Table of Changes CAMH Update 2, September 2010

Transcription

1 Comprehensive Accreditation Manual for Hospitals: The Official Handbook Table of Changes Due to a new publishing process, we are providing replacement pages for your entire manual. To update your manual, please remove and recycle the pages from behind each tab in your manual, 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 new EPs 16, 17 and 18 to LD Added new introduction and new and revised EPs 1 36 for revised MS Updates to the National Patient Safety Goals (NPSGs) regarding the use of supporting evidence for clinical practices, effective January 1, 2011 A change in the scoring category for NPSG , EP 8, from A to C A major reorganization and edit of The Accreditation Process (ACC) chapter to improve navigation of the chapter, understanding of its subject matter, and ease of reading, effective immediately. Major changes to the ACC chapter include the following: Revised decision categories for 2011 including the retirement of the categories of Provisional Accreditation and Conditional Accreditation and the introduction of two new categories of Accreditation with Follow-up Survey and Contingent Accreditation, effective January 1, 2011 Revised accreditation decision rules for 2011, effective January 1, 2011 New definitions for Accreditation with Follow-up Survey and Contingent Accreditation added to the Glossary (GL), effective January 1, 2011 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

2 Title page and Table of Contents Title page and Contents Updated title page Effective immediately page Foreword (FW) Entire chapter New for 2011 Effective immediately How to Use This Manual (HM) Entire chapter Minor editorial changes Effective immediately Removed description of scoring and decision process Revised Keys to Successfully Using This Manual section Requirements for Accreditation Accreditation Participation Requirements (APR) Entire chapter Revised note 1 for Effective January 1, 2011 APR , EP 1 Environment of Care (EC) Entire chapter Revised EC , Effective January 1, 2011 EP 1 Updated EC , EP 1 Emergency Management (EM) Entire chapter No changes 2

3 Human Resources (HR) Entire chapter Added standards link Effective January 1, 2011 and Note 4 to HR , EP 1 Added EPs 16 and 18 to HR Updated reference in Introduction to HR Infection Prevention and Control (IC) Entire chapter No changes Information Management (IM) Entire chapter No changes Leadership (LD) Entire chapter Added new EPs 16, 17 Effective January 1, 2011 and 18 to LD Added new EP 14 to LD Changed scoring category for LD , EP 26 Life Safety (LS) Entire chapter No changes Medication Management (MM) Entire chapter Added tier 3 to Effective January 1, 2011 MM , EP 2 3

4 Medical Staff (MS) Entire chapter Added new introduc- Effective March 31, 2011 tion and new and revised EPs 1 36 for revised MS National Patient Safety Goals (NPSG) Added standards link Effective January 1, 2011 for MS , EP 1 Revised note for MS , EP 9 Added EP 7 to MS Deleted standards links for MS , EPs 1, 6, 9 12; MS , EP 4; MS , EP 8; MS , EPs 1 5 Entire chapter Revised text and deleted Effective January 1, 2011 note for NPSG , EP 1 Revised NPSG , EP 6 Revised NPSG , EP 11 and added footnote Revised NPSG , EP 7 Changed scoring category and revised NPSG , EP 8 Revised UP , EP 3 4

5 Nursing (NR) Entire chapter No changes Provision of Care, Treatment, and Services (PC) Entire chapter Added EP 7 to Effective January 1, 2011 PC Deleted EP 14 for PC Added PC Added Note 2 to PC , EP 3 Performance Improvement (PI) Entire chapter No changes Record of Care, Treatment, and Services (RC) Entire chapter Revised text and added Effective January 1, 2011 note to EP 1; added EP 10; and added note to EP 28 for RC Rights and Responsibilities of the Individual (RI) Entire chapter Added EPs 28 and 29 to Effective January 1, 2011 RI Revised standards links to EP 1; revised text and added note to EP 2; and revised text and standards links for EP 3 for RI Transplant Safety (TS) Entire chapter No changes Waived Testing (WT) Entire chapter No changes 5

6 Policies, Procedures, and Other Information The Accreditation Process (ACC) Entire chapter Reorganized and edited Editorial changes effecentire chapter to im- tive immediately (Note: prove readability These changes will not Created a chapter table show up in shaded text) of contents Revisions to policies, Tagged topics related to decision categories, and deemed status recog- decision rules effective nition in the chapter January 1, 2011 (see retable of contents with a placement pages for denew CMS icon tails) Added new description of Concurrent Survey Option 6

7 Clarified minimum requirements for initial survey Clarified the description of the survey postponement and survey refusal processes Updated description of the e-app and how and when to notify The Joint Commission of changes Revised descriptions of survey agenda activities Revised description for the Life Safety Code Specialist Scope of Service Revised titles and descriptions of accreditation decision categories d and renumbered figures and tables to match revised decision categories and improve understanding Clarified the process for central office review of summary reports Updated accreditation decision rules for 2011 Revised review and appeal procedures 7

8 Sentinel Events (SE) Entire chapter Clarified information Effective immediately about how surveyors handle sentinel events during the survey process Created a new Table 2 for not reviewable sentinel events Added restraint death under the root cause of security systems and processes in Table 3 Made changes to submission deadlines to reflect the new decision rules Minor editorial changes The Joint Commission Quality Report (QR) Entire chapter Minor editorial changes Effective immediately Performance Measurement and the ORYX Initiative (PM) Entire chapter Updated requirements Effective January 1, 2011 for psychiatric hospitals Updated description of ORYX performance measure report Simplifying Compliance Activities (SCA) Entire chapter No changes Staffing Effectiveness Indicators (SEI) d Figures 1 Effective immediately through 4 Entire chapter Minor changes Effective January 1,

9 Required Written Documentation (RWD) Entire chapter Minor change in MS Effective January 1, 2011 section Early Survey Policy Option (ESP) Entire chapter Minor changes to HR, Effective January 1, 2011 LD, and MS sections Appendix A: Medicare Requirements for Hospitals (AXA) Entire chapter Added information Effective January 1, 2011 about Condition of Participation Utilization Review Glossary Entire chapter Updated definitions for Effective January 1, 2011 the revised accreditation decision categories Index Entire chapter Revised index Effective immediately 9

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