2025 Joint Commission Accreditation Update for Hospitals and Critical Access Hospitals

Tuesday, Nov. 28

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

8:30 a.m. — Welcome & Introductions

8:35 a.m. — 2023-24 Updates to The Joint Commission Accreditation Survey Process

• • TJC survey process changes
  • most frequently cited requirements
  • what’s new for 2023 and 2024
  • NEW – health care equity requirements

9:45 a.m. — Break

10 a.m. — Medication Management: Challenges and Strategies

• • NEW medication compounding requirements
  • antibiotic stewardship
  • complex medication orders (titration, patient preference, therapeutic duplication, range orders, etc.)
  • emerging issues in medication safety

12:15 p.m. — Questions

12:30 p.m. — Program Adjourns

Wednesday, Nov. 29

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

8:25 a.m. — Welcome

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

• • suicide risk (screening, assessment, ligature risk assessments, management of the high-risk patient)
  • understanding the continuum of behavioral health
  • the impact of substance misuse and trauma-informed care
  • restraints and seclusion

10:30 a.m. — Break

10:45 a.m. — Priorities and Trends in The Joint Commission Requirements

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

12:15 p.m. — Questions

12:30 p.m. — Program Adjourns

Thursday, Nov. 30

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

8:25 a.m. — Welcome

8:30 a.m. — Focus on Infection Prevention — Challenges and Strategies

• • • infection prevention oversight and leadership accountability
    • guiding infection prevention practice
    • practical challenges in infection prevention
    • emerging issues in infection prevention

10:30 a.m. — Break

10:45 a.m. — Priorities and Trends in The Joint Commission Chapters

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

12:15 p.m. — Questions

12:30 p.m. — Program Adjourns

Friday, Dec. 1

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

10:15 a.m. — Break

10:30 a.m. — Environment of Care and Life Safety: Challenges and Strategies (cont.) and New Emergency Management Requirements

• • • environment of care
    • life safety
    • emergency management

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.

Kathy Eichner, MSN, RN, 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, PharmD, RPh, 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, Dr. 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, Dr. 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 Dr. Mansur’s philosophies.

Dr. 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.

Dr. 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, RN, 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., MN, RN, 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. Dr. 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.

Dr. 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.

Dr. 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.

Dr. 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.

Dr. 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.

Charles O. Stevenson, MHA, RA, CHFM, CHSP, brings years of experience to Joint Commission Resources, with specific expertise in life safety and environment of care consulting. Stevenson’s knowledge base is unique as he has comprehensive skills directly related to strategic planning, project development, programming, design and construction of capital improvement projects. He has expertise in performance improvements and transition planning processes and facilities operations.

Stevenson has contributed to national publications and presented at national conferences. He is a member of American Society of Healthcare Engineers, Hospital Engineers of Northern Illinois, and past member of American Institute of Architects and Loyola University Chicago Project Management Curriculum Advisory Board.

Before joining Joint Commission Resources, Stevenson was the Director of Project Planning and Development and Director of Facility Management for Northwest Community Healthcare.