Last updated 1/23/12, 12:30 p.m. CT
Comprehensive Accreditation Manual for Hospitals (CAMH)
The Updates
Revised Contents Page for the Portable CAMH (10/08)
2009 Update 1 Table of Changes (6/09)
2009 Update 2 Table of Changes (10/09)
2010 Update 1 Table of Changes (6/10)
2010 Update 2 Table of Changes (9/10)
2011 Update 1 Table of Changes (3/11)
2011 Update 2 Table of Changes (9/11)
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Accreditation Participation Requirements (APR)
Errata for All 2009 Accreditation and Certification Manuals (APR, LS, PC, RI) (5/09)
New Method to Record an Immediate Threat to Health or Safety Situation (APR) (9/11)
No PPr Submission Required in Year of the Triennial or Biennial Survey (APR) (10/11)
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Environment of Care (EC)
Errata to 2009 Requirements for EC, IC, LS, MM, NPSG, and PC (2/09)
Additional Scoring Changes for All 2009 Accreditation Manuals (EC, LD, LS, MM, PC, PI, RI) (6/09)
Errata for 2009 Accreditation Manuals for EC and NPSG (8/09)
New and Revised Hospital Elements of Performance Related to CMS Application Process (EC, HR, LD, MS, PC, PI, RI) (10/09)
Standards Project Focuses on High-Value Standards: Eliminated and Revised EPs (EC, LD, MM, PC, RI) (6/10)
Deleted MOS and Scoring Categories (EC, IM, MM, MS, PC, PI, RC) (6/10)
New and Revised Requirements to Meet Relevant CoPs (EC, EM, IM, LD, LS, PC, TS) (3/11)
Updated Fire Protection Systems Requirements for Hospitals (EC) (5/11)
Standards Changes in Response to California Law for Organizations Performing CT Scans (EC, PC) (1/12)
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Emergency Management (EM)
New and Revised Requirements to Meet Relevant CoPs (EC, EM, IM, LD, LS, PC, TS) (3/11)
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Human Resources (HR)
Summary of March Changes from CMS Hospital Deeming Application (HR, LD, MM, MS, NR, PC, RC, RI) (5/09)
New and Revised Hospital Elements of Performance Related to CMS Application Process (EC, HR, LD, MS, PC, PI, RI) (10/09)
New and Revised Requirements to Improve Patient-Provider Communication (HR, PC, RC, RI) (1/10)
New Psychiatric Hospital EPs (HR, LD, MS, PC, RC) (6/10)
Update on the Implementation Plan for Patient-Centered Communication Standards (HR, PC, RC, RI) (8/10)
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Infection Prevention and Control (IC)
Errata to 2009 Requirements for EC, IC, LS, MM, NPSG, and PC (2/09)
Revised Scoring for All 2009 Accreditation Manuals (IC, IM, LD, MM, PC) (5/09)
Clarification on Reducing Infection Risks Associated with Medical Equipment, Devices, and Supplies (IC) (10/09)
Revision to Note Regarding Level of Disinfection (IC) (4/11)
Revised Influenze Vaccination Standard IC.02.04.01 (IC) (12/11)
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Information Management (IM)
Revised Scoring for All 2009 Accreditation Manuals (IC, IM, LD, MM, PC) (5/09)
Deleted MOS and Scoring Categories (EC, IM, MM, MS, PC, PI, RC) (6/10)
Correction: Approved Abbreviations List Is Not Required Under IM.02.02.01 (6/10)
New and Revised Requirements to Meet Relevant CoPs (EC, EM, IM, LD, LS, PC, TS) (3/11)
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Leadership (LD)
Summary of March Changes from CMS Hospital Deeming Application (HR, LD, MM, MS, NR, PC, RC, RI) (5/09)
Revised Scoring for All 2009 Accreditation Manuals (IC, IM, LD, MM, PC) (5/09)
Additional Scoring Changes for All 2009 Accreditation Manuals (EC, LD, LS, MM, PC, PI, RI) (6/09)
Staffing Effectiveness Standard Suspended (LD, NR) (8/09)
New and Revised Hospital Elements of Performance Related to CMS Application Process (EC, HR, LD, MS, PC, PI, RI) (10/09)
Clarification on Respiratory Care Orders in Hospitals (LD, PC) (1/10)
Staffing Effectiveness Requirements (LD, PI) (1/10)
Correction for Missing Scoring Categories (LD, PC, PI, RI) (3/10)
Standards Project Focuses on High-Value Standards: Eliminated and Revised EPs (EC, LD, MM, PC, RI) (6/10)
New Psychiatric Hospital EPs (HR, LD, MS, PC, RC) (6/10)
New EPs Related to Utilization Review (LD) (11/10)
New and Revised Requirements to Meet Relevant CoPs (EC, EM, IM, LD, LS, PC, TS) (3/11)
Joint Commission Realigns Telemedicine Requirements with CMS Changes (LD, MS) (10/11)
Final Telemedicine Standards (LD, MS) (1/12)
Leadership Standard Clarified to Address Behaviors That Undermine a Safety Culture (LD) (1/12)
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Life Safety (LS)
Errata to 2009 Requirements for EC, IC, LS, MM, NPSG, and PC (2/09)
Errata for All 2009 Accreditation and Certification Manuals (APR, LS, PC, RI) (5/09)
Additional Scoring Changes for All 2009 Accreditation Manuals (EC, LD, LS, MM, PC, PI, RI) (6/09)
New and Revised Requirements to Meet Relevant CoPs (EC, EM, IM, LD, LS, PC, TS) (3/11)
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Medication Management (MM)
Errata to 2009 Requirements for EC, IC, LS, MM, NPSG, and PC (2/09)
Summary of March Changes from CMS Hospital Deeming Application (HR, LD, MM, MS, NR, PC, RC, RI) (5/09)
Revised Scoring for All 2009 Accreditation Manuals (IC, IM, LD, MM, PC) (5/09)
Revised Definition of "Physician" (MM, MS, PC, RI) (6/09)
Additional Scoring Changes for All 2009 Accreditation Manuals (EC, LD, LS, MM, PC, PI, RI) (6/09)
Standards Project Focuses on High-Value Standards: Eliminated and Revised EPs (EC, LD, MM, PC, RI) (6/10)
Deleted MOS and Scoring Categories (EC, IM, MM, MS, PC, PI, RC) (6/10)
Clarification on Expiration of Multi-dose Vials (6/10)
Deletion of Requirement for Pharmacist Review of Off-Label Medication Use (MM) (3/11)
Correction to Standard MM.05.01.09, EPs 7-9 (6/11)
Updated Medication Selection Criteria for Hospitals (MM) (1/12)
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Medical Staff (MS)
Summary of March Changes from CMS Hospital Deeming Application (HR, LD, MM, MS, NR, PC, RC, RI) (5/09)
Revised Definition of "Physician" (MM, MS, PC, RI) (6/09)
New and Revised Hospital Elements of Performance Related to CMS Application Process (EC, HR, LD, MS, PC, PI, RI) (10/09)
Revisions to MS.01.01.01 Approved (4/10)
Deleted MOS and Scoring Categories (EC, IM, MM, MS, PC, PI, RC) (6/10)
Reinstatement of Antidiscrimination Requirements (6/10)
New Psychiatric Hospital EPs (HR, LD, MS, PC, RC) (6/10)
Joint Commission Realigns Telemedicine Requirements with CMS Changes (LD, MS) (10/11)
Final Telemedicine Standards (LD, MS) (1/12)
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National Patient Safety Goals (NPSG)
Errata to 2009 Requirements for EC, IC, LS, MM, NPSG, and PC (2/09)
NPSG 8 (Medication Reconciliation) Will Not Be Scored in 2009 (3/09)
Errata for 2009 Accreditation Manuals for EC and NPSG (8/09)
2010 National Patient Safety Goals (10/09)
Revised Universal Protocol for 2010 (10/09)
Errata to NPSG Chapter as Published in 2010 Comprehensive Accreditation Manuals and 2009 Update 2 (12/09)
Clarification on Site Marking Under the Universal Protocol (2/10)
Corrections to NPSGs on Medication Labeling and MDROs (NPSG) (3/10)
No New National Patient Safety Goals, Only Minor Revisions for 2011 (NPSG) (8/10)
Modification to NPSG.01.03.01, EP 1, Re: The Use of Automated ID Tech in Blood Transfusions (NPSG) (11/10)
Modifications to Goal on Reconciling Medication Information (1/11)
New and Revised Requirements to Meet Relevant CoPs (EC, EM, IM, LD, LS, PC, TS) (3/11)
Assessing Baseline Coagulation Status Under NPSG.03.05.01 (NPSG) (5/11)
New Infection-Related NPSG for 2012 (7/11)
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Nursing (NR)
Summary of March Changes from CMS Hospital Deeming Application (HR, LD, MM, MS, NR, PC, RC, RI) (5/09)
Staffing Effectiveness Standard Suspended (LD, NR) (8/09)
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Provision of Care, Treatment, and Services (PC)
Errata to 2009 Requirements for EC, IC, LS, MM, NPSG, and PC (2/09)
Summary of March Changes from CMS Hospital Deeming Application (HR, LD, MM, MS, NR, PC, RC, RI) (5/09)
Revised Scoring for All 2009 Accreditation Manuals (IC, IM, LD, MM, PC) (5/09)
Errata for All 2009 Accreditation and Certification Manuals (APR, LS, PC, RI) (5/09)
Revised Definition of "Physician" (MM, MS, PC, RI) (6/09)
Additional Scoring Changes for All 2009 Accreditation Manuals (EC, LD, LS, MM, PC, PI, RI) (6/09)
New and Revised Hospital Elements of Performance Related to CMS Application Process (EC, HR, LD, MS, PC, PI, RI) (10/09)
Clarification on Respiratory Care Orders in Hospitals (LD, PC) (1/10)
New and Revised Requirements to Improve Patient-Provider Communication (HR, PC, RC, RI) (1/10)
Correction to Criticality Tiers Published in Perspectives (LD, PC, PI, RI) (3/10)
Standards Project Focuses on High-Value Standards: Eliminated and Revised EPs (EC, LD, MM, PC, RI) (6/10)
Deleted MOS and Scoring Categories (EC, IM, MM, MS, PC, PI, RC) (6/10)
New Psychiatric Hospital EPs (HR, LD, MS, PC, RC) (6/10)
Update on the Implementation Plan for Patient-Centered Communication Standards (HR, PC, RC, RI) (8/10)
Standards Changes in Response to California Law for Organizations Performing CT Scans (EC, PC) (1/12)
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Performance Improvement (PI)
Additional Scoring Changes for All 2009 Accreditation Manuals (EC, LD, LS, MM, PC, PI, RI) (6/09)
New and Revised Hospital Elements of Performance Related to CMS Application Process (EC, HR, LD, MS, PC, PI, RI) (10/09)
Staffing Effectiveness Requirements (LD, PI) (1/10)
Correction to Criticality Tiers Published in Perspectives (LD, PC, PI, RI) (3/10)
Deleted MOS and Scoring Categories (EC, IM, MM, MS, PC, PI, RC) (6/10)
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Record of Care, Treatment, and Services (RC)
Summary of March Changes from CMS Hospital Deeming Application (HR, LD, MM, MS, NR, PC, RC, RI) (5/09)
New and Revised Requirements to Improve Patient-Provider Communication (HR, PC, RC, RI) (1/10)
Deleted MOS and Scoring Categories (EC, IM, MM, MS, PC, PI, RC) (6/10)
New Psychiatric Hospital EPs (HR, LD, MS, PC, RC) (6/10)
Update on the Implementation Plan for Patient-Centered Communication Standards (HR, PC, RC, RI) (8/10)
Clarification of Documentation Requirement for Informed Consent (RC) (12/10)
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Rights and Responsibilities of the Individual (RI)
Summary of March Changes from CMS Hospital Deeming Application (HR, LD, MM, MS, NR, PC, RC, RI) (5/09)
Errata for All 2009 Accreditation and Certification Manuals (APR, LS, PC, RI) (5/09)
Revised Definition of "Physician" (MM, MS, PC, RI) (6/09)
Additional Scoring Changes for All 2009 Accreditation Manuals (EC, LD, LS, MM, PC, PI, RI) (6/09)
New and Revised Hospital Elements of Performance Related to CMS Application Process (EC, HR, LD, MS, PC, PI, RI) (10/09)
New and Revised Requirements to Improve Patient-Provider Communication (HR, PC, RC, RI) (1/10)
Correction to Criticality Tiers Published in Perspectives (LD, PC, PI, RI) (3/10)
Standards Project Focuses on High-Value Standards: Eliminated and Revised EPs (EC, LD, MM, PC, RI) (6/10)
Update on the Implementation Plan for Patient-Centered Communication Standards (HR, PC, RC, RI) (8/10)
Revision to Patient Visitation Standard (RI) (3/11)
Revisions to Standards for Patient Visitation Rights (RI) (8/11)
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Transplant Safety (TS)
Revisions to EP 9 of TS.01.01.01 (Notification to Organ Procurement Orgs) (3/09)
New and Revised Requirements to Meet Relevant CoPs (EC, EM, IM, LD, LS, PC, TS) (3/11)
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Waived Testing (WT)
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The Accreditation Process (ACC)
Corrections to a Few Accreditation Decision Rule 'Links' (11/08)
Laboratory Accreditation Decisions Will Not Affect Hospital Decisions (12/08)
Update on The Joint Commission's Hospital Deeming Auhtority Application (12/08)
Remaining Component to the 2009 Accreditation Decision Methodology, Including Thresholds (12/08)
Clarification for Pediatric Emergency Medications and Immediate Threat to Life (1/09)
Update on the 2009 Decision Process (2/09)
Updated Deposit and Fee Policies (2/09)
Approved: Revisions to the Public Information Policy (4/09)
Approved: An Extension for Extension Surveys (5/09)
The Joint Commission's Position on Steam Sterilization (7/09)
2010 Updates to Accreditation and Certification Decision Rules (8/09)
Shorter Time Frame for Second Survey Under the Early Survey Policy (9/09)
Correction to New Fraud and Abuse Accreditation Decision Rule (9/09)
Clarification on Conducting Extension Surveys (10/09)
Revision to the ESC Tool on Secure Extranet (10/09)
Number of Inpatient Records Required for Initial Survey and On Site Review (10/09)
Decision Rule for Preliminary Denial of Accreditation Eliminated (12/09)
New Preliminary Denial of Accreditation Process (12/09)
2011 Accreditation and Certification Decision Rules (11/10)
Refined Accreditation and Certification Decision Categories (11/10)
Modification to Policy on Conducting a Full Survey Within 3 Years of a Full Survey (12/10)
Policy for Accreditation Status of Orgs That Temporarily Cease Provision of Services (12/10)
Revised Public Information Policy (1/11)
Revisions to the Review and Appeal Procedures for Adverse Decisions (8/11)
2012 Accreditation and Certification Decision Rules (9/11)
Revisions to 2012 Decision Rules for Contingent Accrediation (1/12)
Errata: Reinstated Decision Rule for Accreditation with Follow-Up Survey in 2012 (2/12)
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Sentinel Events (SE)
Suspension of "Automatic" Sentinel Event Adverse Decision (5/10)
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The Joint Commission Quality Report (QR)
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Performance Measurement and the ORYX® Initiative (PM)
HBIPS Core Measure Set Now Required for Certain Freestanding Psychiatric Hospitals (10/10)
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Simplifying Compliance Activities (SCA)
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Staffing Effectiveness Indicators (SEI)
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Required Written Documentation (RWD)
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Early Survey Policy Option (ESP)
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Appendix A: Medicare Requirements for Hospitals (AXA)
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Glossary (GL)
Revised Definition of "Physician" (6/09)
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