Index

To view the Joint Commission Perspectives cumulative index for the years 2000–2008, scroll down or click on the appropriate letter. To print this page, click on the "Print This Page" link in the upper right-hand corner.

Index references should be interpreted in the following manner: "Dec 2000, 10" means page 10 of the December issue of Joint Commission Perspectives for the year 2000.

Abbreviations and acronyms, Oct 2005, 5

Abbreviations do-not-use kit, Aug 2005, 12

Account representative model, Sep/Oct 2000, 17

Account representatives, Jan 2001, 4

Customers First Intitative, Nov 2006, 2

Accreditation

Accreditation Process Improvement (API), Oct 2002, 3

award certificate, Nov/Dec 2000, 2

certificates, Sep 2002, 5

commendation dissolved, Jan/Feb 2000, 6

conditional, Sep 2001, 5; Aug 2003, 1, 3

decision categories, Sep 2001, 7

decision categories changes, Oct 2002, 13

decision process and decision rules, Jan/Feb 2000, 6, 11; Nov/Dec 2000, 5

decisions. See Accreditation decision categories

decision rules, Aug 2003, 5; Aug 2007, 3–9

fees for, Mar 2006, 4

history of, Nov 2001, 4

Joint Commission e-mails, Sep 2005, 6

for office-based surgery, Mar 2008, 1, 3

on-site validation surveys, Jan 2006, 5

options for long term care organizations, Sep 2002, 5-6

ORYX initiative, Oct 2002, 2, 9

and patient safety, Aug 2007, 1, 10

peer coaches, Oct 2003, 8

and physician participation, Oct 2002, 14

preliminary denial of, Aug 2003, 1, 3

priority focus process, Oct 2002, 8-9

process, Oct 2003, 8

and PHRP program, Mar 2003, 3

process improvements, Oct 2002, 1, 3, 13

self-assessment process, Oct 2002, 6-7

Shared Visions–New Pathways, Oct 2002, 1, 3

standards compliance issues, Apr 2005, 6

standards review project, Oct 2002, 4-5

and subscription billing services, Apr 2005, 5

system accreditation option refinements, May 2006, 4–5

and type I recommendations, Oct 2002, 13

and unannounced surveys, Jan 2006, 4

Accreditation appeal process, May 2008, 5

Accreditation award

display and use correction, Feb 2006, 8

Accreditation certificates, May 2001, 7

Accreditation Clinic (department)

admissions assessments in long term care, Jan/Feb 2000, 9

application of rehabilitation standards, Jul/Aug 2000, 4

fair hearing and appeal process, Nov/Dec 2000, 6

filming/videotaping of patient care activities, Nov/Dec 2000, 6

hepatitis vaccination, Sep/Oct 2000, 11

HIPAA compliance, Sep/Oct 2000, 11

organ donation, Sep/Oct 2000, 11

separation of medical staff and credentialing process, Jan/Feb 2000, 9

standards clarification, Jan/Feb 2000, 9

surveying in-hospital long term care, Jul/Aug 2000, 4

temporary privileges, Nov/Dec 2000, 6

Accreditation Committee, Dec 2002, 8-9

functions of, Dec 2002, 8

and Shared Visions—New Pathways, Dec 2002, 9

Accreditation contract, Dec 2005, 8; Dec 2006, 4

future changes to, Dec 2005, 8

Accreditation decision categories. See also Adverse accreditation decisions

Conditional Accreditation, Sep 2004, 7; May 2006, 1, 3

denial of accreditation, Nov/Dec 2000, 5

dissolution of accreditation with commendation, Jan/Feb 2000, 6

modified timeline for adverse decisions, Jan/Feb 2000, 11

not accredited, Nov/Dec 2000, 5

preliminary denial of accreditation, May/Jun 2000, 11; Nov/Dec 2000, 5; May 2006, 1, 3

and licensure verification, Nov/Dec 2000, 8; Sep 2004, 7

revisions to categories and definitions of, May/Jun 2000, 11

Accreditation decision process, Dec 2003, 13; Jan 2004, 17-20

decision categories, Jan 2003, 5; Jan 2004, 19

ESC submission, Jan 2004, 18-19

follow-up activities, Jan 2004, 18-19

goal of, Jan 2004, 17

process design characteristics, Jan 2004, 18

scoring compliance, Jan 2004, 17-18

scoring guidelines, Jan 2004, 20

stages of, Jan 2003, 4-5

Accreditation decision rules, Dec 2003, 13; Jul 2005, 10-11; Aug 2006, 1, 3–6

Accreditation, Jul 2005, 11

clarifications, Sep 2005, 9

Conditional Accreditation, Jul 2005, 11

Conditional Accreditation Follow-up, Jul 2005, 11

deleted rules, Jul 2005, 10

Denial of Accreditation, Jul 2005, 10, 11

new rules, Jul 2005, 10-11

Provisional Accreditation, Jul 2005, 11

PDA04, PDA04a, Apr 2007, 5

Accreditation Manager Plus, Jun 2005, 11

and PPR tool, Jun 2005, 11

Accreditation manuals, Mar 2004, 10; Oct 2005, 3; Apr 2006, 5

and biannual updates, Nov 2005, 8; Apr 2006, 5

schedule for, Oct 2005, 3

updates for March 2008, Apr 2008, flap insert

Accreditation Manual for Assisted Living (AMAL). See also Assisted living accreditation program

launch of assisted living accreditation program, Jul/Aug 2000, 1-2, 4

standards revisions for 2001, Nov/Dec 2000, 7

licensure verification at expiration, Nov/Dec 2000, 8

Accreditation Manual for Office-Based Surgery Practices (AMDBS), Feb 2001, 2; Apr 2001, 1, 3

errata, Mar 2002, 2, 10-11

Accreditation Manual for Preferred Provider Organizations (AMPPO), Mar 2001, 4. See also preferred provider organizations

standards revisions for 2001, Jul/Aug 2000, 9; Nov/Dec 2000, 7

environment of care, Jul/Aug 2000, 18-19

leadership, Jul/Aug 2000, 9, 16-17

licensure verification at expiration, Nov/Dec 2000, 8

Accreditation Participation Requirements (APRs), Nov/Dec 2000, 5; Sep 2004, 1, 3; Aug 2007, 11

changes to, Dec 2002, 5

correction to, Jun 2006, 5

errata to 2004 requirements, May 2004, 6-7

laboratory proficiency testing, July 2006, 4

for Medicare/Medicaid certification-based long term care, Nov 2004, 5

National Patient Safety Goals, Aug 2003, 7

National Patient Safety Goals compliance, Sep 2002, 12

Periodic Performance Review (PPR), Sep 2004, 1, 3; Jun 2003, 7; Oct 2003, 1, 4; Jan 2004, 9, 10

APR 14, Aug 2005, 1, 3

public involvement, Mar 2004, 11

Quality Report adherence, Mar 2005, 4

revisions for hospitals, Aug 2007, 11; Feb 2008, 3

staff education on employee safety reporting, Jan 2005, 7

surveyors as consultants, Jun 2003, 6

survey observers, Sep 2002, 12

timeliness of data and information submission, Jun 2005, 7-8

unannounced surveyor mentoring, Apr 2003, 5

Accreditation policies and procedures, Nov/Dec 2000, 8

correction to, Apr 2005, 10

Accreditation process, May 2004, 10; Aug 2004, 12; May 2005, 8

audio conferences, Jun 2004, 1, 3

closing conference, Apr 2004, 8-9

communication of results, Apr 2004, 2, 8-9

conflict of interest, Dec 2003, 5

corrections to, Nov 2005, 5

e-mail communication, Jun 2004, 7, 9

exit conference, Apr 2004, 9

“firewall” guidelines, Dec 2003, 5

“Jayco”™, Apr 2004, 1

and measurement process, Aug 2004, 12

measures of success (MOS), Apr 2004, 1

Quality Report, Apr 2004, 1

scan process, Jul 2004, 1, 3

survey scoring, Jul 2004, 1

surveyor preparation for, Apr 2004, 11

systems evaluation approach for, May 2005, 8

timeline charts, Apr 2004, 1, 3

Accreditation process improvement (API) initiative, Sep/Oct 2000, 14; May 2001, 7; Oct 2002, 3. See also Oversight Task Force for Accreditation Process Improvement

concepts identified for inclusion, Sep/Oct 2000, 14

customizing the on-site survey process, Sep/Oct 2000, 14

18-month event, May 2001, 7

field engagement plan, Sep/Oct 2000, 14

individual-centered evaluation, Jan 2001, 1, 3

information-driven agenda, Jan/Feb 2000, 10-11; Mar/Apr 2000, 2, 6; Jan 2001, 4

Internet-based process, Sep/Oct 2000, 14

possible eighteenth-month on-site survey intervals, Sep/Oct 2000, 14

self-assessment activities, Sep/Oct 2000, 14

using outcome and performance measurement data, Sep/Oct 2000, 14

off-shift survey visits, Mar/Apr 2000, 7; Sep/Oct 2000, 3; Nov/Dec 2000, 10-11; Feb 2001, 5

short-notice surveys, May 2001, 7

Accreditation Report, Jan 2004, 14, 16, 21

components of, Jan 2004, 21

follow-up activities, Jan 2004, 21

sample, Jan 2004, 26-27

Accreditation survey, Jul 2005, 15

closing conference, Oct 2002, 10

corrective action plan, Oct 2002, 10

due date extensions, Nov 2002, 5

electronic invoices, Nov 2005, 2

and emergency management preparation, Jun 2002, 6-7

Evidence of Standards Compliance (ESC), Jul 2003, 4

and ESC report, Jul 2005, 15

extension surveys, Nov 2002, 5

fee adjustments, Oct 2004, 11

fees, Nov 2005, 2

leadership interview, Oct 2002, 10

Life Safety Code® Specialists, Dec 2004, 1

medical students supervision, Feb 2006, 9

misinterpretation of information, Feb 2006, 7

multiorganization option, Nov 2002, 5

opening conference, Oct 2002, 10

postsurvey process, Apr 2006, 8–10

process revisions, Oct 2002, 10-11

Quality Report, Jul 2003, 1, 3-4

random announced validation survey, Oct 2005, 3

and requirements for improvement, Apr 2006, 8

resurveys, Jul 2005, 15

staffing effectiveness, Jul 2002, 5-6

surveyor identity check, Jun 2006, 4

timeline model, Jan 2003, 3

training for surveyors on, Feb 2006, 4

unannounced surveys, Feb 2006, 4

validation surveys, Apr 2006, 11

visits to care and service areas, Oct 2002, 10

Accreditation survey process, Jan 2004, 1-4. See also Survey process

assessing emergency management plan, Dec 2001, 6-7

assessing history and physicals, Apr 2001, 8

CEO exit briefing, Jan 2004, 13

changes in onsite survey, Jan 2001, 4

competence assessment process, Jan 2004, 12-13

consultations, Feb 2002, 1

critical access hospitals, Jan 2002, 1

daily briefing, Jan 2004, 12

18-month event, May 2001, 7

electronic application for, Aug 2001, 1, 3

emergency management requirements, Feb 2002, 1

engaging physicians in, Jul 2001, 8

environment of care session, Jan 2004, 13

focused surveys, Feb 2001, 6-7

individual-centered evaluation, Jan 2001, 1, 3

individual tracer activity, Jan 2004, 11-12

information-driven agenda, Jan 2001, 4

laboratory proficiency testing, Feb 2002, 8

leadership session, Jan 2004, 13

Life Safety Code® building tour, Jan 2004, 13

medical staff credentialing and privileging, Jan 2004, 13

for office-based surgery centers, Apr 2001, 3

off-shift visits, Feb 2001, 5

online application for, Aug 2001, 1, 3

opening conference and orientation, Jan 2004, 11

Periodic Performance Review (PPR), Jan 2004, 7-10

physician engagement in, Jan 2004, 9

physician role, Mar 2002, 1, 3

pilot surveys, Jan 2004, 14-15

pilot survey testing, Apr 2003, 1-3

Priority Focus Process (PFP), Jan 2004, 5

process, Jan 2001, 1, 3

proficiency testing, Jan 2004, 12

program-specific changes, Jan 2001, 4; Sep 2001, 1, 3-4

random unannounced, Jan 2001, 5

re-entered organizations, Jul 2001, 6

special issue resolution, Jan 2004, 12

survey activities, Jan 2004, 11-13

survey planning session, Jan 2004, 11

surveyor training, Apr 2003, 2

systems analysis, Feb 2002, 1

system tracer activity, Jan 2004, 12

tailored survey policy, May 2001, 8, 9; Sep 2001, 2

type I recommendations, Feb 2002, 10-11

Accreditation Watch, Oct 2005, 4

Accredited, Jan 2004, 19, 21; Aug 2006, 6; Aug 2007, 8–9

Acronyms and abbreviations, Oct 2005, 5

Action plans, May/Jun 2000, 14; Oct 2005, 4

Administrative rules, Sep 2005, 5; Aug 2006, 6; Aug 2007, 9; Sep 2007, 14

Adverse accreditation decisions, May/Jun 2000, 5; Nov/Dec 2000, 5

publicly disclosable, Nov/Dec 2000, 5

revised categories, May/June 2000, 11

Adverse cardiac events, Nov 2005, 3

Adverse events. See also Sentinel events

reporting, Mar 2001, 6-7; Oct 2001, 3; Jun 2008, 7

Advocates Coalition for the Appropriate Use of Restraints, Jul/Aug 2000, 14

Agency for Healthcare Research and Quality, Mar/Apr 2000, 13

Aggregation and decision rules, Aug 2003, 1, 3-7

conditional accreditation, Aug 2003, 1, 3

preliminary denial of accreditation, Aug 2003, 1, 3

scoring of standards, Aug 2003, 1

Alcohol-based hand rubs, July 2006, 3

Alternative 4, Sep/Oct 2000, 13

Ambulatory care

2005 National Patient Safety Goals, Aug 2004, 3-4, 10

abbreviations do-not-use list, Aug 2005, 4

accreditation decision methodology refinements, Aug 2006, 8

accreditation manual corrections, Jan 2006, 7

Accreditation Participation Requirement correction, Jun 2006, 5; Nov 2006, 5

Accreditation Participation Requirement revision, Nov 2006, 7

accreditation process corrections, Nov 2005, 5

accreditation program redesign, Feb 2001, 2

award display and use correction, Feb 2006, 8

biannual comprehensive manual updates, Nov 2005, 8, 11

clinical/service groups (CSGs), Oct 2003, 7, 11

and competence assessment, Jan 2001, 6-7

compliance issues, Nov 2003, 3

compliance issues for 2003, May 2004, 3

and continuum of care standards, Feb 2001, 4

contracted services standards revisions, Jul 2007, 4–5, 6–8

decision rule, Apr 2007, 5

element of performance correction, Mar 2004, 7

elements of performance revisions, May 2004, 7, 8, 9

e-mail communication on PPR, Jun 2004, 7, 9

and environment of care standards, May 2001, 4-5, 9

epidemics management standard, Jul 2004, 4

errata to standards and elements of performance, Dec 2003, 6-8

hand hygiene, Mar 2006, 3; May 2007, 12

hand hygiene guidelines, Feb 2008, 4–5

implementation of program-specific tracers, Nov 2006, 4

infection control revisions, Feb 2004, 5-6

information management standard revision, Aug 2005, 6

labeling of medications revision, Feb 2006, 3

leadership standards revisions, Aug 2005, 5

look-alike, sound-alike drugs, Oct 2004, 8-9

management of human resources revisions, Jun 2006, 8

medication management revision, Apr 2005, 8

medication use, Sep 2001, 8-9

National Patient Safety Goals, Mar 2004, 1, 3; Jul 2005, 3, 8-10; Aug 2005, 9-10; July 2006, 1, 5–8, 30–31

National Patient Safety Goals (2008), Jul 2007, 1, 9–22

and office-based surgery, Feb 2001, 2; Apr 2001, 1, 3

online application for survey, Aug 2001, 1, 3

patient safety standards revisions, Jul 2003, 6-11

Periodic Performance Review (PPR), Sep 2004, 1, 3, 8-9

and Periodic Performance Review (PPR), Jun 2003, 7; Oct 2003, 1-5; Nov 2005, 6

Periodic Performance Review (PPR), Jan 2005, 1, 3

pilot survey, Jan 2004, 14-15

priority focus process reports, Nov 2006, 3

and random unannounced surveys, Jan 2001, 5; Sep 2003, 4; Dec 2005, 7

random unannounced surveys, Jan 2005, 3

random unannounced survey topics, Dec 2002, 1, 3

restraint use, Sep 2001, 8-9

revisions to management of information, Jun 2003, 3

scoring revisions, Feb 2001, 5; Aug 2004, 13-14

and Sentinel Event Alert recommendations, May 2001, 10

simplifying compliance activities, Mar 2001, 6-7

standard corrections and/or revisions, Jun 2006, 6, 9-10; Dec 2006, 6; Dec 2007, 6; Jan 2008, 7

standards applicability grids, Jun 2005, 6

standards applicability grid revisions, Nov 2006, 5

standards changes, Feb 2006, 5

Standards Improvement Initiative (SII), Dec 2006, 5; Apr 2007, 1, 3; Apr 2007, 1, 3; Oct 2007, 9; Dec 2007, 7

electronic manual, Jun 2008, 11

Standards Review Project, Jan 2004, 3-4

standards revisions, Jun 2004, 5-6; Dec 2004, 6; Mar 2005, 8-9; Jun 2005, 7, 10; Jul 2005, 12-13; May 2006, 7; July 2006, 3; Nov 2006, 5, 7

and Statement of Conditions™, Oct 2005, 7-8

survey changes, Jan 2001, 4

systems accreditation evaluation approach, May 2005, 8

system accreditation option changes, Aug 2006, 8

system accreditation option refinements, May 2006, 4–5

track record requirements, Jan 2008, 4

transplant and implant tissue storage and issuance standards, Feb 2005, 8-9

top type I recommendations, Apr 2001, 6

unannounced surveys, Apr 2008, 1, 3–4

Universal Protocol endorsement, Feb 2004, 1-4

Universal Protocol, Jul 2006, 30–31

and USP-NF survey compliance, Apr 2004, 4

waived testing revisions, Jul 2004, 7-8

Ambulatory care accreditation program. See also Comprehensive Accreditation Manual for Ambulatory Care (CAMAC)

consolidation to home care pharmacy program, Nov/Dec 2000, 5

health advisory on endoscope reprocessing, Jan/Feb 2000, 8

infusion services, Nov/Dec 2000, 15

integrating outcomes into accreditation process, Jan/Feb 2000, 1, 3

patient centered care, Codman Award winner, Mar/Apr 2000, 3-4

pharmacy-related accreditation activities to home care program, Nov/Dec 2000, 15

random unannounced surveys, Sep/Oct 2000, 6-9

re-engineering care, Mar/Apr 2000, 3

Ambulatory care infusion

consolidation to home care pharmacy program, Nov/Dec 2000, 15

and pharmacy-related accreditation activities, Nov/Dec 2000, 15

American Academy of Orthopedic surgeons, Jan/Feb 2000, 14

American Association of Nurse Anesthesiologists (AANA), Jul/Aug 2000, 10

American Case Management Association (ACMA), Jan 2003, 8

Franklin Award of Distinction, Jan 2003, 8

American College of Physicians (ACP), Nov 2001, 5, Dec 2001, 24

American College of Surgeons (ACS), Nov 2001, 1, 5, Dec 2001, 24

American Dental Association (ADA), Sep/Oct 2000, 10; Nov 2001, 5

American Diabetes Association guidelines, Aug 2006, 10

American Hospital Association (AHA), Jan/Feb 2000, 12; Mar/Apr 2000, 14; Nov/Dec 2000, 12; Nov 2001, 5; Dec 2001, 24

American Medical Association (AMA), Jan 2001, 2; Aug 2001, 5; Nov 2001, 5; Dec 2001, 24

American Society of Anesthesiologists, Jan/Feb 2000, 4; Jul/Aug 2000, 10

American Society for Healthcare Engineering, Jan/Feb 2000, 13; Dec 2001, 9, 24

American Stroke Association, Apr 2004, 8

Anesthesia awareness, Dec 2004, 10-11

frequency of, Dec 2004, 10

Joint Commission recommendations, Dec 2004, 11

prevention and management of, Dec 2004, 10-11

reducing risk of, Dec 2004, 11

Anesthesia care

changes in, Jul/Aug 2000, 10-12

interim survey process for transitional standards, Jan/Feb 2000, 4

revised standards for, Jul/Aug 2000, 11-12

API initiative. See Accreditation process improvement initiative; Oversight Task Force for Accreditation Process Improvement

Appeal procedures, Nov/Dec 2000, 9

Application for survey. See Online application for survey

Ask the Experts (department)

behavioral restraint and seclusion, Jan 2001, 8

environment of care issues, Mar 2001, 8

Health Insurance Portability and Accountability Act of 1996 (HIPAA), Jul 2001, 7, 11

Assessment (PE)

anesthesia care, Jul/Aug 2000, 8-9, 11

discharge planning, Nov/Dec 2000, 13

rehabilitation therapy, Sep 2002, 9, 11

Assisted living, Jan 2001, 3

2005 National Patient Safety Goals, Aug 2004, 4

abbreviations do-not-use list, Aug 2005, 4

accreditation eligibility criteria, Feb 2002, 5

accreditation importance, Oct 2001, 4, 11

accreditation program discontinuation, Oct 2005, 9

and competence assessment, Jan 2001, 6-7

changes in 2004, Dec 2003, 13

compliance issues, Nov 2003, 3

hand hygiene, Mar 2006, 3

and Life Safety Code®, Aug 2003, 2

look-alike, sound-alike drugs, Oct 2004, 8-9

National Patient Safety Goals, Mar 2004, 1, 5; Jul 2005, 3-4; Aug 2005, 9-10; July 2006, 1, 5, 8–11;

National Patient Safety Goals (2008), Jul 2007, 1, 9–22

online application for survey, Aug 2001, 1, 3

and Sentinel Event Alert recommendations, May 2001, 10

and staffing effectiveness, Jun 2003, 8-11

staffing effectiveness standard revisions, Feb 2005, 3-6

standards changes, Dec 2002, 2

standards revisions, Sep 2002, 6-8; Sep 2003, 6-7, 11; Nov 2004, 2; Dec 2004, 6; Jun 2005, 10

waived testing revisions, Jul 2004, 7-8

Assisted living accreditation program, Jul/Aug 2000, 1-2, 4. See also Accreditation Manual for Assisted Living (AMAL)

health services coordination designation, Jul/Aug 2000, 2

pilot testing of standards, Jul/Aug 2000, 2

tailored survey policy, Sep/Oct 2000, 16

Audio conferences

on patient care, Jun 2004, 3

on priority focus areas (PFA), Jun 2004, 1, 3

on tracers, Jun 2004, 3

Average daily census (ADC), May 2006, 3

Award winners, Codman, Jan 2006, 1, 8

Greater Cincinnati Patient Safety ICU, Jan 2006, 8

Kizer, Kenneth W., Jan 2006, 8

Memorial Health Center, Jan 2006, 1

Pikes Peak Mental Health Center, Jan 2006, 1

Shady Grove Adventist Hospital, Jan 2006, 8

Backup communication systems, Dec 2001, 16-17

external, Dec 2001, 17

internal, Dec 2001, 16-17

media management checklist, Dec 2001, 17

Balanced Budget Act of 1997 (BBA), Sep/Oct 2000, 17

Basic Building Information (BBI), Oct 2005, 7-8

electronic submission, Jun 2006, 4

Bed rail safety, Nov 2002, 14-15

Joint Commission recommendations, Nov 2002, 15

root causes and risk reduction strategies, Nov 2002, 14

Behavioral health care

2005 National Patient Safety Goals, Aug 2004, 4-5

abbreviations do-not-use list, Aug 2005, 4

accreditation manual corrections, Jan 2006, 7

Accreditation Participation Requirement correction, Jun 2006, 5

accreditation process corrections, Nov 2005, 5

analyzing data, case study, Mar 2001, 10-11

award display and use correction, Feb 2006, 8

biannual comprehensive manual updates, Nov 2005, 8, 11

clinical/service groups (CSGs), Oct 2003, 7, 11

and competence assessment, Jan 2001, 6-7

compliance issues, Nov 2003, 3

compliance issues for 2003, May 2004, 3

and continuum of care standards, Feb 2001, 4

contracted services standards revisions, Jul 2007, 4–5, 6–8

delegation of restraint and seclusion orders, Jul 2002, 4

elements of performance revisions, May 2004, 7, 8, 9

e-mail communication on PPR, Jun 2004, 7, 9

and environment of care standards, May 2001, 4-5, 9

epidemics management standard, Jul 2004, 4

errata to standards and elements of performance, Dec 2003, 6-9

financial audit requirements, Jan 2002, 3

hand hygiene, Mar 2006, 3; May 2007, 12

implementation of program-specific tracers, Nov 2006, 4

infection control revisions, Feb 2004, 5-6

information management standard revision, Aug 2005, 6

initial assessments, Oct 2001, 5-7

Joint Commission appointment, May 2007, 15

leadership standards revisions, Aug 2005, 5

look-alike, sound-alike drugs, Oct 2004, 8-9

management of human resources revisions, Jun 2006, 8

medication management revision, Apr 2005, 8

National Patient Safety Goals, Mar 2004, 1, 3; Jul 2005, 4; Aug 2005, 9-10; July 2006, 1, 5, 11–13

National Patient Safety Goal correction, Aug 2006, 2

National Patient Safety Goals (2008), Jul 2007, 1, 9–22

and off-shift survey visits, Feb 2001, 5

online application for survey, Aug 2001, 1, 3

opioid addiction treatment programs, Feb 2002, 8

ORYX performance measurement requirements, Mar 2006, 9-12

and ORYX data submissions, Jan 2001, 2

and ORYX data transmission requirements, Dec 2002, 6

patient safety standards revisions, Jul 2003, 6, 8-9

Periodic Performance Review (PPR), Sep 2004, 1, 3, 8-9

and Periodic Performance Review (PPR), Jun 2003, 7; Oct 2003, 1-5; Nov 2005, 6

Periodic Performance Review (PPR), Jan 2005, 1, 3

pilot survey, Jan 2004, 14-15

priority focus process reports, Nov 2006, 3

and random unannounced surveys, Jan 2001, 5; Sep 2003, 4; Dec 2005, 7

random unannounced surveys, Jan 2005, 3

random unannounced survey topics, Dec 2002, 1, 3

recovery support standards, Aug 2005, 6

and restraints, Jan 2001, 8

retired standards, Feb 2005, 2

revisions to management of information, Jun 2003, 3

safety and error reduction standards, May 2002, 9-15

scoring revisions, Feb 2001, 5; Aug 2004, 13-14; Nov 2006, 7

scoring scale omittance, Jan 2003, 3

short-term credentialing and privileging, Aug 2005, 7

standards changes, Dec 2002, 2; Feb 2006, 5

standards corrections, Dec 2006, 7; Apr 2008, 7

Standards Improvement Initiative (SII), Apr 2007, 1, 3

Standards Review Project, Jan 2004, 3-4

standards revisions, Sep 2002, 13-15; Jun 2004, 5; Dec 2004, 6-7; Mar 2005, 8-9; Jun 2005, 10; Jul 2005, 12-13; Jun 2006, 9–10; July 2006, 3

standards matrix corrections, Nov 2002, 2

and Statement of Conditions™, Oct 2005, 7-8

survey changes, Jan 2001, 4

task force, Dec 2004, 2

top type I recommendations, Apr 2001, 6

track record requirements, Jan 2008, 4–5

hand hygiene guidelines, Feb 2008, 4–7

standard corrections and/or revisions, Jan 2008, 7

track record requirements, Jan 2008, 4–5

unannounced surveys, Apr 2008, 1, 3–4

updated manuals for, Oct 2004, 11

using data to prevent a sentinel event, case study, Feb 2001, 9-10

using performance measurement data, Apr 2001, 9-10

and USP-NF survey compliance, Apr 2004, 4

waived testing revisions, Jul 2004, 7-8

Behavioral health care accreditation program. See also Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC)

ensuring best practice treatments, Codman award winner, Mar/Apr 2000, 3

integrating outcomes into accreditation process, Jan/Feb 2000, 1, 3

off-shift survey visits, Mar/Apr 2000, 7; Nov/Dec 2000, 10-11

random unannounced surveys, Sep/Oct 2000, 6-9

Behavior management and treatment, Sep 2002, 13-15

assessment based, Sep 2002, 14

data collection and analysis, Sep 2002, 15

family participation, Sep 2002, 14

individualized, Sep 2002, 14, 15

process, Sep 2002, 14

prohibitions of, Sep 2002, 15

review of aversive procedures, Sep 2002, 14-15

rights of individual, Sep 2002, 15

staff competency, Sep 2002, 15

time-out usage, Sep 2002, 15

Benchmarking, Jul 2002, 9

radar charts, Jul 2002, 9

Berwick, Donald M., Mar/Apr 2000, 1, 5

Biological and airborne safety, Oct 2004, 1

Bioterrorism, national response, Dec 2001, 2

Bon Secours Maria Manor Nursing and Rehabilitation Center, Codman Award winner, Mar/Apr 2000, 1, 4-5

Building design requirements, May 2001, 4-5

Business associate agreement (BAA), Mar 2005, 6

amendments to, Mar 2005, 6

Bylaws and self governance, Mar 2004, 9

Canadian Medical Association (CMA), Nov 2001, 4

Care of the dying

and organ procurement and donation, Jul 2001, 4, 6

Care involvement

for assisted living, Jul 2005, 4

for disease-specific care, Jul 2005, 6

for home care, Jul 2005, 6

for laboratory, Jul 2005, 7

Care, treatment, and services (TX)

access to, Jul/Aug 2000, 16

rehabilitation therapy, Sep 2002, 9, 11

standards revisions for 2001, Jul/Aug 2000, 8-9

anesthesia care standards, Jul/Aug 2000, 10-12

random unannounced surveys, Sep/Oct 2000, 8

restraint and seclusion, Jul/Aug 2000, 14-15; Sep/Oct 2000, 15, 19

Case in Point (department)

behavioral health performance measurement data, Apr 2001, 9-10

Hinsdale Hospital, staffing effectiveness requirements, Jul 2002, 6-8

sentinel event prevention, Feb 2001, 9-10

staffing and quality issues, Aug 2001, 8-9

CDC/WHO Hand Hygiene Guidelines

applicability, Apr 2008, 6

Center for Behavioral Health, Codman winner, Mar/Apr 2000, 1, 3

Centers for Disease Control and Prevention (CDC), Jan/Feb 2000, 8; Sep/Oct 2000, 11

and Joint Commission partnership, Dec 2002, 7

handwashing guidelines, Mar 2003, 9-10

Centers for Medicare & Medicaid Services (CMS), Nov 2001, 3; Oct 2005, 9

and deemed status, Jun 2008, 9

deemed status for HMOs and PPOs, Jul 2002, 8

and hospital quality measures, Nov 2004, 1

organ procurement COPs, Aug 2002, 8

and organ transplant center certification program, Oct 2005, 9

and restraint and seclusion guidelines, Jul 2002, 4

Special Focus Facility, Jun 2008, 8

CEO exit briefing, Jan 2004, 13

Certification, Sep 2005, 5; Sep 2007, 13–14

Certification appeal process, May 2005, 10

Certification decision rules, Sep 2005, 4-6; Sep 2007, 10–14

Certification examination, surveyor, Aug 2002, 6-7

Certification Participation Requirements (CPR), Dec 2005, 3-5

PPR, CPR 13, Apr 2007, 6, 7

Chassin, Mark R., Sep 2007, 1, 9; Oct 2007, 1, 3–4

Chronic kidney disease (CKD) certification, Feb 2006, 1, 11

Kidney Disease Outcome Quality Initiative (K/DOQI) guidelines, Feb 2006, 11

Clarification Validation Survey (CVS), May 2008, 5

CLIA ’88 regulations revisions, Jul 2004, 5-6, 11

Clinical alarms, Aug 2005, 10

Clinical alarm systems, Sep 2003, 3

for disease-specific care, Jul 2005, 5

Clinical laboratories

Centers for Medicare & Medicaid Services, Apr 2007, 4

deemed status for, Jan 2003, 10

Clinical Laboratory Improvement Amendments (CLIA), Nov 2001, 3; Dec 2006, 6–7; Apr 2007, 4

certificates, Dec 2006, 6–7

Clinical/service groups (CSGs), Aug 2003, 9-10; Oct 2003, 7, 11; Jan 2004, 5-6, 25; Apr 2004, 11; May 2004, 10; Sep 2007, 8

data use on, Jan 2004, 5

identification of, Jan 2004, 14

Clinical trials and research

Partnership for Human Research Protection, Inc (PHRP), Mar 2003, 3

Clinton, President William

President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry, Sep/Oct 2000, 2

Closing conference, Apr 2004, 8-9

Accreditation Report, Apr 2004, 9

Evidence of Standards Compliance (ESC), Apr 2004, 9

Codman, Ernest A., Jan 2006, 1, 8

improvement descriptions, Feb 2002, 4, 9

pioneering work of, Nov 2001, 1

Codman Awards, Ernest A.

award, reduction of accounts receivable days, Jan 2001, 3; Mar 2001, 3

award winners, Jan 2001, 3; Mar 2001, 1-3; Feb 2002, 4, 9; Jan 2005, 4; Jan 2006, 1, 8

outcomes measurement, Feb 2004, 8-9

Committee on Healthcare Safety (CHS), Jul/Aug 2000, 18-19

Communication, Aug 2005, 9; July 2006, 5–6, 8–9, 11–12, 13–14, 16–17, 19–20, 22–23, 25–26

effectiveness, Sep 2003, 1, 3; Feb 2008, 8–11

for ambulatory care, Jul 2005, 3

for assisted living, Jul 2005, 3

for behavioral health care, Jul 2005, 4

for critical access hospitals, Jul 2005, 4

for disease-specific care, Jul 2005, 5

for home care, Jul 2005, 6

for hospitals, Jul 2005, 6

for laboratory, Jul 2005, 7

for long term care, Jul 2005, 7-8

for office-based surgery, Jul 2005, 3

and emergency management, Jun 2002, 9-10

Communication systems backup, Dec 2001, 16-17

Community emergency planning, May 2003, 5

Community Health Accreditation Program (CHAP), Apr 2006, 4

Comparative performance data, Jul/Aug 2000, 21

Comparison charts, May/Jun 2000, 3, 4; Jan 2001, 10-11; Mar 2001, 11

Competence assessment

checklist, Jan 2001, 7

development of program, Mar/Apr 2000, 8-9

in health care networks, May 2001, 6

in home care, Apr 2001, 11; Nov 2001, 8-9

maintaining survey readiness, Jan 2001, 7

the process, Jan 2004, 12

trouble spots, Jan 2001, 6-7

Competency

of staff, May 2004, 10

Complaint information, May/Jun 2000, 5

Complaint resolution, Jun 2001, 1-3; Oct 2007, 6–7

online reporting, Jun 2006, 1, 3

process, May 2008, 8

top complaint categories, Jun 2001, 3

Complex health care organization, Oct 2002, 15

Complex organizations, May 2001, 8-9; Jul 2001, 2. See also Tailored survey policy

twelve-month grace period, Nov/Dec 2000, 14

weighting component results, May/Jun 2000, 12

Compliance

of standards, May 2006, 6

Compliance assessment, Oct 2003, 9-10

evidence of performance scoring criteria categories, Oct 2003, 10

sample of patient population size choices, Oct 2003, 9

Compliance data, Nov 2002, 1, 11-13

Compliance issues, May 2003, 9-11; Nov 2003, 1, 3-5; May 2004, 1, 3-5

for ambulatory care, Nov 2003, 3

for assisted living, Nov 2003, 3

for behavioral health care, Nov 2003, 3

for critical access hospitals, Nov 2003, 3-4

for health care networks, Nov 2003, 4

for home care, Nov 2003, 4

for hospitals, Nov 2003, 4-5

for laboratory, Nov 2003, 5

for long term care, Nov 2003, 5

for office-based surgery, Nov 2003, 5

Complimentary copy, Perspectives, Jun 2006, 3

Compounding Sterile Products (CSP)

completion date correction, Dec 2004, 8

Comprehensive Accreditation Manual for Ambulatory Care (CAMAC), Apr 2001, 1. See also Ambulatory care

changes in, Feb 2001, 2; Sep 2001, 8-9

dialysis water testing requirements, Jan/Feb 2000, 7

interim survey process for anesthesia care standards, Jan/Feb 2000, 4

pharmacy-related accreditation activities to home care program, Nov/Dec 2000, 15

rehabilitation standards, Jul/Aug 2000, 4

standards revisions for 2001, Jul/Aug 2000, 9; Nov/Dec 2000, 7

anesthesia care, Jul/Aug 2000, 9, 10-12

education, Jul/Aug 2000, 9, 13

emergency management, Jul/Aug 2000, 9, 19-20

environment of care, Jul/Aug 2000, 18-9

fire drills, Jul/Aug 2000, 9, 19

information management, Jul/Aug 2000, 9, 21

licensure verification at expiration, Nov/Dec 2000, 8

utility systems management, Jul/Aug 2000, 9, 19

verifying licensure, Nov/Dec 2000, 7, 8

Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC). See also Behavioral health care

and behavioral restraint, Jan 2001, 8

discharge planning, Sep/Oct 2000, 3

errata to 2005 National Patient Safety Goals, Nov 2004, 9

errata to 2005 Update table of changes, Nov 2004, 9

initial assessments, Oct 2001, 5-7

interim survey process for anesthesia care standards, Jan/Feb 2000, 4

rehabilitation standards, Jul/Aug 2000, 4

restraint and seclusion use, Jul/Aug 2000, 15, Sep/Oct 2000, 3

standards revisions for 2001, Jul/Aug 2000, 9; Nov/Dec 2000, 7

anesthesia care, Jul/Aug 2000, 9, 10-12

education, Jul/Aug 2000, 9, 13

emergency management, Jul/Aug 2000, 9, 19-20

environment of care, Jul/Aug 2000, 18-19

fire drills, Jul/Aug 2000, 9, 19

information management, Jul/Aug 2000, 9, 21

licensure verification at expiration, Nov/Dec 2000, 8

restraint and seclusion, Jul/Aug 2000, 9, 14-15

utility systems management, Jul/Aug 2000, 9, 19

verifying licensure, Nov/Dec 2000, 7, 8

Comprehensive Accreditation Manual for Health Care Networks (CAMHCN), May 2001, 6; Nov 2001, 2. See also Health care networks

standards revisions for 2001, Jul/Aug 2000, 9, Nov/Dec 2000, 7

credentialing practitioners, Nov/Dec 2000, 18

leadership, Jul/Aug 2000, 9, 16-17

licensure verification at expiration, Nov/Dec 2000, 8

reviewing office records and practices, Nov/Dec 2000, 18

Comprehensive Accreditation Manual for Home Care (CAMHC), Jan 2003, 6, 11. See also Home care accreditation program

consolidating pharmacy-related accreditation activities, Nov/Dec 2000, 15

determination of eligibility for accreditation program, Nov/Dec 2000, 16-17

rehabilitation standards, Jul/Aug 2000, 4

revisions to, Jan 2003, 6, 11

standards revisions for 2001, Jul/Aug 2000, 9, Nov/Dec 2000, 7

education, Jul/Aug 2000, 9, 13

environment of care, Jul/Aug 2000, 18-19

information management, Jul/Aug 2000, 9, 21

licensure verification at expiration, Nov/Dec 2000, 8

Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH), Jan 2003, 8. See also Hospitals

and behavioral restraint, Jan 2001, 8

changes to, Apr 2003, 4

critical access hospitals, Jul/Aug 2000, 3

dialysis water testing requirements, Jan/Feb 2000, 7

discharge planning, Nov/Dec 2000, 13

error reduction standards, Feb 2001, 1, 3; Mar 2001, 5

fair hearing and appeals for temporary privileges, Nov/Dec 2000, 6

filming patient care activities, Nov/Dec 2000, 6

informed consent, Nov/Dec 2000, 6

initial assessments, Oct 2001, 5-7

interim survey process for anesthesia care standards, Jan/Feb 2000, 4

medical staff revisions, Nov/Dec 2000, 9, 13

appointment and reappointment, Nov/Dec 2000, 9

fair hearing and appeal, Nov/Dec 2000, 9

history and physical, Nov/Dec 2000, 9, 13

licensure verification, Nov/Dec 2000, 9

peer review process, Jul/Aug 2000, 22

physician health and wellness, Nov/Dec 2000, 9

practitioner reappraisal, Nov/Dec 2000, 9

telemedicine, Nov/Dec 2000, 9

treatment criteria, Nov/Dec 2000, 13

organ donation, Sep/Oct 2000, 11

patient safety requirements, Nov/Dec 2000, 12

patient safety standards, Feb 2001, 1, 3

rehabilitation standards, Jul/Aug 2000, 4

and restraint authorization, Jun 2001, 6

restraint, “one-hour rule,” Jul/Aug 2000, 15, Sep/Oct 2000, 15

revisions to designated equivalent source, Mar 2002, 11

scoring cap changes, Mar 2001, 5

and staffing effectiveness, Sep 2001, 1, 3-4

standards changes, Feb 2001, 1, 3; Sep 2001, 3-4

standards revisions for 2001, Jul/Aug 2000, 9; Nov/Dec 2000, 7

anesthesia care, Jul/Aug 2000, 9, 10-12

education, Jul/Aug 2000, 9, 13

emergency management, Jul/Aug 2000, 9, 19-20

environment of care, Jul/Aug 2000, 18-19

fire drills, Jul/Aug 2000, 9, 19

information management, Jul/Aug 2000, 9, 21

licensure verification at expiration, Nov/Dec 2000, 8

medical staff revisions, Nov/Dec 2000, 9, 13

peer review, Jul/Aug 2000, 9, 22

restraint and seclusion, Jul/Aug 2000, 9, 14-15

utility systems management, Jul/Aug 2000, 9, 19

supervision of graduate medical students, Sep 2001, 8, 10

survey process changes

in 2000, Jan/Feb 2000, 10-11; Mar/Apr 2000, 2, 6

in 2001, Nov/Dec 2000, 10-11

update revisions for, Jan 2003, 8

update service, Aug 2002, 2

update service changes, Jun 2003, 2

Comprehensive Accreditation Manual for Long Term Care (CAMLTC). See also Long term care

accreditation importance, Oct 2001, 4, 11

erratum, Mar/Apr 2000, 10; Mar 2001, 5

initial assessments, Oct 2001, 5-7

interim survey process for anesthesia care standards, Jan/Feb 2000, 4

pain management, Oct 2001, 4, 11

pharmacy-related accreditation activities to home care program, Nov/Dec 2000, 15

rehabilitation standards, Jul/Aug 2000, 4

revisions, Sep 2001, 6-7

standards revisions for 2001, Jul/Aug 2000, 9; Nov/Dec 2000, 7

anesthesia care, Jul/Aug 2000, 9, 10-12

education, Jul/Aug 2000, 9, 13

emergency management, Jul/Aug 2000, 9, 19-20

environment of care, Jul/Aug 2000, 18-19

fire drills, Jul/Aug 2000, 9, 19

information management, Jul/Aug 2000, 9, 21

licensure verification at expiration, Nov/Dec 2000, 8

utility systems management, Jul/Aug 2000, 9, 19

Comprehensive Accreditation Manual for Long Term Care Pharmacies (CAMLTCP). See also Long term care pharmacy accreditation program; Standards Manual for Home Care Pharmacies

standards revisions for 2001, Jul/Aug 2000, 9; Nov/Dec 2000, 7

education, Jul/Aug 2000, 9, 13

environment of care, Jul/Aug 2000, 18-19

information management, Jul/Aug 2000, 9, 21

licensure verification at expiration, Nov/Dec 2000, 8

Comprehensive Accreditation Manual for Managed Behavioral Health Care (CAMMBHC)

integrating outcomes into accreditation process, Jan/Feb 2000, 1, 3

standards revisions for 2001, Nov/Dec 2000, 7

credentialing practitioners, Nov/Dec 2000, 18

licensure verification at expiration, Nov/Dec 2000, 8

reviewing records and practices, Nov/Dec 2000, 18

Comprehensive Accreditation Manual for Pathology and Clinical Laboratory Services (CAMPCLS). See also Laboratory accreditation program

standards revisions for 2001, Jul/Aug 2000, 9; Nov/Dec 2000, 7

environment of care, Jul/Aug 2000, 18-19

information management, Jul/Aug 2000, 9, 21

licensure verification at expiration, Nov/Dec 2000, 8

Conditional Accreditation, Jan/Feb 2000, 11; May/Jun 2000, 11; Sep 2001, 5; Aug 2003, 1, 3, 4; Jan 2004, 19; Sep 2004, 6; Nov 2004, 3; Jul 2005, 11; Oct 2005, 4, 5; Apr 2006, 8; Aug 2006, 4; Dec 2006, 1, 3; Apr 2007, 5; Aug 2007, 5–7

and on-site validation surveys, Jan 2006, 5

thresholds, Nov 2004, 3; Dec 2005, 9; May 2006, 1, 3; Dec 2006, 1, 3

follow-up, Jul 2005, 11; Aug 2006, 4

thresholds, Dec 2007, 4

Conditional Certification, Sep 2007, 11–12

Conditions of Participation, Jul/Aug 2000, 3; Sep/Oct 2000, 3; Nov/Dec 2000, 1. See also Medicare

Confidential information, Oct 2007, 8

Confidentiality of information, Mar 2002, 5; Sep 2005, 7, 9

litigation disclosure, Mar 2002, 5

Confidentiality, security, and integrity of data and information, Jul/Aug 2000, 21

Conflict of interest policy, Jan 2003, 7; Dec 2003, 5

changes to, Jan 2003, 7

Congressional hearings, Aug 2002, 1, 3

health care safety, Aug 2002, 1, 3

patient safety, Mar/Apr 2000, 12; May/Jun 2000, 13-14

Connect™ extranet site, Jun 2007, 12

Construction barriers, Mar 2001, 8

Consultant use

surveyors for, Jun 2003, 6

Consultation services, Feb 2002, 1

Consumer protection and rights and assisted living community ethics (RI)

medical emergencies management, Sep 2002, 7-8

sexual orientation lifestyle choices, Sep 2002, 6-7

Continuing education, Nov 2001, 4-5

Continuous Service Readiness Program, Oct 2007, 11

Continuum of care (CC)

discharge planning, Nov/Dec 2000, 13

patient safety, Nov/Dec 2000, 12

standard revisions, managed care plans, Jul 2002, 11-12

standards consolidation and revision, Feb 2001, 4

Contracted patient care services, Feb 2003, 5, 8

Contracted services, Nov 2005, 6

clarification of, Mar 2006, 2

and periodic performance review, Nov 2005, 6

standards revisions, Jul 2007, 4–5, 6–8

Control charts, May/Jun 2000, 3, 4; Jan 2001, 10-11

Cooperative Accreditation Initiative, May 2005, 11; Apr 2006, 4

criteria for agreements, May 2005, 11

revisions to, May 2005, 11

Cooperative planning

in emergency management plan, Mar 2003, 6

Copyright, Perspectives, Jun 2006, 3

Core measure data collection activities, Jul 2001, 5

Core measures, hospitals, Jan/Feb 2000, 1; May/Jun 2000, 9-10, 14; Jul/Aug 2000, 5; May 2002, 7-8. See also ORYX

approved core measure sets, May/Jun 2000, 9

expert panels for, May/Jun 2000, 9

implementation plan, May/Jun 2000, 9-10, 14

information line, May/Jun 2000, 14

and patient safety, Sep/Oct 2000, 1

pilot test, May/Jun 2000, 10, 14

pilot testing, May 2002, 7

staffing sufficiency, May 2002, 8

Crafton, Mark A., Jul/Aug 2000, 5

Credentialing. See also Medical staff

designated equivalent source correction, May 2002, 5

hospital-based programs, Jan/Feb 2000, 9

initial surveys, Apr 2001, 2

license verification at expiration, Nov/Dec 2000, 8

short term designation of licensed independent practitioner, Aug 2005, 7

standards revisions, Feb 2003, 10

Credentialing and privileging standards revisions for long term care, Feb 2002, 5, 6-7

Federation of State Medical Boards (FSMB), Mar 2002, 11

Credentials verification, Jan 2003, 6

primary source data, Jan 2003, 6

Creutzfeldt-Jakob Disease (CJD), Aug 2001, 10-11

risk factors, Aug 2001, 10

risk-reduction strategies, Aug 2001, 10-11

Critical access hospitals, Jul/Aug 2000, 3; Jan 2001, 3

2005 National Patient Safety Goals, Aug 2004, 5-6, 10

abbreviations do-not-use list, Aug 2005, 4

Accreditation Participation Requirement revision, Nov 2006, 7

changes in 2004 Dec 2003, 13

compliance issues, Nov 2003, 3-4

compliance issues for 2003, May 2004, 3-4

contracted services standards revisions, Jul 2007, 4–5, 6–8

core measure correction, Mar 2004, 2

credentialing and privileging revisions, Jun 2006, 8

decision rule, Apr 2007, 5

emergency department standards revisions, Jul 2007, 3

emergency management standards, Jun 2008, 1, 3–6

emergency management standards revisions, Jun 2007, 1, 3–10

hand hygiene, Mar 2006, 3

hand hygiene guidelines, Feb 2008, 4–7

infection control requirement, Jun 2006, 10–11

information management standard revision, Aug 2005, 6

leadership standards revisions, Aug 2005, 5

Life Safety Code® compliance, Apr 2003, 8

and Life Safety Code Specialists, Aug 2007, 13

look-alike, sound-alike drugs, Oct 2004, 5-7

management of human resources revisions, Jun 2006, 8

manual changes, Jan 2008, 11

measurement of organ procurement effectiveness, Mar 2005, 5

medication management revision, Apr 2005, 8

National Patient Safety Goals, Jul 2005, 4-5, 8-10; Aug 2005, 9-10; July 2006, 1, 5, 13–16, 30–31

National Patient Safety Goals (2008), Jul 2007, 1, 9–22

Nursing chapter, Nov 2006, 10-11

ORYX performance measurement requirements, Mar 2006, 9-12

patient flow system tracer, Mar 2008, 10

physical practices, Jan 2008, 11

primary source verification implementation, May 2005, 5

primary source verification revision, Mar 2005, 3-4

and Priority Focus Process reports, Sep 2007, 8

roller latches usage, Mar 2004, 5-6

standard corrections and/or revisions, Dec 2004, 7; Mar 2005, 8-9; Jun 2005, 7, 10; Jul 2005, 12-13; Feb 2006, 5; May 2006, 7; standard revisions, Jun 2006, 7, 9–10; July 2006, 3; Sep 2006, 10; Nov 2006, 10–11; Jun 2007, 14, 15; Sep 2007, 3–6; Nov 2007, 8, 9; Dec 2007, 5; Jan 2008, 6, 7; Feb 2008, 4; Apr 2008, 7

Standards Improvement Initiative, Oct 2007, 9; Dec 2007, 7

electronic manual, Jun 2008, 11

and standards improvement initiative (SII), Dec 2006, 5; Apr 2007, 1, 3

standards requirements, Jan 2002, 1

and Statement of Conditions™, Oct 2005, 7-8

survey process, Jan 2002, 1-2

track record requirements, Jan 2008, 4–5

transplant and implant tissue storage and issuance standards, Feb 2005, 8-9

unannounced surveys, Apr 2008, 1, 3–4

Universal Protocol, Jul 2006, 30–31

and USP-NF survey compliance, Apr 2004, 4

Critical care hospital

labeling of medications revision, Feb 2006, 3

Critical focus areas, Oct 2002, 2

Cultural barriers and language needs, Jun 2008, 10

Cultural and linguistic services, Nov 2004, 5

study of, Nov 2004, 5

Customers First Initiative, Nov 2006, 2

Cytology proficiency testing, May 2005, 6

Daily briefing, Jan 2004, 12

Damper testing requirements, Sep 2007, 8

Data collection

on language and communication needs, Aug 2005, 6

for long term care staffing effectiveness, Jun 2003, 8-9

on standards compliance issues, Apr 2005, 6

Data entry

manual, Apr 2007, 3

Data and information, standards for, Jul/Aug 2000, 21

Data and information submission, Jun 2005, 7-8

Data release to government agencies, Apr 2005, 4

and confidentiality of information, Apr 2005, 4

revisions to, Apr 2005, 4

Data set, Apr 2006, 3

expansion in hospitals, Apr 2006, 3

Decision rules, Aug 2003, 1, 3-7; Aug 2006, 1, 3–6

accreditation, Aug 2003, 5

Accredited, Aug 2006, 6

additions to, Aug 2006, 1

clarifications to, Aug 2006, 1

Conditional Accreditation, Aug 2003, 4; Aug 2006, 4

Denial of Accreditation, Aug 2006, 3

evidence of standards compliance (ESC), Aug 2003, 3, 5, 6

measure of success (MOS), Aug 2003, 5, 6

Preliminary Accreditation, Aug 2003, 5; Aug 2006, 6

Preliminary Denial of Accreditation, Aug 2003, 4; Aug 2006, 3–4

Provisional Accreditation, Aug 2003, 4-5; Aug 2006, 4–5

Decontamination education, Dec 2001, 3

bioterrorism preparedness, Dec 2001, 20-21

Deemed status, Sep/Oct 2000, 15; Nov/Dec 2000, 1, 3; Feb 2002, 8; Jul 2002, 8; Jun 2008, 9

and ambulatory care surgical centers, Feb 2003, 7

certification, Jan 2003, 10

for laboratories, Jan 2003, 10

compliance, Jul/Aug 2000, 15; Nov/Dec 2000, 1, 3

disparity rate, Nov/Dec 2000, 1

for HMOs and PPOs, Jul 2002, 8

opioid addiction treatment programs, Feb 2002, 8

Deep sedation/analgesia, Jul/Aug 2000, 10

Deep vein thrombosis (DVT), Jan 2005, 5; Nov 2005, 3

Dementia special care unit (DSCU)

standards requirements changes, Jun 2001, 5

Denial of Accreditation, Nov/Dec 2000, 5; Jan 2004, 19; Jul 2005, 10, 11; Oct 2005, 4; Aug 2006, 3; Aug 2007, 4–5

Denial of certification, Sep 2005, 4; Sep 2007, 10

Department of Health and Human Services. See also Health Care Finance Administration

and critical access hospitals, Jul/Aug 2000, 3

Office of Inspector General, Jan/Feb 2000, 6; Sep/Oct 2000, 3; Nov/Dec 2000, 3, 13

reports on health care quality, Sep/Oct 2000, 3

Diabetes management, Aug 2001, 5

performance measurement, Aug 2001, 5

Digital Alarm Communicator Transmitter (DACT), Mar 2008, 5

Dimensions of performance, Jan/Feb 2000, 5

Disasters

lessons learned through, Mar 2006, 5-7, 15

Disaster drills

and mock patients, Mar 2001, 8

Disaster preparedness, Dec 2005, 1, 8

planning guide, Dec 2005, 1, 8

“Standing Together” examples, Dec 2005, 1, 8

Disaster privileges, Feb 2003, 6

Discharge planning

and behavioral health care, Sep/Oct 2000, 3

criteria outlined for plan of care, Nov/Dec 2000, 13

in hospitals, Nov/Dec 2000, 13

informing patients of discharge/transfer planning activities, Nov/Dec 2000, 13

Discharge records, Sep 2001, 6-7

Disease reduction in elderly

for assisted living, Jul 2005, 4

for disease-specific care, Jul 2005, 5

for long term care, Jul 2005, 8

Disease-specific care (DSC) certification programs, Aug 2001, 4; Apr 2002, 5-6; Jan 2003, 9-10; Feb 2006, 1, 11

Disease-specific care

2005 National Patient Safety Goals, Aug 2004, 6-7

abbreviations do-not-use list, Aug 2005, 4

annual subscription billing, Nov 2007, 6

certification, Aug 2001, 4

certification decision rules, Sep 2007, 10–14

Certification Participation Requirements, Dec 2005, 3-5

chronic kidney disease (CKD), Feb 2006, 1, 11

development of, Aug 2001, 4

EP scoring category changes, Aug 2006, 7–8

hand hygiene, Mar 2006, 3

hand hygiene guidelines, Feb 2008, 4–7

look-alike, sound-alike drugs, Oct 2004, 8-9

lung volume reduction surgery (LVRS), Feb 2006, 1, 11

manual updates, Nov 2007, 9

measurement requirements, May 2004, 2

National Patient Safety Goals, Mar 2004, 1, 4; Jul 2005, 5; Aug 2005, 9-10; July 2006, 1, 5, 16–19, 30–31

National Patient Safety Goals (2008), Jul 2007, 1, 9–22

performance measurement requirements revisions, Jun 2007, 11

policy revisions to, Jan 2003, 9-10

primary stroke center certification, Jun 2005, 3-6

and Quality Check®, Jun 2008, 9

recertification reviews correction, Aug 2006, 9

review process for certification, Apr 2002, 5-6

standards for, Apr 2002, 6

standards revisions, Jun 2005, 10

track record requirements, Jan 2008, 4–5

Universal Protocol, Jul 2006, 30–31

Disparity rates, Nov/Dec 2000, 1, 3

Early Survey Policy

Option 2 correction, Jun 2004, 3-4

Education (PF)

basic health practices and safety, Jul/Aug 2000, 13

behavioral health care safety and error reduction standard revisions, May 2002, 10

emergency management programs, Dec 2001, 3

improving efforts, Feb 2001, 11

medical equipment or supplies, Jul/Aug 2000, 13

nutrition, Jul/Aug 2000, 13

patient safety, Nov/Dec 2000, 12

resident safety and error reduction standard revisions, Apr 2002, 7-8

Education and communication

standard revisions, managed care plans, Jul 2002, 12

Eisenberg, John M., Nov 2007, 1, 3–4; Mar 2008, 12, 13

and Codman Award, Jan 2008, 3

Eisenberg Patient Safety and Quality Awards, John M., May 2003, 2; Nov 2003, 6; Nov 2004, 6-7; Nov 2005, 9

Patient Safety and Quality Award, Nov 2006, 6–7

Electronic application for survey. See Online application for survey

Electronic manual (E-dition), Jun 2008, 11

Electronic Statement of Conditions™ (e-SOC), Nov 2006, 1, 3; Jan 2008, 8

Electronic submissions

of complaints, Jun 2006, 1, 3

of sentinel event reporting, Jun 2006, 1, 3

Statement of Conditions, Jun 2006, 4

Elements of performance (EPs), Dec 2003, 13; Apr 2006, 9

corrections, Dec 2003, 6-12; Feb 2004, 10-12; Mar 2004, 7; Apr 2004, 6

scoring clarification, Jan 2006, 10

Emergency care services

filming/videotaping of, Nov/Dec 2000, 6

Emergency department standards revisions, Jul 2007, 3

Emergency drills, Sep 2002, 9-10

Emergency identification, Dec 2001, 3

Emergency management, Dec 2001, 1-24

analysis of hazard vulnerability, Dec 2001, 8-9

assessment process, Dec 2001, 6-7

checklist, Dec 2001, 11

checklist correction, Mar 2002, 3

communication during crisis, Dec 2001, 16-17

community integration, Jun 2002, 9-10

communitywide sharing of information, Jun 2002, 5-6

and cooperative planning, Mar 2003, 6; May 2003, 5

and disaster preparedness, Dec 2005, 1, 8

education programs, Dec 2001, 3

failure mode, effect, and criticality analysis (FMECA), Dec 2001, 9

fiscal responsibilities, Jun 2002, 9

and Greater New York Hospital Association, Apr 2003, 9-11

learned lessons from September 11, Dec 2001, 12

managing people and resources, Dec 2001, 12, 18

mental health issues, Jun 2002, 10

mental health needs follow-up, Dec 2001, 19, 23

national bioterrorism response, Dec 2001, 2

nuclear biological and chemical decontamination, Dec 2001, 20-21

preparation, Dec 2001, 13-15

preparation for mass casualty event, Dec 2001, 10-11

resources, Dec 2001, 24

response during natural emergency, Dec 2001, 22-23

standards, Dec 2001, 4-5

standards compliance expectations, Jun 2008, 1, 3–6

standards revisions, Jun 2002, 5-6; Jun 2007, 1, 3–10

survey process preparation, Jun 2002, 6-7

survey process requirements, Feb 2002, 1

Emergency management plan

emergency privileging of LIPs, Sep 2002, 4

Emergency preparedness, Jul/Aug 2000, 19-20

and OSHA, Oct 2004, 1

public policy roundtable, Apr 2002, 3

E-mail communication, Jun 2004, 7, 9

Endoscope reprocessing, Jan/Feb 2000, 8

Environment of care. See also Management of the environment of care

generator tests, Jun 2007, 18

inaccessible fire and smoke dampers, Jun 2007, 18–19

roller latches, Mar 2004, 5-6

Environment of care session, Jan 2004, 13

Environment of care requirements

building design, May 2001, 4-5

common questions on, Mar 2001, 8

equipment maintenance, May 2001, 4-5

patient safety, May 2001, 4, 9

Environmentally preferable purchasing (EPP), Jan/Feb 2000, 12

Environmental Protection Agency (EPA), Mar 2001, 8

Environmental safety and equipment management (EC)

emergency drills, Sep 2002, 9-10

hazard vulnerability analysis, Sep 2002, 9-10

Epidemics management, Jul 2004, 4

Equipment maintenance requirements, May 2001, 4-5

Ergonomics

and OSHA, Oct 2004, 1

Ernest A. Codman Awards, Jan 2008, 3, 10

application availability, Mar 2003, 4, 10

categories for, Mar 2003, 4

Eisenberg, John MD, Apr 2003, 7

and Eisenberg Award, Jan 2008, 3

learning from award winners, Mar/Apr 2000, 3-5

Noble, John MD, Apr 2003, 7

recipients, Jan/Feb 2000, 13; Mar/Apr 2000, 1; Feb 2003, 1, 3; Jan 2005, 4

review process, Mar 2003, 4, 10

Event notification posting time, Apr 2007, 4

Evidence of performance (EP)

scoring criteria categories, Oct 2003, 10

Evidence of Standards Compliance (ESC), Jul 2003, 4; Aug 2003, 3, 5, 6; Apr 2004, 9; Sep 2005, 5; Apr 2006, 8–9; Aug 2006, 5; Aug 2007, 7­–8; Sep 2007, 13

clarification process, Nov 2007, 7

on-site survey, Aug 2006, 5

and random unannounced on-site validation surveys, Dec 2005, 6

submission of report, Jan 2004, 18-19, 21

time line, Aug 2003, 6

Evidence of Standards Compliance Report, Apr 2005, 6

time frame reduction, Apr 2005, 6

Exit conference, Apr 2004, 9

Exit maps, Mar 2001, 8

Extension survey, Jul/Aug 2000, 3; Nov/Dec 2000, 14; Nov 2002, 5

External Quality Review of Psychiatric Hospitals, Sep/Oct 2000, 3; Nov/Dec 2000, 13

External Review of Hospital Quality, Jan/Feb 2000, 6; Sep/Oct 2000, 3; Nov/Dec 2000, 3

Extranet site, Apr 2007, 4

Extranet service

certification customer access, Dec 2006, 4

Fact on Fiction, The, Nov 2002, 3; Mar 2006, 4; Oct 2007, 4; Apr 2008, 5–6

accreditation fees, Mar 2006, 4

accreditation survey preparation, Feb 2005, 7

clinical/service groups (CSG), Apr 2004, 11

disease-specific care recertification reviews, Aug 2006, 9

infection control data, Apr 2005, 10

National Patient Safety Goals, Nov 2003, 7

Periodic Performance Review (PPR), Apr 2004, 10-11; May 2004, 10

PPR Option 2, Nov 2003, 7

priority focus areas (PFA), Apr 2004, 11; May 2004, 10

Quality Report, Nov 2003, 7

rapid response teams, Mar 2006, 4

Shared Visions–New Pathways, inaccuracies, Mar 2003, 6

surveyor preparation, Apr 2004, 11

tracer methodology, Apr 2004, 10

unannounced surveys, Apr 2004, 10-11

Failure mode, effect, and criticality analysis (FMECA), Dec 2001, 9

Failure mode and effects analysis (FMEA), Nov 2002, 6; Jan 2004, 15-16

Fair hearings and appeals, Mar 2004, 9-10

Fall prevention; Aug 2005, 10; July 2006, 10, 15–16, 21, 24, 28–29

for assisted living, Jul 2005, 4

for critical access hospitals, Jul 2005, 5

for disease-specific care, Jul 2005, 5

for home care, Jul 2005, 6

for hospitals, Jul 2005, 7

for long term care, Jul 2005, 8

FAQs (Frequently Asked Questions), Dec 2004, 5

standards clarification, Dec 2004, 5

Fatal falls, Jan 2001, 9

Federation of State Medical Boards (FSMB), Mar 2002, 11

Fees, survey, Jan/Feb 2000, 5-6; Oct 2004, 11

clarification of, May/Jun 2000, 10

Financial stability

and emergency management plans, Jun 2002, 9

Fire safety; Mar 2008, 4

and assisted living, Sep 2003, 6-7, 11

Digital Alarm Communicator Transmitter (DACT), Mar 2008, 5

equipment maintenance, Jan 2008, 7

prevention of surgical fires, Sep 2003, 10-11

transmitting of alarm signals, Mar 2008, 4–5

Fire and smoke dampers, Jun 2007, 18–19

testing frequency requirements, Jun 2007, 19

Focused practitioner performance review, Sep 2003, 5

Focused surveys, Feb 2001, 6-7

Food and Drug Administration (FDA), Jan/Feb 2000, 8; Mar 2001, 8

Center for Devices and Radiological Health (CDRH), Jan/Feb 2000, 8

Franklin Award of Distinction, Jan 2003, 8; Oct 2007, 9

evaluation criteria for, Jan 2003, 8

Frequently Asked Questions. See FAQs.

Future accreditation process. See Oversight Task Force for Accreditation Process Improvement

Generator tests, Jun 2007, 18

Gift Policy, May 2007, 11

Good practices database, May 2001, 6, 10

Governing body

delegation of appointment and reappointment, Nov/Dec 2000, 9

of Joint Commission, Jan/Feb 2000, 6; May/Jun 2000, 5, 9; Sep/Oct 2000, 10

Government Accountability Office study, May 2006, 13

Greater New York Hospital Association (GNYHA), Apr 2003, 9-11

communication systems, Apr 2003, 9

Emergency Preparedness Coordinating Council (EPCC), Apr 2003, 9

Hospital Emergency Response Data System (HERDS), Apr 2003, 9

Hand hygiene, Mar 2006, 3; May 2007, 12; Apr 2008, 6

guidelines, Feb 2008, 4–7

hand rubs, Mar 2006, 3

measurement methods, May 2007, 12

Hand rubs, alcohol-based, Jul 2006, 3

Handwashing guidelines, Mar 2003, 9-10

Hazardous materials and waste, Jan/Feb 2000, 12-13

regulations, Mar 2001, 8

Hazard vulnerability analysis (HVA), Dec 2001, 8-9; Sep 2002, 9-10

Hazelden Foundation case study, performance measurement data, Apr 2001, 9-10

Health care–acquired infections, Sep 2003, 1, 3

Health care-associated infection risk reduction

for ambulatory care, Jul 2005, 3

for assisted living, Jul 2005, 3

for behavioral health care, Jul 2005, 4

for critical access hospitals, Jul 2005, 5

for disease-specific care, Jul 2005, 5

for home care, Jul 2005, 6

for hospitals, Jul 2005, 7

for laboratory, Jul 2005, 7

for long term care, Jul 2005, 8

for office-based surgery, Jul 2005, 3

Health Care Financing Administration (HCFA), May/Jun 2000, 5; Jul/Aug 2000, 3; Sep/Oct 2000, 1; Nov/Dec 2000, 1, 3, 12; Mar 2001, 7

allegation surveys, Nov/Dec 2000, 1, 3

and Hospital Quality Oversight Initiative, Nov/Dec 2000, 3

Interim Final Rule for Patient Rights, Sep/Oct 2000, 15

Life Safety Code^® compliance, Nov/Dec 2000, 3

Medicare validation program, Nov/Dec 2000, 1

“one-hour rule,” restraint, Jul/Aug 2000, 15; Sep/Oct 2000, 15

and patient safety, Sep/Oct 2000, 1

PRO (peer review organization) 6th Scope of Work, May/Jun 2000, 10

quality oversight process, Sep/Oct 2000, 3

reporting of disparity rate, Nov/Dec 2000, 1

validation surveys, Nov/Dec 2000, 1, 3

Healthcare Information Technology Advisory Panel, Nov 2005, 10-11

Health care network accreditation program. See also Comprehensive Accreditation Manual for Health Care Networks (CAMHCN)

establishing networkwide care standards, Codman Award winner, Mar/Apr 2000, 5

integrating outcomes into accreditation process, Jan/Feb 2000, 1, 3

Health care networks

accreditation revisions, Nov 2003, 7-8

appendices additions, Mar 2002, 5

and competence assessment, Jan 2001, 6-7; May 2001, 6

changes in 2004, 13

compliance issues, Nov 2003, 4

compliance issues for 2003, May 2004, 4

credentialing standards revisions, Feb 2003, 10

errata to 2004 requirements, May 2004, 6-7

and National Patient Safety Goals, Sep 2003, 9; July 2006, 1, 5–31

National Patient Safety Goals (2008), Jul 2007, 1, 9–22

scoring revisions, Feb 2001, 5

standards changes, Dec 2002, 3

standards revisions, Jul 2002, 2, 10

supplement, Nov 2001, 2

top type I recommendations, Apr 2001, 6

Health Care Quality Measurement and Reporting, May/Jun 2000, 14

Health care safety

congressional hearings, Aug 2002, 1, 3

Health Care Staffing Services Certification, Feb 2005, 1, 7; Jan 2006, 6; Apr 2008, 6

annual subscription billing, Nov 2007, 6

certification decision rules, Sep 2007, 10–14

certification manual, Dec 2007, 11

Certification Participation Requirements, Dec 2005, 3-5

hand hygiene guidelines, Apr 2008, 6

Periodic Performance Review, Apr 2007, 6, 7; Dec 2007, 9

and Quality Check®, Jun 2008, 9

revised review cycle, Jan 2006, 6

standardized performance measures, Jul 2007, 23

standard revisions, Nov 2006, 9

track record requirements, Jan 2008, 4–5

Health Insurance Portability and Accountability Act (HIPAA), Sep/Oct 2000, 11; Mar 2001, 7; Jul 2001, 7, 11

disclosure policies, Jul 2001, 7

and JCAHO, Jul 2001, 7

and JCAHO standards, Jul 2001, 7, 11

regulations coverage, Jul 2001, 7

regulations implementation, Jul 2001, 11

and state laws, Jul 2001, 7

Health literacy, May 2007, 13

Health practices, Jul/Aug 2000, 13

Health promotion and disease prevention

standard revisions, managed care plans, Jul 2002, 12-13

Health services coordinator., Jul/Aug 2000, 2

Helfrick, John F., Sep/Oct 2000, 10, 13

Hepatitis vaccination requirements, Sep/Oct 2000, 11

High-alert medications, Sep 2003, 3, Jul 2004, 3

Hinsdale Hospital, case study, Jul 2002, 6-8

staffing effectiveness requirements, Jul 2002, 6-8

HIPAA. See Health Insurance Portability and Accountability Act

History & physical examinations (H&Ps), Apr 2001, 8

History and physicals

medical staff requirements, Nov/Dec 2000, 9, 13

Home care

2005 National Patient Safety Goals, Aug 2004, 7

abbreviations do-not-use list, Aug 2005, 4

accreditation decision methodology refinements, Aug 2006, 8

accreditation manual corrections, Jan 2006, 7

Accreditation Participation Requirement correction, Jun 2006, 5

Accreditation Participation Requirement revision, Nov 2006, 7

appendices revisions, May 2006, 9–13

applicability grid correction, Dec 2006, 3

award display and use correction, Feb 2006, 8

biannual comprehensive manual updates, Nov 2005, 8, 11

clinical/service groups (CSGs), Oct 2003, 7, 11

and competence assessment, Jan 2001, 6-7; Apr 2001, 11; Nov 2001, 8-9

compliance issues, Nov 2003, 4

compliance issues for 2003, May 2004, 4

and continuum of care standards, Feb 2001, 4

contracted services standards revisions, Jul 2007, 4–5, 6–8

decision rule, Apr 2007, 5

elements of performance revisions, May 2004, 7, 8, 9

e-mail communication on PPR, Jun 2004, 7, 9

epidemics management standard, Jul 2004, 4

errata to manual applicability grid, Jan 2005, 2

errata to standards and elements of performance, Dec 2003, 7, 9-10

fires in, May 2001, 10

hand hygiene, Mar 2006, 3; May 2007, 12

hand hygiene guidelines, Feb 2008, 4–7

home medical equipment services revision, Feb 2006, 10

implementation of program-specific tracers, Nov 2006, 4–5

infection control revisions, Feb 2004, 5-6

information management standard revision, Aug 2005, 6

look-alike, sound-alike drugs, Oct 2004, 8-9

management of human resources revisions, Jun 2006, 8

manual correction, Dec 2007, 9–10; Jan 2008, 8–9

and Medicare certification, Jan 2008, 6, 7

medication management revision, Apr 2005, 8

and National Patient Safety Goals, Feb 2004, 6-7; Jul 2005, 6; July 2006, 1, 5, 19–22

for 2008, Jul 2007, 1, 9–22

revision, Aug 2005, 8

matrix, Aug 2005, 9-10

online application for survey, Aug 2001, 1, 3

ORYX performance measurement requirements, Mar 2006, 9-12

and ORYX data submissions, Jan 2001, 2

and ORYX data transmission requirements, Dec 2002, 6-7, 15

patient safety standards revisions, Jul 2003, 6-11

Periodic Performance Review (PPR), Sep 2004, 1, 3, 8-9; Jan 2005, 1, 3

and Periodic Performance Review (PPR), Jun 2003, 7; Oct 2003, 1-5; Nov 2005, 6

pilot survey, Jan 2004, 14-15

priority focus process reports, Nov 2006, 3

and random unannounced surveys, Jan 2001, 5; Sep 2003, 4

random unannounced surveys, Jan 2005, 3; Dec 2005, 7

random unannounced survey topics, Dec 2002, 1, 3

revisions to CAMHC, Jan 2003, 6, 11

revisions to management of information, Jun 2003, 3

scoring revisions, Feb 2001, 5; Aug 2004, 13-14

standards changes, Dec 2002, 3; Feb 2006, 5

Standards Improvement Initiative (SII), Dec 2006, 5; Apr 2007, 1, 3; Oct 2007, 9; Dec 2007, 7

electronic manual, Jun 2008, 11

standards revisions, Jun 2005, 7, 10; Jul 2005, 12, 13; Jun 2006, 9–10; July 2006, 3

Standards Review Project, Jan 2004, 3-4

system accreditation option changes, Aug 2006, 8

survey changes, Jan 2001, 4

standards revisions, Jun 2004, 5

waived testing revisions, Jul 2004, 7-8

survey notification omission, Mar 2004, 6-7

systems accreditation evaluation approach, May 2005, 8

system accreditation option refinements, May 2006, 4–5

track record requirements, Jan 2008, 4–5

top type I recommendations, Apr 2001, 6-7

unannounced surveys, Apr 2008, 1, 3–4

updated manual for, Oct 2004, 11

and USP-NF survey compliance, Apr 2004, 4

Home care accreditation program. See also Comprehensive Accreditation Manual for Home Care

consolidating pharmacy-related accreditation activities, Nov/Dec 2000, 15

determination of eligibility for accreditation program, Nov/Dec 2000, 16-17

improving timeliness of care, Codman Award winner, Mar/Apr 2000, 4-5

integrating outcomes into accreditation process, Jan/Feb 2000, 1, 3

random unannounced surveys, Sep/Oct 2000, 6-9

redesign, Nov/Dec 2000, 16

Home care organizations

standard revisions, Sep 2002, 9-10, 11

Home medical equipment

standards corrections, May 2007, 4

HomeReach, Jan 2001, 3, Mar 2001, 1, 2

Hospital accreditation program. See also Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH); Hospitals

critical access hospitals, Jul/Aug 2000, 3

health advisory on endoscope reprocessing, Jan/Feb 2000, 8

integrating outcomes into accreditation process, Jan/Feb 2000, 1, 3

interim survey process for anesthesia care standards, Jan/Feb 2000, 4

maintaining survey readiness, Sep/Oct 2000, 4, 5

Medicare validation program, Nov/Dec 2000, 1, 3

off-shift survey visits, Mar/Apr 2000, 7; Sep/Oct 2000, 3; Nov/Dec 2000, 10-11

patient-centered care, Codman Award winner, Mar/Apr 2000, 4

patient unit visits, Mar/Apr 2000, 6

random unannounced surveys, Sep/Oct 2000, 6-9

survey process changes

in 2000, Jan/Feb 2000, 10-11; Mar/Apr 2000, 2, 6

in 2001, Nov/Dec 2000, 10-11

Hospital Quality Measures Project, Sep/Oct 2000, 2

Hospitals. See also Comprehensive Accreditation Manual for Hospitals (CAMH); hospital accreditation program

2005 National Patient Safety Goals, Aug 2004, 7-8, 10

abbreviations do-not-use list, Aug 2005, 4

accreditation decisions thresholds, May 2006, 1, 3

accreditation manual corrections, Jan 2006, 7

Accreditation Participation Requirement corrections and/or revisions, Jun 2006, 5; Nov 2006, 7; Aug 2007, 11; Feb 2008, 3

accreditation process correction, May 2005, 7

award display and use correction, Feb 2006, 8

and behavioral restraint, Jan 2001, 8

biannual comprehensive manual updates, Nov 2005, 8, 11

CAMH Update changes, Apr 2003, 4

clinical/service groups, Aug 2003, 9-10

and competence assessment, Jan 2001, 6-7

completing history and physicals, Apr 2001, 8

compliance issues, Nov 2003, 4-5

compliance issues for 2003, May 2004, 4-5

and continuum of care standards, Feb 2001, 4

contracted patient care services, Feb 2003, 5, 8

contracted services standards revisions, Jul 2007, 4–5, 6–8

cooperative planning in emergency management, Mar 2003, 6

core measures, Jul 2001, 5; May 2002, 7-8

credentialing and privileging revisions, Jun 2006, 8

cultural and linguistic issues, Nov 2004, 5

and developing habits, Oct 2001, 1-3

data set expansion, Apr 2006, 3

decision rule, Apr 2007, 5

disaster privileges, Feb 2003, 6

and environment of care standards, May 2001, 4-5, 9

element of performance correction, Mar 2004, 7

elements of performance revisions, Apr 2004, 6; May 2004, 7, 8, 9

e-mail communication on PPR, Jun 2004, 7, 9

emergency department standards revisions, Jul, 3

emergency management standards, Jun 2008, 1, 3–6

emergency management standards revisions, Jun 2007, 1, 3–10

epidemics management standard, Jul 2004, 4

errata to standards and elements of performance, Dec 2003, 6-7, 9-10

establishment of annual national patient safety goals, May 2002, 1-2

hand hygiene, Mar 2006, 3; May 2007, 12

hand hygiene guidelines, Feb 2008, 4–7

implementation of program-specific tracers, Nov 2006, 4–5

improvement projects, Jun 2007, 12–13

infection control requirement, Jun 2006, 10–11

infection control revisions, Feb 2004, 5-6

information management standard revision, Aug 2005, 6

initial assessments, Oct 2001, 5-7

inpatient diabetes certification, Aug 2006, 10–11

intent statement revisions, Jun 2002, 4

Joint Commission Connect™ extranet site, Jun 2007, 12

labeling of medications revision, Feb 2006, 3

leadership standards revisions, Aug 2005, 5

Life Safety Code®® Specialist(s), Dec 2004, 1; Aug 2007, 13

LIP delegation of restraint orders and evaluation, May 2002, 6

look-alike, sound-alike drugs, Oct 2004, 5-7

management of human resources revisions, Jun 2006, 8

management of information scoring clarification, Jun 2004, 10

measurement of organ procurement effectiveness, Mar 2005, 5

and medical/surgical restraint protocols, Jun 2001, 6

medication management revision, Apr 2005, 8

National Patient Safety Goals, Jul 2005, 6-7, 8-10; July 2006, 1, 5, 22–25, 30–31

for 2008, Jul 2007, 1, 9–22

matrix, Aug 2005, 9-10

Nursing chapter, Nov 2006, 10-11

and off-shift visits, Feb 2001, 5

online application for survey, Aug 2001, 1, 3

Organization Performance Reports, Jun 2002, 1

organ retrieval, Feb 2001, 7

ORYX data revisions, Aug 2005, 8

ORYX performance measurement requirements, Mar 2006, 9-12

and ORYX requirements, Sep 2003, 5-6

outpatient performance measures, Jan 2008, 1, 8

patient flow management, Feb 2004, 13-14

patient flow system tracer, Mar 2008, 10

patient safety and error reduction standards, Feb 2001, 1, 3; Mar 2001, 5

patient safety report, May 2007, 1, 3

patient safety standards revisions, Jul 2003, 6, 8-9

patient safety system implementation, Aug 2007, 1, 10

performance measure reporting, May 2008, 4–5

Periodic Performance Review (PPR), Sep 2004, 1, 3, 8-9; Jan 2005, 1, 3

and Periodic Performance Review (PPR), Jun 2003, 7; Oct 2003, 1-5; Nov 2005, 6

pilot survey, Jan 2004, 14-15

primary source verification, Jan 2003, 6; Mar 2005, 3-4

implementation, May 2005, 5

Priority Focus Process (PFP), Aug 2003, 9

priority focus process reports, Nov 2006, 3

quality assessment and performance improvement program, Apr 2003, 8

quality measures, Nov 2004, 1

Quality Reports, Jun 2007, 17

quality and safety report, Dec 2007, 1, 3

and random unannounced surveys, Jan 2001, 5; Sep 2003, 4

random unannounced surveys, Jan 2005, 3

and random unannounced surveys, Dec 2005, 7

random unannounced survey topics, Dec 2002, 1, 3

reviewing standards, Jul 2001, 3

revisions to management of information, Jun 2003, 3

revisions to telemedicine standards, Jun 2003, 4-5

roller latches usage, Mar 2004, 5-6

SCIP venous thromboembolism measure rates, May 2008, 6

scoring revisions, Feb 2001, 5; May 2001, 2

smoke-free campuses, Jun 2007, 10

and staffing effectiveness, Sep 2001, 1, 3-4; Jul 2002, 5-6

staffing effectiveness standard revisions, Feb 2005, 3-5

standard corrections and/or revisions, Jul 2002, 2; Sep 2002, 4; Oct 2002, 14; Jun 2004, 5; Oct 2004, 10; Dec 2004, 3-5, 7; Mar 2005, 8-9; Jun 2005, 7, 9, 10; Jul 2005, 12-13; Feb 2006, 5; Jun 2006, 7, 9–10; July 2006, 3; Sep 2006, 10; Nov 2006, 8, 9, 10–11; Dec 2006, 5; Jun 2007, 14, 15, 16; Aug 2007, 15; Sep 2007, 3–6; Nov 2007, 8, 9; Jan 2008, 6, 7; Feb 2008, 4; Apr 2008, 7

standards compliance, Jul 2001, 3

Standards Improvement Initiative, Dec 2006, 5; Apr 2007, 1, 3; Oct 2007, 9; Dec 2007, 7

electronic manual, Jun 2008, 11

Standards Review Project, Jan 2004, 3-4

and Statement of Conditions™, Oct 2005, 7-8

Strategic Surveillance System (S3), Sep 2006, 1, 3–5; May 2007, 4–5; Jun 2007, 12–13; Sep 2007, 15; Apr 2008, 5–6

supervision of graduate medical students, Aug 2001, 2; Sep 2001, 8

surge hospitals, Feb 2006, 10

Surgical Care Improvement Project (SCIP), Nov 2005, 1, 3

surveyors for small, rural hospitals, Aug 2001, 2

telemedicine requirements, Feb 2003, 4

top type I recommendations, Apr 2001, 7; Feb 2001, 7

track record requirements, Jan 2008, 4–5

transplant and implant tissue storage and issuance standards, Feb 2005, 8-9

unannounced surveys, Apr 2008, 1, 3–4

Universal Protocol endorsement, Feb 2004, 1-4

and USP-NF survey compliance, Apr 2004, 4-5

waived testing revisions, Jul 2004, 7-8

Hospital, Language, and Culture Study, Jun 2008, 10

Human resources. See Management of human resources

Human resources (HR)

certification of basic life support, Sep 2002, 7-8

Hurricane Wilma, Mar 2006, 5-7, 15

communication issues, Mar 2006, 6

community planning, Mar 2006, 6

human resources and staffing, Mar 2006, 7

lessons learned from, Mar 2006, 5-7, 15

patient care issues, Mar 2006, 6

security issues, Mar 2006, 7

transportation issues, Mar 2006, 6-7

Universal Protocol, Jul 2006, 30–31

utilities and facilities, Mar 2006, 7

Hyperbilirubinemia, Jun 2001, 10-11

risk factors, Jun 2001, 10

Immediate threat to life, May 2006, 7; May 2008, 9

and on-site validation surveys, May 2006, 7

situation elimination time limits, May 2008, 9

Implementation task force, May 2008, 7

Import tool e-PFI transmission, Apr 2007, 3

Improving network performance

standard revisions, managed care plans, Jul 2002, 13-14

Improving organization performance (PI)

behavioral health care safety and error reduction standard revisions, May 2002, 10-11

errata to 2004 requirements, May 2004, 7

and ORYX, Jan/Feb 2000, 1, 3

patient safety requirements, Nov/Dec 2000, 12

and random unannounced surveys, Sep/Oct 2000, 7

resident safety and error reduction standard revisions, Apr 2002, 8-9

Individual-centered evaluations, Jan 2001, 1, 3

Individual tracer activity, Jan 2004, 11-12

Infant death and injury, Sep 2004, 14-15

Joint Commission recommendations, Sep 2004, 15

risk reduction strategies, Sep 2004, 15

root cause identification, Sep 2004, 14-15

Infection control, Feb 2003, 11; Aug 2005, 10; July 2006, 7–8, 9, 10, 12, 15, 17, 20, 23–24, 26, 28, 29; May 2008, 10

epidemics management, Jul 2004, 4

handwashing guidelines, Mar 2003, 9-10

root causes and risk reduction strategies, Mar 2003, 9

Speak Up campaign, Dec 2004, 9

Speak Up™ materials, May 2008, 10

Infection control data

public reporting, Apr 2005, 10

Infection control and prevention, Feb 2004, %-6

standards and chapter revision, Feb 2004, 5-6

Infection Control Expert Panel, Apr 2003, 6, 11

panel members, Apr 2003, 6

standards compliance, Apr 2003, 6

Infection control requirement, Jun 2006, 10–11

Influenza and pneumonia, Aug 2005, 10

Influenza vaccination measure, Dec 2007, 8

Information accuracy and truthfulness policy, Jun 2003, 6; Apr 2005, 7; Sep 2006, 10

clarification of, Apr 2005, 7

Information-driven agenda, Jan/Feb 2000, 10-11; Mar/Apr 2000, 2, 16

Information-driven survey agenda, Jan 2001, 3, 4

Information management, Sep 2001, 6-7. See also Management of information

Informed consent

for filming or videotaping of patient care activities, Nov/Dec 2000, 6

Infusion pump safety, Sep 2003, 3

IngentaConnect, Mar 2005, 2

benefits of, Mar 2005, 2

Initial assessments, Oct 2001, 5-7

behavioral health challenges, Oct 2001, 6-7

hospital challenges, Oct 2001, 5

long term care challenges, Oct 2001, 5-6

pharmacy and home care challenges, Oct 2001, 7

strategies for staying in compliance, Oct 2001, 7

Initial surveys

and elimination of track record requirements, Sep 2007, 7–8

Inpatient diabetes certification, Aug 2006, 10–11

In Sight (department), Jan 2001, 2; Feb 2001, 2; Mar 2001, 2; Apr 2001, 2; May 2001, 2; Jun 2001, 2; Jul 2001, 2; Aug 2001, 2; Sep 2001, 2; Oct 2001, 2; Jan 2002, 2; Feb 2002, 2; Mar 2002, 2; Apr 2002, 2; May 2002, 2; Jun 2002, 2; Jul 2002, 2; Aug 2002, 2; Sep 2002, 2; Nov 2002, 2; Dec 2002, 2; Jan 2003, 2; Feb 2003, 2; Mar 2003, 2; Apr 2003, 2; May 2003, 2; June 2003, 2; July 2003, 2; Aug 2003, 2; Sep 2003, 2; Oct 2003, 2; Nov 2003, 2; Dec 2003, 2; Feb 2004, 2; Mar 2004, 2; Apr 2004, 2; May 2004, 2; Jun 2004, 2; Jul 2004, 2; Aug 2004, 2; Sep 2004, 2; Oct 2004, 2; Nov 2004, 2; Dec 2004, 2; Jan 2005, 2; Feb 2005, 2; Mar 2005, 2; Mar 2005, 2; Apr 2005, 2; May 2005, 2; Jun 2005, 2; Jul 2005, 2; Aug 2005, 2; Sep 2005, 2; Oct 2005, 2; Nov 2005, 2; Dec 2; Jan 2006, 2; Feb 2; Mar 2006, 2; Apr 2006, 2; May 2006, 2; Jun 2006, 2; July 2006, 2; Aug 2006, 2; Sep 2006, 2; Oct 2006, 2; Nov 2006, 2; Dec 2006, 2; Jan 2007, 2; Feb 2007, 2; Mar 2007, 2; Apr 2007, 2; May 2007, 2; June 2007, 2; July 2007, 2; Aug 2007, 2; Sep 2007, 2; Oct 2007, 3; Nov 2007, 2; Dec 2007, 2; Jan 2008, 2; Feb 2008, 2; Mar 2008, 2; Apr 2008, 2; May 2008, 2; Jun 2008, 2

Integrated delivery systems

2005 National Patient Safety Goals, Aug 2004, 10

National Patient Safety Goals (2007), July 2006, 30

National Patient Safety Goals matrix, Aug 2005, 9-10

Interpretive Guidelines, Dec 2004, 5

National Patient Safety Goals, Dec 2004, 5

Institute for Healthcare Improvement (IHI), Mar/Apr 2000, 5; Jun 2003, 2; Jul 2003, 2; Mar 2005, 1; Feb 2006,

“100,000 Lives Campaign,” Mar 2005, 1; Feb 2006, 11

quality improvement changes, Mar 2005, 1

Institute of Medicine (IOM), Mar/Apr 2000, 12-14; May/Jun 2000, 13; Sep/Oct 2000, 2

recommendations for improving care, Mar/Apr 2000, 13

report, Crossing the Quality Chasm: A New Health System for the 21st Century, May 2001, 1-3, 8

report, To Err is Human: Building a Safer Health System, Mar/Apr 2000, 12-13; Sep/Oct 2000, 2; Nov 2001, 5

resource list, May 2001, 3

Institute for Safe Medication Practices (ISMP), Mar/Apr 2000, 11; Sep/Oct 2000, 8; Nov 2001, 10

Web site, Nov 2001, 10

Interim weighted decision rules, Mar 2004, 8

International Classification for Patient Safety (ICPS), Nov 2007, 5

International Patient Safety Goals, Feb 2006, 8

Jackson, Marguerite M., Sep/Oct 2000, 10

Jacott, William E., Mar/Apr 2000, 1

"Jayco"® extranet site, Feb 2003, 9; Oct 2003, 6-7; Jan 2004, 23; Apr 2004, 1; Sep 2004, 11, 13; Jan 2006, 4; Dec 2005, 11

information available on, Jan 2006, 4

online site, Oct 2003, 6-7

sample homepage, Oct 2003, 7

security of, Feb 2003, 9

and Shared Visions–New Pathways, Feb 2003, 9

unannounced surveys, Jan 2006, 4

Web site, Feb 2003, 9

JCAHO National Patient Safety Goals. See National Patient Safety Goals

John M. Eisenberg Patient Safety and Quality Awards, Nov 2004, 6-7; Nov 2005, 9; Nov 2006, 6–7

Joint Commission on Accreditation of Healthcare Organizations (JCAHO, Joint Commission)

Accreditation and Certification Operations Dept. interim executive vice president, Apr 2007, 5

anniversary celebration, Nov 2001, 1, 4-5

Annual Invitational Training Conference, Mar 11; Feb 2006, 4

annual national patient safety goals, May 2002, 1-2

Board of Commissioners, Jan/Feb 2000, 6; May/Jun 2000, 5, 9; Sep/Oct 2000, 10; Mar 2002, 3

business associate agreement, Feb 2003, 8

and CDC partnership, Dec 2002, 7

complaint hotline, Sep 2002, 16

Connect™ extranet site, Jun 2007, 12; Apr 2008, 5

corporate priorities, Jan 2002, 4

deemed status and opioid addiction treatments, Feb 2002, 8

efforts to reduce medical errors, Mar/Apr 2000, 12-13

e-mail distributions, Jan 2005, 10-11

extranet site, Sep 2004, 11, 13; Apr 2007, 4

Frequently Asked Questions (FAQs), Jun 2002, 11

gift policy, May 2007, 11

Gold Seal of Approval™, Apr 2004, 9

health literacy, May 2007, 13

history of, Nov 2001, 1, 4-5

Hospitals, Language, and Culture study, Feb 2008, 9; Jun 2008, 10

improvement projects, Jun 2007, 12–13

and infection control-related sentinel events, Mar 2003, 11

International Center for Patient Safety, Apr 2005, 1-2

Invitational Training Conference, Feb 2004, 15

leadership, Jan/Feb 2000, 1; May/Jun 2000, 3; Jul/Aug 2000, 5; Sep/Oct 2000, 2, 19. See also O’Leary, Dennis S.

The Leapfrog Group partnership, Apr 2002, 3

litigation and confidentiality, Mar 2002, 5

Nursing Advisory Council (NAC), Mar 2003, 1-2

Office of Quality Monitoring, Jun 2001, 1-3

pain management measures, Apr 2002, 2, 4

patient safety Web site, Jun 2005, 1-2

performance measures library, Jan 2006, 11

position statement on medical error reporting, Sep/Oct 2000, 12

president, Sept 2007, 1, 9; Oct 2007, 1, 3–4

prohibited terms, Dec 2003, 14-15

public policy action plan, Apr 2002, 1, 3

Quality Check™, Jan/Feb 2000, 6; May/Jun 2000, 5; Nov/Dec 2000, 5; May 2007, 14; Jun 2008, 9

receives grant to study smoke-free hospital campuses, Jun 2007, 10

Report on Quality and Safety, Dec 2007, 1, 3

reporting of sentinel events, Jan 2006, 9

Requirements, Aug 2002, 11; Nov 2004, 9

Resources, Aug 2001, 11

revised mission statement, Jan/Feb 2000, 5

Satellite Network, Mar/Apr 2000, 14; Jul/Aug 2000, 8

security notice, May 2005, 4

seeks feedback on proposed infection control revisions, Jun 2007, 11

Sentinel Event Advisory Group, Jul 2007, 1

Sentinel Event Policy, May 2005, 1, 3-5

Speak Up^SM program, May 2002, 3; May 2007, 14; Jun 2008, 7–8

staff cutbacks, Sep/Oct 2000, 17

Standards Interpretation Group (SIG), Jun 2002, 11; Sep 2002, 4; May 2004, 1

Standards and Survey Procedures (SSP) committee, Jan 2002, 1; Jul 2002, 4; Feb 2006, 5

strategic plan and objectives, Jan 2002, 4

Strategic Surveillance System (S3), Jun 2007, 12–13

subscription billing services, Apr 2005, 5

survey fees, Jan/Feb 2000, 5-6; May/Jun 2000, 10

surveyor certification examinations, Aug 2002, 6-7

Surveyor Conference, Feb 2003, 11

surveyor education, Mar/Apr 2000, 10

Web site, Jan/Feb 2000, 4, 9, 14; May/Jun 2000, 3, 14; Jul/Aug 2000, 3, 8; Sep/Oct 2000, 9; Nov/Dec 2000, 5; Mar 2001, 6-7; Apr 2001, 3; Nov 2001, 2; Jan 2002, 1, 5, 8, 11; Feb 2002, 8; Mar 2002, 7, 8; Jun 2002, 11; Jul 2002, 10; Aug 2002, 11; Sep 2002, 4; Nov 2003, 11; May 2004, 3; May 2006, 6; May 2007, 14

Quality Check™, Jan/Feb 2000, 6; May/Jun 2000, 5; Nov/Dec 2000, 5

standards clarifications, Jan/Feb 2000, 9; Mar/Apr 2000, 10; Sep/Oct 2000, 20

Joint Commission Connect

extranet site, Apr 2007, 4; Apr 2008, 5

Joint Commission International (JCI)

patient safety Web site, Jun 2005, 1-2

Joint Commission Perspectives

complimentary copy distribution, Jun 2006, 3

copyright information, Jun 2006, 3

Joint Commission Resources (JCR), Sep/Oct 2000, 13; Mar 2005, 11

and measures of success, Mar 2005, 11

Perspectives Web site, Aug 2002, 11

“Smart Patient” book collaboration, Mar 2006, 1

Web site, Aug 2002, 3

Kernicterus prevention, Jun 2001, 10-11; Nov 2004, 10-11

Joint Commission recommendations, Jun 2001, 11; Nov 2004, 11

key elements of, Nov 2004, 10-11

revised guidance to, Nov 2004, 10

risk-reduction strategies, Jun 2001, 11

root causes, Jun 2001, 10-11

Kidney Disease Outcome Quality Initiative (K/DOQI) guidelines, Feb 2006, 11

King-Bruwaert House, Jul/Aug 2000, 1

Kings Harbor Multicare Center

Codman Award, quality of life, Jan 2001, 3; Mar 2001, 2-3

Kizer, Kenneth W., Sep/Oct 2000, 1

Lab Advantage™, Mar 2003, 5

educational resources, Mar 2003, 5

elements of, Mar 2003, 5

and Joint Commission, Mar 2003, 5

and proficiency testing, Mar 2003, 5

transplant and implant tissue storage and issuance standards revisions, Feb 2005, 9, 11

Web site, Mar 2003, 5

Labeling of medications revision, Feb 2006, 3

Laboratories. See also Pathology and clinical laboratory services

Laboratory

2005 National Patient Safety Goals, Aug 2004, 8-9

abbreviations do-not-use list, Aug 2005, 4

accreditation, May 2007, 6

accreditation manual corrections, Jan 2006, 7; Mar 2008, 3

Accreditation Participation Requirement (APR), July 2006, 4

correction, Jun 2006, 5

revision, Nov 2006, 7

accreditation process corrections, Nov 2005, 5

accreditation program, Apr 2007, 4

award display and use correction, Feb 2006, 8

biannual comprehensive manual updates, Nov 2005, 8, 11

contracted services standards revisions, Jul 2007, 4–5, 6–8

Cooperative Accreditation Initiative clarification, Apr 2005, 7

cytology proficiency testing, May 2005, 6

decision rule, Apr 2007, 5

hand hygiene, Mar 2006, 3

infection control revisions, Feb 2004, 5-6

information accuracy and truthfulness policy, Sep 2006, 10

management of human resources revisions, Jun 2006, 8

National Patient Safety Goals, Mar 2004, 1, 4-5; Jul 2005, 7; July 2006, 1, 5, 25–26

for 2008, Jul 2007, 1, 9–22

matrix, Aug 2005, 9-10

noncompliance citations, Aug 2005, 11

and Periodic Performance Review, Aug 2005, 1, 3; Nov 2005, 6

priority focus areas, May 2007, 6

priority focus process reports, Nov 2006, 3

proficiency testing practices, May 2008, 14–15

scoring revisions, Aug 2004, 13-14

standards changes, Feb 2006, 5, 9

standard clarification, Jun 2006, 6

Standards Improvement Initiative (SII), Apr 2007, 1, 3

standard revisions, Jun 2006, 8, 9–10; July 2006, 3

standards revisions or corrections, Aug 2004, 11-12; Sep 2004, 2; Jun 2005, 10; Jul 2005, 12, 13-14; Nov 2006, 8

and track record requirements, Dec 2007, 6

unannounced surveys, Apr 2008, 1, 3–4

Laboratory accreditation program. See also Comprehensive Accreditation Manual for Pathology and Clinical Laboratory Services (CAMPCLS)

terminology elimination, Dec 2002, 7

validation surveys, Nov/Dec 2000, 3

Laboratory care

CLIA ’88 regulations revisions, Jul 2004, 5-6, 11

compliance issues for 2003, May 2004, 5

elements of performance revisions, May 2004, 7, 8, 9

epidemics management standard, Jul 2004, 4

quality control revisions, Jul 2004, 9-11

waived testing revisions, Jul 2004, 7-8

Laboratory and point-of-care testing

errata to standards and elements of performance, Dec 2003, 10-11

Laboratory services

and accreditation revisions, Nov 2003, 2, 11

CLIA changes, Feb 2002, 8

clinical/service groups (CSGs), Oct 2003, 7, 11

compliance issues, Nov 2003, 5

hazard identification and avoidance, Mar 2002, 6-7

Lab Advantage™, Mar 2003, 5

pilot survey, Jan 2004, 14-15

proficiency testing updates, Feb 2002, 8

revisions to management of information, Jun 2003, 3

Standards Review Project, Jan 2004, 3-4

Lake Grove at Maple Valley

Codman Award, restraint use reduction, Jan 2001, 3; Mar 2001, 1

Language barriers, Feb 2008, 8–11

Language needs and cultural barriers, Jun 2008, 10

Leadership (LD)

access to care, Jul/Aug 2000, 16-17

behavioral health care safety and error reduction standard revisions, May 2002, 11-14

errata to 2004 requirements, May 2004, 7-8

intent statement revisions, near misses, Jun 2002, 4

license verification, Nov/Dec 2000, 8, 9

medical emergencies management, Sep 2002, 7-8

and non-employee responsibilities, Aug 2005, 5

and ORYX, Jan/Feb 2000, 1, 3

and patient flow management, Feb 2004, 13-14

patient safety requirements, Nov/Dec 2000, 12

and PDA rules for complex organizations, Jul 2001, 2

resident safety and error reduction standards revisions, Apr 2002, 9-11

revisions, Aug 2007, 14

sentinel event review practices, Jul/Aug 2000, 16-17

standard revisions, managed care plans, Jul 2002, 13

standards revisions, Aug 2005, 5

Leadership session, Jan 2004, 13

Leapfrog Group, The, Apr 2002, 3

Leave of absence/deployment clarification, Jan 2005, 5

Left ventricle assist device

Certification Participation Requirements, Dec 2005, 3-5

Lessons Learned (department)

medication errors, Mar/Apr 2000, 11

wrong-site surgery, Jan/Feb 2000, 14

Licensed independent practitioners (LIPs)

and accreditation process, Mar 2002, 1, 3

assessing competency of, Jan 2001, 6-7

authorization of restraint protocol, Jun 2001, 6; Sep 2001, 6-7

credentialing and privileging of, Sep/Oct 2000, 7; Nov/Dec 2000, 18

delegation of restraint orders and evaluations, May 2002, 6

designation of short-term credentialing and privileging, Aug 2005, 7

emergency privileging of, Sep 2002, 4

in health care networks, May 2001, 6

and non-employee responsibilities, Aug 2005, 5

and orders for behavioral restraint, Jan 2001, 8;

orders for restraint or seclusion, Jul/Aug 2000, 15, Sep/Oct 2000, 15

reappointment cycle, Jan 2002, 11

revised definition of, Nov 2005, 6

and task delegation, Nov 2005, 6

Licensure verification

at expiration, Nov/Dec 2000, 8

medical staff requirements in hospitals, Nov/Dec 2000, 9

Life Safety Code^®, Nov/Dec 2000, 3; Mar 2001, 8; Aug 2003, 2; Oct 2005, 7; Apr 2007, 3

and assisted living, Aug 2003, 2

building tour, Jan 2004, 13

relaxation of requirements, Nov 2002, 4

revisions, Nov 2002, 4

Specialists, Dec 2004, 1; Aug 2007, 13

training, Mar 2005, 1