04.05 <\/td>\n<\/tr>\n
585<\/td>\nStandard PC.04.01.01
Elements of Performance for PC.04.01.01
Standard PC.04.01.03
Elements of Performance for PC.04.01.03 <\/td>\n<\/tr>\n
586<\/td>\nStandard PC.04.01.05
Elements of Performance for PC.04.01.05
Standard PC.04.02.01
Elements of Performance for PC.04.02.01 <\/td>\n<\/tr>\n
587<\/td>\nRecord of Care, Treatment, and Services (RC)
Standard RC.01.01.01
Elements of Performance for RC.01.01.01
IV. Superb Access to Care
Provision of Care, Treatment, and Services (PC)
Standard PC.02.04.01
Elements of Performance for PC.02.04.01 <\/td>\n<\/tr>\n
588<\/td>\nV. Systems-Based Approach to Quality and Safety
Leadership (LD)
Standard LD.03.04.01
Elements of Performance for LD.03.04.01 <\/td>\n<\/tr>\n
589<\/td>\nStandard LD.03.07.01
Elements of Performance for LD.03.07.01
Standard LD.03.08.01
Elements of Performance for LD.03.08.01 <\/td>\n<\/tr>\n
590<\/td>\nStandard LD.03.09.01
Elements of Performance for LD.03.09.01 <\/td>\n<\/tr>\n
592<\/td>\nStandard LD.03.10.01
Elements of Performance for LD.03.10.01
Standard LD.04.01.05
Elements of Performance for LD.04.01.05 <\/td>\n<\/tr>\n
593<\/td>\nStandard LD.04.01.11
Elements of Performance for LD.04.01.11
Medication Management (MM)
Standard MM.04.01.01
Elements of Performance for MM.04.01.01
Provision of Care, Treatment, and Services (PC)
Standard PC.01.03.01
Elements of Performance for PC.01.03.01
Performance Improvement (PI)
Standard PI.01.01.01 <\/td>\n<\/tr>\n
594<\/td>\nElements of Performance for PI.01.01.01
Standard PI.03.01.01
Elements of Performance for PI.03.01.01 <\/td>\n<\/tr>\n
595<\/td>\nStandard PI.04.01.01
Elements of Performance for PI.04.01.01 <\/td>\n<\/tr>\n
597<\/td>\nGlossary (GL) <\/td>\n<\/tr>\n
633<\/td>\nIndex (IX) <\/td>\n<\/tr>\n<\/table>\n","protected":false},"excerpt":{"rendered":"

Comprehensive Accreditation Manual for Ambulatory Care (CAMAC)<\/b><\/p>\n\n\n\n\n
Published By<\/td>\nPublication Date<\/td>\nNumber of Pages<\/td>\n<\/tr>\n
Joint Commission<\/b><\/a><\/td>\n2023<\/td>\n700<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n","protected":false},"featured_media":411577,"template":"","meta":{"rank_math_lock_modified_date":false,"ep_exclude_from_search":false},"product_cat":[2851],"product_tag":[],"class_list":{"0":"post-411570","1":"product","2":"type-product","3":"status-publish","4":"has-post-thumbnail","6":"product_cat-joint-commission","8":"first","9":"instock","10":"sold-individually","11":"shipping-taxable","12":"purchasable","13":"product-type-simple"},"_links":{"self":[{"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/product\/411570","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/product"}],"about":[{"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/types\/product"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/media\/411577"}],"wp:attachment":[{"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/media?parent=411570"}],"wp:term":[{"taxonomy":"product_cat","embeddable":true,"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/product_cat?post=411570"},{"taxonomy":"product_tag","embeddable":true,"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/product_tag?post=411570"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}