An Education Day With The Joint Commission
An Education Day withThe Joint CommissionDecember 16-17, 2019
Welcome to TheJointCommission!2 2019 The Joint Commission. All Rights Reserved.
Ambulatory CareAccreditation Process3 2019 The Joint Commission. All Rights Reserved.
Alisha MorrisonBusiness Development Manager, Ambulatory Care ServicesKelley McCannAssociate Director, Accreditation and Certification OperationsJoint CommissionAmbulatory CareAccreditation Process
Objectives1. Introduction to The JointCommission2. Explain the accreditation optionsfor your organization3. Lay out a roadmap of how to getstarted with The Joint Commission4. Provide a high-level overview ofthe pre- and post-survey process5 2019 The Joint Commission. All Rights Reserved.
The Joint CommissionFour Entities – One Visionall people always experience theSAFESTHIGHEST QUALITYBEST-VALUEhealth care across all settings.6 2019 The Joint Commission. All Rights Reserved.
Ambulatory Health Care AccreditationWhat’s Unique About Our ProgramRobust state recognition of accreditationfor licensure, spanning 34 states29 states that require licensure for ambulatorysurgery centers, rely on our accreditationprogram22 states require accreditation as a criterion forproviders operating office based surgery centersFederal recognition of accreditation, CMSDeeming recognition for ambulatorysurgery centersJoint Commission ambulatory accreditation isrecognized by CMS as a means to achieveMedicare certification.Payer recognition of accreditation Anthem recognition for federally-qualifiedhealth centers, birthing centers, convenientcare centers, urgent care centers, ambulatorysurgery centers, and dialysis centers.7 2019 The Joint Commission. All Rights Reserved.
Ambulatory Health Care AccreditationAbout Ambulatory Care SurveyorsCadre of 50 surveyors: MD’s, RN’s, NP’s, and administratorswith previous ambulatory experienceClinical experience: urgent care, surgery center administration,nursing, VA, podiatrist, surgeons, anesthesiologists,community clinics, internal medicine, dentists, radiologists“Employee” Surveyors – ambulatory care professionals,full/part-time, many employed in ambulatory settingsSurvey 30-120 organizations annuallySource for Leading Practices & Education8 2019 The Joint Commission. All Rights Reserved.
Ambulatory Health Care AccreditationWho Can Apply? Must be in the US or its territories. If not, operatedby US government or under a charter Has a license or registration to conduct serviceswithin its scope Can demonstrate continuous improvement of itstreatment, care or services Identifies the services it provides directly, undercontract or through some other arrangement Provides services that can be evaluated under JointCommission standards Must have served at least 10 total patients with twoactive at the time of survey Procedures performed are ordered by a licensedindependent practitioner9 2019 The Joint Commission. All Rights Reserved.
ASC Deemed Status10 2019 The Joint Commission. All Rights Reserved.
ASC Accreditation Accrediting ASCs since 1976 ASC Deeming Authority since 1996 CMS determined that The JointCommission’s standards andsurvey process meet or exceedthose established by CMS. ASCs accredited by The JointCommission are eligible to berecognized by CMS for participationin the Medicare and Medicaidprograms. Over 1,000 Accredited ASCs*Effective December 20, 2014 through December 20, 2020,CMS Renews Joint Commission Deeming Authority forAmbulatory Surgery Centers1111 2019 The Joint Commission. All Rights Reserved.
Deemed Status Facts Built into survey process, survey evaluates both Joint Commissionambulatory care standards and additional Medicare Conditions for Coverage(CfCs) Available CMS crosswalk in ambulatory care manual Deemed ASCs will not need to undergo full CMS surveys Provides a moreeducational surveyexperience Includes a Life SafetyCode surveyor More time added forclinical support12 2019 The Joint Commission. All Rights Reserved.
ASCs Seeking Deemed StatusKnow Additional CMS RequirementsPrepare List of surgical cases from 6 months prior to survey All hospital transfers from past 12 months Documents related to your infection control program Infection Control Worksheet (to be completed bysurveyor on-site) Observation of at least two surgical procedures,one in its entirety, during the surveyYour survey will be unannounced–survey dates will not beprovided to your facility (mandated by CMS).CMS, not The Joint Commission, grants the final decision forMedicare certification.13 2019 The Joint Commission. All Rights Reserved.
Deemed ASC Setting FAQQ: When do Ambulatory Surgery Centers(ASCs) with deemed status have to apply withanother CMS-approved accrediting organizationin order to avoid the loss of deemed status?A: February 8, 2020, which is 60 calendar daysfrom the date IMQ announced its intention tovoluntarily terminate its CMS-approvedaccreditation program. In addition to completing anapplication, deemed ASCs must also providewritten notice to its state agency that it hassubmitted an application to another CMS-approvedaccrediting organization.14 2019 The Joint Commission. All Rights Reserved.
Deemed ASC Setting FAQQ: When do ASCs with deemed status have toobtain accreditation from another CMS-approvedaccrediting organization to avoid the loss ofdeemed status?A: October 26, 2020, which is 180 calendar daysfrom the effective date of IMQ’s planned voluntarytermination as a CMS-approved accreditingorganization. However, this extension is onlyavailable to deemed ASCs that apply with anotherCMS-approved accrediting organization by February8, 2020.15 2019 The Joint Commission. All Rights Reserved.
California OutpatientSurgical Settings16 2019 The Joint Commission. All Rights Reserved.
California Outpatient Surgical SettingsSubject to the Medical Board of California (MBC)accreditation mandateFalls under The Joint Commission’s Office-Based Surgery (OBS) ProgramOBS Eligibility Includes:3 patients served, with at least 1 patient having a procedure at the time of surveyLimited to business occupancy: Defined as an occupancy that can only havethree or fewer individuals at the same time, who are either rendered incapable ofself-preservation in an emergency or are undergoing general anesthesiaMust be surgeon-owned or surgeon-operatedProvides invasive procedures to patients. Local anesthesia, minimal sedation,conscious sedation, or general anesthesia are administered17 2019 The Joint Commission. All Rights Reserved.
Key Differences: OBS vs. ASCOBS Cannot be used for MedicareDeemed Status Business Occupancy Serve 3 patients with 1 activeat the time of survey 1 Day Survey ASCMedicare Deemed Statusoption availableBusiness or AmbulatoryHealth Care OccupancyServe 10 patients with 2active at the time of surveyMinimum of 2 Survey Days*Day 1Day 2Day 1ClinicianClinicianClinician*Note: LSC added for ASCs withAmbulatory Health Care Occupancy*based on annual case volume, in many cases,this may include an additional clinician day1818LSC 2019 The Joint Commission. All Rights Reserved.
California Outpatient Surgical SettingsFAQQ: When do California Outpatient SurgicalSettings subject to the Medical Board of California(MBC) accreditation mandate have to achieveaccreditation with another MBC-approvedaccrediting organization?A: IMQ will not be conducting initial or renewalsurveys during 2020. IMQ is meeting with theMedical Board of California (MBC) to determine howthis cessation in survey activity will impact IMQaccredited organizations subject to the MBCaccreditation mandate.19 2019 The Joint Commission. All Rights Reserved.
Pre-ApplicationProcess20 2019 The Joint Commission. All Rights Reserved.
Pre-Application ProcessReach out to Joint Commission’s Ambulatory CareBusiness Development Manager – Alisha eceive your complementary online access toonline standards manual (e-dition)Determine survey timeline with BusinessDevelopment ManagerComplete application for accreditation withBusiness Development manager21 2019 The Joint Commission. All Rights Reserved.
Preparing for SurveyMonths leading up to vey readydate)ReviewStandardsIdentifyconsistency ofcurrentprocesses toJointCommissionrequirementsPerform mocksurveyActual JointCommissionSurvey22 2019 The Joint Commission. All Rights Reserved.
Preparing for SurveyRequired Written Documentation23 2019 The Joint Commission. All Rights Reserved.
Preparing for SurveyReady to Go BinderPerformance/Quality Improvement DataInfection Control Surveillance DataInfection Control PlanEnvironment of care data, management plans, meetingminutes and annual evaluationsOrganizational chartSchedule of surgeries/procedures for each survey day24 2019 The Joint Commission. All Rights Reserved.
Preparing for SurveyMost Common FindingsAmBuzz – Top 10 Cited Standards with Compliance Tips:http://bit.ly/2jX0LxM25 2019 The Joint Commission. All Rights Reserved.
Preparing for SurveySurvey Activity Guide Blueprint for the survey Contains: Readiness guide Agenda Ready to go document list Activity list26 2019 The Joint Commission. All Rights Reserved.
Preparing for SurveySurvey NotificationFor initial, announced surveys 30 days prior to onsite visit via an automated emailFor unannounced surveys (Deemed ASCs) Assign staff to check your extranet site (JointCommission Connect) Notification available at 7:30 am morning of yoursurveyFor all surveys The organization has up to 15 black out days to use as“avoid dates” for survey27 2019 The Joint Commission. All Rights Reserved.
What to Expect DuringYour Survey28 2019 The Joint Commission. All Rights Reserved.
Surveyor ArrivalPrepare a plan of action for staff to follow:1. Confirming ID of the surveyor(s) and validation of survey2. Who to notify upon their arrival3. Location for the surveyors’ work area4. Name badges5. Parking6. “Ready to Go” Binder29 2019 The Joint Commission. All Rights Reserved.
Onsite SurveySurvey Team – Deemed ASCsMinimum 1Ambulatory CareSurveyor for two days 1 Life Safety CodeSurveyor for 1 day*based on annual case volume, in many cases, thismay include an additional clinician day for volumes 30030 2019 The Joint Commission. All Rights Reserved.
Onsite SurveySurvey Team – Medical PracticeMinimum 1Ambulatory CareSurveyor for two days*based on annual patient visits31 2019 The Joint Commission. All Rights Reserved.
Onsite Survey OverviewPatient Tracer Methodology Observation of direct patient careReview of clinical recordsStaff questions & dialogueReview of policiesObservation related to: Infection control Environment of care Patient Safety Goals System Tracers Infection prevention Medication management32 2019 The Joint Commission. All Rights Reserved.
On-Site ProcessHints During the Survey It’s okay not to know the answer Avoid the lip syncing act, let everyone be involved Use this time to ask questions Surveyors are reviewing systems, not individuals Use the surveyor as a resource33 2019 The Joint Commission. All Rights Reserved.
On-Site ProcessHints During the Survey The surveyors will notice things you don’t see If they ask for materials, please find them ASAP If changes are needed in the agenda, please ask Time will go by very quickly There are no surprises at closing34 2019 The Joint Commission. All Rights Reserved.
Post Survey Process35 2019 The Joint Commission. All Rights Reserved.
Post Survey ProcessWhat happens after your survey?Evidence ofStandardsCompliance(ESC) due 60calendar daysfollowingreceipt of finalsurvey reportposted on JCConnect siteSurvey Reportswill be postedwithin 10business daysUpon postingof final report,Clarificationdue within 10business daysCELEBRATEFinal accreditationdecision will be madeafter Joint Commissionreceives and approvesthe ESC.Use publicity kit toannounce youraccreditation36 2018 The Joint Commission. All Rights Reserved.
Post Survey ProcessSurvey Analysis for Evaluating Risk (SAFER ) A transformative approach foridentifying and communicating risklevels associated with deficienciescited during surveys Helps organizations prioritize andfocus corrective actions Provides one, comprehensive visualrepresentation of survey findings37 2018 The Joint Commission. All Rights Reserved.
Scope38 2018 The Joint Commission. All Rights Reserved.
Likelihood to Harm39 2018 The Joint Commission. All Rights Reserved.
Post Survey ProcessEvidence Of Standards Compliance (ESC)The Evidence of StandardsCompliance (ESC), alsoreferred to as correctiveaction, is a concise report ofactions taken by anorganization to correct areasidentified as Requirementsfor Improvement during asurvey.ASSIGNING ACCOUNTABILITY Who is ultimately responsible Leadership Involvement (if SAFER)CORRECTING THE NON-COMPLIANCE Preventive Analysis (if SAFER) What actions taken and whenENSURING SUSTAINED COMPLANCE What procedures or activities have beenidentified to monitor compliance? What is the frequency of the monitoringactivities? What data will be collected from theseactivities? To whom, and how often, will this databe reported40 2018 The Joint Commission. All Rights Reserved.
Evidence Of Standards CompliancePrioritized Follow-up ActionsSAFER Matrix MODERATE / PATTERN,MODERATE/WIDESPREADMODERATE / LIMITED,LOW / PATTERN,LOW / WIDESPREADRequired Follow-Up Activity 60 day Evidence of Standards Compliance (ESC) ESC will also include two additional areas surroundingLeadership Involvement and Preventive Analysis 60 day Evidence of Standards Compliance (ESC)LOW/LIMITED41 2018 The Joint Commission. All Rights Reserved.
Additional FieldsLeadership Involvement Success of change is dependent on its sustainability withinorganizations Success and sustainability are highly influenced by supportfrom the top level of leadershipPreventive Analysis Ensures the corrective action does not simply fix the issue athand Focuses on identifying and addressing underlying reasonsthat caused the issue Efforts also focused on preventing future occurrences of thehigh risk issue42 2018 The Joint Commission. All Rights Reserved.
AccreditationInvestment43 2019 The Joint Commission. All Rights Reserved.
Ambulatory Care Accreditation – PricingSpecial Pricing Considerations for IMQ-accreditedorganizations onlyWaiver of the application deposit fee of 1,70010% discount on applicable annual fees for theinitial 3-year accreditation periodExtended time period (90 days from time ofinvoice) to make final accreditation fee payments44 2019 The Joint Commission. All Rights Reserved.
Ambulatory Care Accreditation – PricingFee estimates Across three years Annual fee* Based on annual case volumeo Billed each January 1o Initial applications: prorated based on timingof application On-site survey feeo Based on number of surveyors/days*Discounted at 10% for IMQ Customers for first cycle (first three years)45 2019 The Joint Commission. All Rights Reserved.
Investment vestmentYear 2annual*fee20%Year 1(includesannual fee*and onsitefee)60%20%Year 3annual*fee46 2019 The Joint Commission. All Rights Reserved.*Discounted at 10% for IMQ Customers for first cycle (first three years)
Resources forReadiness47 2019 The Joint Commission. All Rights Reserved.
Getting to GoldResources: Standards Support On-Line FAQs StandardsInterpretationGroup/Engineers Submit on-lineform48 2019 The Joint Commission. All Rights Reserved.
Getting to GoldSurvey Activity Guide– Provides “blueprint” for survey– Available on Joint CommissionConnect once application issubmitted– Can be provided prior tosubmitting application– Includes “Ready-To-Go” listtemplate to assist pre-surveypreparation49 2019 The Joint Commission. All Rights Reserved.
Getting to GoldHeads Up Report– Heads-Up Reports (HUR) are anew survey readiness resourcedocument.– Each HUR identifies topics/themesthat surveyors have noticed andcited while conducting recentsurveys.– The HUR provides examples ofways organizations can trace anduncover similar issues in their ownorganizations, and what factorsmay have contributed to theproblem.50 2019 The Joint Commission. All Rights Reserved.
Getting to Gold Developed by the Joint Commission Center forTransforming Health Care Innovative, online application Separate from Accreditation Complimentary to Joint Commission AccreditedorganizationsGuidesorganizations in accuratelymeasuring their actualperformanceIdentifiesbarriers to excellenceperformanceDirectsorganizations to provensolutions customized toaddress particular barriers51 2019 The Joint Commission. All Rights Reserved.
Getting to GoldIndustry News/Resources AmBuzz: Bi-Monthly Blog Ambulatory CareLinkedIn Showcase Page Ambulatory Care TwitterFeed Enterprise ContentLibrary Index - containslinks to current JointCommission content,organized into typicaltopic areas in asearchable PDF52 2019 The Joint Commission. All Rights Reserved.
Getting to GoldAmbulatory Care HAI PortalSee: http://bit.ly/2CaK9ue53 2019 The Joint Commission. All Rights Reserved.
Getting to GoldPhysical Environment PortalSee: www.jointcommission.org/JCPEP54 2019 The Joint Commission. All Rights Reserved.
Getting to GoldEmergency Management Portal55https://www.jointcommission.org/emergency management.aspx 2019 The Joint Commission. All Rights Reserved.
Standards &Survey Process:Key Things toKnow56 2019 The Joint Commission. All Rights Reserved.
Maureen Vance, MSN, RNProject Director Clinical, Division of Healthcare Quality EvaluationStandards Alignmentand Comparison
Objectives1. Describe alignment with requirements fordeemed Ambulatory Surgical Centers (ASCs)2. Discuss comparison and alignment of IMQ andJoint Commission requirements for allAmbulatory Health Care (AHC) organizations3. Identify areas addressed in Joint Commissionaccreditation standards that are not included inIMQ requirements58 2019 The Joint Commission. All Rights Reserved.
Requirements for Deemed ASCs Joint Commission and IMQ Standards align withall CMS’ Conditions for Coverage includingrequirements in the following areas: Distinct entity Compliance with State licensure Governing body Quality assessment and performanceimprovement (QAPI) program Design of operating room Emergency preparedness plan59 2019 The Joint Commission. All Rights Reserved.
Requirements for Deemed ASCs Standards align with all CMS’ Conditions forCoverage including: (continued) Separate recovery room and waiting area Personnel are trained in the use of emergencyequipment and CPR Registered nurse is available for emergencytreatment whenever a patient is in the ASC Medications are under the direction of anindividual designated responsible forpharmaceutical services60 2019 The Joint Commission. All Rights Reserved.
Requirements for Deemed ASCs Requirements align with all CMS’ Conditions forCoverage including: (continued) Use of CMS Infection Control worksheet: Infection control program is under thedirection of a designated and qualifiedindividual Infection control program seeks to minimizeinfections and communicable diseases Nationally recognized infection controlguidelines are selected and implemented61 2019 The Joint Commission. All Rights Reserved.
Comparison of Requirements for AHC orgs62 2019 The Joint Commission. All Rights Reserved.
Comparison of Requirements for AHC orgs63 2019 The Joint Commission. All Rights Reserved.
Comparison of Requirements for AHC orgs64 2019 The Joint Commission. All Rights Reserved.
Comparison of Requirements for AHC orgs65 2019 The Joint Commission. All Rights Reserved.
Comparison of Requirements for AHC orgs66 2019 The Joint Commission. All Rights Reserved.
Areas addressed by Joint Commission notfound in IMQ requirements67 2019 The Joint Commission. All Rights Reserved.
Areas addressed by Joint Commission notfound in IMQ requirements68 2019 The Joint Commission. All Rights Reserved.
Areas addressed by Joint Commission notfound in IMQ requirements69 2019 The Joint Commission. All Rights Reserved.
Areas addressed by Joint Commission notfound in IMQ requirements70 2019 The Joint Commission. All Rights Reserved.
Joyce Webb MBA, BSN, RNProject Director, Division of Healthcare Quality EvaluationSurvey Process Overview
Objectives:1. Provide a high-level overview of onsite surveyprocesses2. Review areas where IMQ and JointCommission survey processes are similar3. Provide an overview of areas specific to JointCommission’s survey process4. Review sample ambulatory care survey agendas72 2019 The Joint Commission. All Rights Reserved.
Prior to the onsite survey:Pre-survey processes are similar to IMQ’s Application is submitted and reviewed An Account Executive is assigned to reviewthe application Pre-survey analysis is conducted Scope of the survey is determined73 2019 The Joint Commission. All Rights Reserved.
Prior to the onsite survey: Facility is contacted to discuss surveyreadiness dates Survey agenda is developed On-site survey is scheduled Electronic notification of survey event A template agenda with a list of onsitesurvey activities is posted to theorganization’s Joint CommissionConnect extranet site74 2019 The Joint Commission. All Rights Reserved.
Prior to the onsite survey: Organization preps for the onsite surveyand plans for surveyor arrival Identify who will participate in a surveyoverview meeting with the survey teamand who will accompany the survey teamthroughout the onsite survey75 2019 The Joint Commission. All Rights Reserved.
Prior to the onsite survey:- Review applicable standards and thesurvey activity guide- Evaluate what documents needed forsurveyor review during a surveyorpreliminary planning session76 2019 The Joint Commission. All Rights Reserved.
Survey Document List (excerpt)77 2019 The Joint Commission. All Rights Reserved.
Deemed ASC Surveys: Similar to IMQ’s CMS deemed surveys are unannounced Deemed ASC surveys include a review ofcompliance with Life Safety Coderequirements Deemed ASC surveys are be surveyed byclinician(s) and Life Safety Code surveyors78 2019 The Joint Commission. All Rights Reserved.
During the onsite survey: Similar to IMQ’s Survey starts at 8 am with an opening conference Survey agenda is reviewed Discuss topics to be covered during the surveyand sites/clinics to be visited Review of requested documents – (org chart,surgical schedule, 6-month list of surgeries, sitesthat sterilize instruments) Opportunity to answer questions from theorganization and review the organization’sexpectations for the survey79 2019 The Joint Commission. All Rights Reserved.
Orientation session:An interactive discussion focused on: how the organization is governed and operated the organization’s performance improvementprocessesSurveyor planning session Review clinic locations and surgery schedule Need at least 2 active patients Plan survey sites to visit For deemed ASCs -will observe at least onesurgical procedure, CMS IC Worksheet80 2019 The Joint Commission. All Rights Reserved.
Individual Tracer Activity: Where the most survey activity occurs Direct observation and review of the care,treatment, or services provided to selected patients Starts where the patient is, waiting room, examroom/dental operatory Moves to any areas in which the patient receivedcare, treatment, or services. Includes interviews with patients, staff andpractitioners and medical record review Examines processes related to IC and med mgmt81 2019 The Joint Commission. All Rights Reserved.
Competence and Credentials Review Competence assessment process practitioners Orientation, education, and training processes Review sample of credentials filesEnvironment of Care, EmergencyMgmt and Life Safety Facility tour, review of equipment and utilitymaintenance logs, safety drills Assessment of fire safety complianceLeadership session- interactive sessionfocused on oversight82 2019 The Joint Commission. All Rights Reserved.
Survey report Summarizes areas of noncomplianceExit Conference Survey findings are presented to orgrepresentativesAccreditation decision Survey report is submitted to corporate office,which notifies org of the final accreditationdecisionProcesses are similar83 2019 The Joint Commission. All Rights Reserved.
Sample Survey Agenda-Medical/Dental Clinic:84 2019 The Joint Commission. All Rights Reserved.
Sample Survey Agenda-ASC:85 2019 The Joint Commission. All Rights Reserved.
Sample Survey Agenda-OBS:86 2019 The Joint Commission. All Rights Reserved.
Onsite survey Educational and informative event: Sharing of observations Good practices & opportunities Leaders/managers/staff encouraged toparticipate, look, listen, and askquestions87 2019 The Joint Commission. All Rights Reserved.
ComplianceStrategies88 2019 The Joint Commission. All Rights Reserved.
Elizabeth Even, MSN, RN, CENAssociate Director, SIGJohn Raisch, CHFMEngineer, SIG EngineeringCompliance Strategiesfor Joint CommissionSurveys
Standards Interpretation Group (SIG) Assist and educate both internal and externalcustomers in the interpretation and application ofthe standards with the goal of consistentlyimproving the quality of healthcare and patientsafety. Dedicated subject matter experts related to topicsrelated to Joint Commission requirements90 2019 The Joint Commission. All Rights Reserved.
Ask a Question Standards Online Form91 2019 The Joint Commission. All Rights Reserved.
datacausessolutionsUsing data to drive solutions for success
Introduction to the SAFER MatrixAmbulatory Accreditation Program results Nationwide 11/1/18-10/31/19Immediate Threat to LifeLikelihood to Harm 22.8%LIMITEDPATTERNWIDESPREADScope93 2019 The Joint Commission. All Rights Reserved.
What’s new?94 2019 The Joint Commission. All Rights Reserved.
Medication Management RequirementsMM.01.01.03: high-alert andhazardous medications.MM.01.02.01: lookalike/sound-alike medications.Requirements: List development Actions to take to prevent errors*look-a-like/sound-a-like medications require annual review95 2019 The Joint Commission. All Rights Reserved.
MM.01.01.03 & MM.01.02.01 Patterns ofCausation Lack of individualized list, outdated list Sample medications are not included Lack of staff education and understanding onprocess to avoid medication errors Inconsistent implementation of policy i.e. High-alert stickers not used in anesthesiacarts96 2019 The Joint Commission. All Rights Reserved.
MM.01.01.03 & MM.01.02.01Compliance Tactics Ensure that all medications areconsidered for inclusion on the list Update periodically and withany changes to formulary, sites,etc. Ensure staff education on processto avoid errors Routine process checksimplemented by leadership97 2019 The Joint Commission. All Rights Reserved.
MM.03.0.01 Medication StorageTrends Proper temperature storage of medication along withmonitoring Storage of medications outside of package insertrecommendations Security of medications98 2019 The Joint Commission. All Rights Reserved.
MM.03.01.01 Patterns of Causation Lack of training on how to useprogrammable thermometers Lack of staff understanding for documentation ofprogrammable thermometers Incorrect interpretation of requirement formedication security Staff placing dates on items when they areopened (unacceptable) versus expired(acceptable)99 2019 The Joint Commission. All Rights Reserved.
MM.03.01.01 Compliance Tactics Placement of new temperaturedevicesshould be done by dedicated staffmembers New locations should have GAPanalysis to determine complianceissues for storage and security Validation of State and Federalrequirements regarding medicationsecurity Routine process checksimplemented by leadership100 2019 The Joint Commission. All Rights Reserved.
Dormitory Refrigerators The Joint Commissiondoes not prohibit the use ofdormitory style refrigerators Requirement based ongovernment fundedvaccine programs101 2019 The Joint Commission. All Rights Reserved.
102 2019 The Joint Commission. All Rights Reserved.
Most Frequently Cited Infection Control (IC)Standards103 2019 The Joint Commission. All Rights Reserved.
IC.02.02.01 EP2The organizationimplements infectionprevention and controlactivities when doing thefollowing: Performingintermediate and high-leveldisinfection and sterilizationof medical equipment,devices, and supplies.104 2019 The Joint Commission. All Rights Reserved.
IC.02.02.01 EP2 ObservationsDisinfectant wipes were used toclean vaginal probes which werecharacterized as a cleanser, butnot a disinfectant.105 2019 The Joint Commission. All Rights Reserved.
IC.02.02.01 Patterns of Causation Lack of qualified infection controlleadership Knowledge gap surrounding IFU Lack of staff training andcompetencies Lack of leadership oversight Off-site clinics Procedures and instrument reprocessing Inconsistent policy implementation106 2019 The Joint Commission. All Rights Reserved.
IC.02.02.01 Compliance Tactics Ensure adequate qualified infectioncontrol (IC) leadership Periodic review of IC program Ensure necessary resources to supportIC program are available Appropriate staff training andcompetencies Routine process checks implementedby leadership107 2019 The Joint Commission. All Rights Reserved.
IC.02.01.01 EP2 Th
Robust state recognition of accreditation for licensure, spanning 34 states 29 states that require licensure for ambulatory surgery centers, rely on our accreditation program 22 states require accreditation as a criterion for providers operating office based surgery centers Payer recognition of accreditation
May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)
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On an exceptional basis, Member States may request UNESCO to provide thé candidates with access to thé platform so they can complète thé form by themselves. Thèse requests must be addressed to esd rize unesco. or by 15 A ril 2021 UNESCO will provide thé nomineewith accessto thé platform via their émail address.
̶The leading indicator of employee engagement is based on the quality of the relationship between employee and supervisor Empower your managers! ̶Help them understand the impact on the organization ̶Share important changes, plan options, tasks, and deadlines ̶Provide key messages and talking points ̶Prepare them to answer employee questions
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Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. Crawford M., Marsh D. The driving force : food in human evolution and the future.
