1 CAMH Update 1, June 2010 Table of Changes CAMH Update 1, June 2010 Standard, element of performance, and scoring changes in this update include the following: ■ Clarifications to IM.02.02.01, EPs 2 and 3 regarding standardized terminology, effective immediately ■ New note to UP.01.02.01, EP 3 regarding defining the limited circumstances to del- egate site marking in the “National Patient Safety Goals” (NPSG) chapter, effective immediately Additional changes include the following: ■ New information on the required Business Associate agreement in “e Accredita- tion Process” (ACC) chapter, effective immediately ■ New text on Preliminary Denial of Accreditation for organizations without proper license, certificate, or permit in the ACC chapter, effective immediately Refer to the following table (pages 2–12) and the actual updated pages for more infor- mation on these and other revisions. To update your manual, please remove and recycle the pages listed in the “Remove Pages” column from your CAMH, and insert the new pages listed in the “Insert Pages” column. Check boxes have been provided for your convenience to track the removal and addition of pages. Major revisions to the accreditation policies and standards-related information are high- lighted on your replacement pages. Minor editorial changes are not highlighted. CAMH Update 1 Comprehensive Accreditation Manual for Hospitals
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CAMH 2010 UPD1 book - Joint Commission€“PC-64 PC-5–PC-6 PC-15–PC-20 PC-23–PC-26 ... Measure of Success Submission Time Line* Deleted decision rule PDA04 and renumbered the
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1CAMH Update 1, June 2010
Table of ChangesCAMH Update 1, June 2010
Standard, element of performance, and scoring changes in this update include the following:■ Clarifi cations to IM.02.02.01, EPs 2 and 3 regarding standardized terminology,
eff ective immediately■ New note to UP.01.02.01, EP 3 regarding defi ning the limited circumstances to del-
egate site marking in the “National Patient Safety Goals” (NPSG) chapter, eff ective immediately
Additional changes include the following:■ New information on the required Business Associate agreement in “Th e Accredita-
tion Process” (ACC) chapter, eff ective immediately ■ New text on Preliminary Denial of Accreditation for organizations without proper
license, certifi cate, or permit in the ACC chapter, eff ective immediately
Refer to the following table (pages 2–12) and the actual updated pages for more infor-mation on these and other revisions.
To update your manual, please remove and recycle the pages listed in the “Remove Pages” column from your CAMH, and insert the new pages listed in the “Insert Pages” column. Check boxes have been provided for your convenience to track the removal and addition of pages.
Major revisions to the accreditation policies and standards-related information are high-lighted on your replacement pages. Minor editorial changes are not highlighted.
CAMHUpdate 1
Comprehensive Accreditation Manual for Hospitals
2 CAMH Update 1, June 2010
CAMHUpdate 1
Comprehensive Accreditation Manual for Hospitals
Remove Pages Insert Pages Type of Change
Title page and Copyright page❏ Previous title page
and copyright page (i–ii)
❏ Updated title page and copyright page (i–ii)
Updated month and year for 2010 Update 1 release
Environment of Care (EC)❏ EC-7–EC-18❏ EC-21–EC-22
❏ EC-7–EC-18❏ EC-21–EC-22
■ Deleted Measure of Success icon for EC.02.01.01, EPs 7 and 11
■ Deleted Measure of Success icon for EC.02.01.03, EP 6
■ Changed scoring category to an A and deleted Measure of Suc-cess icon for EC.02.02.01, EP 7*
■ Deleted Measure of Success icon for EC.02.02.01, EP 8
■ Deleted Measure of Success icon for EC.02.03.01, EP 1
■ Deleted Measure of Success icon for EC.02.03.05, EPs 3, 4, and 18
■ Changed scoring category to an A and deleted Measure of Suc-cess icon for EC.02.03.05, EPs 7, 9, 12, 16, 17, 19, and 20*
■ Deleted Measure of Success icon for EC.02.04.01, EP 3
■ Deleted Measure of Success icon for EC.02.04.03, EP 1
* Eff ective immediately.
3CAMH Update 1, June 2010
CAMHUpdate 1
Comprehensive Accreditation Manual for Hospitals
Remove Pages Insert Pages Type of Change
EC (continued)■ Deleted Measure of Success icon
for EC.02.05.01, EP 3■ Deleted Measure of Success icon
for EC.02.05.05, EP 1■ Deleted Measure of Success icon
for EC.02.05.07, EP 2■ Deleted EPs 4, 5, 6, and 18 for
EC.02.06.01■ Added tier 3 icon to
EC.02.06.01, EP 20*Emergency Management (EM)❏ EM-17–EM-18 ❏ EM-17–EM-18 ■ Changed scoring category to a C
for EM.02.02.13, EPs 7 and 8*Infection Prevention and Control (IC)❏ IC-7–IC-14 ❏ IC-7–IC-14 ■ Added standards reference link
to IC.01.05.01, EP 8*■ Changed standards reference
link to IC.02.01.01, EP 9*■ Changed text for IC.02.02.01,
EP 1*■ Changed text to Note for
IC.02.02.01, EP 2*■ Deleted standards reference link
to IC.03.01.01, EP 6
* Eff ective immediately.
4 CAMH Update 1, June 2010
CAMHUpdate 1
Comprehensive Accreditation Manual for Hospitals
Remove Pages Insert Pages Type of Change
Information Management (IM)❏ IM-7–IM-8 ❏ IM-7–IM-8b ■ Changed scoring category to a
C for IM.02.01.03, EP 6*■ Changed scoring category to an
A and deleted Measure of Suc-cess icon for IM.02.02.01, EP 1*
■ Changed text for IM.02.02.01, EP 2*
■ Changed text and added Note 2 to IM.02.02.01, EP 3*
■ Changed scoring category to an A and deleted Measure of Suc-cess icon for IM.02.02.03, EP 2*
■ Added EP 8 for LD.01.05.01, eff ective July 15, 2010
■ Deleted LD.02.04.01, EP 3■ Deleted LD.03.02.01, EP 2■ Deleted LD.03.03.01, EP 2■ Deleted LD.03.04.01, EP 2■ Deleted LD.03.05.01, EP 2■ Added standards reference link
to LD.03.05.01, EP 7*■ Deleted LD.03.06.01, EP 2■ Added missing scoring category
A to LD.04.03.01, EP 26*■ Added missing scoring category
A to LD.04.03.07, EPs 1 and 2*
* Eff ective immediately.
5CAMH Update 1, June 2010
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Comprehensive Accreditation Manual for Hospitals
Remove Pages Insert Pages Type of Change
LD (continued)■ Added explanation to creden-
tialing and privileging section of introduction for LD.04.03.09*
■ Added Note 1 and Note 3 to LD.04.03.09, EP 4, eff ective July 15, 2010
■ Added lead-in text and note to LD.04.03.09, EP 9, eff ective July 15, 2010
■ Changed text for LD.04.04.05, EPs 1, 5, 7, 9, 12, and 14*
■ Changed text and added bullet to LD.04.04.05, EP 13*
Th e Accreditation Process (ACC)❏ ACC-1–ACC-92❏ ACC-105–ACC-106
❏ ACC-1–ACC-92❏ ACC-105–ACC-106
■ Added new information on the required Business Associate agreement*
■ Updates to the payment policy*■ Updated information on gener-
ating a survey agenda*■ Added new text on Preliminary
Denial of Accreditation for organizations without proper license, certifi cate, or permit*
■ Added information about the Medicare certifi cation recom-mendation letter for hospitals that use Joint Commission accreditation for deemed status purposes*
■ Updated the process fl owchart for Immediate Th reat to Health or Safety situations*
■ Updated the fi gure about the Measure of Success Submission Time Line*
■ Deleted decision rule PDA04 and renumbered the remaining rules*
■ Made editorial changes and updates*
* Eff ective immediately.
11CAMH Update 1, June 2010
CAMHUpdate 1
Comprehensive Accreditation Manual for Hospitals
Remove Pages Insert Pages Type of Change
Sentinel Events (SE)❏ SE-1–SE-6❏ SE-15–SE-18
❏ SE-1–SE-6❏ SE-15–SE-18
■ Clarifi ed information about how surveyors handle sentinel events during the survey process*
■ Clarifi ed information about Th e Joint Commission’s response if a hospital has not undertaken serious improvement eff orts regarding sentinel events*