• Blog Post
  • June 22, 2021
  • CPI

The Joint Commission Comprehensive Accreditation Manual for Hospitals’ Alignment to CPI Training

For more than 40 years, CPI has led the market in crisis prevention and de-escalation training for hospitals and health care facilities—arming health care professionals with evidence-based techniques and knowledge to foster an environment of patient-centered care.
 
CPI continues to align with the expectations outlined in the Joint Commission Comprehensive Accreditation Manual for Hospitals, including the most recent changes that were announced on June 18, 2021.
 
In this blog, we’ll break down the latest Joint Commission standards and highlight how CPI aligns with each portion you will be required to meet by January 1, 2022
 

Elements of Performance: Environment of Care (EC.02.01.01)

“The hospital conducts an annual work-site analysis related to its workplace violence program. The hospital takes action to mitigate or resolve the workplace violence safety and security risks based upon findings from the analysis.”
 
What does this mean?
The hospital manages safety and security risks.
 
You must facilitate an annual analysis of your worksite, covering the following areas:
  • A proactive examination of the worksite
  • An investigation of the facility’s workplace violence events
  • An examination of how the policies and procedures, training, education, and environmental design reflect best practices and conform to applicable laws and regulations
How CPI can help
CPI provides support to organizations looking to review existing policies and has the expertise to provide support and consultation around the effective implementation of any workplace violence prevention plan. Our Policy Development Series can be critical to helping your organization develop and review your current policies and procedures.
 

Elements of Performance: Environment of Care (EC.04.01.01)

“The hospital establishes a process(es) for continually monitoring, internally reporting, and investigating the following: injuries to patients and others within the hospital’s facilities, occupational illnesses and staff injuries, incidents of damage to its property or the property of others, safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence. 
 
Based on its process(es), the hospital reports and investigates the following: safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence.”

Note 1: All the incidents and issues listed above may be reported to staff in quality assessment, improvement, or other functions as well as to the designated leader of the workplace violence reduction effort. A summary of such incidents may also be shared with the person designated to coordinate safety management activities. 

Note 2: Review of incident reports often requires that legal processes be followed to preserve confidentiality. Opportunities to improve care, treatment, or services, or to prevent similar incidents, are not lost as a result of following the legal process.
 
What does this mean?
The hospital collects information to monitor conditions in the environment.
 
You are required to have a process in place for both monitoring and investigating all safety and security incidents—including workplace violence situations—that involve anyone within your facility.
 
How CPI can help
CPI Nonviolent Crisis Intervention®, 2nd Edition Training provides a model for staff to assess and gather incident data as they evaluate each incident. This critical process provides opportunities for you to adjust and improve your facility’s intervention strategies at earlier stages of the crisis.
 

Elements of Performance: Human Resources (HR.01.05.03)

“As part of its workplace violence prevention program, the hospital provides training, education, and resources (at time of hire, annually, and whenever changes occur regarding the workplace violence prevention program) to leadership, staff, and licensed practitioners. The hospital determines what aspects of training are appropriate for individuals based on their roles and responsibilities.  

The training, education, and resources address prevention, recognition, response, and reporting of workplace violence as follows: 
  • What constitutes workplace violence 
  • Education on the roles and responsibilities of leadership, clinical staff, security personnel, and external law enforcement 
  • Training in de-escalation, nonphysical intervention skills, physical intervention techniques, and response to emergency incidents 
  • The reporting process for workplace violence incidents” 
What does this mean?
Staff participate in ongoing education and training.
 
Your facility must provide training, education, and supplemental resources to all staff. The education and resource requirements highlight that staff need to understand what workplace violence is as it relates to your organization, the roles of everyone involved in interventions, and the reporting process you have in place post-incident. The training requirement should be appropriate for each person’s roles and responsibilities.
 
How CPI can help
As part of our ongoing support, CPI will work alongside your team to complete a complimentary risk assessment for your facility. In addition to ensuring all staff are trained at the appropriate level based on their role and responsibilities, this collaboration allows us to gain a better understanding of your needs, whether it is additional instructors, training resources, or more advanced training.
 
CPI’s train-the-trainer model positions several selected staff as the content experts across your facility. CPI provides training to those selected staff members first. With support and training materials from CPI, your now certified staff members can teach their training to additional employees. Providing training throughout your facility becomes more feasible than ever. Because your certified staff are providing the training, they can easily customize the training and related materials to cater to each person’s roles and responsibilities.
 

Elements of Performance: Leadership (LD.03.01.01)

“The hospital has a workplace violence prevention program led by a designated individual and developed by a multidisciplinary team that includes the following:
  • Policies and procedures to prevent and respond to workplace violence
  • A process to report incidents in order to analyze events and trends
  • A process for follow up and support to victims and witnesses affected by workplace violence, including trauma and psychological counseling, if necessary
  • Reporting of workplace violence incidents to the governing body”
 
What does this mean?
Leaders create and maintain a culture of safety and quality throughout the hospital.
 
Your facility must have a workplace violence prevention program in place. The program’s leader will oversee a multidisciplinary team that coordinates the policies and procedures to prevent and respond to workplace violence. The team must also develop a process for reporting incidents to necessary parties, including the governing body, in addition to providing follow-up support for those involved.
 
How CPI can help
Organizations seeking to update their policies and procedures can turn to CPI for a variety of resources, tools, and services to support this initiative. Our team of experts can assist in identifying the appropriate staff to manage your workplace violence prevention program, and ensure it aligns with the Joint Commission standards.
 
As part of a comprehensive violence prevention initiative, CPI recommends that organizations adopt policies and procedures that reflect the philosophy and strategies taught in our Nonviolent Crisis Intervention®, 2nd Edition training.
 
Ensuring your facility is meeting the Joint Commission’s updated standards is critical to the Care, Welfare, Safety, and SecuritySM of your staff, patients, and visitors.
 
View the detailed updates from the Joint Commission and learn how CPI aligns with the standards you are required to meet.
 
Schedule a free risk assessment with a CPI representative, to review the current policies you have in place, discuss the areas in which challenges are arising, and identify the appropriate steps to ensure you meet the Joint Commission’s requirements by January 1, 2022.

 
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