Welcome your TJC surveyors with confidence. This extensive program serves as an annual update to TJC accreditation processes, requirements, changes, and current challenges for hospitals. Essential elements of the requirements, as well as enhanced discussion regarding the most challenging and urgent accreditation issues, will be presented.

This year, participants will receive insight on the most pressing TJC survey topics, including the following.

• Medication compounding requirements from USP 797 and what to expect from a TJC survey
• The influence of health care equity on safety and outcomes for everyone
• The environment of care, which shows up in more than half of all TJC survey findings

Whether you are new to accreditation or a seasoned professional, this annual TJC update is an opportunity to learn and improve on strategies for success in accreditation.

Objectives

Upon completion of the program, participants will be able to:

• Describe the hospital and critical access hospital survey process for 2023
• Identify frequent and challenging findings with TJC requirements
• Describe new or modified TJC requirements for 2023
• Discuss the high-priority key concepts in TJC requirements chapters and implementation strategies, as well as suggestions for successful compliance
• Identify new medication compounding requirements from USP 797 and what to expect from a TJC survey
• Discuss how health equity makes an impact on safety and outcomes
• Understand that half of all TJC survey findings are in the environment of care

Part - 1 

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

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

Part - 2

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

Priorities and Trends in The Joint Commission Requirements

• NEW — health care equity requirements
• National patient safety goals
• Provision of care
• Leadership

Part - 3

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

Priorities and Trends in The Joint Commission Requirements

• NEW — health care equity requirements
• National patient safety goals
  • Provision of care
  • Leadership

Part - 4

Environment of Care and Life Safety: Challenges and Strategies

• Environment of care
• Life safety

Environment of Care and Life Safety: Challenges and Strategies (cont.) and New Emergency Management Requirements

• Environment of care
• Life Safety
• Emergency management