Page 528 - eBook Version 8 Book 1 of 2 JUL 2022

STANDARD OPERATING PROCEDURE Research Administration SOP No: R-Adm-001 SOP Title: Joint Commission Readiness
1. PURPOSE
The purpose of this Standard Operating Procedure (SOP) is to describe the standard procedures to be followed for Joint Commission Readiness
2. INTRODUCTION
"Our mission is to make life better for children through ongoing assessment of regulatory readiness and the development of sustainable practices that embrace and promote a culture of safety and excellence ." -Accreditation & Regulatory Affairs
THE JOINT COMMISSION-
“Children’s Health is accredited by The Joint Commission (TJC). TJC is one of several organizations that has been granted permission by the Federal Government to accredit healthcare organizations in order to ensure their compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (COP). TJC conducts these surveys every 18-36 months which is considered our survey window. To foster a culture of continuous survey readiness, TJC surveys are unannounced. Therefore, Children’s Health must be ready for an onsite visit at any time.”
3. SCOPE
This SOP applies to Research Administration.
4. RESPONSIBILITIES
4.1 Research Administration
The Research Administrative Coordinator (RAC), Director or Sr. Director, Team Leads (TLs), Clinical Research Coordinators (CRCs), and Clinical Research Associates (CRAs) will work together to maintain a culture of safety and compliance to ensure we are dually supporting our mission and the accreditation of our institution by following the procedures as outlined in detail in Section 5.
5. SPECIFIC PROCEDURE: JOINT COMMISSION READINESS: PROACTIVE PRACTICES
5.1.1 Do our job right
5.1.1.1 Review the Standards section of the Survey Readiness Guide
5.1.2 Ensure patient safety is paramount
5.1.2.1 Review the National Patient Safety Goals (NSPG) of the Survey Readiness Guide: 5.1.2.1.1 IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION
5.1.2.1.2 IMPROVE THE EFFECTIVENESS OF COMMUNICATION AMONGST CAREGIVERS
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