Catalog Number : ncd1583
Title : Joint Commission: New & Revised Accreditation Requirements for Hospitals
Speaker : Sue Dill

Webplay Recording Date : 2-18-2009
Webplay Price : $ 225 for two weeks viewing

Webinar Overview:

January 5, 2009 the Joint Commission issued a 46 page document that updated the new and revised Joint Commission accreditation requirements for hospitals. Hospitals that are accredited by the Joint Commission have deemed status by CMS. This means that they can be reimbursement for Medicare and Medicaid patients. Hospitals are required by federal regulation to still be in compliance with the CMS Hospital conditions of participations. These changes were made to ensure there is compliance with the CMS CoPs. Hospitals have until July 1, 2009 before they are scored. Many of these were very confusing for hospitals. This program will explain the important ones and cross walk it to the CMS standard. For example, the hospital must maintain copies of medical records for patients who have received blood or a blood component. The hospital must have a fully funded plan to make sure these medical records are maintained in the event of a closure.

Webinar Objectives:

• Recall that all hospitals accredited by TJC must still meet the CMS hospital conditions of participation when the hospital accepts Medicare or Medicaid reimbursement
• Discuss that the 46 pages of changes by TJC will be surveyed after July 1, 2009

Webinar Agenda/Outline:

• History of accreditation of TJC
• History and introduction into the CMS Hospital CoPs
• How to locate final copy of hospital CoPs issued October 17, 2008
• Critical access hospitals and regular hospital standards
• Deemed status
• Locating a copy of the new TJC standards
• Environment of Care sections changes
  • Radiation exposure, meters and badges test
  • Calibration of nuclear medicine equipment
  • Areas in hospital must be free of odors (perfumes etc.)
• Leadership section changes
  • Many changes in this chapter
  • Corrective action plan for infection control problems
  • Annual operating budget
  • Long term capital expenditure plan
  • ED integrated with other departments
  • Director for anesthesia, nuclear medicine and respiratory care
  • Services hospital must provide
  • Lab tests in nuclear medicine
  • PI projects
• Human Resource section changes
  • Dietary manager requirement
  • Sufficient number of medical record staff
  • Pharmacist in charge
  • Supervisor of the OR
  • OR staff
  • Training for all staff who give blood
  • Orientation to P&P in orientation and documentation
• Infection Control section changes
  • Infection control policies and procedures
  • System for investigating infections
  • Log of incidents and requirements for log
• Medication Management changes
  • Storage of medications
  • Security of medications
  • Abuses and losses of controlled substances
  • Prepare medications according to standards
• Medical Staff changes
  • MS bylaws
  • Documenting H&Ps
  • Voting members of Medical Staff
  • ED P&Ps
  • P&P on emergencies
  • On call physician
  • autopsy
• Nursing Chapter changes
  • CNO
  • RN to supervise nursing care
  • Adequate number of nursing staff
  • RN on duty at all times
• Provision of Care changes
  • Blood and IV medication
  • Look back program
  • Potentially infectious blood
  • Verbal orders
  • Medication orders
  • CRNA
  • Scope of practice
  • Equipment required in the OR
  • Preoperative assessment
  • Post anesthesia assessment
  • Tissue policies and procedures
  • Restraint and seclusion (many sections)
  • Reporting restraint deaths
• Record of care changes
  • All orders are dated
  • MR for every patient
  • Authentication of orders
  • H&P
  • OR Register
• Patient Rights changes
  • Access to medical records
  • Complaints and grievance (many)
  • Right to have family member notified of admission
  • Right to have family doctor notified of admission

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.