Regulations
Federal, State, & Accreditation Organizations
What are the three regulatory bodies?
Accredited Agency under contract with CMS to survey hospitals in Maryland
What is TJC?
This is the name of TJC's new, streamlined, and collaborative survey approach launching in 2026.
What is Accreditation 360?
To achieve accreditation, TJC requires organizations to have an integrated team to move from a culture of blame to a culture of this.
What is patient safety
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?
Patient Safety and Risk assessment teams, often prompted by a TJC-defined "sentinel event," must perform this type of analysis to identify root causes and prevent future harm.
What is a Root Cause Analysis (RCA)?
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)?
This type of culture encourages staff to report errors without fear of punishment.
What is "Just Culture" or Fair & Just Culture ?
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?
This technique, such as SBAR, is used to close the loop in communication between a sender and receive
What is closed-loop communication ?
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)?
The extent to which team members are aware of the status of a particular clinical event, the status of the team's patients, and operational issues impacting the team.
What is situational awareness?
Backronym of the "SAFER" matrix
What is the 'Survey Analysis For Evaluating Risk'?