JCR CAMCAH 2021

$178.21

Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH)

Published By	Publication Date	Number of Pages
Joint Commission	2021

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Category: Joint Commission

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Description

Continuous compliance starts with staff who know what The Joint Commission requires. The 2021 Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH) provides all the key information your organization needs to power performance improvement and maintain continuous standards compliance. It features the official Joint Commission standards, National Patient Safety Goals, and other accreditation requirements, including standards and elements of performance for the optional Primary Care Medical Home certification. The portable CAMCAH is spiral bound with color-coded tabs that allow you to find exactly what you need for standards compliance or survey readiness when you need it. It’s lean and light, making it a perfect on-the-go reference. Keep it handy in meetings, during orientation and training, and as a practical overview of the Joint Commission’s accreditation requirements for everyone in your organization, from staff to leaders. Then, get ready to power performance improvement and excellence in your organization! Please note: The CAMCAH is delivered annually. For the most up-to-date standards throughout 2021, access your E-dition on your Joint Commission ConnectTM extranet site or consider purchasing the E-dition Critical Access Hospital version. Not sure if your organization is a critical access hospital? A critical access hospital is defined by CMS as hospital that offers limited services and is located more than 35 miles from a hospital or another critical access hospital, or is certified by the state as being a necessary provider of health care services to residents in the area. It maintains no more than 25 beds that could be used for inpatient care. This manual won’t apply unless you meet those criteria. Key Topics: • “Gold tab” standards requirements including the standards, National Patient Safety Goals, and Accreditation Participation Requirements effective January 1, 2021 • “Blue tab” 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: • Integrated regulatory requirements for critical access hospital recognition • Icons to help navigate documentation requirements as well as risk areas • “What’s New” summary of changes made since the previous edition Standards: All critical access hospital standards Setting: Critical access hospitals Key Audience: Staff responsible for accreditation, patient safety, or quality improvement in critical access hospitals or the distinct part psychiatric and/or rehabilitation distinct part units within a critical access hospital.

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2021 CAMCAH
19	Cover
20	The Joint Commission Mission
21	Contents
23	Introduction: How The Joint Commission Can Help You Move Toward High Reliability (INTRO)
24	I. Introduction to Joint Commission Accreditation
26	II. About the
39	III. Steps to Achieving and Maintaining Compliance
47	IV. Get Extra Help
51	Patient Safety Systems (PS) Introduction
52	What Does This Chapter Contain?
54	Becoming a Learning Organization
55	The Role of Critical Access Hospital Leaders in Patient Safety
61	Data Use and Reporting Systems
64	A Proactive Approach to Preventing Harm
67	Encouraging Patient Activation
68	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
70	References
73	Appendix. Key Patient Safety Requirements
99	Accreditation Participation Requirements (APR) Overview
100	Chapter Outline
101	Requirements, Rationales, and Elements of Performance
111	Environment of Care (EC) Overview
114	Chapter Outline
115	Standards, Rationales, and Elements of Performance
157	Emergency Management (EM) Overview
159	Chapter Outline
160	Standards, Rationales, and Elements of Performance
187	Human Resources (HR) Overview
188	Chapter Outline
189	Standards, Rationales, and Elements of Performance
201	Infection Prevention and Control (IC) Overview
203	Chapter Outline
204	Standards, Rationales, and Elements of Performance
217	Information Management (IM) Overview
218	Chapter Outline
219	Standards, Rationales, and Elements of Performance
225	Leadership (LD) Overview
229	Chapter Outline
230	Standards, Rationales, and Elements of Performance
267	Life Safety (LS) Overview
270	Chapter Outline
271	Standards, Rationales, and Elements of Performance
317	Medication Management (MM) Overview
320	Chapter Outline
321	Standards, Rationales, and Elements of Performance
345	Medical Staff (MS) Overview
347	Chapter Outline
348	Standards, Rationales, and Elements of Performance
381	National Patient Safety Goals (NPSG) Chapter Outline
382	Requirements, Rationales, and Elements of Performance
401	Nursing (NR) Overview
402	Chapter Outline
403	Standards, Rationales, and Elements of Performance
407	Provision of Care, Treatment, and Services (PC) Overview
409	Chapter Outline
410	Standards, Rationales, and Elements of Performance
457	Performance Improvement (PI) Overview
459	Chapter Outline
460	Standards, Rationales, and Elements of Performance
465	Record of Care, Treatment, and Services (RC) Overview
466	Chapter Outline
467	Standards, Rationales, and Elements of Performance
477	Rights and Responsibilities of the Individual (RI) Overview
479	Chapter Outline
480	Standards, Rationales, and Elements of Performance
495	Transplant Safety (TS) Overview
497	Chapter Outline
498	Standards, Rationales, and Elements of Performance
507	Waived Testing (WT) Overview
510	Chapter Outline
511	Standards, Rationales, and Elements of Performance
517	The Accreditation Process (ACC) Notices ACC Chapter Contents
519	Overview
521	Accreditation Policies
544	Before the Survey
549	During the Survey
567	After the Survey
578	Between Accreditation Surveys
590	Decision Rules for Organizations Seeking Initial Accreditation
594	Decision Rules for Organizations Seeking Reaccreditation
599	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
601	Process for Organizations That Meet Decision Rule PDA04
602	Review and Appeal Procedures
609	Standards Applicability Grid (SAG)
645	Sentinel Events (SE) I. Sentinel Events
649	II. Goals of the Sentinel Event Policy
650	III. Responding to Sentinel Events
657	IV. The Sentinel Event Database
658	V. Determination That a Sentinel Event Is Subject to Review VI. Optional On-Site Review of a Sentinel Event
659	VII. Disclosable Information VIII. The Joint Commission’s Response IX. Sentinel Event Measures of Success (SE MOS)
660	X. Handling Sentinel Event–Related Documents XI. Oversight of the Sentinel Event Policy
661	XII. Survey Process
662	Appendix. Accreditation Requirements Related to Sentinel Events
665	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
666	What Will My Quality Report Contain?
667	What Is Quality Check?
668	Can My Critical Access Hospital Comment on Its Quality Report?
669	What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
671	Information Released by The Joint Commission Guidelines for Publication
673	Performance Measurement and the ORYX Initiative (PM) Overview The Continued Role of ORYX
674	Accelerate PI™
675	Use of Performance Measure Data ORYX Requirements for Critical Access Hospitals
677	Required Written Documentation (RWD)
678	List of EPs Requiring Written Documentation for Critical Access Hospitals by Service
685	Early Survey Policy (ESP)
691	Primary Care Medical Home Certification Option (PCMH) Overview Primary Care Medical Home Model
695	Standards, Rationales, Elements of Performance, and Scoring Specific to the Primary Care Medical Home Certification Option I. Patient-Centered Care
708	II. Comprehensive Care
711	III. Coordinated Care
717	IV. Superb Access to Care
718	V. Systems-Based Approach to Quality and Safety
727	Appendix A: Medicare Requirements for Critical Access Hospitals (AXA)
733	Appendix B: Medicare Requirements for Critical Access Hospitals with DPUs (AXB)
753	Glossary (GL)
793	Index (IX)