2009 Standards FAQs

Standards Frequently Asked Questions
Comprehensive Accreditation Manual for Office-Based Surgery Practices(CAMOBS)


Status Definitions

Emergency Management

Emergency ExercisesUpdatedNov 24, 2008
Emergency ManagementUpdatedNov 24, 2008
Tabletop DrillsRevisedNov 24, 2008

Environment of Care

Defibrillators - Life Support or Non-life Support EquipmentNewJun 15, 2009
Installation of Call ButtonsRevisedAug 07, 2009
Labeling Oxygen and other Compressed Gas CylindersNewNov 24, 2008
Locking of Electrical PanelsNewNov 24, 2008
Mounting Sharps Boxes/ContainersRevisedMar 09, 2009
Placement of Alcohol Based Hand Rub (ABHR) DispensersNewNov 24, 2008
Security of Syringes and NeedlesUpdatedNov 24, 2008
Smoke-free CampusNewNov 24, 2008
Staff Only RefrigeratorsUpdatedNov 24, 2008
Standpipe Fire Hose TestingUpdatedNov 24, 2008
Undersink StorageUpdatedJun 29, 2009
Utility System and Acquired IllnessUpdatedNov 24, 2008

Human Resources

Health Care Industry/Vendor RepresentativesNewApr 15, 2009
Human Resource Standards Applicability to Contracted and Volunteer PersonnelUpdatedNov 24, 2008
Peer ReferencesUpdatedNov 24, 2008
Permission to Administer Moderate SedationUpdatedFeb 11, 2009
Primary Source VerificationUpdatedNov 24, 2008
Requirements for Criminal Background ChecksUpdatedNov 24, 2008
Time Periods for Completing the Credentialing ProcessUpdatedNov 24, 2008

Infection Prevention and Control

Food And Drinks In Patient Care AreasRevisedNov 24, 2008
Licensed Independent Practitioner Health ScreeningUpdatedNov 24, 2008
“Penny in a Cup"NewNov 24, 2008

Information Management

Acceptable Abbreviation ListRevisedNov 24, 2008
Authentication of DocumentationUpdatedNov 24, 2008
Authentication Using A Single DocumentUpdatedNov 24, 2008
Credentialing And Privileging For Providers From Joint Commission Accredited OrganizationUpdatedNov 24, 2008
Medical Record Security After HoursUpdatedNov 24, 2008
Minimum Patient Information - MedicationUpdatedNov 24, 2008
One Licensed Independent Practitioner (LIP) Signing for AnotherUpdatedNov 24, 2008
Operative ReportsUpdatedNov 24, 2008
Summary Lists- Divergent ComponentsUpdatedNov 24, 2008

Life Safety

One-Time Extension Based on Unforeseen ConditionsUpdatedNov 24, 2008
Exit MapsUpdatedNov 24, 2008

Medication Management

Define Concentrated KCLRevisedNov 24, 2008
Medication Refrigeration Temperature LogsUpdatedNov 24, 2008
Security of Anesthesia Cart MedicationsUpdatedNov 24, 2008

National Patient Safety Goals


NPSG 1 - Patient Identification


NPSG.01.01.01

Two_Patient_IdentifiersNewDec 09, 2008

NPSG.01.03.01

Transfusion Administration SafetyNewDec 09, 2008

NPSG 2 - Communication Among Caregivers


NPSG.02.01.01

Read Back OrdersNewDec 09, 2008

NPSG.02.02.01

Do Not Use AbbreviationsNewDec 09, 2008

NPSG.02.03.01

Critical Tests, Results and ValuesNewDec 09, 2008

NPSG.02.05.01

Hand-off CommunicationsNewDec 09, 2008

NPSG 3 - Medication Safety


NPSG.03.03.01

Look-Alike/Sound-Alike DrugsNewDec 09, 2008

NPSG.03.04.01

Labeling in Procedural AreasNewDec 09, 2008

NPSG 7 - Health Care-Associated Infections


NPSG.07.01.01

Hand HygieneUpdatedJun 04, 2009

NPSG.07.02.01

Infection-Related Sentinel EventsNewDec 09, 2008

NPSG.07.05.01

Surgical Site Infection (SSI)NewDec 09, 2008

NPSG 8 - Medication Reconciliation


NPSG.08.01.01

Reconciliation Upon ArrivalNewDec 09, 2008

NPSG.08.02.01

Reconciliation Upon TransferNewDec 09, 2008

NPSG.08.03.01

Reconciliation Upon DepartureNewDec 09, 2008

NPSG 11 - Surgical Fires


NPSG.11.01.01

Surgical FiresNewDec 09, 2008

NPSG 13 - Patient Involvement


NPSG.13.01.01

Patient InvolvementNewDec 09, 2008

Universal Protocol


General

ApplicabilityNewNov 24, 2008
Potential Barriers and Risks for Unintended ConsequencesNewNov 24, 2008
Requirement or AdviceNewNov 24, 2008
Statement and Persistence of the ProblemNewNov 24, 2008

Pre-procedure Verification

ChecklistNewNov 24, 2008
Procedures Outside the ORNewNov 24, 2008
Verification in Pre-procedure AreaNewNov 24, 2008

Procedure Site marking

Dental proceduresRevisedNov 24, 2008
Exceptions to Site MarkingUpdatedFeb 12, 2009
Obvious wound or lesionRevisedNov 24, 2008
Refusal of site markingRevisedNov 24, 2008
ResidentsUpdatedFeb 17, 2009
Spinal surgery casesRevisedNov 24, 2008
Who should mark the siteNewNov 24, 2008
Bilateral ProceduresNewMar 11, 2009

Procedure Time out

Documentation of Time-OutNewMar 11, 2009
Time-out Prior to AnesthesiaNewNov 23, 2008
Time-out without the SurgeonNewNov 24, 2008
Two Time-outsNewNov 24, 2008

Provision of Care, Treatment, and Services

Adverse Tissue Reaction PoliciesUpdatedNov 24, 2008
Breathalyzers, Continuous Glucose Monitoring Systems, Pulse Oximeters & Transcutaneous BilirubinometersRevisedNov 24, 2008
Content of the History and PhysicalRevisedNov 24, 2008
LPNs Performing AssessmentRevisedNov 24, 2008
Pre-Induction Assessment For Sedation And AnesthesiaUpdatedNov 24, 2008
Preprocedure VerificationNewJan 13, 2009
Sedation and AnesthesiaUpdatedNov 24, 2008
Tissue Source Facilities - Verification of Licensing & RegistrationUpdatedNov 24, 2008
Traceability of RecordsUpdatedNov 24, 2008

Record of Care, Treatment, and Services

One LIP Signing for AnotherUpdatedNov 24, 2008

Waived Testing

Color-Blind TestingUpdatedNov 24, 2008
Patient/Client Self Glucose TestingUpdatedNov 24, 2008
Professional Vs. Home Use Tests (Glucose Meters, Etc.)UpdatedNov 24, 2008
Provider Performed Microscopy Procedures (P.P.M.P.)UpdatedNov 24, 2008
Reagents Stored With Medications Or SpecimensUpdatedNov 24, 2008
Screening Vs. DefinitiveUpdatedNov 24, 2008
Waived Testing & Proficiency TestingUpdatedNov 24, 2008