The Joint Commission 2014 for ASC's - Session 1
Video Training
Category: Accreditation
Title: The Joint Commission 2014 for ASC's; Session #1 out of 3 Series
Presenter: Cathy Montgomery, RN, President of Excellentia Advisory Group
Cathy has over 20 years of experience in healthcare services management. During her position as Regional Manager for Barnes Hospital, Cathy oversaw several physician practices. As Regional Administrator for Novamed, she oversaw operations of the physician practices, as well as the ambulatory surgery centers and optical shops in the Metro St. Louis and Illinois areas. Under her direction, a state-of-the-art refractive surgery center was also designed and opened in St. Louis, MO.
Cathy is Founder and President of Excellentia Advisory Group, a consulting and development company serving both the surgical industry through ASC’s as well as surgical hospitals and office-based surgical practices. Cathy’s passion has been teaching compliance to CMS Conditions of Coverage, AAAHC accreditation, and assisting ASCs with their survey readiness.
Description: This DVD is Session #1 in a 3-session series teaching you everything that you need to know about the preparation for and passing your Joint Commission accreditation for ambulatory surgery centers. The material content is current through 2014 standards.
The OVERVIEW of Cathy’s seminar presentation is about:
- *General discussion of TJC specifics including 2014 update to definition of time and Sentinel Events.
- *Leadership-Exploration of the responsibilities, necessary policies and procedures and how to manage contracted services. Board Meeting template provided.
- *HR-including OSHA requirements, staff qualifications (including new 2014 requirements for CT techs), orientation and credentialing (the top Joint Commission citation!). OSHA Risk assessment provided.
- *Information Management-Various HIPAA requirements as well as TJC requirements. (HIPAA risk assessment provided).
- *QA/PI-What is the expectation and how to comply. (Examples of customizable Sharps Safety plan provided as well as tools for Hand Hygiene)
- *Record of Care-What’s required.
- *Rights and Responsibilities-In-depth discussion of Advanced Directives as well as Grievance & complaint requirements. Language examples provided.
This presentation should be viewed by the facility Administrator, Director of Clinical Services and any/all staff and providers in order to obtain maximum effectiveness of the training.
Note-taking version of this PowerPoint Presentation. CLICK HERE to download.
Other handouts associated with this presentation can be downloaded by selecting/clicking:
1. Blood and Body Fluid Exposure Report Form
3. Business Associate Agreement
4. Business Associate Decision Tree
5. Cover Letter
8. Emloyee Health File Worksheet
10. Hand Hygiene Analysis Form
12. HIPAA Risk Assessment Checklist
18. Orientation of Agency PRN Nurses
20. OSHA Employee Exposure Determination
21. OSHA Pictograms
22. OSHA 3642
23. Patient Dismissal from Care Policy
24. QAPI Plan 1
25. Revision to Patient Right CMS Letter
26. Sharps Injury Hazard Observation During Environmental Rounds
27. Sharps Injury Prevention Program
29. Sharps Workbook
30. Summary Report Survey of Healthcare Personnel
31. Summary Report Survey to Measure Culture of Safety
32. Survey and Cert Letter 13_20_CMS
33. Survey of Healthcare Personnel on Occupational Exposure
34. Survey to Measure Healthcare on Culture of Safety
36. Worksheet for Estimating the Annual and Average Cost of Needlesticks
Once you and any/all staff have reviewed this presentation, you will be eligible to receive a Certificate of Participation worth 1.5 Credit Hours of continuing education. You simply contact us at events@excellentiagroup.com requesting your certificates, using the Certificate Request Form found in the link below. You will need to provide a typed list of all participants first and last names, position title (RN ,BSN, etc.), license numbers (if professionals) and date of completion.
* Excellentia Advisory Group LLC is approved by the California Board of Registered Nursing, Provider CEP 15481: Issue Date: 4/6/2010;
CLICK HERE for Certificate Request Form