SL1 - TJC Compliance Library
(Policies, Procedures, Forms & Other Documents)

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Notice: We are currently in the process of updating this library. Please fogive any quirks during this transition, but feel free to share any suggestions/constructive criticism as it unforlds.  Thank you.  R. Fields, MD.

1000 Special

1010 (ASP) Accreditation & Survey Process

1010.00 - Highlights & 2009 Pre-Publication Preview  {Info}

1010.10 - Accreditation Process {Info}

  • Periodic Performance Review (PPR) {Info}

1010.20 - Pre - Survey (Prep) {Info}

1010.30 - During Survey  {Info}

1010.40 - Post Survey  {Info} 

1010.50 - The Standards

1030 (SE) Sentinel Events 

1030.00 - Highlights  {Info} 

1030.10 - General/References

•  Sentinel Event Statistics [Info]

1030.20 - Recent Alerts  [TJC Index of Issues]

Issue 43 - Aug 27, 2009 (revised 9/8/09): Leadership Committed to Safety  [SE Alert #43]  [JCR Resources]

Issue 42 - Dec 11, 2008: Safely Implementing Health Information and Converging Technologies  [SE Alert #42]  [JCR Resources]  [7/9/08 Teleconf 18-pg PDF]

Issue 41 - Sep 24, 2008: Preventing Errors Relating to Commonly Used Anticoagulants  [SE Alert # 41]  [7.5-Min Podcast

Issue 40 - July 9, 2008: Behaviors that undermine a culture of safety  [SE Alert #40]  [JCR Resources]  [8-Min Podcast]

1040 (NPSG) National Patient Safety Goals

1040.00 - Highlights  {Info}
1040.10 - General/References
1040.20 - Goals & Compliance Tips
  • TJC References/Compliance Tips  {Info}

  • NPSG02 (A-E) - {2010Info}

  • NPSG03 (B-E) - {2010Info}

  • NPSG07 - Hand Hygiene - {2010Info}

  • NPSG08 - Medication Reconciliation {2010Info}

  • NPSG09 - Falls Prevention and Management  {2010Info}

  • NPSG13 - Patient Involvement (and communication)  {2010Info}

  • NPSG15 - Suicide Risk Assessment/Prevention/Treatment  - {Info}

  • NPSG16 - Recognition and response to changes in a patient’s condition  {2010Info}

1050 (APR) Accreditation Participation Requirements

1050.00 - Highlights  {Info} 

1050.08 - APR 8

  • Hospital Complaints: Quality Incident Review Criteria  [Info]

 

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1100 Patient-Focused Functions

1110 (RI) Ethics, Rights, and Responsibilities

1110.00 - Highlights  {Info}

1110.01  RI - Org Ethics

1110.02  RI - Pt Rights

• Patient Recording/Filming/Photo (RI.2.50) Sample Policy (DOC)  (DB contrib from TS)

• Psychiatric Advance Directives 

-- Bazelon Center:  [Info]  includes sample forms

-- Duke University Program on Psychiatric Advance Directives [Infoincludes toolkit

-- National Resource Center on Psychiatric Advance Directives (NRC-PAD)  [Info]

1120 (PC) Provision of Care, Treatment, and Services

 1120.00 - Highlights  {Info}

1120.01  PC - Entry/Admission

1120.02  PC - Assessment/Diagnostics

1120.03  PC - Abuse

1120.04  PC - Planning Care

1120.05  PC - Providing Care & Treatment
  • Dual Diagnosis - {Info}

  • Recovery Oriented Care (includes TIC and IMR)  - {Info}

  • Smoking Cessation  {Info}
1120.06  PC - Pt/Family Education
1120.07  PC - Nutrition
1120.08  PC - Pain, End of Life
  • Pain
  • End of Life 

    • The EPEC Project (Education in Palliative and end-of-Life Ccare)

    • EPERC (End of Life/Palliative Education Resource Center)
1120.09  PC - Resusitation Services
1120.11  PC - Restraint & Seclusion - Gen
  • Sample Forms & Checklist  - {Info}
  • Restraint and Seclusion Reduction   - {Info}
1120.12  PC - Restraint & Seclusion - BHC

  • Restraint and Seclusion: TJC  - {Info}

  • Restraint and Seclusion: CMS   - {Info}

  • Restraint and Debriefings  - {Info}
1120.13  pc - High Risk/Special Procedures
  • BMP: General - {Info}

  • BMP: Child/Adolescent -  {Info}

1120.20  pc - Illness, Disease & Disorders

1120.30  pc - Patient Populations 

  • Forensic & Sex Offender Populations  -  {Info}

1120.40  pc - Treatments & Therapies

1130 (MM) Medication Management

1130.00  MM - Highlights  {Info}

1130.01  MM - Pt-Specific Info

1130.02  MM - Selection & Procurement

1130.03  MM - Ordering & Prescribing

Principles of Antipsychotic Prescribing for Policy Makers, Circa 2008. Translating Knowledge to Promote Individualized Treatment (PDF) - NASMHPD Medical Directors Statement

• MHPD's Medical Directors’ Statement on Comparative Effectiveness of Antipsychotic Medications and Individualized Treatment (pdf)  Includes 4 broad recommendations for best practice use and some excellent references with full text available.

1130.04  MM - Preparing & Dispensing

1130.05  MM - Administration

1130.06  MM - Monitoring

1130.07  MM - High Risk/Alert Medications

High-Risk/Alert Meds  {TJCfaq, ISMPpdf, SEalert}

1130.08  MM - Evaluation

1140 (IC) Surveillance, Prevention, and Control of Infection

1140.00  IC  Highlights  {Info}

•  CDC:  Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Novel Influenza A (H1N1) Virus Infection in a Healthcare Setting 

CDC Podcasts - Dozens of free  IC-related podcasts.  Most less than 5 minutes.  Some in Spanish.  TJC/CDC Podcast: Improving Your H1N1 Flu Vaccination Program -  (30-min Podcast) with PowerPoint (47 slides)

1140.01  IC - Program/Components

MRSA:  Ex: Plan of Care by (CMHC), 2007 CDC guidelines

1140.02  IC - Structure/Resources

1200 Organization Functions

1210 (PI)  Improving Organization Performance

1210.00  PI - Highlights  {Info}

1210.01  PI - Data Collection & Monitoring

Utilization Review/Management & Chart Audits  {ResPg}

 Patient and Staff Satisfaction/Perceptions  (Pt)  (Staff)

1210.02  PI - Data Analysis, Oryx, Core Measures, Etc
  • PI & Data Management Tools (e.g., Flowcharts, FMECA, RCA)  {Info}

  • Hospital- Based, Inpatient Psychiatric Services (HBIPS) Test Set - {Info}

1210.03  PI - Performance Improvement

  • General References/Resources (e.g., Links, Demming)  [info]
  • TJC Dimensions of Performance (9)  - {Info}

1220 (LD) Leadership 

1220.00  LD - Highlights (e.g., 2009 Leadership Standards)  [Info]

1220.10  LD - Structure (Governance)

Governing Body Role(s) - Corporate Compliance  OIG: Corporate Responsibility and Health Care Quality – A Resource for Health Care Boards of Directors {PDF}

1220.20  LD - Relationships (Leadership/Management)

1220.30  LD - Culture/System Performance (Data/Planning/Communication/PI/Staffing)

1220.40  LD - Operations (Implementation)


1230 (EC) Management of the Environment of Care

1230.00  EC - Highlights  {Info}

1230.01  EC - Planning/Implementation
  • Emergency Management  {Info}
1230..02  EC - Measuring/Improvement


1240 (HR) Management of Human Resources

1240.00  HR - Highlights  {Info}

1240.01  HR - Planning/Disaster Responsibilities

1240.02  HR - Orientation, Training, and Education

 Social Intelligence Skills for Government Managers (SISGM) - {Info}

Critical Incident Stress Management and the Assaulted Staff Action Program {PDF} [HTML]

Paving New Ground - Peers Working In In-Patient Settings by Gayle Bluebird, National Consumer Survivor Consultant  [Info

1240.03  HR - Assessing Competence

Competency - {Comp-based JD Guide-PDF}, {Fundamentals - PDF}, Ex: RN Competencies (GBHC)

Staffing Effectiveness - {TJC FAQ}  {Detailed Background}

1250 (IM) Management of Information

1250.00  MI - Highlights  {Info}

1250.01  MI - IM Planning

1250.02  MI - Confidentiality/Security

1250.03  MI - IM Processes

• Electronic Medical Records (EMR) : See IM Highlights @ March 2208 {Info}

Computerized physician/provider order entry (CPOE): See IM Highlights @ May 2208 {Info}

1250.04  MI - Info-Based Decision Making

1250.05  MI - Knowledge-Based Info

1250.06  MI - Pt-Specific Info

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1300 Structures with Functions

1310 (MS) Medical Staff

1310.00  MS - Highlights  {Info}

1310.01  MS - Structure

1310.02  MS - Management of Care

1310.03  MS - Performance Improvement
1310.04  MS - Credentialing & Privileging

Focused Professional Practice Evaluation (FPPE) - FPPE Evaluation ReportFPPE Bylaws

Ongoing Professional Practice Evaluation (OPPE) - [OPPE Form]  {InfoOPPE Bylaws

Core/Bundled Privileges: TJC FAQ (April 2008)

Reappointment/Reprivileging Dates: TJC clarification 1/104

Primary Source Verification: :  PSV FAQ, Education PSV, DEA, AMA Profiles, ABMS,

See also SL3_3103: Credentialing Websites 

1310.05  MS - Continuing Ed

1320 (NR) Nursing

1320.00  NR - Highlights  {Info}
1320.01  NR - Exec Role
1320.02  NR - Exec Qualifications
1320.03  NR - Policies/Procedures

 


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