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Tracers with AMP. Tracers with AMP® is a cost-effective software tool that allows you to analyze your organization's performance, prioritize improvements, assess organizational risk, increase collaboration and build automated reports for leadership and frontline staff. JOINT COMMISSION RESOURCES PORTAL ECM+. ECM® Plus contains over 90,000 lines of data and over 500,000 links mapping from Joint Commission Standards and EPs to the related Federal CoPs, SOM, State Regulations, and related national organizations. Mock Survey Tool. Mock surveys are a critical tool when it comes to the continuous improvement of patient safety and helpingyou
ONLINE EDUCATION
Online Education. Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization. Participants can access educational programs featuring the most sought-after Joint Commission content, or view the recording available 24/7. Education. Conferencesand Seminars.
ONLINE COURSES
Each Course: Features up-to-date content that supports The Joint Commission’s accreditation and certification requirements. Includes a variety of “progress check” assessments designed to test the learner’s understanding of the topic. Is delivered in an easy-to-use, interactive format. Contains a post-test that evaluatesthe learner’s
MEDICATION MANAGEMENT AND SAFETY Medication systems are extremely complex with multiple risk points. New medication therapies, new technologies, and new regulatory requirements add to the complexity. It’s critically important to design processes that, in addition to meeting Joint Commission and other regulatory requirements, provide optimal patient safety. BUILDING CONSTRUCTION & DESIGN ADVISORY SERVICES Phase Two. When the building has achieved approximately 95% completion, our experts will complete an on-site assessment to field verify compliance to the architectural drawings and Joint Commission standards. During this on-site assessment, our experts will: Compare the built environment to the drawings. Evaluate the built environmentto Joint
2020 - 2021 - JCRINC.COM 2020 - 2021 Joint Commission Publications Suvey adiness uide for Surgical Settings 201fi 13 ff478315ffi3ff471fi 78 ff 2179806596 560860825608 096 201fi 3ff47835JCR PORTAL
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RISK ASSESSMENT SECOND EDITION Senior Editor: Kathleen DeMase Project Manager: Lisa King Associate Director, Publications: Helen M. Fry, MA Associate Director, Production and Meeting Support:Johanna Harris Executive Director, Publications and Education: Catherine Chopp Hinckley, MA, PhD Joint Commission/JCR Reviewers for YOUR TOTAL QUALITY AND SAFETY RESOURCE Evolving with Care. We understand even throughout this time of uncertainty your quality goals and desire to learn and improve haven’t wavered. We’ve transitioned many of our products and services to be delivered virtually, so you can continue to learn and be supported, with greater peace of mind. Explore all our virtualservices.
LOGIN.JCRINC.COM
Tracers with AMP. Tracers with AMP® is a cost-effective software tool that allows you to analyze your organization's performance, prioritize improvements, assess organizational risk, increase collaboration and build automated reports for leadership and frontline staff. JOINT COMMISSION RESOURCES PORTAL ECM+. ECM® Plus contains over 90,000 lines of data and over 500,000 links mapping from Joint Commission Standards and EPs to the related Federal CoPs, SOM, State Regulations, and related national organizations. Mock Survey Tool. Mock surveys are a critical tool when it comes to the continuous improvement of patient safety and helpingyou
ONLINE EDUCATION
Online Education. Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization. Participants can access educational programs featuring the most sought-after Joint Commission content, or view the recording available 24/7. Education. Conferencesand Seminars.
ONLINE COURSES
Each Course: Features up-to-date content that supports The Joint Commission’s accreditation and certification requirements. Includes a variety of “progress check” assessments designed to test the learner’s understanding of the topic. Is delivered in an easy-to-use, interactive format. Contains a post-test that evaluatesthe learner’s
MEDICATION MANAGEMENT AND SAFETY Medication systems are extremely complex with multiple risk points. New medication therapies, new technologies, and new regulatory requirements add to the complexity. It’s critically important to design processes that, in addition to meeting Joint Commission and other regulatory requirements, provide optimal patient safety. BUILDING CONSTRUCTION & DESIGN ADVISORY SERVICES Phase Two. When the building has achieved approximately 95% completion, our experts will complete an on-site assessment to field verify compliance to the architectural drawings and Joint Commission standards. During this on-site assessment, our experts will: Compare the built environment to the drawings. Evaluate the built environmentto Joint
2020 - 2021 - JCRINC.COM 2020 - 2021 Joint Commission Publications Suvey adiness uide for Surgical Settings 201fi 13 ff478315ffi3ff471fi 78 ff 2179806596 560860825608 096 201fi 3ff47835JCR PORTAL
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RISK ASSESSMENT SECOND EDITION Senior Editor: Kathleen DeMase Project Manager: Lisa King Associate Director, Publications: Helen M. Fry, MA Associate Director, Production and Meeting Support:Johanna Harris Executive Director, Publications and Education: Catherine Chopp Hinckley, MA, PhD Joint Commission/JCR Reviewers for YOUR TOTAL QUALITY AND SAFETY RESOURCE Evolving with Care. We understand even throughout this time of uncertainty your quality goals and desire to learn and improve haven’t wavered. We’ve transitioned many of our products and services to be delivered virtually, so you can continue to learn and be supported, with greater peace of mind. Explore all our virtualservices.
MEDICATION MANAGEMENT AND SAFETY Medication systems are extremely complex with multiple risk points. New medication therapies, new technologies, and new regulatory requirements add to the complexity. It’s critically important to design processes that, in addition to meeting Joint Commission and other regulatory requirements, provide optimal patient safety.2020 - 2021
2020 - 2021 Joint Commission Publications Suvey adiness uide for Surgical Settings 201fi 13 ff478315ffi3ff471fi 78 ff 2179806596 560860825608 096 201fi 3ff47835 CMS/MEDICARE AND REGULATORY SERVICES Every expert on the JCR CMS team is a former surveyor for CMS or for State Survey Agencies on behalf of CMS. We’ve worked with Medicare/Medicaid participating organizations of all types and in all states all across the entire country including: *The use of Joint Commission Resources (JCR) advisory services is not necessary toobtain a Joint
CONTINUOUS SERVICE READINESS Joint Commission Resources’ (JCR) Continuous Service Readiness® ( CSR®) program is a subscription-based consulting and education service that provides you with a dedicated consultant. Your JCR consultant will work with your organization on topics such as: Disease-Specific Care Certification. Joint Commission standardscompliance.
TOMMIE MURRAY
Prior to joining the Joint Commission Resources (JCR) as a Continuous Service Readiness® Consultant, Ms. Murray was the Vice President of Quality for a health system in an academic network. This position included Regulatory Readiness, Performance Improvement, Patient Safety, Infection Prevention, Risk Management and Medical StaffServices.
RANDALL SHARSHAN
With a long career in health care — first in facilities, then as a physical environment surveyor — Mr. Randall Sharshan has the expertise to guide health care organizations through accreditation, regulatory compliance, life safety, safety and security operations,and
ROOT CAUSE ANALYSIS IN HEALTH CARE vii Patient safety events can cause serious harm or death. They affect anyone. To address and prevent these threats, health care organizations must dig deep to unearth the root ACCREDITATION MANAGEMENT SKILLS: DEVELOPING AN EFFECTIVE (continued on page 8) I f Joint Commission surveyors found your organization to be noncompliant with a standard, you will receive a Requirement for Improvement (RFI) that details the issue. PLANNING, DESIGN, AND CONSTRUCTION OF HEALTH CARE Table of Contents iii Table of ConTenTs Foreword. . v by Debra Levin, M.A., president and CEO, The Center for Health Design and Anjali Joseph, Ph.D., director of research, The Center for Health DesignONLINE EDUCATION
Online Education. Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization. Participants can access educational programs featuring the most sought-after Joint Commission content, or view the recording available 24/7. Education. Conferencesand Seminars.
JOINT COMMISSION RESOURCES PORTAL ECM+. ECM® Plus contains over 90,000 lines of data and over 500,000 links mapping from Joint Commission Standards and EPs to the related Federal CoPs, SOM, State Regulations, and related national organizations. Mock Survey Tool. Mock surveys are a critical tool when it comes to the continuous improvement of patient safety and helpingyou
BUILDING CONSTRUCTION & DESIGN ADVISORY SERVICES Phase Two. When the building has achieved approximately 95% completion, our experts will complete an on-site assessment to field verify compliance to the architectural drawings and Joint Commission standards. During this on-site assessment, our experts will: Compare the built environment to the drawings. Evaluate the built environmentto Joint
2020 - 2021 - JCRINC.COM 2020 - 2021 Joint Commission Publications Suvey adiness uide for Surgical Settings 201fi 13 ff478315ffi3ff471fi 78 ff 2179806596 560860825608 096 201fi 3ff47835 COVID-19 LESSONS LEARNED: A RESOURCE FOR RECOVERY DELOITTE i. Leadership Issue During the COVID-19 response, health care organizations mounting the most effective response to surges in demand for complex care have demonstrated strong safety cultures featuring high-performing, collaborative, and resilient teams. JCR PORTAL - AMP.JCRINC.COM Tutorial Video × . Your browser does not support HTML5 video. PlayDismiss Dismiss
TOMMIE MURRAY
Prior to joining the Joint Commission Resources (JCR) as a Continuous Service Readiness® Consultant, Ms. Murray was the Vice President of Quality for a health system in an academic network. This position included Regulatory Readiness, Performance Improvement, Patient Safety, Infection Prevention, Risk Management and Medical StaffServices.
CJCP HANDBOOK
Page 3 CJCP® certification is awarded to those professionals who meet eligibility standards and pass a rigorous examination. CJCP® certification is valid for a three (3)-year period from the date of a RISK ASSESSMENT SECOND EDITION Senior Editor: Kathleen DeMase Project Manager: Lisa King Associate Director, Publications: Helen M. Fry, MA Associate Director, Production and Meeting Support:Johanna Harris Executive Director, Publications and Education: Catherine Chopp Hinckley, MA, PhD Joint Commission/JCR Reviewers for ROOT CAUSE ANALYSIS IN HEALTH CARE vii Patient safety events can cause serious harm or death. They affect anyone. To address and prevent these threats, health care organizations must dig deep to unearth the rootONLINE EDUCATION
Online Education. Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization. Participants can access educational programs featuring the most sought-after Joint Commission content, or view the recording available 24/7. Education. Conferencesand Seminars.
JOINT COMMISSION RESOURCES PORTAL ECM+. ECM® Plus contains over 90,000 lines of data and over 500,000 links mapping from Joint Commission Standards and EPs to the related Federal CoPs, SOM, State Regulations, and related national organizations. Mock Survey Tool. Mock surveys are a critical tool when it comes to the continuous improvement of patient safety and helpingyou
BUILDING CONSTRUCTION & DESIGN ADVISORY SERVICES Phase Two. When the building has achieved approximately 95% completion, our experts will complete an on-site assessment to field verify compliance to the architectural drawings and Joint Commission standards. During this on-site assessment, our experts will: Compare the built environment to the drawings. Evaluate the built environmentto Joint
2020 - 2021 - JCRINC.COM 2020 - 2021 Joint Commission Publications Suvey adiness uide for Surgical Settings 201fi 13 ff478315ffi3ff471fi 78 ff 2179806596 560860825608 096 201fi 3ff47835 COVID-19 LESSONS LEARNED: A RESOURCE FOR RECOVERY DELOITTE i. Leadership Issue During the COVID-19 response, health care organizations mounting the most effective response to surges in demand for complex care have demonstrated strong safety cultures featuring high-performing, collaborative, and resilient teams. JCR PORTAL - AMP.JCRINC.COM Tutorial Video × . Your browser does not support HTML5 video. PlayDismiss Dismiss
TOMMIE MURRAY
Prior to joining the Joint Commission Resources (JCR) as a Continuous Service Readiness® Consultant, Ms. Murray was the Vice President of Quality for a health system in an academic network. This position included Regulatory Readiness, Performance Improvement, Patient Safety, Infection Prevention, Risk Management and Medical StaffServices.
CJCP HANDBOOK
Page 3 CJCP® certification is awarded to those professionals who meet eligibility standards and pass a rigorous examination. CJCP® certification is valid for a three (3)-year period from the date of a RISK ASSESSMENT SECOND EDITION Senior Editor: Kathleen DeMase Project Manager: Lisa King Associate Director, Publications: Helen M. Fry, MA Associate Director, Production and Meeting Support:Johanna Harris Executive Director, Publications and Education: Catherine Chopp Hinckley, MA, PhD Joint Commission/JCR Reviewers for ROOT CAUSE ANALYSIS IN HEALTH CARE vii Patient safety events can cause serious harm or death. They affect anyone. To address and prevent these threats, health care organizations must dig deep to unearth the rootONLINE COURSES
Each Course: Features up-to-date content that supports The Joint Commission’s accreditation and certification requirements. Includes a variety of “progress check” assessments designed to test the learner’s understanding of the topic. Is delivered in an easy-to-use, interactive format. Contains a post-test that evaluatesthe learner’s
CONFERENCES AND SEMINARS Conferences and Seminars. Our live, virtual and on-demand conferences and seminars are held throughout the year to provide you with the latest opportunities for education and networking with expert faculty and peers. Conferences and Seminars. Interested in Being a ConferenceExhibitor?
ENVIRONMENT OF CARE
The JCR Advantage. Our practice is made up of Environment of Care experts with over 320 combined years of hands-on health care experience in a variety of settings across the continuum of care. Our team has worked or currently works as mechanical and electrical engineers, safety officers, architects, facility directors, nurses,and infection
CONTINUOUS SERVICE READINESS Joint Commission Resources’ (JCR) Continuous Service Readiness® ( CSR®) program is a subscription-based consulting and education service that provides you with a dedicated consultant. Your JCR consultant will work with your organization on topics such as: Disease-Specific Care Certification. Joint Commission standardscompliance.
MEDICATION MANAGEMENT AND SAFETY Medication systems are extremely complex with multiple risk points. New medication therapies, new technologies, and new regulatory requirements add to the complexity. It’s critically important to design processes that, in addition to meeting Joint Commission and other regulatory requirements, provide optimal patient safety. HAND HYGIENE PRACTICES The Joint Commission Big Book of Checklists for Infection Prevention and Control 41 Published in The Joint Commission Big Book of Checklists for Infection Prevention RISK ASSESSMENT SECOND EDITION Senior Editor: Kathleen DeMase Project Manager: Lisa King Associate Director, Publications: Helen M. Fry, MA Associate Director, Production and Meeting Support:Johanna Harris Executive Director, Publications and Education: Catherine Chopp Hinckley, MA, PhD Joint Commission/JCR Reviewers forRANDALL SHARSHAN
With a long career in health care — first in facilities, then as a physical environment surveyor — Mr. Randall Sharshan has the expertise to guide health care organizations through accreditation, regulatory compliance, life safety, safety and security operations,and
ROOT CAUSE ANALYSIS IN HEALTH CARE vii Patient safety events can cause serious harm or death. They affect anyone. To address and prevent these threats, health care organizations must dig deep to unearth the root OSHAOSHA & WORKER SAFETY GUIDELINES FOR ZERO TOLERANCE Page 8 Copyright 2015 The Joint Commission Environment of Care News, August 2015, Volume 18, Issue 8 A ccording to the Bureau of Labor Statistics, in 2013, 27 of the YOUR TOTAL QUALITY AND SAFETY RESOURCE Emergency Management Services. We are here to help you evaluate your response and recovery efforts related to Joint Commission Emergency Management standards and CMS CoPs, but more importantly to help your organization support its patients and staff during another emergency. Background Image: Image: A businesswoman speaks with a male colleagueONLINE EDUCATION
Online Education. Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization. Participants can access educational programs featuring the most sought-after Joint Commission content, or view the recording available 24/7. Education. Conferencesand Seminars.
ONLINE COURSES
Each Course: Features up-to-date content that supports The Joint Commission’s accreditation and certification requirements. Includes a variety of “progress check” assessments designed to test the learner’s understanding of the topic. Is delivered in an easy-to-use, interactive format. Contains a post-test that evaluatesthe learner’s
CONFERENCES AND SEMINARS Conferences and Seminars. Our live, virtual and on-demand conferences and seminars are held throughout the year to provide you with the latest opportunities for education and networking with expert faculty and peers. Conferences and Seminars. Interested in Being a ConferenceExhibitor?
JOINT COMMISSION RESOURCES PORTAL ECM+. ECM® Plus contains over 90,000 lines of data and over 500,000 links mapping from Joint Commission Standards and EPs to the related Federal CoPs, SOM, State Regulations, and related national organizations. Mock Survey Tool. Mock surveys are a critical tool when it comes to the continuous improvement of patient safety and helpingyou
JCR PORTAL - AMP.JCRINC.COM Tutorial Video × . Your browser does not support HTML5 video. PlayDismiss Dismiss
TOMMIE MURRAY
Prior to joining the Joint Commission Resources (JCR) as a Continuous Service Readiness® Consultant, Ms. Murray was the Vice President of Quality for a health system in an academic network. This position included Regulatory Readiness, Performance Improvement, Patient Safety, Infection Prevention, Risk Management and Medical StaffServices.
RANDALL SHARSHAN
With a long career in health care — first in facilities, then as a physical environment surveyor — Mr. Randall Sharshan has the expertise to guide health care organizations through accreditation, regulatory compliance, life safety, safety and security operations,and
ROOT CAUSE ANALYSIS IN HEALTH CARE vii Patient safety events can cause serious harm or death. They affect anyone. To address and prevent these threats, health care organizations must dig deep to unearth the root OSHAOSHA & WORKER SAFETY GUIDELINES FOR ZERO TOLERANCE Page 8 Copyright 2015 The Joint Commission Environment of Care News, August 2015, Volume 18, Issue 8 A ccording to the Bureau of Labor Statistics, in 2013, 27 of the YOUR TOTAL QUALITY AND SAFETY RESOURCE Emergency Management Services. We are here to help you evaluate your response and recovery efforts related to Joint Commission Emergency Management standards and CMS CoPs, but more importantly to help your organization support its patients and staff during another emergency. Background Image: Image: A businesswoman speaks with a male colleagueONLINE EDUCATION
Online Education. Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization. Participants can access educational programs featuring the most sought-after Joint Commission content, or view the recording available 24/7. Education. Conferencesand Seminars.
ONLINE COURSES
Each Course: Features up-to-date content that supports The Joint Commission’s accreditation and certification requirements. Includes a variety of “progress check” assessments designed to test the learner’s understanding of the topic. Is delivered in an easy-to-use, interactive format. Contains a post-test that evaluatesthe learner’s
CONFERENCES AND SEMINARS Conferences and Seminars. Our live, virtual and on-demand conferences and seminars are held throughout the year to provide you with the latest opportunities for education and networking with expert faculty and peers. Conferences and Seminars. Interested in Being a ConferenceExhibitor?
JOINT COMMISSION RESOURCES PORTAL ECM+. ECM® Plus contains over 90,000 lines of data and over 500,000 links mapping from Joint Commission Standards and EPs to the related Federal CoPs, SOM, State Regulations, and related national organizations. Mock Survey Tool. Mock surveys are a critical tool when it comes to the continuous improvement of patient safety and helpingyou
JCR PORTAL - AMP.JCRINC.COM Tutorial Video × . Your browser does not support HTML5 video. PlayDismiss Dismiss
TOMMIE MURRAY
Prior to joining the Joint Commission Resources (JCR) as a Continuous Service Readiness® Consultant, Ms. Murray was the Vice President of Quality for a health system in an academic network. This position included Regulatory Readiness, Performance Improvement, Patient Safety, Infection Prevention, Risk Management and Medical StaffServices.
RANDALL SHARSHAN
With a long career in health care — first in facilities, then as a physical environment surveyor — Mr. Randall Sharshan has the expertise to guide health care organizations through accreditation, regulatory compliance, life safety, safety and security operations,and
ROOT CAUSE ANALYSIS IN HEALTH CARE vii Patient safety events can cause serious harm or death. They affect anyone. To address and prevent these threats, health care organizations must dig deep to unearth the root OSHAOSHA & WORKER SAFETY GUIDELINES FOR ZERO TOLERANCE Page 8 Copyright 2015 The Joint Commission Environment of Care News, August 2015, Volume 18, Issue 8 A ccording to the Bureau of Labor Statistics, in 2013, 27 of theONLINE COURSES
Each Course: Features up-to-date content that supports The Joint Commission’s accreditation and certification requirements. Includes a variety of “progress check” assessments designed to test the learner’s understanding of the topic. Is delivered in an easy-to-use, interactive format. Contains a post-test that evaluatesthe learner’s
BUILDING CONSTRUCTION & DESIGN ADVISORY SERVICES Phase Two. When the building has achieved approximately 95% completion, our experts will complete an on-site assessment to field verify compliance to the architectural drawings and Joint Commission standards. During this on-site assessment, our experts will: Compare the built environment to the drawings. Evaluate the built environmentto Joint
ENVIRONMENT OF CARE
The JCR Advantage. Our practice is made up of Environment of Care experts with over 320 combined years of hands-on health care experience in a variety of settings across the continuum of care. Our team has worked or currently works as mechanical and electrical engineers, safety officers, architects, facility directors, nurses,and infection
COMPLIANCE SUSTAINABILITY PROGRAM The Environment of Care ® (EC) and Life Safety (LS) chapters contain more regulations than any other chapter in the Joint Commission accreditation manual. Also, the increasing complexity of and conflict among federal, state, and local regulations make it more CONTINUOUS SERVICE READINESS Joint Commission Resources’ (JCR) Continuous Service Readiness® ( CSR®) program is a subscription-based consulting and education service that provides you with a dedicated consultant. Your JCR consultant will work with your organization on topics such as: Disease-Specific Care Certification. Joint Commission standardscompliance.
COVID-19 LESSONS LEARNED: A RESOURCE FOR RECOVERY DELOITTE i. Leadership Issue During the COVID-19 response, health care organizations mounting the most effective response to surges in demand for complex care have demonstrated strong safety cultures featuring high-performing, collaborative, and resilient teams. PRODUCTS AND SERVICES FOR BEHAVIORAL HEALTH CARE Publications. JCR publishes an extensive collection of accreditation and certification manuals, periodicals, and books/e-books, including Documentation of Care, Treatment, or Services in Behavioral Health Care: Your Go-To Guide, to help your behavioral health care staff prepare for everyday challenges. *The use of Joint CommissionResources
CJCP HANDBOOK
Page 3 CJCP® certification is awarded to those professionals who meet eligibility standards and pass a rigorous examination. CJCP® certification is valid for a three (3)-year period from the date of a ROOT CAUSE ANALYSIS IN HEALTH CARE vii Patient safety events can cause serious harm or death. They affect anyone. To address and prevent these threats, health care organizations must dig deep to unearth the root OSHAOSHA & WORKER SAFETY GUIDELINES FOR ZERO TOLERANCE Page 8 Copyright 2015 The Joint Commission Environment of Care News, August 2015, Volume 18, Issue 8 A ccording to the Bureau of Labor Statistics, in 2013, 27 of the Skip to Main Content Coronavirus Resources*
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