2017 ComprehensiveComprehensive Accreditation ... Accreditation Accreditation ... Acronyms Used in...

2017CAMHUpdate 1

ComprehensiveComprehensive AccreditationAccreditationManualManual forfor HospitalsHospitals

CAMH Update 1, July 2017 i

What’s NewJuly 2017 ReleaseEffective as Noted

This “What’s New” section is intended to help get you up to speed regarding thesubstantive changes that have been made to the CAMH since its previous update. Majorchanges to requirements, accreditation policies and procedures, and other importantinformation in this update include the following:n Reordered and streamlined “The Accreditation Process” (ACC) chapter to reduce

redundancy, improve information flow, and enrich customer understandingn Updated the decision rules for 2017 in the ACC chaptern Revised “The Joint Commission Quality Report” (QR) chapter to reflect changes in

ORYX® reporting, as The Joint Commission no longer requires measure setreporting

Please refer to the table that begins on the following page for more details about thisupdate. Revisions to content within this update are highlighted using shaded text withinthe replacement pages.

E-dition July 1, 2017, Release

2017CAMHUpdate 1

ComprehensiveComprehensive AccreditationAccreditation ManualManual forforHospitalsHospitals

CAMH Update 1, July 2017ii

TypeType ofof ChangeChange EffectiveEffectiveDateDate

TitleTitle PagePage andand ContentsContents PagePageq Updated title page and contents page Effective

immediatelyIntroduction:Introduction: HowHow TheThe JointJoint CommissionCommission CanCan HelpHelp YouYou MoveMove TowardToward HighHighReliabilityReliability (INTRO)(INTRO)q Table 1. Acronyms Used in This Manual: Updated tableq Use the Standards to Improve Care, Treatment, or Services:

Updated the list of challenging standardsq Stimulate Improvement: Updated guidance for standards questionsq Requesting Permission to Copy Content from the Manual:

Removed the mailing address for copy requests but retained the e-mail address

q Minor editorial revisions

EffectiveJuly 1, 2017

PatientPatient SafetySafety SystemsSystems (PS)(PS)q Changed “high-volume” to “high-frequency” when referring to areas

organizations should prioritize when conducting a proactive riskassessment

q Appendix: RI.01.01.01, EP 5: Added cross-references toRI.01.01.03, EPs 2 and 3



AccreditationAccreditation RequirementsRequirementsAccreditationAccreditation ParticipationParticipation RequirementsRequirements (APR)(APR)q APR.07.01.01, EP 1: Added language to Note 1 clarifying the

participation of surveyor management staff in the survey process;moved language about survey fees into new Note 2



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EnvironmentEnvironment ofof CareCare (EC)(EC)q EC.01.01.01: Added Note 2 for deemed-status hospitals requiring

compliance with the 2012 edition of NFPA 99: Health CareFacilities Code; added Note 3 with a link to further information onwaiver and equivalency requests

q EC.02.03.05, EP 19: Updated NFPA reference to 2012q EC.02.04.01, EP 4: Revised Note 3 by requiring a 100%

completion rate for scheduled maintenance activities for non-high-risk medical equipment in an alternative equipment maintenance(AEM) program inventory and adding that AEM frequency isdetermined by the hospital


q EC.02.04.03, EP 2: Added language to Note 3 stating that AEMfrequency is determined by the organization

q EC.02.04.03, EP 14: Changed compliance requirement for deemed-status hospitals in Note from Life Safety Code to Health CareFacilities Code

q EC.02.05.05, EP 6: Revised Note by requiring a 100% completionrate for scheduled maintenance activities for non-high-risk utilitysystems components in an AEM program inventory and adding thatAEM frequency is determined by the hospital



EmergencyEmergency ManagementManagement (EM)(EM)q EM.03.01.03, EP 15: Removed cross-references to EC.04.01.03, EP

1 and EC.04.01.05, EP 3EffectiveJuly 1, 2017


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HumanHuman ResourcesResources (HR)(HR)q HR.01.02.01, EP 1: Added cross-reference to HR.01.02.05, EP 19q HR.01.02.05, EPs 1–3: Added cross-reference to HR.01.02.05, EP

19q HR.01.02.07, EPs 1 and 2: Added cross-reference to HR.01.02.05,

EP 19


q HR.01.04.01, EP 1: Deleted cross-references to EC.03.01.01, EPs 1and 3

q HR.01.04.01, EP 2: Deleted cross-reference to EC.02.03.01, EP 10InfectionInfection PreventionPrevention andand ControlControl (IC)(IC)q No changesInformationInformation ManagementManagement (IM)(IM)q No changesLeadershipLeadership (LD)(LD)q LD.01.03.01, EP 5: Added cross-reference to MM.09.01.01, EP 1q LD.01.05.01, EP 6: Specified that accountability is for the quality of

care provided to patientsq LD.04.04.05: Changed to reflect that close calls is the term usually

used instead of near misses in the Introduction and EP 3


LifeLife SafetySafety (LS)(LS)q LS.01.01.01, EP 1: Added Note requiring that deemed-status

hospitals comply with the 2012 Life Safety Codeq LS.01.01.01, EP 4: Replaced Notes 3 and 4 with new Note 3 that

provides a link to further information on waiver and equivalencyrequests



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q LS.01.02.01, EP 1: Added LS.01.02.01, EP 15 to list ofrequirements evaluated in the hospital’s written interim life safetymeasure (ILSM) policy

q LS.01.02.01, EP 15: Added EP requiring hospital policy to allowthe use of other ILSMs not addressed in EPs 2–14

q LS.02.01.10, EP 5: Added Note 2 for deemed-status hospitals onmeeting applicable provisions of the Life Safety Code TIA 12-1

q LS.02.01.20, EP 1: Added Note for deemed-status hospitals onmeeting applicable provisions of the Life Safety Code TIA 12-4



q Clarified that the following standards apply to AHCO classificationrequirements for hospitals and added language about provisions thatmust be met by AHCO application:n LS.03.01.10n LS.03.01.20n LS.03.01.30n LS.03.01.34n LS.03.01.35n LS.03.01.40n LS.01.03.50n LS.03.01.70

MedicationMedication ManagementManagement (MM)(MM)q MM.09.01.01, EP 8: Added documentation icon Effective

July 1, 2017MedicalMedical StaffStaff (MS)(MS)q MS.13.01.01, EP 1: Added cross-references to LD.04.03.09, EPs 4

and 23 in bulleted item regarding evidence of internal review ofpractitioner’s performance of privileges



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NationalNational PatientPatient SafetySafety GoalsGoals (NPSG)(NPSG)q No changesNursingNursing (NR)(NR)q No changesProvisionProvision ofof Care,Care, Treatment,Treatment, andand ServicesServices (PC)(PC)q No changesPerformancePerformance ImprovementImprovement (PI)(PI)q No changesRecordRecord ofof Care,Care, Treatment,Treatment, andand ServicesServices (RC)(RC)q No changesRightsRights andand ResponsibilitiesResponsibilities ofof thethe IndividualIndividual (RI)(RI)q RI.01.01.01, EP 5: Added cross-references to RI.01.01.03, EPs 2

and 3EffectiveJuly 1, 2017

TransplantTransplant SafetySafety (TS)(TS)q No changesWaivedWaived TestingTesting (WT)(WT)q No changesAccreditationAccreditation ProcessProcess InformationInformationTheThe AccreditationAccreditation ProcessProcess (ACC)(ACC)q Removed all references to Contingent Accreditation (CONT) as this

decision rule category has been eliminatedq Notices: Moved paragraph about Joint Commission Connect™ as the

primary means of communication from the end of the chapter to thebeginning


q Eligibility Requirements for Initial Surveys: Incorporated languagefrom the now-deleted “Initial Surveys” section to eliminateredundancy of content

q Tailored Survey Policy: Clarified that laboratory services are amongthe components to which this policy applies


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q Inclusion of Physician Practices in Survey: Deleted parentheticallimiting provider-based practices to those that are not freestandingand added Note clarifying that an organization’s inclusion ofphysician practices is optional

q Multiorganization Option: Deleted paragraph regarding the surveyteam leaders’ maintenance of team continuity and compilation ofinformation for corporate summation

q Contracted Services: Clarified that laboratory services providedunder contract are included in the evaluation of contractuallyprovided care, treatment, and services

q Accrediting in Accordance with CMS Certification Numbers:Clarified that the Centers for Medicare & Medicaid Services (CMS)requires each Joint Commission–accredited hospital with its ownCMS Certification Number (CCN) to demonstrate full compliancewith all applicable Joint Commission standards

q Information That Is Publicly Disclosed on Request: Deletedlanguage restricting the availability of an organization’s accreditationhistory to the past seven years

q Process for Responding to a Complaint: Changed time frames forresponding to complaints from calendar days to business days

q An Organization’s Secure Joint Commission Connect™ Site: Updatedto reflect that Joint Commission Connect is the primary means ofcommunication between The Joint Commission and accreditedorganizations

q Accreditation Contract and Business Associate Agreement: Deletedlanguage about contracts’ availability (via the extranet) for printing/approval and governmental organizations’ ability to enter intounique contracts with The Joint Commission

q Annual and Survey Fees: Updated to reflect that failure to payoverdue amounts will result in a loss of accreditation with noopportunity for appeal or reinstatement

q During the Survey: Incorporated language about embeddingstandards into routine operations from the now-deleted section“The On-Site Survey”


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q Survey Notification (formerly “Unannounced Surveys”): Renamed,reorganized, and revised section by adding information aboutnotifying organizations of unannounced, announced, and short-notice survey events

q Patient Flow Tracer: Removed section (but kept description oftracer in Table 2. Hospital-Specific Tracer Applicability andObjectives)

q Survey Agenda: Changed the web address in the footnote to connectto the 2017 Survey Activity Guide

q Immediate Threat to Health or Safety: Made the following changes:n Updated time frame within which The Joint Commission will

notify CMS of an immediate threat (in deemed status scenarios)from 24 hours to 2 business days of confirming it

n Revised to reflect that resolution of an immediate threat maychange accreditation status from Preliminary Denial ofAccreditation (PDA) to a time-limited PDA and Accreditationwith Follow-Up Survey (AFS)

q Figure 2. Process flow for Immediate Threat to Health or Safety(ITHS) situations at organizations seeking reaccreditation: Deletedreferences to Contingent Accreditation and replaced “AccreditationCommittee” with “executive leadership”

q Figure 3. Survey Analysis for Evaluating Risk (SAFER) matrix:Updated matrix to include descriptors

q How Accreditation Decisions Are Made: Made the followingchanges:n Revised to reflect that organizations recommended for a PDA02

decision are required to submit a Plan of Correction (instead ofan ESC) within 10 business days and to have a validation surveywithin 60 days

n Updated to reflect that resolution of an Immediate Threat toHealth or Safety situation may result in a change from PDA toAFS


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q The Accreditation Decision Process: Added bullet point stating thatorganizations recommended for a PDA02 decision are required tosubmit a Plan of Correction (instead of an ESC) within 10 businessdays and to have a validation survey within 60 days

q Central Office Review of Summary Reports: Deleted section toeliminate redundancy of content

q Decision Categories for Organizations Seeking AccreditationRenewal:n Streamlined description of AFSn Deleted Contingent Accreditation and noted that there are now

four possible categories for reaccreditation surveysq Figure 4. Continuum of survey activity outcomes for organizations

seeking renewal of accreditation: Deleted Contingent Accreditationq Decision Outcomes for Organizations Seeking Initial Accreditation:

Clarified that organizations found out of compliance with JointCommission requirements during their initial survey mayvoluntarily withdraw from the accreditation process with nodecision rendered if they have not yet submitted their ESC in theallotted time

q Figure 5. SAFER matrix placement and required follow-upactivities: Streamlined figure for readability

q Corrective ESC: Revised to reflect that organizations recommendedfor a PDA02 decision are required to submit a Plan of Correction(instead of an ESC) within 10 business days and to have a validationsurvey within 60 days

q The Process for Accreditation with Follow-up Survey, ContingentAccreditation, or Preliminary Denial of Accreditation: Deletedsection to eliminate obsolete and redundant content

q Figure 6. Process flow for a Preliminary Denial of Accreditation(PDA) decision: Deleted figure

q Figure 7. Process flow for a Contingent Accreditation (CONT)decision: Deleted figure

q Top Performer on Key Quality Measures: Deleted section


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q Focused Standards Assessment (FSA): Clarified content and updatedto reflect that the FSA tool now includes the SAFER methodology

q Clarification Validation Survey (CVS): Deleted sectionq On-site Follow-up Survey for a Condition-level Deficiency:

Clarified that these surveys occur according to CMS regulationsq Decision Rules for Organizations Seeking Initial Accreditation:

Moved section and reordered the decision rule categoriesq Decision Rules for Organizations Seeking Reaccreditation: Made the

following changes:n Moved section and reordered the decision rule categoriesn Revised decision rule AFS10 to reflect that surveyors no longer

evaluate the Plan for Improvementn Added AFS11 on Immediate Threat to Health and Safety

abatement surveys and AFS12 on fraud and abusen Eliminated Contingent Accreditation decision rule categoryn Replaced former decision rule PDA06 regarding Contingent

Accreditation with new PDA06 regarding organizations with anAFS decision that fail to resolve all RFIs after two opportunitiesto submit ESCs

n Added PDA09 for deemed-status organizations that fail theirsecond Medicare follow-up survey as a result of a one or moreConditions of Participation scored as a Condition-leveldeficiency

n Added PDA10 for organizations with patients at risk due topossible fraud or abuse

n Removed failure to resolve Contingent Accreditation status as acause for Denial of Accreditation (DA) decision rule DA02

n Added failure to submit a Plan of Correction as a cause fordecision rule DA04

n Added DA05 regarding organizations in the sustainingimprovement program that fail to participate in JointCommission intervention


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q Process for Organizations That Meet Decision Rule PDA02: Madethe following changes:n Renamed section (formerly titled “Preliminary Denial of

Accreditation Due to Patterns, Trends, or Repeat Findings”)n Relocated section (formerly included as part of “The Process for

Accreditation with Follow-up Survey, Contingent Accreditation,or Preliminary Denial of Accreditation” section)

n Revised to reflect the new process for organizations that receive aPDA02 decision (including the required submission of a Plan ofCorrection within 10 business days followed by a validationsurvey within 60 calendar days)

n Added new Figure 6. PDA02 decision process flowq Process for Organizations That Meet Decision Rule PDA04: Made

the following changes:n Renamed section (formerly titled “Preliminary Denial of

Accreditation for Organizations Without Proper License,Certificate, or Permit”)

n Relocated section (formerly included as part of “The Process forAccreditation with Follow-up Survey, Contingent Accreditation,or Preliminary Denial of Accreditation” section)

n Streamlined content and removed reference to ContingentAccreditation

q Review and Appeal Procedures: Made the following changes:n Deleted former Figure 8. Process flow for the appeal of a

Preliminary Denial of Accreditation decisionn Deleted several sections to reflect elimination of Contingent

Accreditation decision category and streamlined content toeliminate redundancies

q Minor editorial revisionsStandardsStandards ApplicabilityApplicability GridGrid (SAG)(SAG)q LS.01.02.01, EP 15: Added EP with applicability to all five services

(Acute, Long Term Acute Care, Psychiatric, Surgical Specialty, andSwing Beds services)



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SentinelSentinel EventsEvents (SE)(SE)q Removed “near miss” throughout chapter, in deference to the more

accurate term “close call”q Clarified throughout chapter that action plans must be correctiveq Updated references to “Board of Commissioners” and

“Accreditation Committee” with “executive leadership” throughoutthe chapter to align with the current process at The JointCommission


q Definition of Sentinel Event:n Expanded footnote concerning an unintended foreign object to

define the term after surgeryn Added language to distinguish patient safety events from sentinel

events and added a reference to the “Patient Safety Systems” (PS)chapter

q Oversight of the Sentinel Policy: Deleted reference to aggregatingde-identified data; changed “Sentinel Event Hotline” to “Office ofQuality and Patient Safety”

q Survey Process:n Added language to clarify that surveyors are not authorized to

review root cause analysis documents and determine credibility,thoroughness, or acceptability

n Specified that surveyors can only apply the related standards andelements of performance to assess performance improvementpractices

n Added specific standards referencesq Minor editorial revisions


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TheThe JointJoint CommissionCommission QualityQuality ReportReport (QR)(QR)q Introduction: Clarified reporting is of ORYX chart-abstracted

performance measure informationq What Will My Quality Report Contain?:

n Revised the title of Figure 1 to “Legend of National PatientSafety Goal Quality Indicator Symbols” and updated cross-references


n Revised Quality Indicators section on National QualityImprovement Goals to reflect changes to ORYX chart-abstractedperformance measure reporting requirements

q Information Released by The Joint Commission: Removedinformation about the display of measure set information (as TheJoint Commission no longer requires measure set reporting) andrevised the description of how individual measures are displayed,including through the use of comparative symbols (plus, minus,check, or star)

q Guidelines for Publication: Revised guidelines to reflect revisedreporting requirements including the use of comparative symbols

q Minor editorial revisionsPerformancePerformance MeasurementMeasurement andand thethe ORYXORYX®® InitiativeInitiative (PM)(PM)q Revised the term performance measure data to chart-abstracted

performance measure data to align with the revised reportingrequirements

q Deleted the term measure set to align with the revised reportingrequirements


q Current Requirements for Hospitals: Revised the entire section toalign with the recent elimination of measure set reporting

q Requirements for Small Hospitals: Revised the entire section toclarify the measurement reporting required by small hospitals


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q Requirements for Psychiatric Hospitals: Eliminated the exemptionof psychiatric hospital’s with an average daily census of 10 or fewerinpatients from reporting data

q Use of Performance Measure Data: Updated contact information forgeneral ORYX requirement queries

q Minor editorial revisionsRequiredRequired WrittenWritten DocumentationDocumentation (RWD)(RWD)q Added MM.09.01.01, EP 8 Effective

July 1, 2017EarlyEarly SurveySurvey PolicyPolicy (ESP)(ESP)q No changesPrimaryPrimary CareCare MedicalMedical HomeHome CertificationCertification OptionOption (PCMH)(PCMH)q No changesAppendixAppendix A:A: MedicareMedicare RequirementsRequirements forfor HospitalsHospitals (AXA)(AXA)q No changesAppendixAppendix B:B: SpecialSpecial ConditionsConditions ofof ParticipationParticipation forfor PsychiatricPsychiatric HospitalsHospitals (AXB)(AXB)q No changesGlossaryGlossaryq Revised the following terms:

n accreditation decisions (in particular, revised Limited, TemporaryAccreditation, Accreditation with Follow-up Survey, andPreliminary Denial of Accreditation and deleted ContingentAccreditation)

n appeal process


n designated equivalent sourcen Evidence of Standards Compliance (ESC) reportn Focused Standards Assessment (FSA)


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n Plan of Action (POA)n Requirement for Improvement (RFI)n Review Hearing Panel



2017 ComprehensiveComprehensive Accreditation ... Accreditation Accreditation ... Acronyms Used in...

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