The evolution of The Joint Commission’s accreditation process continues. In January 2013, the accreditor introduced the Intracycle Monitoring Profile (ICMP) to help accredited organizations with their ongoing compliance efforts at “touch points” throughout the triennial cycle. ICMP (now called...

As noted in Chapter 1, the scoring methodology, categories A and C and direct and indirect impact elements of performance (EP) have been eliminated. Each requirement for improvement (RFI) will be placed on the SAFER Matrix, and all RFIs will have to be corrected within 60 days, which follows the...

The survey coordinator’s job is vital. Not knowing when surveyors will arrive at the organization presents challenges, both in ensuring that organizational priorities address issues related to accreditation and compliance and in keeping those issues at the forefront of everyone’s minds. Most...

As we described in Chapter 1, the survey team uses the tracer methodology to conduct on-site surveys. This chapter will focus on patient tracers—that is, following the road map of care, treatment, and services provided to patients during their stay in your hospital. Tracing each step of your...

Note: Additional information on Infection Control, Medication Management, Data Management, and Emergency Management tracers can be found in download below

If we think of a patient tracer as a map of the care patients receive during an individual visit (from admission...

Note: Many patient tracer tools can be found in download file below

This book has covered quite a bit of information. Remember that the tracer methodology is a very fluid process. As organizational priorities, standards, and systems change, so will your tracer tools—and...

Note: The checklist is in the 3rd page of the download file below

Some of the National Patient Safety Goals (NPSG) have moved into standards as elements of performance (EP). Recent changes are as follows:

  • Three goals in the area of infection control (
  • ...
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Survey Training Essentials has the information your staff needs to be ready for survey day. It’s packed with checklists and tools for department managers and games, presentations, and tracers to keep members engaged.

This electronic toolkit is thoroughly updated...

Note: The checklist is in the 3rd page of the download file below

This chapter continues to draw more requirements for improvement from surveyors than almost any other chapter, aside from Life Safety and Infection Control. The EC chapter addresses facilities...

Note: The checklist is in the 3rd page of the download file below

Staffing, orientation, licensure, certification, training, and competency continue to be hot topics with emphasis on verifying every applicant’s licensure, certification, registration, training,...

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