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Joint Commission Mandatory Educational Requirements for LIP's

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Darren Denton

on 8 August 2013

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Transcript of Joint Commission Mandatory Educational Requirements for LIP's

Mandatory Educational Requirements for Physcians and Licensed Independent Practitioners
Joint Commission Requirements
APR.09.01.01--The Hospital notifies the public about how to contact management and the Joint Commission to reprt concerns about patient safety and Quality of Care Methods.
Joint Commission Requirements
APR.09.01.02--Any individual who provides care, services, or treatment can report concerns without retaliatory actions from the hospital.
Joint Commission Requirements
EC.03.01.01--Staff and LIP's are familiar with their roles and responsibilities relative to their environment of care.
Joint Commission Requirements
HR.01.05.03--Staff participates in ongoing education and training. EP13--The hospital provides education and training that addresses how to identify early warning signs of a change in a patient's condition and how to respond to a deteriorating patient, including how and when to contact responsible clinicians.
Joint Commission Requirements
IC.01.05.03--The hospital has a written infection control and prevention plan.
IC.02.04.01--The hospital offers vaccinations against influenza to LIP's and staff members.
Joint Commission Requirements
IM.01.01.03--The hospital plans for continuity of its information management processes. EP3 the hospital plans for managing interuptions to information processes. LIP's and staff will be trained on downtime procedures when electronic information systems are unavailable.
Joint Commission Requirements
LD.01.07.01--The governing body, senior managers, and leaders of the organized medical staff have knowledge needed for their roles in the hospital or they seek guidance to fulfill their roles.
Joint Commission Requirements
MS.11.01.01--The medical staff implements a process to identify and manage matters of individual for LIP's which is seperate from actions taken for discipinary purposes.
Joint Commission Requirements
MS.03.01.03--The management and coordination of each patient's care and treatment , and services is the responsibility of a practitioner with appropriate privileges.
Joint Commission Requirements
NPSG.03.05.01--Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.
EP7--Provide education regarding anticoagulants to prescribers, staff, patients, and families.
Joint Commission Requirements
NPSG.07.03.01--Implement evidence based practices to prevent HAI's due to MDRO's in acute care hospitals.
EP2--Based on the results of the risk assessment, educate staff and LIP's about HAI's, MDRO's, and prevention strategies at hire and anually.
Joint Commission Requirements
NPSG.07.04.01--Implement evidence based practices to prevent CLABSI's.
EP1--Educate staff and LIP's who are involved in managing central lines about the importance of prevention. Education occurs upon hire and anually.
Joint Commission Requirements
NPSG.07.05.01--Implement evidence based practices to prevent SSI's.
EP1--Educate staff and LIP's about SSI's and the importance of prevention. Education occurs upon hire and anually.
Joint Commission Requirements
PC.03.05.09--Restraints and seclusions (for hospitals that use TJC for deemed status purposes.)
EP2--The physicians, clinical psychologists, and other LIP's authorizaed to order restsraints and seclusion through hospital policy and in accordance with with law and regulation, have a working knowledge of the hopsital policy regarding the use of restraints and seclusion
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