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Take note: Several important changes in February CAMH update

Accreditation Connection, February 28, 2005

The changes included in the JCAHO's February update include:

APR 17--Effective immediately, this APR says staff know that they may express concern about the hospital's safety or quality of care to the JCAHO. The elements of performance for APR 17 say that the hospital must let staff know, and must demonstrate, that it will not exercise disciplinary action for employees who report concerns to the JCAHO.

IC.4.10--Scoring category for EP 2 (hand hygiene program that complies with Centers for Disease Control and Prevention guidelines) changed to A, effective immediately.

EC.8.10--EP 6 (lighting is controlled by patients) is no longer applicable to hospitals, effective immediately.

IM.6.10--EP 9 (timing of discharge documentation) has additional language, effective immediately, "after discharge, not to exceed 30 days after discharge."

IM.6.30--EP 1 (provisional diagnoses) has a minor language addition, the article "A" at the beginning of the EP. EP 2 (types of information recorded in operative or other high-risk procedure reports) adds more substantial language to the end of the EP: "the name of the surgeon and assistants, procedures(s) performed and the description of each procedure, findings, estimated blood loss, specimens removed, disposition of each specimen, and postoperative diagnosis." EP 10 is new, and it reads: "The history and physical examination and the results of any indicated diagnostic tests are recorded before the operative or other high-risk procedures." All three EP changes are effective immediately.

MS.1.20--The overview of the MS chapter has new language that specifies medical staff membership criteria may now include licensed independent practitioners and other practitioners. EP 9 clarifies methods for selecting and removing "members and the organized medical staff" officers. EP 10 is new and says that when administrative procedures associated with processes in EPs 12-18 are explained in the medical staff governance documents that complement the bylaws (i.e., rules and regulations), the following must be included: A method for approving administrative procedures, criteria to identify supplementary documents, and administrative procedures approved by the medical staff and the governing body. All MS.1.20 changes are effective immediately.

NR.3.10--The standard and EP 10 include a small language addition: "nursing staff plans," effective immediately.

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