3. The data are analyzed and actions taken to reduce near-miss events. (Also see MMU.7.1, ME 3)
Improvement
Standard
QPS.8 Improvement in quality and safety is achieved and sustained.
Intent of QPS.8
The organization uses the information from data analysis to identify potential improvements or reduce (or prevent) adverse events. Routine monitoring data, as well as data from intensive assessments, contribute to this understanding of where improvement should be planned and what priority should be given to the improvement. In particular, improvements are planned for the priority data collection areas identified by leaders.
Measurable Elements of QPS.8
Standard
QPS.9 Improvement and safety activities are undertaken for the priority areas identified by the organization’s leaders.
Intent of QPS.9
The organization uses appropriate resources and involves those individuals, disciplines, and departments closest to the processes or activities to be improved. Responsibility for planning and carrying an improvement is assigned to individuals or a team, any needed training is provided, and information management (also see Glossary) or other resources are made available.
Once planned, data are collected during a test period to demonstrate that the planned change was actually an improvement. To ensure that the improvement is sustained, monitoring data are then collected for ongoing analysis. Effective changes are incorporated into standard operating procedure, and any necessary staff education is carried out. The organization documents those improvements achieved and sustained as part of its quality management and improvement program.
Measurable Elements of QPS.9
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1. The priority areas identified by the organization’s leaders are included in improvement activities. (Also see QPS.3, ME 1)
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2. Human and other resources needed to carry out an improvement are assigned or allocated.
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3. Changes are planned and tested.
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4. Changes that resulted in improvements are implemented.
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5. Data are available to demonstrate that improvements are effective and sustained.
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6. Policy changes necessary to plan, carry out and sustain the improvement are made.
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7. Successful improvements are documented.
Standard
QPS.10 An ongoing program of identifying and reducing unanticipated adverse events and safety risks to patients and staff is defined and implemented.
Intent of QPS.10
Organizations need to adopt a proactive process to evaluate near misses and other high-risk processes for which a failure would result in a sentinel event. One tool that provides such a proactive analysis of the consequences of an event that could occur in a critical, high-risk process is failure mode and effects analysis (also see Glossary). The organization can also identify and use similar tools to identify and reduce risks, such as a hazard vulnerability analysis (also see Glossary).
To use this or similar tools effectively, the organization’s leaders need to adopt and learn the approach, agree on a list of high-risk processes in terms of patient and staff safety, and then use the tool on a priority risk process. Following analysis of the results, the organization’s leaders take action to redesign the process or similar actions to reduce the risk in the process. This risk-reduction process is carried out at least once per year and documented.
Measurable Elements of QPS.10
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1. The organization’s leaders adopt a process by which it identifies high-risk areas in terms of patient and staff safety.
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2. The organization’s leaders prioritize patient and staff safety risks at least once annually.
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3. The organization conducts and documents use of a proactive risk-reduction tool at least annually on one of the priority risk processes.
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4. The organization’s leaders take action to redesign high-risk processes based on the analysis.
Prevention and Control of Infections (PCI)
Overview
The goal of an organization’s infection prevention and control program is to identify and reduce the risks of acquiring and transmitting infections among patients, staff, health care professionals, contract workers (also see “contracted services” in Glossary), volunteers, students, and visitors.
The infection risks and program activities may differ from organization to organization, depending on the organization’s clinical activities and services, patient population(s) served, geographic location, patient volume, and number of employees.
Effective programs have in common identified leaders, well-trained staff, methods to identify and proactively address infection risks, appropriate policies and procedures, staff education, and coordination throughout the organization.
Standards
The following is a list of all standards for this function. They are presented here for your convenience without their intent statements or measurable elements. For more information about these standards, please see the next section in this chapter, Standards, Intents, and Measurable Elements.
PCI.1 One or more individuals oversee all infection prevention and control activities. This individual(s) is qualified in infection control practices through education, training, experience, or certification (also see Glossary).
PCI.2 There is a designated coordination mechanism for all infection control activities that involves physicians, nurses, and others as appropriate to the size and complexity of the organization.
PCI.3 The infection control program is based on current scientific knowledge, accepted practice guidelines, and applicable law and regulation.
PCI.4 The organization’s leaders provide adequate resources to support the infection control program.
PCI.5 The organization designs and implements a comprehensive program to reduce the risks of health care–associated infections in patients and health care workers.
PCI.5.1 All patient, staff, and visitor areas of the organization are included in the infection control program.
PCI.6 The organization establishes the focus of the health care–associated infection prevention and reduction program.
PCI.7 The organization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk.
PCI.7.1 The organization reduces the risk of infections by ensuring adequate equipment cleaning and sterilization and the proper management of laundry and linen.
PCI.7.2 The organization reduces the risk of infections through proper disposal of waste.
PCI.7.3 The organization has a policy and procedure on the disposal of sharps and needles.
PCI.7.4 The organization reduces the risk of infections in the facility associated with operations of the food service and of mechanical and engineering controls.
PCI.7.5 The organization reduces the risk of infection in the facility during demolition, construction and renovation.
PCI.8 The organization provides barrier precautions and isolation procedures that protect patients, visitors and staff from communicable diseases and protects immunosuppressed patients from acquiring infections to which they are uniquely prone.
PCI.9 Gloves, masks, eye protection, other protective equipment, soap, and disinfectants are available and used correctly when required.
PCI.10 The infection control process is integrated with the organization’s overall program for quality improvement and patient safety.
PCI.10.1 The organization tracks infection risks, infection rates, and trends in health care–associated infections.
PCI.10.2 Monitoring includes using indicators related to infection issues that are epidemiologically important to the organization.
PCI.10.3 The organization uses risk, rate, and trend information to design or modify processes to reduce the risk of health care–associated infections to the lowest possible levels.
PCI.10.4 The organization compares its health care–associated infection rates with other organizations through comparative databases.
PCI.10.5 The results of infection monitoring in the organization are regularly communicated to leaders and staff.
PCI.10.6 The organization reports information on infections to appropriate external public health agencies.
PCI.11 The organization provides education on infection control practices to staff, doctors, patients, and, as
appropriate, family and other caregivers.
Standards, Intents, and Measurable Elements
Program Leadership and Coordination
Standard
PCI.1 One or more individuals oversee all infection prevention and control activities. This individual(s) is qualified in infection control practices through education, training, experience, or certification.
Intent of PCI.1
The infection prevention and control program has oversight appropriate to the organization’s size, level of risks, complexity of activities and the program’s scope. One or more individuals, acting on a full-time or part-time basis, provide that oversight as part of their assigned responsibilities or job description. Their qualification depends on the activities they will carry out and may be met through
Measurable Elements of PCI.1
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1. One or more individuals oversee the infection control program.
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2. The individual(s) is qualified for the organization’s size, level of risks, and program scope and complexity.
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3. The individual(s) fulfill program oversight responsibilities as assigned or described in a job description.
Standard
PCI.2 There is a designated coordination mechanism for all infection control activities that involves physicians, nurses, and others as appropriate to the size and complexity of the organization.
Intent of PCI.2
Infection prevention and control activities reach into every part of a health care organization (also see Glossary) and involve individuals in multiple departments and services, for example, in clinical departments, facility maintenance, food services, housekeeping, laboratory, pharmacy and sterilization services. There is a designated mechanism to coordinate the overall program. That mechanism may be a small work group, a coordinating committee, task force or other mechanism. Responsibilities include, for example, setting criteria to define health care–associated infections (also see Glossary), establishing data (also see Glossary) collection (surveillance) methods, designing strategies to address infection prevention and control risks, and reporting processes. Coordination involves communicating with all parts of the organization to ensure that the program is continuous and proactive.
Whatever the mechanism chosen by the organization to coordinate the infection control program, physicians and nurses are represented and engaged in the activities with the infection control professionals. Others may be included as determined by the organization’s size and complexity of services (for example, epidemiologist, data collection expert, statistician, central sterilization manager, microbiologist, pharmacist, housekeeping services, environmental or facilities services, operating theater supervisor).
Joint Commission International Accreditation Standards for Hospitals, Third Edition
Measurable Elements of PCI.2
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1. There is a designated mechanism for the coordination of the infection control program.
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2. Coordination of infection control activities involves physicians.
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3. Coordination of infection control activities involves nurses.
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4. Coordination of infection control activities involves the infection control professionals.
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5. Coordination of infection control activities involves others as appropriate to the organization.
Standard
PCI.3 The infection control program is based on current scientific knowledge, accepted practice guidelines, and applicable law and regulation.
Intent of PCI.3
Information is essential to an infection control program. Current scientific information is required to understand and implement effective surveillance and control activities and can come from many national or international sources, for example, the World Health Organization (WHO) publishes hand hygiene and other guidelines. Practice guidelines (also see Glossary) provide information on preventive (also see Glossary) practices and infections associated with clinical and support services. Applicable laws and regulations define elements of the basic program, the response to infectious disease outbreaks and any reporting requirements.
Measurable Elements of PCI.3
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1. The infection control program is based on current scientific knowledge.
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2. The infection control program is based on accepted practice guidelines.
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3. The infection control program is based on applicable law and regulation.
Standard
PCI.4 The organization’s leaders provide adequate resources to support the infection control program.
Intent of PCI.4
The infection control program requires adequate staff to meet the program goals and the needs of the organization, as determined by the oversight body/mechanism and approved by the organization’s leadership.
In addition, the infection control program requires resources to provide education to all staff, and supplies such as alcohol hand rubs for hand hygiene. The leaders of the organization ensure that the program has adequate resources to effectively carry out the program.
Information management (also see Glossary) systems are an important resource to support the tracking of risks, rates, and trends in health care–associated infections. Information management functions support data analysis, interpretation, and presentation of findings. In addition, infection control program data and information are managed with those of the organization’s quality management and improvement program.
Measurable Elements of PCI.4
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1. The infection control program is adequately staffed as approved by the leadership.
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2. The organization’s leaders allocate adequate resources for the infection control program.
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3. Information management systems support the infection control program.
Focus of the Program
Standard
PCI.5 The organization designs and implements a comprehensive program to reduce the risks of health care–associated infections in patients and health care workers.
Intent of PCI.5
For an infection prevention and control program to be effective, it must be comprehensive, encompassing both patient care and employee health. The program is guided by a plan that identifies and addresses the infection issues that are epidemiologically important to the organization. In addition, the program and plan are appropriate to the organization’s size and geographic location, services, and patients. The program includes systems to monitor (also see Glossary) infections and investigate outbreaks of infectious diseases. Policies and procedures guide the program. The periodic assessment of risk and setting of risk-reduction goals guides the program.
Measurable Elements of PCI.5
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1. There is a comprehensive program and plan to reduce the risk of health care–associated infections in patients.
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2. There is a comprehensive program and plan to reduce the risk of health care–associated infections in health care workers. (Also see SQE.8.4)
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3. The program includes systematic and proactive surveillance activities to determine usual (endemic) rates of infection.
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4. The program includes systems to investigate outbreaks of infectious diseases. (Also see International Patient Safety Goal 5, ME 1)
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5. The program is guided by appropriate policies and procedures.
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6. Risk-reduction goals and measurable objectives are established and regularly reviewed.
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7. The program is appropriate to the organization’s size and geographic location, services, and patients.
Standard
PCI.5.1 All patient, staff, and visitor areas of the organization are included in the infection control program.
Intent of PCI.5.1
Infections can enter the organization via patients, families, staff, volunteers, visitors, and other individuals such as trade representatives. Thus, all areas of the organization where these individuals are found must be included in the program of infection surveillance, prevention, and control.
Measurable Elements of PCI.5.1
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1. All patient care areas of the organization are included in the infection control program.
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2. All staff areas of the organization are included in the infection control program.
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3. All visitor areas of the organization are included in the infection control program.
Standard
PCI.6 The organization establishes the focus of the health care–associated infection prevention and reduction program.
Intent of PCI.6
Each organization must identify those epidemiologically important infections, infection sites, and associated devices and procedures that will provide the focus of efforts to prevent and reduce the risk and incidence of health care–associated infections. Organizations consider, as appropriate, infections and processes that involve
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respiratory tract—such as the procedures and equipment associated with intubation, mechanical ventilatory support, tracheostomy, and so on;
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urinary tract—such as the invasive procedures (also see Glossary) and equipment associated with indwelling urinary catheters, urinary drainage systems, and their care, and so on;
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intravascular invasive devices—such as the insertion and care of central venous catheters, peripheral venous lines, and so on;
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surgical sites—such as their care and type of dressing and associated aseptic procedures;
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epidemiologically significant diseases and organisms—multi-drug resistant organisms, highly virulent infections; and
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emerging or reemerging infections with the community.
Measurable Elements of PCI.6
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1. The organization has established the focus of the program to prevent or reduce the incidence of health care–associated infections.
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2. Respiratory tract infections are included as appropriate to the organization.
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3. Urinary tract infections are included as appropriate to the organization.
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4. Intravascular invasive devices are included as appropriate to the organization.
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5. Surgical wounds are included as appropriate to the organization.
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6. Epidemiologically significant diseases and organisms are included as appropriate to the organization and its community.
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7. Emerging or reemerging infections are included as appropriate to the organization and its community.
Standard
PCI.7 The organization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk.
Intent of PCI.7
Health care organizations assess and care for patients using many simple and complex processes, each associated with a level of infection risk to patients and staff. It is thus important for an organization to review and monitor those processes and, as appropriate, implement needed policies, procedures, education, and other activities to reduce the risk of infection.
Measurable Elements of PCI.7
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1. The organization has identified those processes associated with infection risk. (Also see MMU.5, ME 1)
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2. The organization has implemented strategies to reduce infection risk in those processes. (Also see MMU.5, ME 1)
❒ 3. The organization identifies which risks (also see PCI.7.1 through PCI.7.5) require policies and or procedures, staff education, practice changes, and other activities to support risk reduction.
Standard
PCI.7.1 The organization reduces the risk of infections by ensuring adequate equipment cleaning and sterilization and the proper management of laundry and linen.
Intent of PCI.7.1
Infection risk is minimized with proper cleaning, disinfection and sterilization processes, such as the cleaning and disinfection of endoscopes, sterilization of surgical supplies and other invasive or non-invasive patient care equipment. Cleaning, disinfection and sterilization can take place in a centralized sterilization area or in other areas of the organization such as endoscope clinics with proper oversight. Also, the proper management of laundry and linen can result in reduced contamination (also see Glossary) of clean linen and infection risk to staff from soiled laundry and linen.
Infection risk increases with the reuse of single-use devices. When single-use devices are reused there is a hospital policy that guides such reuse. The policy is consistent with regulatory and professional standards. The policy includes identification of a) devices and materials that can never be reused; b) the maximum number of reuses for devices and materials that are reused; c) the types of wear, cracking, etc., that indicate the device cannot be reused; d) the cleaning process for devices that starts immediately after use and follows a clear protocol (also see
Glossary); and e) the process for the collection, analysis and use of infection control data related to reused devices and materials.
Measurable Elements of PCI.7.1
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1. Equipment cleaning and sterilization methods in a central sterilization service are appropriate for the type of equipment.
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2. Equipment cleaning, disinfection and sterilization methods conducted outside of a central sterilization service are appropriate for the type of equipment.
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3. When single-use devices and materials are reused, there is a policy that includes items a) through e) in the intent statement, and the policy is implemented.
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4. Laundry and linen management are appropriate to minimize risk to staff and patients.
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5. There is a coordinated oversight process for all cleaning, disinfection and sterilization throughout the organization.
Standard
PCI.7.2 The organization reduces the risk of infections through proper disposal of waste.
Intent of PCI.7.2
Health care organizations produce considerable waste each day. Frequently that waste is or could be infectious. Thus, the proper disposal of waste contributes to the reduction of infection risk in the organization. This is true for the disposal of body fluids and materials contaminated with body fluids, the disposal of blood and blood components, and waste from the mortuary and postmortem areas, when present.
Joint Commission International Accreditation Standards for Hospitals, Third Edition
Measurable Elements of PCI.7.2
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1. Disposal of infectious waste and body fluids are managed to minimize transmission risk.
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2. The handling and disposal of blood and blood components are managed to minimize transmission risk.
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3. Operation of the mortuary and postmortem area are managed to minimize transmission risk.
Standard
PCI.7.3 The organization has a policy and procedure on the disposal of sharps and needles.
Intent of PCI.7.3
The improper disposal of sharps and needles presents a major staff safety challenge. The organization ensures that a policy is implemented that adequately addresses all steps in the process from the type and use of containers, the disposal of the containers and the surveillance of the process of disposal.
Measurable Elements of PCI.7.3
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1. Sharps and needles are collected in dedicated, puncture-proof containers which are not re-used.
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2. The hospital disposes of sharps and needles safely or contracts with sources that ensure the sharps containers are disposed of in dedicated hazardous waste sites or by an appropriate process.
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3. The disposal of sharps and needles is consistent with infection control policies of the organization.
Standard
PCI.7.4 The organization reduces the risk of infections in the facility associated with operations of the food service and of mechanical and engineering controls.
Intent of PCI.7.4
Engineering controls, such as positive ventilation systems, biological hoods in laboratories, and thermostats on refrigeration units and on water heaters used to sterilize dishes and kitchen equipment, are examples of the important role environmental standards and controls contribute to good sanitation and the reduction of infection risks in the organization.
Measurable Elements of PCI.7.4
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1. Kitchen sanitation and food preparation and handling are appropriate to minimize infection risk.
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2. Engineering controls are implemented as appropriate to minimize infection risk in appropriate areas of the organization.
Standard
PCI.7.5 The organization reduces the risk of infection in the facility during demolition, construction and renovation.
Intent of PCI.7.5
When planning demolition, construction, or renovation, the organization uses risk criteria that address the impact of the renovation or new construction on air quality requirements, infection control, utility requirements, noise, vibration, and emergency (also see Glossary) procedures.
Measurable Elements of PCI.7.5
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1. The organization uses risk criteria to assess the impact of renovation or new construction.
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2. The risks and impact of the renovation or construction on air quality and infection control activities is assessed and managed.
Isolation Procedures
Standard
PCI.8 The organization provides barrier precautions and isolation procedures that protect patients, visitors and staff from communicable diseases and protects immunosuppressed patients from acquiring infections to which they are uniquely prone.
Intent of PCI.8
The organization develops policies and procedures that establish the isolation and barrier procedures for the hospital. These are based on the method of disease transmission and address individual patients who may be infectious or immunosuppressed, as well as the influx of large numbers of patients with contagious infections. The isolation procedures address staff and visitor protection, the patient environment and the cleaning of the room during the stay and after the patient is discharged.
Measurable Elements of PCI.8
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1. Patients with known or suspected contagious diseases are isolated in accordance with organization policy and recommended guidelines.
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2. Policies and procedures address the separation of patients with communicable diseases from patients and staff who are at greater risk due to immunosuppression or other reasons.
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3. The organization has a strategy of dealing with an influx of patients with contagious diseases.
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4. Appropriate negative pressure rooms are available and monitored routinely for infectious patients who require isolation.
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5. Staff are educated in the management of infectious patients.
Barrier Techniques and Hand Hygiene
Standard
PCI.9 Gloves, masks, eye protection, other protective equipment, soap, and disinfectants are available and used correctly when required.
Intent of PCI.9
Hand hygiene, barrier techniques, and disinfecting agents are fundamental tools for proper infection prevention and control. The organization identifies those situations in which masks, eye protection, gowns, or gloves are required and provides training in their correct use. Soap, disinfectants, and towels or other means of drying are located in those areas where handwashing and disinfecting procedures are required. Hand hygiene guidelines (use of guidelines is scored at International Patient Safety Goal 5, ME 2) are adopted by the organization and posted in appropriate areas, and staff are educated in proper handwashing, hand disinfection, or surface disinfection procedures.
Measurable Elements of PCI.9
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1. The organization identifies those situations for which gloves and/or masks or eye protection are required.
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2. Gloves and/or masks or eye protection are correctly used in those situations.
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3. The organization identifies those areas where handwashing and hand disinfection or surface disinfecting procedures are required.
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4. Handwashing and hand disinfection procedures are used correctly in those areas.
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5. The organization has adopted hand hygiene guidelines from an authoritative source.
Integration of the Program with Quality Improvement and Patient Safety
Standards
PCI.10 The infection control process is integrated with the organization’s overall program for quality improvement and patient safety.
PCI.10.1 The organization tracks infection risks, infection rates, and trends in health care–associated infections.
PCI.10.2 Monitoring includes using indicators related to infection issues that are epidemiologically important to the organization.
PCI.10.3 The organization uses risk, rate, and trend information to design or modify processes to reduce the risk of health care–associated infections to the lowest possible levels.
PCI.10.4 The organization compares its health care–associated infection rates with other organizations through comparative databases.
PCI.10.5 The results of infection monitoring in the organization are regularly communicated to leaders and staff.
PCI.10.6 The organization reports information on infections to appropriate external public health agencies.
Intent of PCI.10 through PCI.10.6
The infection control process is designed to lower the risk of infection for patients, staff, and others. To reach this goal, the organization must proactively monitor and track risks, rates, and trends in health care–associated infections. The organization uses monitoring information to improve infection prevention and control activities and to reduce health care–associated infection rates to the lowest possible levels. An organization can best use monitoring data and information by understanding similar rates and trends in other similar organizations and contributing data to infection-related databases.
Measurable Elements of PCI.10
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1. Infection control activities are integrated into the organization’s quality improvement and patient safety program. (Also see QPS.1.1, ME 4)
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2. The leadership of the infection control program is included in the organization’s quality and patient safety program’s oversight mechanism.
Measurable Elements of PCI.10.1
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1. Health care–associated infection risks are tracked.
-
2. Health care–associated infection rates are tracked.
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3. Health care–associated infection trends are tracked.
Measurable Elements of PCI.10.2
Measurable Elements of PCI.10.3
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1. Processes are redesigned based on risk, rate, and trend data and information.
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2. Processes are redesigned to reduce infection risk to the lowest levels possible.
Measurable Elements of PCI.10.4
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1. Health care–associated infection rates are compared to other organizations’ rates through comparative databases. (Also see QPS.4.2, ME 2 and MCI.20.3, ME 3)
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2. The organization compares its rates to best practices (also see Glossary) and scientific evidence.
Measurable Elements of PCI.10.5
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1. Monitoring results are communicated to medical staff.
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2. Monitoring results are communicated to nursing staff.
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3. Monitoring results are communicated to management.
Measurable Elements of PCI.10.6
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1. Infection control program results are reported to public health agencies as required. (Also see MCI.20.1)
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2. The organization takes appropriate action on reports from relevant public health agencies.
Education of Staff about the Program
Standard
PCI.11 The organization provides education on infection control practices to staff, doctors, patients, and, as appropriate, family and other caregivers.
Intent of PCI.11
For an organization to have an effective infection control program, it must educate staff members about the program when they begin work in the organization and regularly thereafter. The education program includes professional staff, clinical and nonclinical support staff, and even patients and families, including trade people and other visitors. Patients and families are encouraged to participate in the implementation and use of infection prevention and control practices in the organization.
The education is provided as part of the orientation of all new staff and is refreshed periodically, or at least when there is a change in the policies, procedures, and practices that guide the organization’s infection prevention and control program. The education also includes the findings and trends from the monitoring activities. (Also see SQE.7)
Measurable Elements of PCI.11
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1. The organization provides education about infection prevention and control.
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2. Clinical staff and other professional staff are included in the program.
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3. Patients and families are included when appropriate to the patient’s needs and condition.
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4. All staff are oriented to the policies, procedures, and practices of the infection prevention and control program. (Also see SQE.7 and GLD.5.4)
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5. Periodic staff education includes new policies and procedures.
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6. Periodic staff education is in response to significant trends in infection data.
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7. Patients and families are encouraged to participate in the infection prevention and control program.
Governance, Leadership, and Direction (GLD)
Overview
Providing excellent patient care requires effective leadership. That leadership comes from many sources in a health care organization, including governing leaders (governance; also see Glossary), leaders, and others who hold positions of leadership, responsibility, and trust. Each organization must identify these individuals and involve them in ensuring that the organization is an effective, efficient resource for the community and its patients.
In particular, these leaders must identify the organization’s mission and make sure that the resources needed to fulfill this mission are available. For many organizations, this does not mean adding new resources but more efficiently using current resources, even when they are scarce. Also, leaders must work together well to coordinate and integrate all of the organization’s activities, including those designed to improve patient care and clinical services.
Effective leadership begins with understanding the various responsibilities and authority of individuals in the organization and how these individuals work together. Those who govern, manage, and lead an organization have both authority and responsibility. Collectively and individually, they are responsible for complying with law and regulation and for meeting the organization’s responsibility to the patient population served. Over time, effective leadership helps overcome perceived barriers and communication problems between departments and services in the organization, and the organization becomes more efficient and effective. Services become increasingly integrated. In particular, the integration of all quality management and improvement activities throughout the organization results in improved patient outcomes (also see Glossary).
Standards
The following is a list of all standards for this function. They are presented here for your convenience without their intent statements or measurable elements. For more information about these standards, please see the next section in this chapter, Standards, Intents, and Measurable Elements.
GLD.1 Governance responsibilities and accountabilities are described in bylaws, policies and procedures, or similar documents that guide how they are to be carried out. GLD.1.1 Those responsible for governance approve and make public the organization’s mission statement.
GLD.1.2 Those responsible for governance approve the policies and plans to operate the organization. GLD.1.3 Those responsible for governance approve the budget and allocate the resources required to meet the organization’s mission.
GLD.1.4 Those responsible for governance appoint the organization’s senior manager(s) or director(s). GLD.1.5 Those responsible for governance collaborate with the organization’s managers. GLD.1.6 Those responsible for governance approve the organization’s plan for quality and patient safety
and regularly receive and act on reports of the quality and patient safety program.
GLD.2 A senior manager or director is responsible for operating the organization and complying with
applicable laws and regulations. GLD.3 The organization’s leaders are identified and are collectively responsible for defining the organization’s mission and creating the plans and policies needed to fulfill the mission.
GLD.3.1 Organization leaders plan with community leaders and leaders of other organizations to meet the
community’s health care needs. GLD.3.2 The leaders identify and plan for the type of clinical services required to meet the needs of the patients served by the organization.
GLD.3.2.1 Equipment, supplies, and medications recommended by professional organizations or by alternative authoritative sources are used. GLD.3.3 The leaders provide oversight of contracts for clinical or management services.
GLD.3.4 The medical, nursing, and other leaders are educated in the concepts of quality improvement. GLD.3.5 Organization leaders ensure that there are uniform programs for the recruitment, retention, development, and continuing education of all staff.
GLD.4 Medical, nursing, and other leaders of clinical services plan and implement an effective organizational structure to support their responsibilities and authority.
GLD.5 One or more qualified individuals provide direction for each department or service in the organization. GLD.5.1 The directors of each clinical department identify, in writing, the services to be provided by the department.
GLD.5.1.1 Services are coordinated and integrated within the department or service and with other
departments and services. GLD.5.2 Directors recommend space, equipment, staffing, and other resources needed by the department or service.
GLD.5.3 Directors recommend criteria for selecting the department or service’s professional staff and
choose or recommend individuals who meet those criteria. GLD.5.4 Directors provide orientation and training for all staff of the department or service appropriate to their responsibilities.
GLD.5.5 Directors monitor the department’s or service’s performance as well as staff performance. GLD.6 The organization establishes a framework for ethical management that ensures that patient care is provided within business, financial, ethical, and legal norms and that protects patients and their rights.
GLD.6.1 The organization’s framework for ethical management includes marketing, admissions, transfer,
and discharge, and disclosure of ownership and any business and professional conflicts that may not be in patients’ best interests.
GLD.6.2 The organization’s framework for ethical management supports ethical decision making in clinical care.
Joint Commission International Accreditation Standards for Hospitals, Third Edition
Standards, Intents, and Measurable Elements
Governance of the Organization
Standard
GLD.1 Governance responsibilities and accountabilities are described in bylaws, policies and procedures, or similar documents that guide how they are to be carried out.
Intent of GLD.1
There is an entity (for example, a ministry of health), an owner(s), or a group of identified individuals (for example, a board or governing body) responsible for overseeing the organization’s operation and accountable for providing quality health care services to its community or to the population that seeks care. This entity’s responsibilities and accountabilities are described in a document that identifies how they are to be carried out. Also described is how the governing entity and the performance of the organization’s managers will be evaluated against organization-specific criteria.
The organization’s governance and management structure is represented or displayed in an organizational chart (also see Glossary) or other document that shows lines of authority and accountability. The individuals represented on the chart are identified by title or name.
Measurable Elements of GLD.1
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1. The organization’s governance structure is described in written documents.
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2. Governance responsibilities and accountabilities are described in the documents.
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3. The documents describe how the performance of the governing entity and managers will be evaluated and any related criteria.
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4. There has been one documented performance evaluation of governance and senior management.
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5. There is an organization chart or document.
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6. Those responsible for governing and managing are identified by title or name.
Standards
GLD.1.1 Those responsible for governance approve and make public the organization’s mission statement. GLD.1.2 Those responsible for governance approve the policies and plans to operate the organization. GLD.1.3 Those responsible for governance approve the budget and allocate the resources required to meet the
organization’s mission. GLD.1.4 Those responsible for governance appoint the organization’s senior manager(s) or director(s). GLD.1.5 Those responsible for governance collaborate with the organization’s managers. GLD.1.6 Those responsible for governance approve the organization’s plan for quality and patient safety and
regularly receive and act on reports of the quality and patient safety program.
Intent of GLD.1.1 through GLD.1.6
The titles or location of the governance structure are not important. What is important are the responsibilities
that must be carried out for the organization to have clear leadership, operate efficiently, and provide quality
health care services. These responsibilities are primarily at the approval level and include
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approving the organization’s mission (also see “mission statement” in Glossary and ACC.1, ME 2);
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approving (or defining approval authority when delegated) the organization’s various strategic and management plans and the policies and procedures needed to operate the organization on a daily basis;
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approving the organization’s participation in health care professional education and in research and the oversight of the quality of such programs;
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approving or providing a budget and resources to operate the organization; and
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appointing or approving the organization’s senior manager(s) or director.
Identifying individuals in a single organizational chart (also see Glossary) does not ensure good communication and cooperation between those who govern and those who manage the organization. This is particularly true when the governance structure is separate from the organization, such as a distant owner or a national or regional health authority. Thus, those responsible for governance develop a process for communicating and cooperating with the organization’s managers to fulfill the organization’s mission and plans.
Measurable Elements of GLD.1.1
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1.Those responsible for governance approve the organization’s mission.
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2.Those responsible for governance ensure the periodic review of the organization’s mission.
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3.Those responsible for governance make public the organization’s mission.
Measurable Elements of GLD.1.2
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1.Those responsible for governance approve the organization’s strategic and management plans and operating policies and procedures.
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2.When approval authority is delegated it is defined in governance policies and procedures.
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3.Those responsible for governance approve organization strategies and programs related to health care professional education and research and then provide oversight of the quality of such programs.
Measurable Elements of GLD.1.3
Measurable Elements of GLD.1.4
Measurable Elements of GLD.1.5
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1. Those responsible for governance use processes that provide and support communication between governance and management.
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2. Those responsible for governance use processes that provide and support cooperation between governance and management.
Measurable Elements of GLD.1.6
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1. Those responsible for governance approve the organization’s plan for quality and patient safety. (Also see QPS.1 Intent)
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2. Those responsible for governance regularly receive and act on reports of the quality and patient safety program. (Also see QPS.1.4, ME 2)
Leadership of the Organization
Standard
GLD.2 A senior manager or director is responsible for operating the organization and complying with applicable laws and regulations.
Intent of GLD.2
Effective leadership is essential for a health care organization (also see Glossary) to be able to operate efficiently and fulfill its mission. Leadership is what individuals provide together and individually to the organization and can be carried out by any number of individuals.
The senior manager or director is responsible for the organization’s overall, day–to-day operations. This includes the procurement and inventory of essential supplies, maintenance of the physical facility, financial management, quality management, and other responsibilities. The individual selected or appointed by the governing body to carry out these functions has the education and experience to do so.
The senior manager or director cooperates with the organization’s managers to define the organization’s mission and plan the policies, procedures, and clinical services related to that mission. Once approved by the governing body, the senior manager or director is responsible for implementing all policies and ensuring that all policies are complied with by the organization’s staff.
The senior manager or director is responsible for the organization’s
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compliance with applicable law and regulation;
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response to any reports from inspecting and regulatory agencies; and
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processes to manage and control human, financial, and other resources.
Measurable Elements of GLD.2
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1. The senior manager or director manages the organization’s day-to-day operations.
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2. The senior manager or director has the education and experience to carry out his or her responsibilities.
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3. The senior manager or director recommends policies to the governing body.
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4. The senior manager or director ensures compliance with approved policies.
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5. The senior manager or director ensures compliance with applicable law and regulation. (Also see ACC.6, MEs 1 and 2)
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6. The senior manager or director responds to any reports from inspecting and regulatory agencies.
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7. The senior manager or director manages human, financial, and other resources. (Also see MMU.2.2, ME 1)
Standard
GLD.3 The organization’s leaders are identified and are collectively responsible for defining the organization’s mission and creating the plans and policies needed to fulfill the mission.
Intent of GLD.3
The leaders of an organization arise from many sources. The governing body names the senior manager or director. The senior manager or director may name other managers. Leaders may have formal titles such as Medical Director or Director of Nursing, or be informally recognized for their seniority, stature, or contribution to the organization. It is important that all leaders of an organization are recognized and brought into the process of defining the organization’s mission. Based on that mission, the leaders work collaboratively to develop the plans and policies needed to fulfill the mission. When the mission and policy framework are set by owners or agencies outside the organization, the leaders work collaboratively to carry out the mission and policies. (Also see ACC.1, MEs 2 and 3)
Measurable Elements of GLD.3
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1. The leaders of the organization are formally or informally identified.
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2. The leaders are collectively responsible for defining the organization’s mission.
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3. The leaders are collectively responsible for creating the policies and procedures necessary to
Standard
GLD.3.1 Organization leaders plan with community leaders and leaders of other organizations to meet the community’s health care needs.
Intent of GLD.3.1
An organization’s mission commonly reflects the needs of the population in its community. Similarly, referral (also see Glossary) and specialty care organizations derive their mission from the needs of patients within larger geographic or political areas.
The needs of patients and communities usually change over time and thus, health care organizations need to engage their communities in the strategic and operational planning of the organization. Organizations do this by seeking opinions or input on an individual or group basis through advisory groups or taskforces, for example.
Thus, it is important for the leaders of a health care organization to meet with, and plan with, recognized community leaders and the leaders of other provider organizations in the community. The leaders plan for a healthier community and recognize that they have responsibility for and an impact on the community, even in the absence of such planning. (Also see MC1.1, ME 3)
Measurable Elements of GLD.3.1
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1. The organization’s leaders plan with recognized community leaders.
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2. The organization’s leaders plan with the leaders of other provider organizations in its community. (Also see PFE.3, MEs 2 and 3)
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3. The organization’s leaders seek the input of individual and group stakeholders in its community as part of its strategic and operational planning.
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4. The organization participates in community education on health promotion and disease prevention.
Standard
GLD.3.2 The leaders identify and plan for the type of clinical services required to meet the needs of the patients served by the organization.
Intent of GLD.3.2
Patient care services are planned and designed to respond to the needs of the patient population. Organization plans describe the care and services to be provided consistent with its mission. The leaders of the various clinical departments and services in the organization determine what diagnostic, therapeutic, rehabilitative, and other services are essential to the community. The leaders also determine the scope and intensity of the various services to be provided by the organization directly or indirectly.
The services planned reflect the strategic direction of the organization and the perspective of the patients cared for by the organization. When an organization uses what is considered “experimental” technology and/or pharmaceutical agents in patient care procedures (that is, technology or agents considered “experimental” either nationally or internationally), there is a process to review and approve such use. It is essential that such approval occur prior to use in patient care. A determination is made if a special patient consent is necessary.
Measurable Elements of GLD.3.2
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1. Organization plans describe the care and services to be provided.
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2. The care and services to be offered are consistent with the organization’s mission. (Also see ACC.1, ME 2)
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3. Leaders determine the type of care and services to be provided by the organization.
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4. Leaders have a process for reviewing and approving, before use in patient care, those procedures, technologies, and pharmaceutical agents considered experimental.
Standard
GLD.3.2.1 Equipment, supplies, and medications recommended by professional organizations or by alternative authoritative sources are used.
Intent of GLD.3.2.1
Risks in clinical care processes are significantly reduced when appropriate and well-functioning equipment is used to provide the planned services. This is especially true for clinical areas such as anesthesia, radiology and diagnostic imaging, cardiology, radiation oncology, and other high-risk services when provided. Adequate supplies and medications are also available and appropriate for planned use and emergent situations. Each organization understands the required or recommended equipment, supplies, and medications necessary to provide the planned services to its patient population. Recommendations on equipment, supplies, and medication can come from a government agency, national or international anesthesia professional organizations, or other authoritative sources.
Measurable Elements of GLD.3.2.1
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1. The organization identifies the recommendations of professional organizations and other authoritative sources in relation to the equipment and supplies it will need to provide the planned services. (Also see MMU.2.2, ME 1)
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2. Recommended equipment, supplies and medications are obtained as appropriate. (Also see MMU.2.2, ME 2)
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3. Recommended equipment, supplies and medications are used. (Also see ASC.3 Intent and ASC.3, ME 1)
Standard
GLD.3.3 The leaders provide oversight of contracts for clinical or management services.
Intent of GLD.3.3
Organizations frequently have the option to either provide clinical and management services directly or arrange for such services through referral, consultation, contractual arrangements, or other agreements. Such services may range from radiology and diagnostic imaging services to financial accounting services. In all cases, there is leadership oversight for such contracts or other arrangements to ensure that the services meet patient needs and are monitored (also see Glossary) as part of the organization’s quality management and improvement activities. Leaders from clinical departments or services provide primary oversight for clinical contracts, and leaders from management provide primary oversight for management contracts.
Department managers receive and act on quality reports from contracting agencies (also see “contracted services” in Glossary) and ensure the reports are integrated into the organization’s quality monitoring process when appropriate. (Also see ACC.4.1, ME 2)
Measurable Elements of GLD.3.3
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1. There is a process for leadership oversight of contracts. (Also see AOP.5.8 and AOP.6.9)
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2. Services provided under contracts and other arrangements meet patient needs.
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3. Contracts and other arrangements are monitored, as appropriate to the nature of the contract, as part of the organization’s quality management and improvement program. (Also see AOP.5.8, ME 6)
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4. Department mangers receive and act on the quality reports of contracting agencies. (Also see AOP.5.8, ME 5)
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5. All diagnostic, consultative and treatment services provided by independent practitioners outside the organization, such as telemedicine and teleradiology, are privileged by the organization to provide such services.
Standard
GLD.3.4 The medical, nursing, and other leaders are educated in the concepts of quality improvement.
Intent of GLD.3.4
A health care organization’s primary purpose is to provide patient care and work to improve patient care outcomes over time by applying quality improvement principles. Thus, the medical, nursing, and other leaders of an organization need to
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be educated in or familiar with the concepts and methods of quality improvement;
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personally participate in quality improvement and patient safety processes; and
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ensure that clinical monitoring includes opportunities for monitoring professional performance.
Measurable Elements of GLD.3.4
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1. Medical, nursing, and other leaders are educated in or are familiar with the concepts and methods of quality improvement.
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2. Medical, nursing, and other leaders participate in relevant quality improvement and patient safety processes. (Also see QPS.1.1, MEs 1 and 4)
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3. Professional performance is monitored as part of clinical monitoring. (Also see SQE.11, SQE.14, and SQE.17)
Standard
GLD.3.5 Organization leaders ensure that there are uniform programs for the recruitment, retention, development, and continuing education of all staff.
Intent of GLD.3.5
An organization’s ability to care for patients is directly related to its ability to attract and retain qualified, competent staff. Leaders recognize that staff retention, rather than recruitment (also see Glossary), provides greater long-term benefit. Retention is increased when leaders support staff advancement through continuing education. Thus, the leaders collaborate to plan and implement uniform programs and processes related to recruitment, retention, development, and continuing education for each category of staff. The organization’s recruitment program considers published guidelines such as those from the WHO, International Council of Nurses, and World Medical Association.
Measurable Elements of GLD.3.5
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1. There is a planned process for staff recruitment. (Also see SQE.2, ME 1)
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2. There is a planned process for staff retention.
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3. There is a planned process for staff personal development and continuing education. (Also see SQE.8)
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4. The planning is collaborative and includes all departments and services in the organization.
Standard
GLD.4 Medical, nursing, and other leaders of clinical services plan and implement an effective organizational structure to support their responsibilities and authority.
Intent of GLD.4
Medical, nursing, and other leaders of clinical services have a special responsibility to patients and to the organization. These leaders
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support good communication between professionals;
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jointly plan and develop policies that guide the delivery of clinical services;
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provide for the ethical practice of their professions; and • oversee the quality of patient care.
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The leaders of the medical and nursing staff create a suitable, effective organizational structure to carry out these responsibilities. The organizational structure(s) and the associated processes used to carry out these responsibilities can provide a single professional staff composed of physicians, nurses, and others or separate medical and nursing staff structures. The structure chosen can be highly organized with bylaws and rules and regulations or can be informally organized. In general, the structure(s) chosen
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includes all of the relevant clinical staff;
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is consistent with the organization’s ownership, mission and structure;
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is appropriate for the organization’s complexity and size of the professional staff; and
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is effective in carrying out the responsibilities listed above.
Measurable Elements of GLD.4
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1.There is an effective organizational structure(s) used by medical, nursing, and other leaders to carry out their responsibilities and authority.
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2.The structure(s) is appropriate to the organization’s size and complexity.
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3.The organizational structure(s) and processes support professional communication.
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4.The organizational structure(s) and processes support clinical planning and policy development.
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5.The organizational structure(s) and processes support oversight of professional ethical issues.
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6.The organizational structure(s) and processes support oversight of the quality of clinical services.
Direction of Departments and Services
Standard
GLD.5 One or more qualified individuals provide direction for each department or service in the organization.
Intent of GLD.5
The clinical care, patient outcomes, and overall management of a health care organization are only as good as the clinical and managerial activities of each individual department or service. Good departmental or service performance requires clear leadership from a qualified individual (also see Glossary). In larger departments or services, leadership may be separated. In such a case, the responsibilities of each role are defined in writing. (Also see ACC.6.1, ME 1; ACS.2, ME 1; AOP.5.9 related to the direction of clinical laboratory services; AOP.6.7 related to the direction of radiology and diagnostic imaging services; MMU.1.1 related to the direction of the pharmacy or pharmaceutical services; and ACS.2 related to the direction of anesthesia services)
Measurable Elements of GLD.5
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1. An individual with appropriate training, education, and experience directs each department or service in the organization. (Also see AOP.5.8, ME 1; AOP.6.7, ME 1; MMU.1.1, ME 1)
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2. When more than one individual provides direction, the responsibilities of each are defined in writing.
Standards
GLD.5.1 The directors of each clinical department identify, in writing, the services to be provided by the department.
GLD.5.1.1 Services are coordinated and integrated within the department or service and with other departments and services.
Intent of GLD.5.1 and GLD.5.1.1
The directors of the organization’s clinical departments collaborate to determine the uniform format and content of the department-specific planning documents. In general, the documents prepared by each clinical department define its goals, as well as identify current and planned services. Department policies and procedures reflect the department’s goals and services, as well as the knowledge, skills and availability of staff required to assess and meet patient care needs.
Clinical services provided to patients are coordinated and integrated within each department of service. For example, there is integration of medical and nursing services. Also, each department or service coordinates and integrates its services with other departments and services. Unnecessary duplication of services is avoided or eliminated to conserve resources.
Measurable Elements of GLD.5.1
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1. Department or service directors have selected and use a uniform format and content for planning documents.
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2. The departmental or service documents describe the current and planned services provided by each department or service.
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3. Each department’s or service’s policies and procedures guide the provision of identified services.
Joint Commission International Accreditation Standards for Hospitals, Third Edition
❒ 4. Each department’s or service’s policies and procedures address the staff knowledge and skills needed to assess and meet patient needs.
Measurable Elements of GLD.5.1.1
Standard
GLD.5.2 Directors recommend space, equipment, staffing, and other resources needed by the department or service.
Intent of GLD.5.2
Each department’s leaders communicate their human resources and other resource requirements to the organization’s senior managers. This helps ensure that adequate staff, space, equipment, and other resources are available to meet patients’ needs at all times. While the directors make recommendations regarding human and other resource needs, those needs change or are not fully met. Thus, directors have a process to respond to resource shortages to ensure safe and effective care for all patients.
Measurable Elements of GLD.5.2
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1. Directors recommend space needed to provide services.
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2. Directors recommend equipment needed to provide services.
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3. Directors recommend the number and qualifications of staff needed to provide services.
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4. Directors recommend other special resources needed to provide services.
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5. Directors have a process to respond to resource shortages.
Standard
GLD.5.3 Directors recommend criteria for selecting the department or service’s professional staff and choose or recommend individuals who meet those criteria.
Intent of GLD.5.3
Directors consider the services provided and planned by the department or service and the education, skills, knowledge, and experience needed by the department’s professional staff to provide those services. Directors develop criteria reflecting this consideration and then select staff. Directors may also work with human resources or other departments in the selection process based on the director’s recommendation.
Measurable Elements of GLD.5.3
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1. The director develops criteria related to the needed education, skills, knowledge, and experience of the department’s professional staff.
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2. The director uses such criteria in selecting or recommending professional staff.
Standard
GLD.5.4 Directors provide orientation and training for all staff of the department or service appropriate to their responsibilities.
Intent of GLD.5.4
Directors ensure that all staff in the department or service understand their responsibilities and establish the orientation and training for new employees. The orientation includes the organization’s mission, the department’s or service’s mission, the scope of services (also see Glossary) provided, and the policies and procedures related to providing services. For example, all staff understand the infection prevention and control procedures within the organization and within the department or service. When new or revised policies or procedures are implemented, staff are appropriately trained. (Also see SQE.7; AOP.5.1, ME 5; AOP.6.2, ME 6; and PCI.11, ME 4)
Measurable Elements of GLD.5.4
Standard
GLD.5.5 Directors monitor the department’s or service’s performance as well as staff performance.
Intent of GLD.5.5
One of the most important responsibilities of a department or service director is to implement the organization’s quality improvement and patient safety program in the department. The selection of department or service level monitors is influenced by: a) the organization’s monitoring and improvement priorities that relate to the department or service; b) the evaluation of the provided services from sources including patient surveys and complaints; c) the need to understand the efficiency (also see Glossary) and cost effectiveness of the services provided; and d) the monitoring of services provided under contractual arrangements. (Also see GLD.3.3)
The director is responsible for ensuring that the monitoring activities provide the opportunity for the evaluation of staff as well as the processes of care. Thus, monitoring includes, over time, all of the services provided. Monitoring data (also see Glossary) and information are important to the department’s or service’s improvement efforts, but are also important to the organization’s quality improvement and patient safety program. (Also see ASC.2, ME 7)
Measurable Elements of GLD.5.5
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1. Directors implement quality monitors that address the services provided in their department or service including criteria a) through d) in the intent statement as appropriate to the department of service.
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2. Directors implement quality monitors related to staff performance in carrying out their responsibilities in the department or service.
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3. Directors implement quality control programs when indicated.
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4. Department or service directors are provided the data and information needed to manage and improve care and services.
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5. Department and service quality monitoring and improvement activities are reported periodically to the quality oversight mechanism of the organization.
Organizational Ethics
Standards
GLD.6 The organization establishes a framework for ethical management that ensures that patient care is provided within business, financial, ethical, and legal norms and that protects patients and their rights.
GLD.6.1 The organization’s framework for ethical management includes marketing, admissions, transfer, and discharge, and disclosure of ownership and any business and professional conflicts that may not be in patients’ best interests.
GLD.6.2 The organization’s framework for ethical management supports ethical decision making in clinical care.
Intent of GLD.6 through GLD.6.2
A health care organization has an ethical and legal responsibility to its patients and community. The leaders understand these responsibilities as they apply to the organization’s business and clinical activities. The leaders create guiding documents to provide a consistent framework to carry out these responsibilities. The organization operates within this framework to
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disclose ownership and any conflicts of interest;
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honestly portray its services to patients;
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provide clear admission, transfer (also see Glossary), and discharge policies;
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accurately bill for its services; and
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resolve conflicts when financial incentives and payment arrangements could compromise patient care.
The framework also supports the organization’s professional staff and patients when confronted by ethical dilemmas in patient care such as donor and transplant decisions, disagreements between patients and their family, and between patients and their care providers, regarding care decisions, and interprofessional disagreements. Such support is readily available.
Measurable Elements of GLD.6
Measurable Elements of GLD.6.1
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1. The organization discloses its ownership. (Also see AOP.5.1, ME 5 and AOP.6.1)
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2. The organization honestly portrays its services to patients.
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3. The organization provides clear admission, transfer, and discharge policies. (Also see ACC.1.1, ME 2; ACC.3, ME 2; and ACC.4, ME 4)
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4. The organization accurately bills for services.
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5. The organization discloses and resolves conflicts when financial incentives and payment arrangements compromise patient care.
Measurable Elements of GLD.6.2
Facility Management and Safety (FMS)
Overview
Health care organizations work to provide a safe, functional, and supportive facility for patients, families, staff, and visitors. To reach this goal, the physical facility, medical and other equipment, and people must be effectively managed. In particular, management must strive to
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reduce and control hazards and risks;
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prevent accidents and injuries; and
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maintain safe conditions.
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Effective management includes planning, education, and monitoring as follows:
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The leaders plan the space, equipment, and resources needed to safely and effectively support the clinical services provided.
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All staff are educated about the facility, how to reduce risks, and how to monitor (also see Glossary) and report situations that pose risk.
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Performance criteria are used to monitor important systems and identify needed improvements.
Written plans are developed and consider the following six areas, when appropriate to the facility and activities of the organization: 1.Safety and Security
❍ Safety—The degree to which the organization’s buildings, grounds, and equipment do not pose a hazard or risk to patients, staff, or visitors.
❍ Security—Protection from loss, destruction, tampering, or unauthorized access or use. 2.Hazardous materials—Handling, storage, and use of radioactive and other materials are controlled, and
hazardous waste is safely disposed. 3.Emergency management—Response to epidemics, disasters, and emergencies is planned and effective. 4.Fire safety—Property and occupants are protected from fire and smoke. 5.Medical equipment—Equipment is selected, maintained, and used in a manner to reduce risks (also see
Glossary). 6.Utility systems—Electrical, water, and other utility systems are maintained to minimize the risks of operating failures.
Laws, regulations, and inspections by local authorities determine in large part how a facility is designed, used, and maintained. All organizations, regardless of size and resources, must comply with these requirements as part of their responsibilities to their patients, families, staff, and visitors.
Organizations begin by complying with laws and regulations. Over time, they become more knowledgeable about the details of the physical facility they occupy. They begin to proactively gather data and carry out strategies to reduce risks and enhance the patient care environment.
Standards
The following is a list of all standards for this function. They are presented here for your convenience without their intent statements or measurable elements. For more information about these standards, please see the next section in this chapter, Standards, Intents, and Measurable Elements.
FMS.1 The organization complies with relevant laws, regulations, and facility inspection requirements.
FMS.2 The organization develops and maintains a written plan(s) describing the processes to manage risks to patients, families, visitors and staff. FMS.3 One or more qualified individuals oversee the planning and implementation of the program to manage
the risks in the care environment. FMS.3.1 A monitoring program provides data on incidents, injuries, and other events that support planning and further risk reduction. FMS.4 The organization plans and implements a program to provide a safe and secure physical environment.
FMS.4.1 The organization inspects all patient care buildings and has a plan to reduce evident risks and provide a safe physical facility for patients, families, staff, and visitors. FMS.4.2 The organization plans and budgets for upgrading or replacing key systems, buildings, or
components based on the facility inspection and in keeping with law and regulation.
FMS.5 The organization has a plan for the inventory, handling, storage, and use of hazardous materials and the control and disposal of hazardous materials and waste. FMS.6 The organization develops and maintains an emergency management plan and program to respond to
likely community emergencies, epidemics, and natural or other disasters. FMS.6.1 The organization tests its response to emergencies, epidemics, and disasters. FMS.7 The organization plans and implements a program to ensure that all occupants are safe from fire, smoke, or other emergencies in the facility.
FMS.7.1 The plan includes prevention, early detection, suppression, abatement, and safe exit from the facility in response to fires and non-fire emergencies. FMS.7.2 The organization regularly tests its fire and smoke safety plan, including any devices related to
early detection and suppression, and documents the results. FMS.7.3 The
