Regulations
Federal, State, & Accreditation Organizations
What are the three regulatory bodies?
Agency under contract with CMS to survey hospitals
What is TJC?
TJCs transformation approach to hospital and healthcare accreditation and certification
What is Accreditation 360?
Professional who works to positively influence the healthcare industry by reducing risk and improving safe patient care
What is a Risk Manager?
These 2 chapters in the Joint Commission Manual will be merged in 2026
What is Environment of care and Life Safety?
Organization that approves Accreditation Agencies "Deemed" to survey on their behalf.
What is the Centers for Medicare & Medicaid Services (CMS)?
Patient Safety, Consumer Awareness, Quality Care and Fiscal Health are key indicators from attaining this status.
What is Accreditation?
Simplified accreditation resources, updated accreditation manual, certifications focused on outcome measures, benchmarking tools and leading practices, and continuous engagement models.
What are the core components of TJC 360?
This federal law, enacted in 1996, established standards for the protection of patient information.
What is HIPAA (Health Insurance Portability and Accountability Act)?
2 Procedures to do in the event of a fire
What is RACE & PASS?
(Extra points for explaining the acronym)
Agency that determines compliance with Maryland State and Federal regulations
What is the Office for Health Care Quality (OHCQ)?
Healthcare Organization Application, Review of Policy & Procedure, Department Surveys, Patient document review, System/Program reviews and staff and patient interviews are all part of this process.
What is the Survey methodology?
Replaces the TJC Survey Activity Guide (SAG)
What is the Survey Process Guide (SPG)?
EMTALA applies to at least 3 locations in the hospital
What is the ED, Psych ED, and L&D?
Verbal expression of dissatisfaction by patient and family that can be resolved at the point of which it occurs
What is a Complaint?
Surveyors come unexpectedly to the hospital
What is an unannounced Survey?
Visual Evaluation Tool surveyors utilize to score organizations during a survey
What is the SAFER Matrix?
Remains the same
What is the new survey process?
The four common strategies for responding to identified risks are Avoid, Transfer, Mitigate, and this.
What is Accept?
Written or verbal expression that has not been resolved at the point of service
What is a Grievance?
Founded in 1951, this not-for-profit organizations currently accredits approx. 80% of US hospitals
What is the Joint Commission (TJC)?
Assigning accountability, correcting non-compliance and ensuring sustained compliance are all elements of this document.
What is the Evidence of Standard Compliance?
New chapter that identifies and reorganizes existing TJC requirements that rise above CMS CoPs.
What is the National Performance Goals (NPGs)?
This type of analysis is used after a serious event to identify underlying system issues rather than just who was at fault.
What is a root cause analysis (RCA) or Serious Event Analysis?
Backronym of the "SAFER" matrix
What is the 'Survey For Evaluating Risk'?