2025 Joint Commission Accreditation Update for Hospitals and Critical Access Hospitals

Tuesday, Dec. 3

7:45 a.m. — Call Begins — Participants Connect

8:30 a.m. — Welcome and Introductions

8:35 a.m. — 2024-25 Updates to The Joint Commission Accreditation Survey Process

• • TJC survey process changes
  • most frequently cited requirements
  • what’s new for 2024 and 2025
  • TJC priorities

10 a.m. — Break

10:15 a.m. — Focus on Infection Prevention – Challenges and Strategies

• • infection prevention oversight and leadership accountability 
  • TJC “revised” infection control and prevention requirements  
  • practical challenges in infection prevention 
  • high-consequence infectious diseases or special pathogens

12:15 p.m. — Questions

12:30 p.m. — Program Adjourns

Wednesday, Dec. 4

7:45 a.m. — Call Begins — Participants Connect

8:25 a.m. — Welcome

8:30 a.m. — Environment of Care and Life Safety: Challenges and Strategies

• • environment of care  
  • life safety

10:30 a.m. — Break

10:45 a.m. — Environment of Care and Life Safety: Challenges and Strategies

• • environment of care  
  • life safety

12:15 p.m. — Questions

12:30 p.m. — Program Adjourns

Thursday, Dec. 5

7:45 a.m. — Call Begins — Participants Connect

8:25 a.m. — Welcome

8:30 a.m. — Medication Management: Challenges and Strategies

• • mastering the new medication compounding requirements (USP 797) 
  • complex medication orders (titration, patient preference, therapeutic duplication, range orders, etc.) 
  • antibiotic stewardship 
  • emerging issues in medication safety 

10 a.m. — Break

10:15 a.m. — Priorities and Trends in The Joint Commission Chapters

• • human resources 
  • information management  
  • medical staff 
  • performance improvement 
  • record of care treatment and services 
  • patient rights and responsibilities 

12:15 p.m. — Questions

12:30 p.m. — Program Adjourns

Friday, Dec. 6

7:45 a.m. — Call Begins — Participants Connect

8:25 a.m. — Welcome

8:30 a.m. — Behavioral Health: Challenges and Strategies

• • current challenges in behavioral health 
  • suicide risk screening, assessment and intervention – frequent findings 
  • restraints and seclusion 
    • changes to CAMBH restraint and seclusion standards and holds
    • frequent findings 

10 a.m. — Break

10:15 a.m. — Priorities and Trends in The Joint Commission Requirements 

• • national patient safety goals  
  • health care equity requirements 
  • leadership 
  • provision of care 

12:15 p.m. — Questions

12:30 p.m. — Program Adjourns

*Times are approximate and fluid based on audience questions and discussions.
*Agenda topics may be modified on short notice due to speaker availability.

Edward Browne, M.S., CHC, CHFM, CHPA, CEPSS-HC, CLSS-HC, FACHE, FASHE, has more than 35 years as a health care engineer and manager. He has managed facility, safety, security, support service and clinical departments in a wide variety of health care settings – from community hospitals to regional health care systems to tertiary teaching institutions, including long-term and chronic disease. Browne’s specialties also include environment of care, life safety, construction, emergency preparedness, hazardous materials management, security, food services, environmental services and real estate.  

Browne has worked nationwide as an environment of care consultant in diverse situations, including mental health and pediatric facilities. He has implemented best practices, bringing his expertise to help facilities work through specific problems and has published numerous articles in several national publications on topics specific to our industry. 

Kathy Eichner, MSN, R.N., CPHQ, CJCP, 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. Eichner 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.

Before joining Joint Commission Resources, Eichner served as both Chief Nursing Officer and Vice President of Quality and Utilization Management in a five-hospital health care system. In these roles, she provided leadership and expertise to the system for patient care operations oversight and Joint Commission accreditation readiness and regulatory compliance, and performance improvement. Previously, Eichner also served as System Director Case Management for this five-hospital system and Director of Collaborative Practice for a community hospital, during which time she was responsible for development and oversight of case management, regulatory compliance, collaborative pathways, clinical outcomes improvement and access management. Eichner’s clinical experiences include intensive care, bone marrow and solid organ transplantation, pediatrics, trauma, and burn management and rehabilitation.

Jeannell Mansur, Pharm.D., R.P.h, CJCP, FASHP, FSMSO, is Principal Consultant for Medication Management and Safety for Joint Commission Resources and Joint Commission International. In this role, she provides direction to hospital leaders on medication safety design, medication system optimization and technology implementation to support patient safety and effectiveness. Her expertise in Lean Six Sigma and change acceleration performance improvement methods and tools is of immense value to organizations that are seeking to implement effective and sustainable improvement to challenging issues. In her role as Principal Consultant, Mansur provides expertise to The Joint Commission enterprise on medication system themes. She has been recognized for her distinguished work by the designation of Fellow with the American Society of Health-System Pharmacists and the American Society for Medication Safety Officers. She is a voting member of the United States Pharmacopeial Convention.

Under the direction of Drs. Donald Berwick and Lucian Leape, Mansur completed training with the Institute for Healthcare Improvement in medication safety. The learning from these leaders and the experiences from this Institute resulted in the crafting of a systems-based approach to medication safety that has molded Mansur’s philosophies.

Mansur has extensive experience in all aspects of medication system design and implementation, as well as hospital pharmacy, which includes clinical, operational and management responsibilities. She was Director of Pharmaceutical Services for 12 years at the University of Chicago Medical Center before she became Executive Director for Pharmacy Informatics, where she was involved in the planning, building and implementation of the organization’s electronic medical record.

Mansur has consulted throughout the U.S. and internationally in Europe, Asia, Africa, Central and South America, the Far East, and the Middle East. She has published and presented extensively in the areas of medication safety and pharmacy operations improvement. Among these publications is the chapter she authored on Medication Safety in “Pediatric Safety in the Emergency Department;” a textbook published jointly by Joint Commission Resources and the American Academy of Pediatrics; an article, “Medication Systems and the Important Role of Pharmacists,” published in 2016 in The Journal of Drugs and Aging; and the chapter she authored, “Immediate-Use Compounding,” in the recently published “Compounding Sterile Preparations, Fourth Edition,” published by the American Society of Health-system Pharmacists.

Karen L. Martin, MPH, R.N., CIC, has consulting expertise, which includes reviewing IC standards to assure compliance, identifying gaps within programs, development of action planning to alleviate gaps, and developing custom education programs to meet the needs of the organization standards and survey process. Martin has conducted consultations in Asia Pacific.

Carol A. Rogers, Ph.D., M.N., R.N., PMHCNS-BC, CJCP, began her career in intensive care nursing. She was a member of the United States Army Nurse Corps and served one year at the 24th Evacuation Hospital in Long Binh, South Vietnam. At the 24th Evacuation Hospital, she was a staff nurse in neurosurgical ICU and charge nurse in the emergency room. Rogers attained the rank of captain before being honorably discharged. Upon returning to Los Angeles as a civilian, she worked as an assistant head nurse in medical ICU at LA County General Hospital. She has held positions as a psychotherapist, nurse manager and clinical specialist in behavioral health.

Rogers previously managed behavioral health units in inpatient and outpatient settings, as well as surgical ICU and step-down units. In this capacity, she was responsible for clinical and fiscal operations, quality improvement, strategic planning, and budgeting for interdisciplinary staff of inpatient and outpatient services. She also served as a facilitator for multidisciplinary quality improvement teams and projects, including restraint reduction in nonpsychiatric settings and an alcohol detoxification protocol.

Rogers’ research and publications have focused on inpatient suicide risk treatment and women’s mental health issues. She co-authored two articles describing one of the first studies examining one-to-one suicide observation from the perspective of suicidal inpatients. The findings from this study have been referenced in many articles examining this intervention in hospital settings. In addition, she co-authored the social support scale used in the ENRICHD multisite clinical trial examining the effect of treatment for depression and low social support on men and women recovering from a myocardial infarction.

Rogers served as an Associate Professor of Nursing at Rush University College of Nursing. In addition, she served as a consultant to an inpatient behavioral health department in Chicago. Currently, she serves as an adjunct professor in the College of Nursing.

Rogers has published articles in Psychiatric Perspectives, Journal of Psychosocial Nursing, Journal of Nursing Education, Journal of Cardiopulmonary Rehabilitation, Research in Nursing and Health, Issues in Mental Health Nursing, and the American Journal of Nursing. She has also published under the name Dr. Carol Rogers Pitula.

Summary of continuing education contact hours awarded for this program:
This program on December 3-6, 2024 will award 15.0 Continuing Education contact hours for the following: ACCME, ANCC, & ACHE.

Criteria for successful completion: 
Full attendance at every session, on all 4 days, and completion of a post-engagement survey are prerequisites for receiving continuing education credits.

In support of improving patient care, this activity has been planned and implemented by the MHA Health Institute and Joint Commission Resources.  Joint Commission Resources is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

By attending the Joint Commission Accreditation Update for Hospitals and Critical Access Hospitals program offered by Joint Commission Resources, participants may earn up to 15.0 ACHE Qualifying Education Hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation.

Faculty Disclosure 

Joint Commission Resources welcomes you to this education program. At the completion of the program, each of you will receive a formal continuing education certificate, denoting the applicable accrediting bodies and hours awarded. 

Physicians attending this program will receive Category 1 Credits towards the AMA Physician’s Recognition Award. In compliance with the Essentials of the Accreditation Council for Continuing Medical Education and the Standards for Commercial Support, all persons involved in a position to control the content of the educational activity, including staff and faculty, have been asked to make formal disclosure. Signed statements have been collected to disclose significant relationships with commercial companies whose products or services may be discussed throughout this event. For speakers and their spouses/partners, significant relationships include receiving from a commercial company research grants, consultancies, honoraria and travel, or other benefits, or having a self-managed equity interest in a company. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation. 

The following staff and speakers have disclosed that neither they nor their spouses/partners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity: 

• • • Kathy Eichner
    • Jeannell Mansur 
    • Carol Rogers 
    • Karen Martin 
    • Edward Browne 

Furthermore, each of the previously named speakers also has attested that their discussions will not include any unapproved or off-label use of products. 

The following staff and speakers have disclosed that they may be discussing any unapproved or off-label uses of products, or that they or their spouses/partners do have financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity. 

Nature of Relevant Financial Relationships 

Please note that your registration request will be submitted to the organizer for approval. Upon approval, instructional materials will be sent to the email address indicated on the registration form.

If you have special needs addressed by the Americans With Disabilities Act, please contact the Missouri Hospital Association.

MHA Health Institute
P.O. Box 60
Jefferson City, MO 65102
Phone: 573-893-3700
Fax: 573-893-2809

For cancellations received in writing before the established deadline date, the registrant will receive a full refund — minus a $100* processing fee per registrant. After the deadline date, no refunds will be granted. Registrants not in attendance will be responsible for the full registration fee. Substitutions are encouraged. We reserve the right to cancel this program because of insufficient registration.

*Unless otherwise specified in the program details.