Provided by MHA Health Institute.
Dates & Location
Wednesday, Nov. 20, and Thursday, Nov. 21
Courtyard by Marriott
3301 LeMone Industrial Blvd.
Register on or before Friday, Nov. 15.
The registration fee includes continental breakfast, refreshments and lunch. Also, a hard copy of the program materials will be provided the day of the conference.
This seminar is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from MHA Management Services Corporation. This seminar also is eligible for use of the MHA Health Institute coupon. Coupons were mailed to MHA-member hospital CEOs on Dec. 17.
Online hotel reservation: http://www.marriott.com/coucy
Group code: JCAJCAA
Hotel cut-off date: Monday, Oct. 28
Request MHA Health Institute room rate:
- king: $119 + tax
- double queen (two queen beds): $119 + tax
Individuals who will be involved with The Joint Commission surveys are encouraged to attend. CEOs, medical executives, nurse executives, quality coordinators, financial officers, education coordinators, information managers and human resources managers also will find the program beneficial.
Welcome your Joint Commission surveyors with confidence. This two-day program serves as an annual update to TJC accreditation process, requirements, changes and current challenges for hospitals. Essential elements of the requirements, as well as enhanced discussion regarding the most challenging and urgent accreditation issues, will be presented.
Upon completion of this program, participants will be able to:
- describe the key areas for the hospital and critical access hospital survey process for 2020
- describe the impact of SAFER Matrix scoring on survey decisions
- identify frequent and challenging findings with TJC requirements, including high-risk processes for condition-level deficiencies
- describe the 4-1-1 high-risk processes identified by TJC for survey
- discuss the high-priority key concepts in TJC requirements chapters, and implementation strategies and suggestions to improve compliance with TJC requirements
Wednesday, Nov. 20
8:30 a.m. — Registration/Continental Breakfast
9 a.m. — Welcome/Review of Objectives
9:15 a.m. — 2020 Updates to The Joint Commission Accreditation Survey Process
- survey process changes and Sentinel Event Alert focus
- challenging requirements and trends in SAFER Matrix scoring
10:15 a.m. — Break
10:30 a.m. — Survey 4-1-1
- suicide assessment and ligature risk
- sterile medication compounding
Noon — Lunch (provided)
1 p.m. — Infection Prevention — Understanding the Regulatory Framework for Infection Prevention Compliance
- framework for regulatory compliance
- addressing the survey 4-1-1 challenges of high-level disinfection and sterilization
2:30 p.m. — Break
2:45 p.m. — Priorities and Trends in TJC Chapters
- environment of care
- life safety
- emergency management
4:30 p.m. — Adjournment
Thursday, Nov. 21
7:30 a.m. — Registration/Continental Breakfast
8 a.m. — Priorities and Trends in TJC Chapters
- provision of care
- waived testing
- transplant safety
9:30 a.m. — Break
9:45 a.m. — Priorities and Trends in TJC Chapters (cont.)
- medication management
- human resources
- record of care
- medical staff and nursing
11:45 a.m. — Lunch (provided)
12:30 p.m. — Priorities and Trends in TJC Chapters (cont.)
- performance improvement
- information management
3 p.m. — Adjournment
Steven Chinn, DPM, M.S., MBA, CJCP, CPHQ, FACHE
Joint Commission Resources
Oakbrook Terrace, Ill.
Dr. Steven Chinn has more than 30 years of clinical and management experience in acute care, behavioral health, and ambulatory and integrated delivery care settings. In his current role as chief accreditation/regulatory officer, he oversees Stanford Health Care’s accreditation, regulatory and licensure compliance programs. He is a clinical associate professor in the division of primary care and population health with the department of medicine at Stanford School of Medicine.
Dr. Chinn has had extensive hands-on experience with quality management, patient safety, risk management, medical staff affairs, infection control, and health care inpatient and outpatient operations. He serves as a faculty member for JCR’s Department of Education and provides educational presentations on hospital and ambulatory accreditation standards, performance improvement, patient safety and medical staff issues. He also serves as a consultant working with health care organizations throughout the U.S., including academic medical centers, community and rural health organizations, United States Department of Defense and Veteran Affairs, and NASA. He also has conducted consultations and educational programs in Europe.
Dr. Chinn formerly was a Joint Commission surveyor for the ambulatory, hospital, behavioral health care and network programs, as well as a health plan evaluator for the California Department of Corporation.
Kathy J. Eichner, MSN, BSN, R.N., CJCP
Joint Commission Resources
Oakbrook Terrace, Ill.
Kathy Eichner works with clients to achieve and sustain compliance with The Joint Commission standards, CMS Conditions of Participation and operational process improvement by bringing her extensive experience in leadership, management, safety, performance improvement, regulatory compliance, outcomes management and case management to her role as Principal Consultant for Joint Commission Resources. A certified Joint Commission Yellow Belt and Change Agent, Eichner collaborates with her clients to identify and achieve optimal performance and compliance in all health care settings including hospitals, ambulatory centers, home care, behavioral health and disease specific care programs. She has provided services for a diverse set of organizations including hospital systems, academic teaching centers, children’s hospitals, behavioral health facilities, community hospitals, the Department of Defense, Indian Health Services and various ambulatory organizations.
Participants must attend the program in its entirety to receive a certificate of completion and continuing education contact hours.
Summary of Continuing Education contact hours awarded for this program:
- ACCME: 11.75 CME - AMA PRA Category 1 Credit(s)
- ANCC: 11.75 CE
- ACHE: 11.75 CE
Criteria for Successful Completion:
- full attendance at every session is a prerequisite for receiving full continuing education credits
- completion of program evaluation form
The Joint Commission is accredited by the Accreditation Council for Continuing Medical Education (ACCME), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the health care team.
The Joint Commission is authorized to award 11.75 hours of preapproved ACHE Qualified Education credit for this program toward advancement, or recertification, in the American College of Healthcare Executives. Participants in this program wishing to have the continuing education hours applied toward ACHE Qualified Education credit should indicate their attendance when submitting an application to the American College of Healthcare Executives for advancement or recertification.
Conflict of Interest:
The Joint Commission maintains control over all continuing education content provided to ensure content integrity and minimize educational bias. All education planners, faculty, content reviewers, authors and others involved with continuing education activities disclose any influencing relationships, or lack thereof, including financial or commercial interests. The Joint Commission ensures the accuracy and consistency of the application of accreditation criteria to ensure appropriateness of relationships and affiliations that may impact education content.
The designation of contact hours, credits and/or approval of this activity refers to the recognition of the educational activity only and does not imply endorsement of any commercial product. The information presented at this program represents the views and opinions of individual presenters and does not reflect the policies, opinions, endorsement of, or promotion by JCR or any accrediting/approving bodies affiliated with this program.
Clinicians should claim only the credit commensurate with the extent of their participation in the activity. The Joint Commission takes responsibility for the content, quality and scientific integrity of this educational activity.