TJC category
Compliance Programs
Requirements about compliance programs, audits, program evaluation, reporting systems, financial integrity controls, and organizational compliance oversight.
Cascade
Source collection
TJC
Category group
Governance Quality Compliance
Category
Compliance Programs
Grouped by instrument
Expand an instrument to inspect matching provisions
Instruments
1
Shown
3
Citation
TJC NPG.12.04.01
The hospital verifies that staff complete all requirements for employment and practice within...
Requires the hospital to verify staff credentials, criminal background checks, health screenings, and scope-of-practice compliance.
Group
Governance Quality Compliance
Category
Compliance Programs
Domain
Medical Staff
Topics
Credential verification, Criminal background check
Citation
TJC NPG.12.05.01
The hospital provides education and training and evaluates staff competence.
Requires the hospital to orient staff, provide ongoing education, and evaluate staff competence at least every three years.
Group
Governance Quality Compliance
Category
Compliance Programs
Domain
Governance Quality
Topics
Staff orientation, Staff education
Citation
TJC PC.13.02.09
The hospital has written policies and procedures that guide the use of restraint or seclusion.
The hospital must maintain written policies and procedures that define the use, training, and monitoring requirements for restraint or seclusion.
Group
Patient Rights Safety
Category
Restraint Seclusion
Domain
Patient Rights
Topics
Restraint policy requirements, Staff training policy