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Friday 8:45 CST, April 28, 2017

Daily Update




























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04/28/2017
Content Page

Occupational Health Accreditation

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Learn more about out latest customer - Federal Occupational Health (FOH)

Related Items: Ambulatory Health Care

04/28/2017
Content Page

Resources for Achieving Behavioral Health Accreditation

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Resources for Achieving Behavioral Health Accreditation - Come Visit Us! List of conferences we will be attending in the next few months has been posted.

04/28/2017
Content Page

National Patient Safety Goals®

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2017 National Patient Safety Goals Now Available!

Related Items: National Patient Safety Goals , NPSG Infection

04/28/2017
Blog

Safety Culture: Shattering the Myths of Perfection and Punishment

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Mistakes happen! Read this blog by Gerry Castro and learn when the system is to blame.

Related Items: Leadership , Blog , Safety Culture

04/27/2017
Standards FAQ

Verification - Education

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HR.01.02.05 EP 3 requires that "The organization verifies and documents that the applicant has the education and experience required by the job responsibilities." Does this mean that verification via primary source is required?

04/26/2017
Standards FAQ

Contract Staff - Applicability of Human Resource Standards (HAP, CAH, AMB, OBS, NCC)

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What are the expectations for complying with the Human Resource (HR) requirements when patient care services are provided via a contractual agreement?

04/26/2017
Standards FAQ

Verification - Primary Source Verification - Definition

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What is Primary Source Verification and to whom does it apply ?  

04/26/2017
Standards FAQ

Operative and High Risk Procedure Reports - Documenting Blood Loss and Specimens

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The requirement found at RC.02.01.03 EP 6 lists the required elements that are to be included in the operative or other high-risk procedure report. The word ‘any’ precedes both estimated blood loss (EBL) and specimen(s) removed. Does this mean that even if there was no blood loss or specimen(s) associated with a procedure that the practitioner must indicate ‘no EBL’ or ‘no specimens’ in the report?

04/26/2017
Topics Library

Hospital Outpatient Department

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Joint Commission accredited hospitals are required to collect and submit data to The Joint Commission for a minimum of six core measure sets.

Related Items: Performance Measurement , Core Measure Set , Transitions of Care and Performance Measurement

04/26/2017
Standards FAQ

Credentialing and Privileging - Consultants

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Does The Joint Commission require licensed independent practitioners (LIP) that provide consultative services to be credentialed or privileged?

04/26/2017
Topics Library

2016 Health Centers Most Challenging Standards

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Joint Commission Ambulatory Care Standards Generating Findings in 20%+ CHCs Surveyed.

Related Items: BPHC Challenging Standards

04/26/2017
Standards FAQ

History and Physical - Non-Credentialed Practitioners

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Can the organization utilize a history and physical that has been performed by someone who is not privileged by the organization? 

04/26/2017
Standards FAQ

Behavioral Health Care - Patient Self-harm Risk Management

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What is the requirement for patient self-harm ligature risk management in Behavioral Health Care?

Related Items: ec.02.06.01

04/26/2017
Standards FAQ

History and Physical - Medical Student

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Is it acceptable for a medical student to perform and document a history and physical in the medical record?

04/26/2017
Standards FAQ

Antimicrobial Stewardship – Multidisciplinary Protocol Requirements - Standard

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Do organizations need to have multidisciplinary protocols for each example in MM.09.01.01, EP 6?

04/26/2017
Standards FAQ

Antimicrobial Stewardship – Improvement Opportunities - Standard MM.09.01.01 EP 8

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Are there any specific improvement opportunities that surveyors will look for regarding the organization’s antimicrobial stewardship program?

04/26/2017
Standards FAQ

Antimicrobial Stewardship – Data Collection, Analysis, and Reporting - Standard MM.09.01.01 EP 7

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What type of antimicrobial stewardship data should organizations collect, analyze, and report?

04/26/2017
Standards FAQ

Antimicrobial Stewardship – Multidisciplinary Team Requirements - Standard MM.09.01.01, EP 4

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If an organization does not have an infectious disease physician on the antimicrobial stewardship multidisciplinary team will it receive a Requirement for Improvement (RFI)?

04/26/2017
Standards FAQ

Antimicrobial Stewardship – Education Requirements for Patients - Standard MM.09.01.01 EP 3

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Do all patients (and families when needed) who are prescribed antimicrobials require education?

04/26/2017
Standards FAQ

Antimicrobial Stewardship - Examples - Standard MM.09.01.01 EPs 1, 3, 5, 6, and 7

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When examples are provided within an EP, are these example considered to be part of the requirement?

04/26/2017
Standards FAQ

Antimicrobial Stewardship – Education Requirements for Residents and Patients - Standard MM.09.01.01 EP 3

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Do all residents and patients (and families when needed) who are prescribed antimicrobials require education?

04/26/2017
Standards FAQ

Antimicrobial Stewardship – Education Requirements for Staff and Licensed Independent Practitioners - Standard MM.09.01.01 EP 2

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Will Joint Commission surveyors review human resource records and medical staff credentialing and privileging records to determine if antimicrobial resistance and antimicrobial stewardship education was provided by the organization?

04/26/2017
Standards FAQ

Antimicrobial Stewardship – Organizational Priority - Standard MM.09.01.01 EP 1

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How will surveyors evaluate that an organization’s leaders have established antimicrobial stewardship as an organizational priority?

04/26/2017
Standards FAQ

Antimicrobial Stewardship – Core Element Documentation - Standard MM.09.01.01 - EP 5

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What type of documentation is needed for MM.09.01.01 EP 5, the required core elements of the antimicrobial stewardship program?

04/26/2017
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