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PolicySource: P&Ps for Compliance with Joint Commission Requirements - Hospital Version, 2020
- Get Started
- Table of Contents
- EC [Go to Page]
- EC_Active Threat Response Procedures
- EC_Compressed Gas Cylinder Management Policy
- EC_Emergency Backup for Medication Refrigeration Policy
- EC_Environment of Care Management Plan Annual Evaluation Process
- EC_Environment of Care Plan
- EC_Fire Drill Procedures
- EC_Fire Response Plan
- EC_Fire Safety Equipment and Building Features Maintenance Policy
- EC_Hazardous Material Spill Response Procedures
- EC_Infection Control During Construction Policy
- EC_Medical Equipment Failure Response Procedures
- EC_Providing Emergency Power to Medication Dispensing Equipment Policy
- EC_Smoke-Free Policy
- EC_Utility System Disruption Response Procedures
- EC_Ventilation in Critical Care Areas Policy
- EM [Go to Page]
- EM_1135 Waiver Request Procedures
- EM_Emergency Communications Plan
- EM_Emergency Management Plan
- EM_Hazard Vulnerability Analysis, Emergency Operations Plan, and Emergency Inventory Evaluation Process
- EM_Integrated Emergency Preparedness Plan
- EM_Licensed Emergency Volunteers Policy
- EM_Nonlicensed Emergency Volunteers Policy
- HR [Go to Page]
- HR_Staff Orientation Plan
- IC [Go to Page]
- IC_Infection Prevention and Control Plan
- IC_Infectious Disease Outbreak Response Procedures
- IC_Staff Influenza Vaccination Policy
- IM [Go to Page]
- IM_Confidentiality and Security of Health Information Policy
- IM_Information Systems Interruption Management Plan
- LD [Go to Page]
- LD_Code of Conduct Policy
- LD_Conflict of Interest Policy
- LD_Patient Flow Management Policy
- LD_System or Process Failures Response Policy
- LS [Go to Page]
- LS_Interim Life Safety Measures Policy
- MM [Go to Page]
- MM_Accessibility of Patient Information Policy
- MM_Antimicrobial Stewardship Procedures
- MM_Automatic Dispensing Cabinets Override Review Policy
- MM_High-Alert and Hazardous Medication Management Policy
- MM_Investigational Medications Management Policy
- MM_Medication Control Policy
- MM_Medication Event Response Policy
- MM_Medication Orders Policy
- MM_Medication Substitution Protocols
- MM_Recalled Medication Management Policy
- MM_Self-Administered Medications Policy
- MS [Go to Page]
- MS_Adverse Decision Appeal Policy
- MS_Clinical Practice Investigations and Corrective Action Policy
- MS_Clinical Privileges Application Processing Procedures
- MS_Dissemination of Privileging Decisions Policy
- MS_Emergency Appraisal Treatment and Referral Policy
- MS_Focused Professional Practice Evaluation Policy
- MS_Graduate Medical Education Supervision and Accountability Policy
- MS_Medical Staff Bylaws, Rules, and Regulations Policy
- MS_Ongoing Professional Practice Evaluation Policy
- MS_Temporary Privileges Policy
- NPSG [Go to Page]
- NPSG_Anticoagulation Management Policy
- NPSG_Central Venous Catheter Management Procedures
- NPSG_Clinical Alarm Management Policy
- NPSG_Critical Diagnostic Test Results Management Policy
- NPSG_Hand Hygiene Policy
- NPSG_Multidrug-Resistant Organism Education for Patients Policy
- NPSG_Preprocedure Verification Procedures
- NPSG_Suicide Risk Assessment and Prevention Policy
- NPSG_Surgical Site Marking Alternative Procedures
- NPSG_Surgical Time-Out Procedures
- NR [Go to Page]
- NR_Nurse Staffing Plan Development Policy
- NR_Nursing Policies and Procedures Development Policy
- PC [Go to Page]
- PC_Adult Electroconvulsive Therapy Policy
- PC_Anesthesia Services Policy
- PC_Blood Handling Policy
- PC_Blood Transfusion Policy
- PC_Discharge Planning Policy
- PC_Fall Risk Assessment and Mitigation Policy
- PC_Individualized Care Plan Development Procedures
- PC_Initial Assessment Procedures
- PC_Ionizing Radiation Safety Policy
- PC_Patient Behavior Management Policy
- PC_Restraint and Seclusion Policy
- PC_Resuscitation Services Policy
- PC_Specimen Management Policy
- PI
- RC [Go to Page]
- RC_Medical Record Entry Authentication Policy
- RC_Medical Record Retention Policy
- RC_Medical Record Timeliness Policy
- RI [Go to Page]
- RI_Advance Directives Policy
- RI_Autopsy Consent Policy
- RI_Informed Consent Policy
- RI_Mistreatment and Misappropriation Prohibition Policy
- RI_Patient Responsibilities Policy
- RI_Patient Rights Policy
- TS [Go to Page]
- TS_Affiliated Organ Procurement Organization Policy
- TS_Family Notification of Organ Donation Procedures
- TS_Identifying Opportunities for Asystolic Recovery of Organs for Donation Policy
- TS_Tissue Adverse Events Investigation Procedures
- WT [Go to Page]
- WT_Waived Testing Competency Assessment Policy [Go to Page]
- Federal Register, 42 CFR Part 74 (Mar 14, 1990). Revision of Laboratory Regulations, (Clinical Laboratory Improvement Amendments of 1988). Section 493.1451 (b) (8) and Section 493.1501 (h) (1 & 2)
- WT_Waived Testing Policy
- WT_Waived Testing Quality Control Policy [Go to Page]
- Federal Register, 42 CFR Part 74 (Mar 14, 1990). Revision of Laboratory Regulations, (Clinical Laboratory Improvement Amendments of 1988). Section 493.1451 (b) (8) and Section 493.1501 (h) (1 & 2)
- Resources [Go to Page]
- General Sources
- Plan Template
- Policy and Procedures Evaluation Checklist
- Policy and Procedures Inventory Template
- Policy Template
- Procedures Template
- Required Policies, Procedures, or Plans
- Required Written Documentation Chapter
- Scoring Rubric for Plan Assessments [Go to Page]