CAMH 2010 UPD1 book - Joint Commission€“PC-64 PC-5–PC-6 PC-15–PC-20 PC-23–PC-26 ... Measure of Success Submission Time Line* Deleted decision rule PDA04 and renumbered the

1CAMH Update 1, June 2010

Table of ChangesCAMH Update 1, June 2010

Standard, element of performance, and scoring changes in this update include the following:■ Clarifi cations to IM.02.02.01, EPs 2 and 3 regarding standardized terminology,

eff ective immediately■ New note to UP.01.02.01, EP 3 regarding defi ning the limited circumstances to del-

egate site marking in the “National Patient Safety Goals” (NPSG) chapter, eff ective immediately

Additional changes include the following:■ New information on the required Business Associate agreement in “Th e Accredita-

tion Process” (ACC) chapter, eff ective immediately ■ New text on Preliminary Denial of Accreditation for organizations without proper

license, certifi cate, or permit in the ACC chapter, eff ective immediately

Refer to the following table (pages 2–12) and the actual updated pages for more infor-mation on these and other revisions.

To update your manual, please remove and recycle the pages listed in the “Remove Pages” column from your CAMH, and insert the new pages listed in the “Insert Pages” column. Check boxes have been provided for your convenience to track the removal and addition of pages.

Major revisions to the accreditation policies and standards-related information are high-lighted on your replacement pages. Minor editorial changes are not highlighted.

CAMHUpdate 1

Comprehensive Accreditation Manual for Hospitals

2 CAMH Update 1, June 2010

CAMHUpdate 1


Remove Pages Insert Pages Type of Change

Title page and Copyright page❏ Previous title page

and copyright page (i–ii)

❏ Updated title page and copyright page (i–ii)

Updated month and year for 2010 Update 1 release

Environment of Care (EC)❏ EC-7–EC-18❏ EC-21–EC-22

❏ EC-7–EC-18❏ EC-21–EC-22

■ Deleted Measure of Success icon for EC.02.01.01, EPs 7 and 11

■ Deleted Measure of Success icon for EC.02.01.03, EP 6

■ Changed scoring category to an A and deleted Measure of Suc-cess icon for EC.02.02.01, EP 7*



■ Deleted Measure of Success icon for EC.02.03.05, EPs 3, 4, and 18

■ Changed scoring category to an A and deleted Measure of Suc-cess icon for EC.02.03.05, EPs 7, 9, 12, 16, 17, 19, and 20*



* Eff ective immediately.


CAMHUpdate 1



EC (continued)■ Deleted Measure of Success icon

for EC.02.05.01, EP 3■ Deleted Measure of Success icon

for EC.02.05.05, EP 1■ Deleted Measure of Success icon

for EC.02.05.07, EP 2■ Deleted EPs 4, 5, 6, and 18 for

EC.02.06.01■ Added tier 3 icon to

EC.02.06.01, EP 20*Emergency Management (EM)❏ EM-17–EM-18 ❏ EM-17–EM-18 ■ Changed scoring category to a C

for EM.02.02.13, EPs 7 and 8*Infection Prevention and Control (IC)❏ IC-7–IC-14 ❏ IC-7–IC-14 ■ Added standards reference link

to IC.01.05.01, EP 8*■ Changed standards reference

link to IC.02.01.01, EP 9*■ Changed text for IC.02.02.01,

EP 1*■ Changed text to Note for

IC.02.02.01, EP 2*■ Deleted standards reference link

to IC.03.01.01, EP 6



CAMHUpdate 1



Information Management (IM)❏ IM-7–IM-8 ❏ IM-7–IM-8b ■ Changed scoring category to a

C for IM.02.01.03, EP 6*■ Changed scoring category to an

A and deleted Measure of Suc-cess icon for IM.02.02.01, EP 1*

■ Changed text for IM.02.02.01, EP 2*

■ Changed text and added Note 2 to IM.02.02.01, EP 3*

■ Changed scoring category to an A and deleted Measure of Suc-cess icon for IM.02.02.03, EP 2*

Leadership (LD)❏ LD-9–LD-10❏ LD-13–LD-14❏ LD-17–LD-20❏ LD-23–LD-24❏ LD-27–LD-36

❏ LD-9–LD-10❏ LD-13–LD-14❏ LD-17–LD-20❏ LD-23–LD-24❏ LD-27–LD-36

■ Added EP 8 for LD.01.05.01, eff ective July 15, 2010

■ Deleted LD.02.04.01, EP 3■ Deleted LD.03.02.01, EP 2■ Deleted LD.03.03.01, EP 2■ Deleted LD.03.04.01, EP 2■ Deleted LD.03.05.01, EP 2■ Added standards reference link

to LD.03.05.01, EP 7*■ Deleted LD.03.06.01, EP 2■ Added missing scoring category

A to LD.04.03.01, EP 26*■ Added missing scoring category

A to LD.04.03.07, EPs 1 and 2*



CAMHUpdate 1



LD (continued)■ Added explanation to creden-

tialing and privileging section of introduction for LD.04.03.09*

■ Added Note 1 and Note 3 to LD.04.03.09, EP 4, eff ective July 15, 2010

■ Added lead-in text and note to LD.04.03.09, EP 9, eff ective July 15, 2010

■ Changed text for LD.04.04.05, EPs 1, 5, 7, 9, 12, and 14*

■ Changed text and added bullet to LD.04.04.05, EP 13*

Medication Management (MM)❏ MM-3–MM-4❏ MM-7–MM-8❏ MM-17–MM-18❏ MM-21–MM-22

❏ MM-3–MM-4❏ MM-7–MM-8❏ MM-17–MM-18❏ MM-21–MM-22

■ MM.07.01.01 listed in chapter outline as no longer applicable to hospitals*

■ Deleted standards reference link from MM.02.01.01, EP 3

■ Changed scoring category to an A, added tier 3 icon, and deleted Measure of Success for MM.05.01.17, EP 2*

■ Deleted Standard MM.07.01.01



CAMHUpdate 1



Medical Staff (MS)❏ MS-7–MS-10❏ MS-25–MS-30❏ MS-37–MS-40

❏ MS-7–MS-10❏ MS-25–MS-30❏ MS-37–MS-40

■ Changed standards reference link for MS.01.01.01, EP 17*

■ Changed scoring category to an A and deleted Measure of Success icon for MS.02.01.01, EP 5*

■ Added new text for EP 3 and renumbered the remaining EPs for MS.06.01.07*

■ Added note to Rationale for MS.06.01.13*

■ Reworded text for MS.06.01.13, EPs 3 and 6*

■ Added new EP 4 and renum-bered the remaining EP for MS.07.01.01*

■ Added lead-in lines to para-graphs and one bullet to the list in Introduction for MS.13.01.01, eff ective July 15, 2010

■ Added text to EP 1 for MS.13.01.01, eff ective July 15, 2010

■ Added EP 4 number to standards reference link for MS.13.01.01, EP 3, eff ective July 15, 2010



CAMHUpdate 1



National Patient Safety Goals (NPSG) ❏ NPSG-7–NSPG-14❏ NPSG-23–NSPG-24

❏ NPSG-7–NSPG-14b❏ NPSG-23–NSPG-24

■ Deleted bullet from list for NPSG.03.04.01, EP 3

■ Added prescribers to text for NPSG.03.05.01, EP 7*

■ Added text to NPSG.07.03.01, EP 3*

■ Added text to NPSG.07.05.01, EP 7*

■ Added note to UP.01.02.01, EP 3*

■ Deleted bullet in note for UP.01.02.01, EP 5

Nursing (NR)❏ NR-5–NR-6 ❏ NR-5–NR-6 ■ Deleted standards reference link

for NR.02.03.01, EP 4



CAMHUpdate 1



Provision of Care, Treatment, and Services (PC)❏ PC-5–PC-6❏ PC-15–PC-20❏ PC-23–PC-26❏ PC-59–PC-60❏ PC-63–PC-64

❏ PC-5–PC-6❏ PC-15–PC-20❏ PC-23–PC-26❏ PC-59–PC-60❏ PC-63–PC-64

■ Added Note 2 to PC.01.02.01, EP 1*

■ Added Note 2 and Note 3 to PC.01.03.03, EP 4*

■ Changed text for PC.02.01.03, EP 20*

■ Deleted Measure of Success icon for PC.02.02.03, EPs 6, 9, and 11

■ Deleted EP 1 and 2 for PC.02.03.03

■ Added text to standard PC.03.01.03*

■ Deleted Measure of Success icon for PC.03.05.17, EP 3

■ Deleted Note 2 for PC.04.01.03, EP 3

Performance Improvement (PI)❏ PI-5–PI-8 ❏ PI-5–PI-8 ■ Changed scoring category to an

A and deleted Measure of Suc-cess icon for PI.01.01.01, EPs 3 and 16*

■ Added EPs 12, 13, and 14 to PI.02.01.01*



CAMHUpdate 1



Record of Care (RC)❏ RC-3–RC-6❏ RC-11–RC-12

❏ RC-3–RC-6❏ RC-11–RC-12

■ Deleted Measure of Success icon for RC.01.01.01, EPs 11 and 19

■ Added standards reference link to RC.01.04.01, EP 4*

■ Deleted Measure of Success icon for RC.02.03.07, EPs 3 and 4

Rights and Responsibilities of the Individual (RI)❏ RI-13–RI-18 ❏ RI-13–RI-18 ■ Deleted RI.01.06.05, EP 1

■ Added standards reference link to RI.01.07.01, EP 6*

■ Added psychiatric to lead-in text for RI.01.07.07*

■ Added Rationale for RI.02.01.01*

■ Revised text for RI.02.01.01, EP 1*

Transplant Safety (TS) ❏ TS-9–TS-10 ❏ TS-9–TS-10 ■ Editorial change*



CAMHUpdate 1



Th e Accreditation Process (ACC)❏ ACC-1–ACC-92❏ ACC-105–ACC-106

❏ ACC-1–ACC-92❏ ACC-105–ACC-106

■ Added new information on the required Business Associate agreement*

■ Updates to the payment policy*■ Updated information on gener-

ating a survey agenda*■ Added new text on Preliminary

Denial of Accreditation for organizations without proper license, certifi cate, or permit*

■ Added information about the Medicare certifi cation recom-mendation letter for hospitals that use Joint Commission accreditation for deemed status purposes*

■ Updated the process fl owchart for Immediate Th reat to Health or Safety situations*

■ Updated the fi gure about the Measure of Success Submission Time Line*

■ Deleted decision rule PDA04 and renumbered the remaining rules*

■ Made editorial changes and updates*



CAMHUpdate 1



Sentinel Events (SE)❏ SE-1–SE-6❏ SE-15–SE-18

❏ SE-1–SE-6❏ SE-15–SE-18

■ Clarifi ed information about how surveyors handle sentinel events during the survey process*

■ Clarifi ed information about Th e Joint Commission’s response if a hospital has not undertaken serious improvement eff orts regarding sentinel events*

■ Editorial changes*Th e Joint Commission Quality Report (QR)❏ QR-1–QR-2❏ QR-5–QR-8

❏ QR-1–QR-2❏ QR-5–QR-8

■ Editorial changes*

Performance Measurement and the ORYX Initiative (PM)❏ PM-1–PM-6❏ PM-9–PM-12

❏ PM-1–PM-6❏ PM-9–PM-12

■ Updated explanation regarding requirements for psychiatric hospitals*

■ Updated the sample quality reports*

Simplifying Compliance Activities (SCA)❏ Remove entire

chapter SCA-1–SCA-8

❏ Insert entire chapter SCA-1–SCA-8

■ Updated Web sites* ■ Editorial revisions*

Required Written Documentation (RWD)❏ RWD-7–RWD-8 ❏ RWD-7–RWD-8 ■ Added PI.02.01.01, EP 14 to

the tables of standards with required written documentation requirements*



CAMHUpdate 1



Early Survey Policy Option (ESP)❏ ESP-1–ESP-6 ❏ ESP-1–ESP-6 ■ Deleted EC.02.06.01, EPs 4–6

and 18 from the EC table■ Added LD.01.05.01, EP 8 to

the LD table*■ Added MS.06.01.07, EP 9 to

the MS table*■ Added MS.07.01.01, EP 5 to

the MS table*■ Deleted RI.01.06.05, EP 1 from

the RI tableGlossary (GL) ❏ GL-3–GL-6 ❏ GL-3–GL-6 ■ Deleted anesthesia defi nition

■ Added biologicals defi nition* Index (IX)❏ Remove entire

chapter IX-1–IX-34

❏ Insert entire chapter IX-1–IX-34

■ Revised Index


Documents

CAMH 2010 UPD1 book - Joint Commission€“PC-64 PC-5–PC-6 PC-15–PC-20 PC-23–PC-26 ... Measure of Success Submission Time Line* Deleted decision rule PDA04 and renumbered the