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Comprehensive Accreditation Manual for Hospitals (CAMH), 2021
- What’s New 2021 CAMH
- Cover
- The Joint Commission Mission
- Contents
- Introduction: How The Joint Commission Can Help You Move Toward High Reliability (INTRO) [Go to Page]
- I. Introduction to Joint Commission Accreditation
- II. About the
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- III. Steps to Achieving and Maintaining Compliance
- IV. Get Extra Help
- Patient Safety Systems (PS) [Go to Page]
- Introduction
- What Does This Chapter Contain?
- Becoming a Learning Organization
- The Role of Hospital Leaders in Patient Safety
- Data Use and Reporting Systems
- A Proactive Approach to Preventing Harm
- Encouraging Patient Activation
- Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
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- References
- Appendix. Key Patient Safety Requirements
- Accreditation Participation Requirements (APR) [Go to Page]
- Overview
- Chapter Outline
- Requirements, Rationales, and Elements of Performance
- Environment of Care (EC) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- Emergency Management (EM) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- Human Resources (HR) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
- Infection Prevention and Control (IC) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- Information Management (IM) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
- Leadership (LD) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- Life Safety (LS) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- Medication Management (MM) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- Medical Staff (MS) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- National Patient Safety Goals (NPSG) [Go to Page]
- Chapter Outline
- Requirements, Rationales, and Elements of Performance
- Nursing (NR) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
- Provision of Care, Treatment, and Services (PC) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- Performance Improvement (PI) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
- Record of Care, Treatment, and Services (RC) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- Rights and Responsibilities of the Individual (RI) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
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- Transplant Safety (TS) [Go to Page]
- Overview
- Chapter Outline
- Standards, Rationales, and Elements of Performance
- Waived Testing (WT) [Go to Page]
- Overview
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- Chapter Outline
- Standards, Rationales, and Elements of Performance
- The Accreditation Process (ACC) [Go to Page]
- Notices
- ACC Chapter Contents
- Overview
- Accreditation Policies
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- Before the Survey
- During the Survey
- After the Survey
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- Between Accreditation Surveys
- Decision Rules for Organizations Seeking Initial Accreditation
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- Decision Rules for Organizations Seeking Reaccreditation
- Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
- Process for Organizations That Meet Decision Rule PDA04
- Review and Appeal Procedures
- Standards Applicability Grid (SAG)
- Sentinel Events (SE) [Go to Page]
- I. Sentinel Events
- II. Goals of the Sentinel Event Policy
- III. Responding to Sentinel Events
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- IV. The Sentinel Event Database
- V. Determination That a Sentinel Event Is Subject to Review
- VI. Optional On-Site Review of a Sentinel Event
- VII. Disclosable Information
- VIII. The Joint Commission’s Response
- IX. Sentinel Event Measures of Success (SE MOS)
- X. Handling Sentinel Event–Related Documents
- XI. Oversight of the Sentinel Event Policy
- XII. Survey Process
- Appendix. Accreditation Requirements Related to Sentinel Events
- The Joint Commission Quality Report (QR) [Go to Page]
- Introduction
- What Is The Joint Commission Quality Report?
- What Will My Quality Report Contain?
- What Is Quality Check?
- Can My Hospital Comment on Its Quality Report?
- What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
- Performance Measurement and the ORYX Initiative (PM) [Go to Page]
- Overview
- The Continued Role of ORYX
- Accelerate PI™
- Use of Performance Measure Data
- Current Requirements for Hospitals
- Required Written Documentation (RWD) [Go to Page]
- List of EPs Requiring Written Documentation for Hospitals
- Early Survey Policy (ESP)
- Primary Care Medical Home Certification Option (PCMH) [Go to Page]
- Overview
- Primary Care Medical Home Model
- Standards, Rationales, Elements of Performance, and Scoring Specific to the Primary Care Medical Home Certification Option
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- Appendix A: Medicare Requirements for Hospitals (AXA) [Go to Page]
- CoP Requirements Assessed by CMS or the Fiscal Intermediary
- Appendix B: Special Conditions of Participation for Psychiatric Hospitals (AXB) [Go to Page]
- Subpart E—Requirements for Specialty Hospitals
- Glossary (GL) [Go to Page]
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- Index (IX) [Go to Page]