Last updated 7/26/10, 2:15 p.m. CT
Comprehensive Accreditation Manual for Hospitals: The Official Handbook (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)
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Accreditation Participation Requirements (APR)
Errata for All 2009 Accreditation and Certification Manuals (APR, LS, PC, RI)
(5/09)
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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)
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Emergency Management (EM)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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Transplant Safety (TS)
Revisions to EP 9 of TS.01.01.01 (Notification to Organ Procurement Orgs)
(3/09)
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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)
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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)
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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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