One chapter that is frequently overlooked is that of the accreditation participation requirements (APR). However, it is important that the APRs do not become the “forgotten standards.” Organizations seeking accreditation for the first time must demonstrate compliance at the time of initial...
National Patient Safety Goals (NPSG) are developed by The Joint Commission (TJC) to create focus on specific patient safety issues impacting healthcare organizations nationally. Working in conjunction with the Patient Safety Advisory Group, TJC establishes evidence-based standards for improving...
Hospitals are on the frontline of emergencies, whether dealing with acts of terror or natural disasters such as fire, floods, and tornadoes. Recent events, including the COVID-19 pandemic, have brought a greater sense of urgency to emergency preparedness. Due to the unpredictability of...
Just as important as the care we provide to our patients is the environment in which it occurs, which is much more than just the space within the walls of the facility. The environment of care (EOC) includes special features that protect patients, visitors, and staff. It includes the equipment...
An organization’s human resources (HR) department is generally the first point of contact for prospective employees. Onboarding, staffing, orientation, licensure, certification, training, and competency are directly connected to an organization’s HR department. Effective healthcare organizations...
The Performance Improvement (PI) chapter might appear small; however, it is receiving more survey attention than in previous years. Organizations focused on continuous improvement recognize that they can only achieve better outcomes if they know where to focus their efforts, and data collection...
The infection control (IC) standards place heavy emphasis on integration, prioritization, collaboration, communication, and involvement of everyone involved with IC practices at your organization. COVID-19 placed a microscope on organizations’ IC practices, strategies, and gaps in compliance....
The role of leadership in the accreditation process has changed significantly over the last several years. Leaders can no longer delegate accreditation to an individual or a department. “Set it and forget it” no longer applies; leaders must be active participants in the process, setting the...
The Joint Commission introduced this chapter devoted to the Life Safety Code®(LSC) in 2009 to address the minimization of fire-related risks and hazards in all healthcare settings. Keep in mind that life safety risks vary depending on the type of healthcare occupancy...
The Information Management (IM) chapter includes only the standards that focus on the management of information—the medical record documentation standards reside in a separate chapter called Record of Care, Treatment, and Services.
You will notice that the IM standards have been...
