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Joint Commission Readiness & Regulatory Compliance

In recent years there have been several changes in the Medication Management (MM) standards. MM is still is one of the highest risk chapters and is a widely discussed chapter during the accreditation process. Surveyors will continue to focus on problematic standards during the tracer process. Most of the medication management standards are surveyed on the nursing units, with close attention to policies. The survey will not only include reviewing of the policy to meet the standard but also to whether the policy is being followed.

The MM Chapter: High Points

  • Safe and Effective Medication Use
  • Selecting and procuring medications
  • Storing medications
  • Preparing, Labeling and Dispensing medications
  • Administering medications
  • Monitoring patients’ reactions to medications
  • Managing emergency medications
  • Managing medications brought in by patients/families
  • Retrieving recalled or discontinued medications
  • Responding to adverse drug events and medication errors
  • LASA, High-Alert & Hazardous Medications

Are you in a constant state of readiness?

Pain Management

The new and revised pain assessment and management standards are reflected in the Leadership; Medical Staff; Provision of Care, Treatment, and Services; and Performance Improvement chapters of The Joint Commission hospital accreditation manual.

The standards require a Joint Commission accredited hospital to establish policies and procedures that address comprehensive clinical assessment of pain; treatment or referral for treatment; and reassessment for patients as it designates, based on patient population and scope of services provided. Are you ready?

Antimicrobial Stewardship

According to TJC standards:

  • Antibiotic stewardship programs should be an organization priority with leadership commitment and support.
  • Education should be provided on antimicrobial resistance and antimicrobial stewardship practices for hospital staff and independent practitioners who use antibiotics.
  • Patient and family education on appropriate use of antibiotics should be provided.
  • A multidisciplinary antimicrobial stewardship team comprising an infectious disease physician, infection preventionist and pharmacist should be organized. T
  • A leader should be appointed to be responsible for the program outcomes.
  • There should be organization-approved protocols.
  • Collection, analysis, and reporting data from the program should be ongoing.
  • The hospital should act on improvement opportunities that are identified by the program.

Are you ready to take action?