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Wednesday 8:20 CST, April 1, 2015

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Topics Library

Core Systems List (for Accreditation and Certification)

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Core Systems List - Updated March 2015

Related Items: Performance Measurement , Performance Measurement Systems

04/01/2015
Standards FAQ

Waived Testing & Proficiency Testing

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Q. Is proficiency testing required for waived tests?

04/01/2015
Standards FAQ

Undersink Storage

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Q: Do the Joint Commission standards prohibit use of under sink cabinets for storage?  

04/01/2015
Standards FAQ

Standpipe Fire Hose Testing

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Q. Do fire hoses for standpipes or fire hose cabinets have to be tested with any particular frequency?  

04/01/2015
Standards FAQ

Smoke-free Campus

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Q. There is some concern about having a smoke free campus and putting that policy in writing.  What are your requirements regarding this?  

04/01/2015
Standards FAQ

Reagents Stored With Medications Or Specimens

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Q: Can laboratory reagents be stored in a refrigerator that also contains medications or laboratory specimens?  

04/01/2015
Standards FAQ

Rapid Group Strep A Strep Testing & Culture Follow-up

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Is it required to perform culture follow-up on all negative rapid Group A Strep screens?

04/01/2015
Topics Library

Sources for Accreditaton-Related Technical Assistance for BPHC-Supported Health Centers

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This list has been compiled solely for the purpose of assisting organizations in identifying and accessing possible technical assistance resources.

Related Items: Survey Preparation

04/01/2015
Standards FAQ

Providing Financial Incentives to Staff

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Q:  What are some examples of how an organization can ensure that when it provides financial incentives to its staff, it has a process to ensure that the integrity of clinical decision making is not compromised?  

04/01/2015
Standards FAQ

Placement of Alcohol Based Hand Rub (ABHR) Dispensers

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Q. What is the requirement regarding placement of alcohol based hand rub dispensers in hallways and in some waiting areas. Although the criteria on horizontal spacing are so specific (4 feet apart), the installation over or directly adjacent to ignition sources is not so clear. Can you provide some direction and explanation for approach to placement?  

04/01/2015
Standards FAQ

"Penny in a Cup"

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Q. My organization uses the “penny in a cup” method for monitoring refrigerator/freezer temperature.  Does this meet Joint Commission standards?  

04/01/2015
Standards FAQ

One-Time Extension Based on Unforeseen Conditions

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Q. When the Joint Commission grants an organization an extension for one or more PFI items, does the organization receive a new six-month window beyond the newly approved completion date?  

04/01/2015
Standards FAQ

Non-licensed, Non-employee Individuals

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What are The Joint Commission’s expectations regarding non-licensed, non-employee individuals in health care organizations, including health care industry representatives (HCIRs)?

Related Items: Non-Employees , Non-licensed , vendors , HCIR

04/01/2015
Standards FAQ

Mounting Sharps Boxes/Containers

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Q. Is there a requirement that sharps/needle boxes or containers be mounted on the wall in patient rooms? If so, what is the required height?  

04/01/2015
Standards FAQ

Minimum Patient Information - Medication

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Q. Does the minimum required patient information for medication management need to be documented in a single form?

04/01/2015
Standards FAQ

Management Plans in Business Occupancies

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Q. Are we expected to have as detailed a management plan for each area in the environment of care for our business occupancies as we do for our hospital?  

04/01/2015
Standards FAQ

Locking of Electrical Panels

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Q. Are electrical panels in patient areas required to be locked?  

04/01/2015
Standards FAQ

Laboratory Report Requirements In The Medical Record

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Q.  Our hospital information system captures data from our laboratory system and provides the results in several other hardcopy and electronic formats accessed by our physicians, such as the physician portal, flash reports, remote web access, etc.  Do all these different reports need to conform to the standards surveyed during the biennial laboratory survey?

04/01/2015
Standards FAQ

Labeling Oxygen and other Compressed Gas Cylinders

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Q. If a cylinder of oxygen is in use in a patient area or in transportation does that cylinder have to be marked as to the level of product in the cylinder? I have found in the NFPA 99 that all.

04/01/2015
Standards FAQ

Infection Control Applicability to Offsite Interpretive Reading Providers

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Q. How do the IC standards apply to interpretive reading providers? We have no contact with patients or specimens-what do we need to do?

04/01/2015
Standards FAQ

Food And Drinks In Patient Care Areas

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Q:  Are food and drinks for staff members allowed in patient care areas?

04/01/2015
Standards FAQ

Color-Blind Testing

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Q.  Is employee color-blind testing required?

04/01/2015
Content Page

Advanced Certification for Acute Stroke Ready Hospitals

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Added Fees Mar 31, 2015 Added Webinar on Mar 13, 2015

03/31/2015
Topics Library

Acute Stroke Ready Hospital Certification Fees

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Disease-Specific Care Certifications are on a two-year cycle. The Acute Stroke Ready Hospital Certification fee consists of two parts: an on-site fee, which is assessed following the on-site review, and an annual subscription fee, which is billed each January.

Related Items: Disease-Specific Care , Hospital

03/31/2015
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