CONTINUOUS READINESS REVIEW (CRR) – CHAPTER LEADERS

  • Chapter Leaders and team members are assigned based on their expertise, position within the facility and oversight of the functions within the associated standards
  • Chapter Leaders are responsible for staying current with associated standard changes and communicating these changes to the team and within the organization
  • Chapter Leaders are responsible for scoring of the Joint Commission Periodic Performance Review (PPR) and setting validation expectations
  • Chapter Leaders and team members will regularly review/revise policies and processes related to the standards under chapter assignments and communicate these revisions to the SDM Education Council or appropriate education approach for the changes
  • Previous RFIs, observations from Joint Commission or CMS surveys, or ongoing tracer activity will be utilized to assist in formulation and implementation of needed process changes

Assigned Content / Chapter / Chapter Leader / Committees that Address Standards
National Patient Safety Goals / NPSG / Accreditation Coordinator / Hospital Quality Council
Ethics, Rights, and Responsibilities / RI / Director, Inpatient Cardiology Services / Ethics Committee
Provision of Care – Oversight (nursing) / PC / Administrative Director, Children’s Hospital / Hospital Quality Council
Provision of Care – Oversight (non-nursing) / PC / Director, Physical Medicine and Rehabilitation / Hospital Quality Council
Entry to Care, Treatment, and Services / PC: 02.01.01, 02.01.05, 02.02.01 / Director, Patient/Family Services / Hospital Quality Council
Pain Management / PC: 01.02.01, 01.02.07, 02.03.01 / Assistant Director, Women/Infant Health / Pain Management Team
Resuscitation Services / PC: 02.01.11 / Director, Adult Critical Care / Rapid Response Team
Restraint and Seclusion / PC: 03.05.01 – PC.03.05.19 / Clinical Coordinator, Adult Critical Care / Restraint Team
Special Procedures - Sedation / PC: 03.01.01, 03.01.05, 03.01.07, 03.01.03 / Operations Supervisor, Surgical Services / Sedation Team
Fall Prevention / Supervisor, Physical Medicine and Rehabilitation / Falls Team
Medication Management (nursing) / MM / Director, Women/Infant Health / Medication Safety Team / Pharmacy & Therapeutics Committee
Medication Management (pharmacy) / MM / Assistant Director, Pharmacy / Medication Safety Team / Pharmacy & Therapeutics Committee
Surveillance, Prevention, and Control of Infection / IC and NPSG 7 / Epidemiology Coordinator / Infection Control Committee
Improving Organizational Performance / PI / Director, Quality Management / Hospital Quality Council
Leadership / LD / Director, Quality Management / Senior Management / Management Administrative Council
Management of the Environment of Care / EC / Director, Plant Engineering / EOC Team
Management of Human Resources / HR / Director, Human Resources/Education / HR Team
Management of Information / IM / Director, InformationSystems / Senior Management
Medical Staff / MS / Chief Medical Officer / Med Executive Committee
Nursing / NR / Chief Nursing Officer / Nursing Administrative Council
Record of Care / RC / Director, Health Information Management / Medical Records Team
Emergency Management / EM / Manager, Trauma and Emergency Management / Emergency Management Committee; Environment of Care Committee
Life Safety / LS / Director, Plant Engineering / Environment of Care Committee
Transplant Safety / TS / Clinical Coordinator, Surgical Services / Director, Adult Critical Care
Waived Testing / WT / Director, Laboratory / Coordinator, Waived Testing