The Joint Commission’s updated accreditation manual is designed to simplify requirements, enhance clarity, and better support healthcare organizations in survey preparation. In this episode of VerifiedRx, host Carolyn Liptak is joined by Dr. Robert Campbell of the Joint Commission and Diana Scott of Vizient to unpack the most significant changes. From the shift to National Performance Goals and medication safety priorities to the latest challenges in compounding, labeling, and hazardous drug handling, the conversation highlights practical insights to help pharmacy leaders stay compliant and survey-ready.

Guest speakers:

Robert Campbell, PharmD, BCSCP

Sr. Director, Standards Interpretation, Accreditation Decision Management,Medication Safety Division of Accreditation and Certification Operations

Joint Commission

Diana Scott, MHA, RN, CPHQ

Principal, Regulatory and Accreditation Services

Vizient

Host:

Carolyn Liptak, , BS Pharm, MBA 

Vizient

Show Notes:

[01:16-01:51] Diana and Robert Backgrounds

[01:52-02:43] Changes made to the hospital and critical access hospital manuals

[02:44-03:09] Changes to the chapters themselves

[03:10-04:08] National Performance Goals and elaborate on those that are relevant to medication safety and pharmacy services

[04:09-05:15] The top medication management challenges

[05:16-06:29] Pain management not being aligned and titration orders

[06:30-06:56] Insufficient communication between pharmacists, prescribers and nurses when it comes to medication orders

[06:57-08:02] Themes around labeling requirements for stored medications

[08:03-08:46] Anything different in removing expired meds from patient care areas and in the pharmacy this area than previous years

[08:47-10:58] Issues related to storing meds specifically per the package insert

[10:59-11:55] Common issues seen inside the pharmacy regarding sterile compounding, noncompliance include hand hygiene, garbing, PPE, and cleaning and disinfecting

[11:56-13:12] More specifics in those area the physical environment and facility cleanliness along with cleaning and disinfection practices

[13:13-14:55] Explaination of how joint Commission defines and evaluates immediate use compounding

[14:56-16:09] The minimum required elements for immediate use compounding competency

[16:10-17:12] Compounding competencies besides immediate use

[17:13-17:54] Expectations for environmental services training

[17:55- 20:14] Concerns around hazardous drugs

[20:15- 21:14] Additional information

Links | Resources:

Joint Commission: THE NEW STANDARD: Accreditation 360

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