3_TJC Accreditation - Comlaince_Combest_Middlecamp_22AUG23.pdf
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- Solicitation number
- W9127S23R6002
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This document provides an overview of the Defense Health Agency's facilities accreditation and compliance program. It outlines the DHA's accreditation assistance process including mock surveys conducted by DHA contractors to prepare military treatment facilities for The Joint Commission triennial surveys. Contractors play an important role in MTF survey readiness by ensuring documentation and maintenance standards are met for areas like infection prevention, construction risk assessments, and interim life safety measures. The presentation summarizes contractor responsibilities for performing inspections, testing and maintenance in accordance with applicable codes and regulations. It also notes opportunities for performance improvement identified during mock surveys. Military treatment facility points of contact are advised to contact the DHA facilities accreditation and compliance team for assistance in survey preparation.
The related federal contract opportunity is a special notice announcing an update to a previous presentation on the DHA Industry Day topics. It includes the slides from the presentation and points of contact for small businesses.
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DHA Industry Day Facilities Operations Branch
Facilities Accreditation and Compliance
22 Aug 2023 Controlled By: DHA Facility Ops Branch CUI Category: PROPIN
DISTRO/LDC: FEDCON
POC: (210) 831-7684
CUI
Improving Health and Building Readiness. Anytime, Anywhere — Always
Agenda
• Facilities Accreditation and Compliance Team
• DHA Accreditation Program DHA-PM 6025.13, Vol 5, Clinical Quality Management in the Military Health
System DHA Program Memorandum 4140.01 Accreditation and Certification
Compliance Management for Defense Health, 13 JUN 22
• Contractor Role in the MTF’s The Joint Commission (TJC) Preparation for Survey
Facilities Accreditation and Compliance Team Chief, Facilities Accreditation & Compliance - Maj Ryan Combest
Email: ryan.s.combest.mil@mail.mil Comm: (210) 536-6192
Facilities Accreditation and Compliance - Mr. Steven Middlecamp Email: steven.p.middlecamp.civ@mail.mil Comm: (210) 536-6191
Facilities Education & Compliance - Ms. Tanya Simulick Email: tanya.m.simulick.ctr@mail.mil Comm: (312) 515-9274
Facility Education & Compliance - Mrs. Anne Guglielmo Email: aguglielmo@nikasolutions.com Comm: (708) 253-9496
Best way to contact us: dha.ncr.j-6.mbx.dha-fe-fob-fac-ac@health.mil mailto:ryan.s.combest.mil@mail.mil mailto:steven.p.middlecamp.civ@mail.mil mailto:tanya.m.simulick.ctr@mail.mil mailto:aguglielmo@nikasolutions.com mailto:dha.ncr.j-6.mbx.dha-fe-fob-fac-ac@health.mil
DHA Accreditation Program
• DHA-PM 6025.13, Vol 5, Clinical Quality Management in the Military Health System
DHA ACP Accreditation Assistance Visit (Mock Survey – DHA contractor executed)
DHA FAC Ad hoc Education and Training Visit
The Joint Commission Triennial Survey
• DHA PM 4140.01 Accreditation and Certification Compliance Management for Defense Health, 13 JUN 22
Transition to Life Safety Code 101: 2021
MTF determines timeframe to update edition based timing of Triennial Survey
Contactor Role in MTF TJC Survey
• Keys to a Medical Treatment Facility Survey Success:
TJC Documentation Operations and Maintenance Library Inspection, Testing and Maintenance Infection Prevention / Pre-Construction Risk Assessments (ICRA/PCRA) Interim Life Safety Measures (ILSM)
Performance of Inspection, Testing and Maintenance in accordance with appropriate NFPA code, applicable code and regulations.
Performance Improvement Opportunities Mock Survey
Contactor Role in MTF TJC Survey
• Mock Survey Example:
Summary
• Please have your TJC POC contact us!
• Thank you for supporting MTF TJC Readiness and Their Successful Triennial Survey!
| DHA Industry Day�Facilities Operations Branch�Facilities Accreditation and Compliance |
| Agenda |
| Facilities Accreditation and Compliance Team |
| DHA Accreditation Program |
| Contactor Role in MTF TJC Survey |
| Contactor Role in MTF TJC Survey |
| Summary |
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