organization develops and implements a plan to limit smoking by staff and patients to designated non–patient care areas of the facility. FMS.8 The organization plans and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results. FMS.8.1 The organization collects monitoring data for the medical equipment management program. These data are used to plan the organization’s long-term needs for upgrading or replacing equipment. FMS.8.2 The organization has a product/equipment recall system. FMS.9 Potable water and electrical power are available 24 hours a day, seven days a week, through regular or alternate sources, to meet essential patient care needs. FMS.9.1 The organization has emergency processes to protect facility occupants in the event of water or electrical system disruption, contamination, or failure. FMS.9.2 The organization tests its emergency water and electrical systems on a regular basis appropriate to the system and documents the results. FMS.10 Electrical, water, waste, ventilation, medical gas, and other key systems are regularly inspected, maintained, and, when appropriate, improved. FMS.10.1 Designated individuals or authorities monitor water quality regularly. FMS.10.2 The organization collects monitoring data for the utility system management program. These data are used to plan the organization’s long-term needs for upgrading or replacing the utility system. FMS.11 The organization educates and trains all staff members about their roles in providing a safe and effective patient care facility. FMS.11.1 Staff members are trained and knowledgeable about their roles in the organization’s plans for fire safety, security, hazardous materials, and emergencies. FMS.11.2 Staff are trained to operate and maintain medical equipment and utility systems. FMS.11.3 The organization periodically tests staff knowledge through demonstration, mock events, and other suitable methods. This testing is then documented. Joint Commission International Accreditation Standards for Hospitals, Third Edition Standards, Intents, and Measurable Elements Leadership and Planning Standard FMS.1 The organization complies with relevant laws, regulations, and facility inspection requirements. Intent of FMS.1 The first consideration for any physical facility is the laws, regulations, and other requirements related to the facility. Such requirements may differ depending on the facility’s age and location and other factors. For example, many building construction codes and fire safety codes, such as for sprinkler systems, apply only to new construction. The organization’s leaders, including governance (also see Glossary) and senior management, are responsible for knowing what national and local laws, regulations, and other requirements apply to the organization’s facilities; implementing the applicable requirements or approved alternative requirements; and planning and budgeting for the necessary upgrading or replacement as identified by monitoring data (also see Glossary) or to meet applicable requirements, and then to show progress toward meeting the plans. (Also see FMS.4.2) When the organization has been cited for not meeting requirements, the leaders take responsibility for planning for and meeting the requirement in the prescribed time frame. Measurable Elements of FMS.1 1. The organization’s leaders know what laws, regulations, and other requirements apply to the organization’s facilities. 2. The leaders implement the applicable requirements or approved alternatives. 3. The leaders ensure the organization meets the conditions of facility inspection reports or citations. Standard FMS.2 The organization develops and maintains a written plan(s) describing the processes to manage risks to patients, families, visitors and staff. Intent of FMS.2 To manage the risks within the environment in which patients are treated and staff work requires planning. The organization develops one master plan or individual plans that include, as appropriate to the organization: a) 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, and visitors. ❍ Security—Protection from loss, destruction, tampering, or unauthorized access or use. b) Hazardous materials—Handling, storage, and use of radioactive and other materials are controlled, and hazardous waste is safely disposed. c) Emergencies—Response to epidemics, disasters, and emergencies is planned and effective. d) Fire safety—Property and occupants are protected from fire and smoke. e) Medical equipment—Equipment is selected, maintained, and used in a manner to reduce risks (also see Glossary). f) Utility systems—Electrical, water, and other utility systems are maintained to minimize the risks of operating failures. Such plans are written and are up-to-date in that they reflect present or recent conditions within the organization’s environment. There is a process for their review and updating. Measurable Elements of FMS.2 1. There are written plan(s) that address the risk areas a) through f) in the intent statement. 2. The plan(s) are current or up to date. 3. The plan(s) are fully implemented. 4. The organization has a process to periodically review and update the plan(s) on an annual basis. Standards 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. Intent of FMS.3 and FMS.3.1 A facility/environment risk management program (also see Glossary) in a large or small organization requires the assignment of one or more individuals to provide leadership and oversight. In a small organization, one individual may be assigned part-time. In a larger organization, several engineers or other specially trained individuals may be assigned. Whatever the assignment, all aspects of the program must be managed effectively and in a consistent and continuous manner. Program oversight includes a) planning all aspects of the program; b) implementing the program; c) educating staff; d) testing and monitoring the program; e) periodically reviewing and revising the program; f) annual reports to the governing body on the effectiveness of the program; and g) providing consistent and continuous organization and management. When appropriate to the organization’s size and complexity, a facility/environment risk committee may be formed and given responsibility for overseeing the program and program continuity. Monitoring all aspects of the program provides valuable data to improve the program and further reduce risks in the organization. Measurable Elements of FMS.3 1. Program oversight and direction are assigned to one or more individuals. 2. The individual(s) is qualified by experience or training. 3. The individual(s) plans and implements the program including elements a) through g) of the intent statement. Measurable Elements of FMS.3.1 ❒ 1. There is a program to monitor all aspects of the facility/environment risk management program. Joint Commission International Accreditation Standards for Hospitals, Third Edition ❒ 2. Monitoring data are used to improve the program. Safety and Security Standards 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. Intent of FMS.4 through FMS.4.2 The organization leaders use available resources well in providing a safe, effective, and efficient facility (also see AOP.5.1, ME 1 and AOP.6.2, ME 1). Prevention and planning are essential to creating a safe and supportive patient care facility. To plan effectively, the organization must be aware of all of the risks present in the facility. This includes safety as well as security risks. The goal is to prevent accidents and injuries; maintain safe and secure conditions for patients, families, staff and visitors; and reduce and control hazards and risks. This is particularly important during periods of construction or renovation. In addition, to ensure security, all staff, visitors, vendors and others in the organization are identified and issued temporary or permanent badges or other identification measures, and all areas intended to be secure, such as the newborn nursery, are secure and monitored. This can be done by comprehensively inspecting the facility, noting everything from sharp and broken furniture that could injure to locations where there is no escape from fire or no way to monitor a secure area. This periodic inspection is documented and helps the organization plan and carry out improvements and budget for longer-term facility upgrading or replacement. Then, by understanding the risks present in the organization’s physical facility, the organization can develop a proactive plan to reduce those risks for patients, families, staff, and visitors. This plan includes safety and security. Measurable Elements of FMS.4 1. The organization has a program to provide a safe and secure physical facility. 2. The program ensures that all staff, visitors and vendors are identified and all security risk areas are monitored and kept secure. (Also see AOP.5.2, MEs 1 and 2 and AOP.6.2, ME 2) 3. The program is effective in preventing injury and maintaining safe conditions for patients, families, staff, and visitors. (Also see International Patient Safety Goal 6, ME 1) 4. The program includes safety and security during times of construction and renovation. 5. The leaders apply resources in accordance with approved plans. Measurable Elements of FMS.4.1 1. The organization has a documented, current, accurate inspection of its physical facilities. 2. The organization has a plan to reduce evident risks based on the inspection. 3. The organization is making progress in carrying out the plan. Measurable Elements of FMS.4.2 1. The organization plans and budgets to meet applicable laws, regulations, and other requirements. 2. The organization plans and budgets for upgrading or replacing systems, buildings, or components needed for the continued operation of a safe and effective facility. (Also see ACC.6.1, ME 5) Hazardous Materials Standard 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. Intent of FMS.5 The organization identifies and safely controls hazardous materials and waste (also see Glossary; AOP.5.1, ME 1; and AOP.6.2, ME 1) according to a plan. Such materials and waste include chemicals, chemotherapeutic agents, radioactive materials and waste, hazardous gases and vapors, and other regulated medical and infectious waste. The plan provides processes for the inventory of hazardous materials and waste; handling, storage, and use of hazardous materials; reporting and investigation of spills, exposures, and other incidents; proper disposal of hazardous waste; proper protective equipment and procedures during use, spill, or exposure; documentation, including any permits, licenses, or other regulatory requirements; and proper labeling of hazardous materials and waste. Measurable Elements of FMS.5 1. The organization identifies hazardous materials and waste and has a current list of all such materials within the organization. (Also see AOP.5.5, ME 1 and AOP.6.6, ME 1) 2. The plan includes safe handling, storage, and use. (Also see AOP.5.1, ME 3 and AOP.6.2, ME 4) 3. The plan includes reporting and investigation of spills, exposures, and other incidents. 4. The plan includes the proper handling of waste within the organization and disposal of hazardous waste in a safe and legal manner. (Also see AOP.6.2, ME 4) 5. The plan includes the proper protective equipment and procedures during use, spill, or exposure. (Also see AOP.5.1, ME 4 and AOP.6.2, ME 5) 6. The plan identifies documentation requirements including any permits, licenses, or other regulatory requirements. 7. The plan includes labeling hazardous materials and waste. (Also see AOP.5.5, ME 5) Emergency Management Standards 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. Intent of FMS.6 and FMS.6.1 Community emergencies (also see Glossary), epidemics, and disasters may directly involve the organization, such as damage to patient care areas as a result of an earthquake, or flu that keeps staff from coming to work. To respond effectively, the organization develops a plan and a program to manage such emergencies. The plan provides processes for a) determining the type, likelihood and consequences of hazards, threats, and events; b) determining the organization’s role in such events; c) communication strategies for events; d) the managing of resources during events, including alternative sources; e) the managing of clinical activities during an event, including alternative care sites; and f) the identification and assignment of staff roles and responsibilities during an event. The plan is tested at least once a year as part of the community wide plan or the organization’s own plan. The testing is appropriate to the likely events. If the organization experiences an actual disaster, activates its plan, and debriefs properly afterwards, this situation represents the equivalent to an annual test. Measurable Elements of FMS.6 1. The organization has identified the major internal and external disasters and major epidemic events which pose significant risks of occurring. 2. The organization plans its response to likely disasters including items a) through f) in the intent. Measurable Elements of FMS.6.1 1. The plan is tested annually. 2. Staff participate in at least one emergency-preparedness test per year. Fire Safety Standards 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. Intent of FMS.7 through FMS.7.2 Fire is an ever-present risk in a health care organization. Thus, every organization needs to plan how it will keep its occupants safe in case of fire or smoke. An organization plans in particular for the prevention of fires through the reduction of risks, such as safe storage and handling of potentially flammable materials, including flammable medical gasses such as oxygen; hazards related to any construction in or adjacent to the patient-occupied buildings; safe and unobstructed means of exit in the event of a fire; early warning, early detection systems such as fire patrols, smoke detectors, or fire alarms; and suppression mechanisms such as water hoses, chemical suppressants, or sprinkler systems. These actions, when combined, give patients, families, staff, and visitors adequate time to safely exit the facility in the event of a fire or smoke. These actions are effective no matter what the age, size, or construction of the facility. For example, a small, one-level brick facility will use different methods than a large, multi-level wooden facility. The organization’s fire safety plan identifies the frequency of inspecting, testing, and maintaining fire protection and safety systems, consistent with requirements; the plan for safely evacuating the facility in the event of a fire or smoke; the process for testing (exercising all or a portion of the plan), at least twice per year; the necessary education of staff to effectively protect and evacuate patients when an emergency occurs; and the participation of staff members in at least one fire safety test per year. All inspections, testing, and maintenance are documented. Measurable Elements of FMS.7 1. The organization plans a program to ensure that all occupants of the organization’s facilities are safe from fire, smoke, or other non-fire emergencies. 2. The program is implemented in a continuous and comprehensive manner to ensure that all patient care and staff work areas are included. Measurable Elements of FMS.7.1 1. The program includes the reduction of fire risks. 2. The program includes the assessment of fire risks when construction is present in or adjacent to the facility. 3. The program includes the early detection of fire and smoke. 4. The program includes the abatement of fire and containment of smoke. 5. The program includes the safe exit from the facility when fire and non-fire emergencies occur. Measurable Elements of FMS.7.2 1. Fire detection and abatement systems are inspected, tested, and maintained at a frequency determined by the organization. 2. The fire and smoke safety evacuation plan is tested at least twice a year. 3. Staff are trained to participate in the fire and smoke safety plan. (Also see FMS.11.1, ME 1) 4. Staff participate in at least one fire and smoke safety test per year. 5. Inspection, testing, and maintenance of equipment and systems are documented. Standard FMS.7.3 The organization develops and implements a plan to limit smoking by staff and patients to designated non–patient care areas of the facility. Intent of FMS.7.3 The organization develops and implements a policy and plan to limit smoking that applies to all patients, families, staff and visitors; and eliminates smoking in the organization’s facilities or minimally limits smoking to designated non–patient care areas that are ventilated to the outside. The organization’s smoking policy identifies any exceptions to the policy related to patients, such as the medical or psychiatric reasons a patient may be permitted to smoke, and those individuals permitted to grant such an exception. When an exception is made, the patient smokes in a designated, nontreatment area, away from other patients. Measurable Elements of FMS.7.3 1. The organization has implemented a policy and plan to eliminate or limit smoking. 2. The plan applies to patients, families, visitors, and staff. 3. There is a process to grant patient exceptions to the plan. Medical Equipment Standards FMS.8 The organization plans and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results. FMS.8.1 The organization collects monitoring data for the medical equipment management program. These data are used to plan the organization’s long-term needs for upgrading or replacing equipment. Intent of FMS.8 and FMS.8.1 To ensure that medical equipment is available for use and functioning properly, the organization inventories medical equipment; regularly inspects medical equipment; tests medical equipment as appropriate to its use and requirements; and does preventive maintenance. Qualified individuals (also see Glossary) provide these services. Equipment is inspected and tested when new and then on an ongoing basis, as appropriate to the equipment’s age and use or based on manufacturer instructions. Inspections, testing results, and any maintenance are documented. This helps ensure the continuity of the maintenance process and helps when doing capital planning for replacements, upgrades, and other changes. Measurable Elements of FMS.8 1. Medical equipment is managed throughout the organization according to a plan. (Also see AOP.5.4, ME 1 and AOP.6.5, ME 1) 2. There is an inventory of all medical equipment. (Also see AOP.5.5, ME 3 and AOP.6.5, ME 3) 3. Medical equipment is regularly inspected. (Also see AOP.5.4, ME 4 and AOP.6.5, ME 4) 4. Medical equipment is tested when new and as appropriate thereafter. (Also see AOP.5.5, ME 5 and AOP.6.5, ME 5) 5. There is a preventive maintenance program. (Also see AOP.5.4, ME 6 and AOP.6.5, ME 6) 6. Qualified individuals provide these services. Measurable Elements of FMS.8.1 1. Monitoring data are collected and documented for the medical equipment management program. (Also see AOP.5.5, ME 7 and AOP.6.5, ME 7) 2. Monitoring data are used for purposes of planning and improvement. Standard FMS.8.2 The organization has a product/equipment recall system. Intent of FMS.8.2 The organization has a process for identifying, retrieving, and returning or destroying products and equipment recalled by the manufacturer or supplier. There is a policy or procedure that addresses the use of any product or equipment under recall. Measurable Elements of FMS.8.2 1. There is a product/equipment recall system in place. 2. Policy or procedure addresses any use of any product or equipment under recall. 3. The policy or procedure is implemented. Utility Systems Standard FMS.9 Potable water and electrical power are available 24 hours a day, seven days a week, through regular or alternate sources, to meet essential patient care needs. Intent of FMS.9 Patient care, both routine and urgent, is provided on a 24-hour basis, every day of the week in a health care organization. Thus, an uninterrupted source of clean water and electrical power is essential to meet patient care needs. Regular and alternate sources can be used. Measurable Elements of FMS.9 1. Potable water is available 24 hours a day, seven days a week. 2. Electrical power is available 24 hours a day, seven days a week. Standards FMS.9.1 The organization has emergency processes to protect facility occupants in the event of water or electrical system disruption, contamination, or failure. FMS.9.2 The organization tests its emergency water and electrical systems on a regular basis appropriate to the system and documents the results. Intent of FMS.9.1 and FMS.9.2 Health care organizations have different medical equipment and utility system (also see Glossary) needs based on their mission (also see “mission statement” in Glossary), patient needs, and resources. Regardless of the type of system and level of its resources, an organization needs to protect patients and staff in emergencies such as system failure, interruption, or contamination (also see Glossary). To prepare for such emergencies, the organization identifies the equipment, systems, and locations that pose the highest risk to patients and staff. For example, it identifies where there is a need for illumination, refrigeration, life support, and clean water for cleaning and sterilization of supplies; assesses and minimizes the risks of utility system failures in these areas; plans emergency power and clean water sources for these areas and needs; tests the availability and reliability of emergency sources of power and water; and documents the results of tests. Measurable Elements of FMS.9.1 1. The organization has identified the areas and services at greatest risk when power fails or water is contaminated or interrupted. 2. The organization seeks to reduce the risks of such events. 3. The organization plans alternate sources of power and water in emergencies. Measurable Elements of FMS.9.2 1. The organization regularly tests alternate sources of water and electricity. 2. The organization documents the results of such tests. Standards FMS.10 Electrical, water, waste, ventilation, medical gas, and other key systems are regularly inspected, maintained, and, when appropriate, improved. FMS.10.1 Designated individuals or authorities monitor water quality regularly. FMS.10.2 The organization collects monitoring data for the utility system management program. These data are used to plan the organization’s long-term needs for upgrading or replacing the utility system. Intent of FMS.10 through FMS.10.2 The safe, effective and efficient operation of utility and other key systems in the organization are essential for patient, family, staff, and visitor safety and for meeting patient care needs. For example, waste contamination in food-preparation areas, inadequate ventilation in the clinical laboratory, oxygen cylinders that are not secured when stored, leaking oxygen lines, and frayed electrical lines all pose hazards. To avoid these and other hazards, the organization has a process for regularly inspecting such systems and performing preventive and other maintenance. During testing, attention is paid to the critical components (for example, switches and relays) of systems. Emergency and backup power sources are tested under planned circumstances that simulate actual load requirements. Improvements are made when necessary, such as enhancing electrical service to areas with new equipment. Water quality can change suddenly due to many causes, some of which can be outside the organization, such as a break in the supply line to the organization or contamination of the city’s water source. Water quality is also a critical factor in clinical care processes such as chronic renal dialysis. Thus, the organization establishes a process to regularly monitor water quality, including the regular biological testing of water used in chronic renal dialysis. The frequency of monitoring is based in part on previous experience with water quality problems. The monitoring can be carried out by individuals designated by the organization, such as staff from the clinical laboratory, or by public health or water control authorities outside the organization judged competent to perform such tests. It is the responsibility of the organization to ensure the testing is completed as required. Monitoring essential systems helps the organization prevent problems and provides the information necessary to make decisions on system improvements and in planning for upgrading or replacing utility systems. Monitoring data are documented. Measurable Elements of FMS.10 1. Utility, medical gas, ventilation and other key systems are identified by the organization. 2. Key systems are regularly inspected. 3. Key systems are regularly tested. 4. Key systems are regularly maintained. 5. Key systems are improved as appropriate. Measurable Elements of FMS.10.1 1. Water quality is monitored regularly. 2. Water used in chronic renal dialysis is tested regularly. Measurable Elements of FMS.10.2 1. Monitoring data are collected and documented for the medical utility management program. 2. Monitoring data are used for purposes of planning and improvement. Staff Education Standards FMS.11 The organization educates and trains all staff members about their roles in providing a safe and effective patient care facility. FMS.11.1 Staff members are trained and knowledgeable about their roles in the organization’s plans for fire safety, security, hazardous materials, and emergencies. FMS.11.2 Staff are trained to operate and maintain medical equipment and utility systems. FMS.11.3 The organization periodically tests staff knowledge through demonstration, mock events, and other suitable methods. This testing is then documented. Intent of FMS.11 through FMS.11.3 The organization’s staff are the primary source of contact with patients, families, and visitors. Thus, they need to be educated and trained to carry out their roles in identifying and reducing risks, protecting others and themselves, and creating a safe and secure facility. (Also see FMS.7.2, ME 3) Each organization must decide the type and level of training for staff and then carry out and document a program for this training and education. The program can include group instruction, printed educational materials, a component of new staff orientation, or some other mechanism that meets the organization’s needs. The program includes instruction on the processes for reporting potential risks, reporting incidents and injuries, and handling hazardous and other materials that pose a risk to themselves and others. Staff responsible for operating or maintaining medical equipment receives special training. The training can be from the organization, the manufacturer of the equipment, or some other knowledgeable source. The organization plans a program designed to periodically test staff knowledge on emergency procedures including fire safety procedures, the response to hazards such as the spill of a hazardous material, and the use of medical equipment that poses a risk to patients and staff. Knowledge can be tested through a variety of means such as individual or group demonstrations, the staging of mock events such as an epidemic in the community, the use of written or computer tests, or other means suitable to the knowledge being tested. The organization documents who was tested and the results of the testing. Measurable Elements of FMS.11 1. For each component of the organization’s facility management and safety program, there is planned education to ensure that staff members can effectively carry out their responsibilities. (Also see AOP.5.1, ME 5 and AOP.6.2, ME 6) 2. The education includes visitors, vendors, contract workers, and others as appropriate to the organization and multiple shifts of staff.  Measurable Elements of FMS.11.1 1. Staff members can describe and/or demonstrate their role in response to a fire. 2. Staff can describe and/or demonstrate actions to eliminate, minimize, or report safety, security, and other risks. 3. Staff can describe and/or demonstrate precautions, procedures, and participation in the storage, handling, and disposal of medical gases, hazardous waste and materials and in related emergencies. 4. Staff members can describe and/or demonstrate procedures and their role in internal and community emergencies and disasters. Measurable Elements of FMS.11.2 1. Staff are trained to operate medical equipment and utility systems appropriate to their job requirements. 2. Staff are trained to maintain medical equipment and utility systems appropriate to their job requirements. Measurable Elements of FMS.11.3 1. Staff knowledge is tested regarding their role in maintaining a safe and effective facility. 2. Staff training and testing are documented as to who was trained and tested and the results. Staff Qualifications and Education (SQE) Overview A health care organization (also see Glossary) needs an appropriate variety of skilled, qualified people to fulfill its mission (also see “mission statement” in Glossary) and meet patient needs. The organization’s leaders work together to identify the number and types of staff needed based on the recommendations from department and service directors. Recruiting (also see Glossary), evaluating, and appointing staff are best accomplished through a coordinated, efficient, and uniform process. It is also essential to document applicant skills, knowledge, education, and previous work experience. It is particularly important to carefully review the credentials (also see Glossary) of medical and nursing staff because they are involved in clinical care processes and work directly with patients. Health care organizations should provide staff with opportunities to learn and advance personally and professionally. Thus, in-service education (also see Glossary) and other learning opportunities should be offered to staff. 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. SQE.1 Organization leaders define the desired education, skills, knowledge, and other requirements of all staff members. SQE.1.1 Each staff member’s responsibilities are defined in a current job description. SQE.2 Organization leaders develop and implement processes for recruiting, evaluating, and appointing staff as well as other related procedures identified by the organization. SQE.3 The organization uses a defined process to ensure that clinical staff knowledge and skills are consistent with patient needs. SQE.4 The organization uses a defined process to ensure that nonclinical staff knowledge and skills are consistent with organization needs and the requirements of the position. SQE.5 There is documented personnel information for each staff member. SQE.6 A staffing plan for the organization, developed collaboratively by the leaders, identifies the number, types, and desired qualifications of staff. SQE.6.1 The staffing plan is reviewed on an ongoing basis and updated as necessary. SQE.7 All clinical and nonclinical staff members are oriented to the organization, the department or unit to which they are assigned and to their specific job responsibilities at appointment to the staff. SQE.8 Each staff member receives ongoing in-service and other education and training to maintain or advance his or her skills and knowledge. SQE.8.1 Staff members who provide patient care and other staff identified by the organization are trained and can demonstrate appropriate competence in resuscitative techniques. SQE.8.2 The organization provides facilities and time for staff education and training. SQE.8.3 Health professional education, when provided within the organization, is guided by the educational parameters defined by the sponsoring academic program. SQE.8.4 The organization provides a staff health and safety program. SQE.9 The organization has an effective process for gathering, verifying, and evaluating the credentials (license, education, training, and experience) of those medical staff permitted to provide patient care without supervision. SQE.10 The organization has a standardized objective, evidence-based procedure to authorize all medical staff members to admit and treat patients and provide other clinical services consistent with their qualifications. SQE.11 There is an ongoing professional practice evaluation of the quality and safety of the clinical care provided by each medical staff member. SQE.12 The organization has an effective process to gather, verify, and evaluate the nursing staff’s credentials (license, education, training, and experience). SQE.13 The organization has a standardized procedure to identify job responsibilities and make clinical work assignments based on the nursing staff member’s credentials and any regulatory requirements. SQE.14 The organization has a standardized procedure for nursing staff participation in the organization’s quality improvement activities, including evaluating individual performance when indicated. SQE.15 The organization has a standardized procedure to gather, verify, and evaluate other health professional staff members’ credentials (license, education, training, and experience). SQE.16 The organization has a standardized procedure to identify job responsibilities and make clinical work assignments based on other health professional staff members’ credentials and any regulatory requirements. SQE.17 The organization has an effective process for other health professional staff members’ participation in the organization’s quality improvement activities. Standards, Intents, and Measurable Elements Planning Standard SQE.1 Organization leaders define the desired education, skills, knowledge, and other requirements of all staff members. Intent of SQE.1 The organization’s leaders define the particular requirements of staff positions. They define the desired education, skills, knowledge, and any other requirements as part of projecting staffing to meet the patients’ needs. Leaders consider the following factors to project staffing needs: The organization’s mission; The mix of patients served by the organization and the complexity and severity of their needs; The services provided by the organization; and The technology used in patient care. The organization complies with laws and regulations that define desired education levels, skills, or other requirements of individual staff members or that define staffing numbers or a mix of staff for the organization. The organization considers the organization’s mission and patients’ needs in addition to requirements of laws and regulations. Measurable Elements of SQE.1 1. The organization’s mission, mix of patients, services, and technology are considered in planning. 2. The desired education, skills, and knowledge are defined for staff. 3. Applicable laws and regulations are incorporated into the planning. Standard SQE.1.1 Each staff member’s responsibilities are defined in a current job description. Intent of SQE.1.1 Individual staff members who are not licensed to practice independently have their responsibilities defined in a current job description (also see Glossary). The job description is the basis for their assignment, orientation to their work, and evaluation of how well they fulfill job responsibilities. A job description is also needed for health professionals when: a) The individual serves in primarily a managerial role, such as a department manager, or in dual clinical and managerial roles, with the managerial responsibilities identified in a job description; b) The individual has some clinical responsibilities for which they have not been authorized to practice independently, such as an independent practitioner learning a new role or new skills (privileging under SQE.10 is an alternative); c) The individual is in an educational program and under supervision and the academic program identifies, for each stage or level of training, what can be done independently and what must be under supervision. The program description can serve as the job description in such cases; and d) The individual is permitted to temporarily provide services in the organization. (Privileging under SQE.10 is an alternative.) When an organization uses national or generic job descriptions, for example, a job description for a “nurse,” it is necessary to augment this type of job description with specific job responsibilities for the types of nurses, for example, intensive care nurse, pediatric nurse, operating theatre nurse, etc. For those permitted by law and the organization to practice independently there is a process to identify and authorize the individual to practice based on education, training, and experience. This process is identified in SQE.9 for medical staff members and in SQE.12 for nursing staff members. The requirements of this standard apply to all types of “staff” who require a job description; full-time, part-time, employed, voluntary, or temporary for example. Measurable Elements of SQE.1.1 1. Each staff member not permitted to practice independently has a job description. (Also see AOP.3, ME 5) 2. Those individuals identified in a) through d) in the intent statement, when present in the organization, have a job description appropriate to their activities and responsibilities or have been privileged if noted as an alternative. 3. Job descriptions are current according to hospital policy. Standard SQE.2 Organization leaders develop and implement processes for recruiting, evaluating, and appointing staff as well as other related procedures identified by the organization. Intent of SQE.2 The organization provides an efficient, coordinated, or centralized process for recruiting individuals for available positions; evaluating the training, skills, and knowledge of candidates; and appointing individuals to the organization’s staff. If the process is not centralized, similar criteria, processes, and forms result in a uniform process across the organization. Department and service directors participate by recommending the number and qualifications of staff needed to provide clinical services to patients, as well as nonclinical support functions, and fulfill any teaching or other departmental responsibilities. Department and service directors also help make decisions about individuals to be appointed to the staff. Thus, the standards in this chapter complement the Governance, Leadership, and Direction standards that describe a department or service director’s responsibilities. Measurable Elements of SQE.2 1. There is a process in place to recruit staff. (Also see GLD.3.5, ME 1) 2. There is a process in place to evaluate the qualifications of new staff. 3. There is a process in place to appoint individuals to the staff. 4. The process is uniform across the organization. 5. The process is implemented. Standard SQE.3 The organization uses a defined process to ensure that clinical staff knowledge and skills are consistent with patient needs.     Intent of SQE.3 Qualified staff members are hired by the organization through a process that matches the requirements of the position with the qualifications of the prospective staff member. This process also ensures that the staff member’s skills are initially and over time consistent with the needs of patients. For the organization’s health professional staff who do not practice under a job description, the process is identified in SQE.9 through SQE.11. For clinical staff under job descriptions, the process includes An initial evaluation to ensure that he or she can actually assume those responsibilities in the job description. This evaluation is carried out before or at the time of starting to perform work responsibilities. The organization may have a “probationary” or other period during which the clinical staff member is closely supervised and evaluated or the process may be less formal. Whatever the process, the organization ensures that staff providing high-risk services or providing care to high-risk patients are evaluated at the time they begin providing care. This evaluation of necessary skills and knowledge and desired work behaviors is carried out by the department or service to which the staff member is assigned. The organization then defines the process for and the frequency of the ongoing evaluation of staff abilities. Ongoing evaluation ensures that training occurs when needed and that the staff member is able to assume new or changed responsibilities. While such evaluation is best carried out in an ongoing manner, there is at least one documented evaluation of each clinical staff working under a job description each year. (The evaluation of those permitted to work independently is found at SQE.11.) Measurable Elements of SQE.3 1. The organization uses a defined process to match clinical staff knowledge and skills with patient needs. (Also see COP.6, ME 4) 2. New clinical staff members are evaluated at the time they begin their work responsibilities. 3. The department or service to which the individual is assigned conducts the evaluation. 4. The organization defines the frequency of ongoing clinical staff evaluation. 5. There is at least one documented evaluation of each clinical staff member working under a job description each year or more frequently as defined by the organization. Standard SQE.4 The organization uses a defined process to ensure that nonclinical staff knowledge and skills are consistent with organization needs and the requirements of the position. Intent of SQE.4 The organization seeks staff that can competently fill the requirement of nonclinical positions. The supervisor of the staff member provides an orientation to the position and ensures that the worker can fulfill the responsibilities of the job description. The staff member receives the required level of supervision and on a periodic basis is evaluated to ensure continuing competence (also see Glossary) in the position. Measurable Elements of SQE.4 1. The organization uses a defined process to match nonclinical staff knowledge and skills with the requirements of the position. (Also see AOP.5.2, MEs 2 and 3 and AOP.6.3, MEs 2 and 3) 2. New nonclinical staff are evaluated at the time they begin their work responsibilities. 3. The department or service to which the individual is assigned conducts the evaluation. 4. The organization defines the frequency of ongoing nonclinical staff evaluation. Joint Commission International Accreditation Standards for Hospitals, Third Edition ❒ 5. There is at least one documented evaluation of nonclinical staff members each year or more frequently as defined by the organization. Standard SQE.5 There is documented personnel information for each staff member. Intent of SQE.5 Each staff member in the organization has a record with information about his or her qualifications, results of evaluations, and work history. The process and records for clinical health profession staff, including those permitted by law and the organization to work independently, is described in SQE.9 for medical staff, SQE.12 for nursing staff, and SQE.15 for other health professionals. The records are standardized and kept current according to organization policy. Measurable Elements of SQE.5 1. Personnel information is maintained for each staff member. 2. Personnel files contain the qualifications of the staff member. 3. Personnel files contain the job description of staff members when applicable. 4. Personnel files contain the work history of the staff member. 5. Personnel files contain the results of evaluations. 6. Personnel files contain a record of in-service education attended by the staff member. 7. Personnel files are standardized and kept current. Standards SQE.6 A staffing plan for the organization, developed collaboratively by the leaders, identifies the number, types, and desired qualifications of staff. SQE.6.1 The staffing plan is reviewed on an ongoing basis and updated as necessary. Intent of SQE.6 and SQE.6.1 Appropriate and adequate staffing is critical to patient care, as well as to all teaching and research activities in which the organization may be engaged. Staff planning is carried out by the organization’s leaders. The planning process uses recognized methods for determining levels of staffing. For example, a patient acuity system is used to determine the number of licensed nurses with pediatric intensive care experience to staff a ten-bed pediatric intensive care unit. The plan is written and identifies the number and types of required staff and the skills, knowledge, and other requirements needed in each department and service. The plan addresses the reassignment of staff from one department or service to another in response to changing patient need or staff shortages; the consideration of staff requests for reassignment based on cultural values or religious beliefs; and the policy and procedure for transferring responsibility from one individual to another (for example, from a physician to a nurse) when the responsibility would fall outside such an individual’s normal responsibility area. Planned and actual staffing is monitored (also see Glossary) on an ongoing basis, and the plan is updated as necessary. When monitored on a department and service level, there is a collaborative process for the organization’s leaders to update the overall plan. Measurable Elements of SQE.6 1. There is a written plan for staffing the organization. 2. The leaders developed the plan collaboratively. 3. The number, types, and desired qualifications of staff are identified in the plan using a recognized staffing method.    4. The plan addresses the assignment and reassignment of staff. 5. The plan addresses the transfer of responsibility from one individual to another. Measurable Elements of SQE.6.1 1. The effectiveness of the staffing plan is monitored on an ongoing basis. 2. The plan is revised and updated when necessary. Orientation and Education Standard SQE.7 All clinical and nonclinical staff members are oriented to the organization, the department or unit to which they are assigned and to their specific job responsibilities at appointment to the staff. Intent of SQE.7 The decision to appoint an individual to the staff of an organization sets several processes in motion. To perform well, a new staff member, no matter what their employment status, needs to understand the entire organization and how his or her specific clinical or nonclinical responsibilities contribute to the organization’s mission. This is accomplished through a general orientation to the organization and his or her role in the organization, and a specific orientation to the job responsibilities of his or her position. The orientation includes, as appropriate, the reporting of medical errors, infection prevention and control practices, the organization’s policies on telephone medication orders, and so on. (Also see GLD.5.4, MEs 1 and 2 and PCI.11, ME 4) Contract workers (also see “contracted services” in Glossary) and volunteers are also oriented to the organization and their specific assignment or responsibilities, such as patient safety and infection prevention and control. Measurable Elements of SQE.7 1. New clinical and nonclinical staff members are oriented to the organization, to the department or unit to which they are assigned, and to their job responsibilities and any specific assignments. 2. Contract workers are oriented to the organization, to the department or unit to which they are assigned, and to their job responsibilities and any specific assignments. 3. Volunteers are oriented to the organization and assigned responsibilities. Standard SQE.8 Each staff member receives ongoing in-service and other education and training to maintain or advance his or her skills and knowledge. Intent of SQE.8 The organization collects data from several sources to understand its staff ’s ongoing education needs. The results of quality and safety monitoring are one source of information to identify staff education needs. Also, monitoring data (also see Glossary) from the facility management program, the introduction of new technology, skill and knowledge areas identified through the review of job performance, new clinical procedures, and future plans to provide new services represent such sources of data. The organization has a process to gather and integrate data from sources to plan the staff education program. Also, the organization determines which staff, such as health professional staff, are required to obtain continuing education to maintain their credentials and how the education of these staff will be monitored and documented. (Also see GLD.3.5, ME 3) To maintain acceptable staff performance, teach new skills, and provide training on new equipment and procedures, the organization provides or arranges for facilities, educators, and time for ongoing in-service and other education. This education is relevant to each staff member as well as to the continuing advancement of the organization in meeting patient needs. For example, medical staff members may receive education on infection prevention and control, advances in medical practice, or new technology. Each staff member’s educational achievements are documented in his or her personnel record. In addition, each organization develops and implements a staff health and safety program appropriate for the health needs of the staff and safety concerns of the organization and staff. Measurable Elements of SQE.8 1. The organization uses various sources of data and information, including the results of quality and safety monitoring, to identify staff education needs. 2. Education programs are planned based on these data and information. 3. Organization staff are provided ongoing in-service education and training. (Also see AOP.5.1, ME 6 and AOP.6.2, ME 7) 4. The education is relevant to each staff member’s ability to meet patient needs, and/or continuing education requirements. Standard SQE.8.1 Staff members who provide patient care and other staff identified by the organization are trained and can demonstrate appropriate competence in resuscitative techniques. Intent of SQE.8.1 Each organization identifies those staff to be trained in resuscitative techniques and the level of training (basic or advanced) appropriate to their role in the organization. The appropriate level of training for those identified is repeated every two years. There is evidence to show if each staff member attending the training actually achieved the desired competency level. Measurable Elements of SQE.8.1 1. Staff members who provide patient care and other staff identified by the organization to be trained in cardiac life support are identified. 2. The appropriate level of training is provided with sufficient frequency to meet staff needs. 3. There is evidence to show if a staff member passed the training. 4. The desired level of training for each individual is repeated every two years. Standard SQE.8.2 The organization provides facilities and time for staff education and training. Intent of SQE.8.2 The organization’s leaders support the commitment to ongoing staff in-service education by making available space, equipment, and time for education and training programs. The availability of current scientific information supports the education and training. The education and training can take place in a centralized location or in several smaller learning and skill development locations throughout the facility. The education can be offered once to all or repeated for staff on a shift-by-shift basis to minimize the impact on patient care activities. Measurable Elements of SQE.8.2 1. The organization provides facilities and equipment for staff in-service education and training. 2. The organization provides adequate time for all staff to participate in relevant education and training opportunities. Standard SQE.8.3 Health professional education, when provided within the organization, is guided by the educational parameters defined by the sponsoring academic program. Intent of SQE.8.3 Frequently health care organizations are the clinical setting for medical, nursing, allied health and other student training. When the organization participates in such training programs, the organization provides a mechanism(s) for oversight of the program(s); • obtains and accepts the parameters of the sponsoring academic program; has a complete record of all trainees within the organization; has documentation of the enrollment status, licensure (also see Glossary) or certifications (also see Glossary) achieved, and academic classification of the trainees; understands and provides the required level of supervision for each type and level of trainee; and integrates trainees into the organization’s orientation, quality, patient safety, infection prevention and control and other programs. Measurable Elements of SQE.8.3 1. The organization provides a mechanism(s) for oversight of the training program(s). 2. The organization obtains and accepts the parameters of the sponsoring academic program. 3. The organization has a complete record of all trainees within the organization. 4. The organization has documentation of the enrollment status, licensure or certifications achieved, and academic classification of the trainees. 5. The organization understands and provides the required level of supervision for each type and level of trainee. 6. The organization integrates trainees into its orientation, quality, patient safety, infection prevention and control and other programs. Standard SQE.8.4 The organization provides a staff health and safety program. Intent of SQE.8.4 The health and safety of an organization’s staff are important to maintain staff health, satisfaction, and productivity. Staff safety is also a part of the organization’s quality and patient safety program. How an organization orients and trains staff, provides a safe workplace, maintains biomedical and other equipment, prevents or controls health care–associated infections (also see Glossary), and many other factors determine the health and well-being of staff. (Also see PCI.5.1, ME 2) A staff health and safety program can be located within the organization or be integrated into external programs. Whatever the staffing and structure of the program, staff understand how to report and be treated for and receive counseling and follow-up for injuries such as needlesticks, exposure to infectious diseases, the identification of risks and hazardous conditions in the facility, and other health and safety matters. The program may also provide for initial employment health screening, periodic preventive immunizations and examinations, treatment for common work-related conditions, such as back injuries, or more urgent injuries. The design of the program includes staff input and draws upon the organization’s clinical resources as well as those in the community. Measurable Elements of SQE.8.4 1. The organization’s leaders and staff plan the health and safety program. 2. The program is responsive to urgent and nonurgent staff needs through direct treatment and referral. (Also see Glossary) 3. Program data informs the organization’s quality and safety program. 4. There is a policy on the provision of staff vaccinations and immunizations. 5. There is a policy on the evaluation, counseling, and follow-up of staff exposed to infectious diseases that is coordinated with the infection prevention and control program. (Also see PCI.5, ME 2) Medical Staff Standard SQE.9 The organization has an effective process for gathering, verifying, and evaluating the credentials (license, education, training, and experience) of those medical staff permitted to provide patient care without supervision. Intent of SQE.9 Physicians, dentists, and others who are licensed to provide patient care without clinical supervision represent those primarily responsible for patient care and care outcomes (also see Glossary). Thus, the organization has the highest level of accountability to ensure that each of these practitioners is qualified to provide safe and effective care and treatment to patients. The organization assumes this accountability by Understanding the applicable laws and regulations that identify those permitted to work independently and confirming that the organization will also permit such practitioners to work independently within the organization; Gathering all available credentials on the practitioner including, at least, evidence of education and training, evidence of current licensure, evidence of current competence through information from other organizations in which the practitioner practiced, and also letters of recommendation and/or other information the organization may require such as health history, pictures, etc.; and • Verification of the essential information such as current registry or licensure, especially when such documents are periodically renewed, and any certifications and evidence of completion of postgraduate education. The organization needs to make every effort to verify essential information, even when the education took place in another country and a significant time ago. Secure Web sites, documented phone confirmation from the source, written confirmation, and third parties, such as a designated, official governmental or nongovernmental agency, can be used. The following situations are considered acceptable substitutes for an organization performing primary source verification (also see Glossary) of credentials: Applicable to hospitals overseen directly by governmental bodies, the government’s verification process, supported by the availability of transparent governmental regulations about primary source verification, plus government licensure and the granting of specific status (e.g., consultant, specialist, etc.) acceptable. Applicable to all hospitals, the existence of an affiliated hospital that has already conducted primary source verification of the candidate, that verification is acceptable as long as the affiliated hospital possesses current JCI accreditation with “full compliance” on its verification process found in SQE.9, ME 2. Applicable to all hospitals, the credentials have been verified by an independent third party such as a designated, official governmental or non-governmental agency as long as the following conditions apply: Any hospital that bases its decisions in part on information from a designated, official governmental or nongovernmental agency should have confidence in the completeness, accuracy, and timeliness of that information. To achieve this level of confidence in the information, the hospital should evaluate the agency providing the information initially and then periodically as appropriate. The principles that guide such an evaluation include the following: The agency makes known to the user which data and information it can provide. The agency provides documentation to the user describing how its data collection, information and development, and verification process(es) are performed. The user and agency agree on the format for transmission of an individual’s credentials information from the agency. The user can easily discern which information, transmitted by the agency, is from a primary source and which is not. When the agency transmits information that can become out of date, it provides the date on which the information was last updated from the primary source. The agency certifies that the information transmitted to the user accurately presents the information obtained by it. The user can discern whether the information transmitted by the agency from a primary source is all of the primary source information in the agency’s possession pertinent to a given item and, if not, where additional information can be obtained. When necessary, the user can engage the agency’s quality control processes to resolve concerns about transmission errors, inconsistencies, or other data issues that may be identified from time to time. The user has a formal arrangement with the agency for communication of any changes in credentialing (also see Glossary) information. Standards compliance requires that primary source verification is carried out for new practitioner applicants beginning four months prior to initial accreditation survey; and current practitioners during a period of three (3) years to ensure that verification has been accomplished by the organization’s triennial accreditation survey. This is accomplished according to a plan that places priority on the verification of the credentials of active practitioners providing high-risk services. When verification is not possible, such as with the loss of records in a disaster, this is documented. The organization gathers and maintains a file of each practitioner’s credentials. The process applies to all types and levels of staff (employed, honorary, contract, and private community staff members). The organization reviews the files of each medical staff member on initial appointment and at least every three years, to ensure that the medical staff member is currently licensed, is not compromised by disciplinary actions of licensing and certification agencies, has sufficient documentation for seeking new or expanded privileges or duties in the organization, and is physically and mentally able to provide patient care and treatment without supervision. Measurable Elements of SQE.9 1. Those permitted by law, regulation, and the organization to provide patient care without supervision are identified. 2. Licensure, education and training are documented and verified according to the parameters found in the intent statement. 3. There is a separate record maintained of the credentials of every medical staff member that contains copies of any required license, certification, or registration and other documents required by the organization. 4. Licensure, certification or registrations are current. 5. There is a standardized procedure to review each record at least every three years. 6. At initial appointment and at least every three years, a determination is made about the current qualification of the individual to provide patient care services. Standard SQE.10 The organization has a standardized objective, evidence-based procedure to authorize all medical staff members to admit and treat patients and provide other clinical services consistent with their qualifications. Intent of SQE.10 The determination of the current clinical competence and making a decision about what clinical services the medical staff member will be permitted to perform, often called “privileging” (also see Glossary), is the most critical determination an organization will make to protect the safety of patients and advance the quality of its clinical services. The organization chooses a standardized process to identify the clinical services for each individual. On initial appointment to the organization, the credentials identified in SQE.9 will be the primary basis for the determination of privileges. If available, letters from previous places of practice, from professional peers awards and other sources of information are also considered. On reappointment, every three years, the organization seeks and uses information in the following general competency areas of clinical practitioners: Patient care—the practitioner provides patient care that is compassionate, appropriate and effective for health promotion, disease prevention, treatment of disease, and care at the end of life. Medical/clinical knowledge—of established and evolving biomedical, clinical and social sciences, and the application of knowledge to patient care and the education of others. Practice-based learning and improvement—using scientific evidence (also see “evidence- [or scientific-] based practices” in Glossary) and methods to investigate, evaluate, and improve patient care practices. d. Interpersonal and communication skills—that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams. e. Professionalism—reflected in a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward patients, their profession, and society. f. System-based practices—through the understanding of the contexts and systems in which health care is provided. There is a standardized objective and evidence-based procedure (also see Glossary) to turn all of this information into a decision regarding the privileges for a practitioner. The procedure is documented in policies and is followed. The medical staff leaders can demonstrate how the procedure was effective in the initial appointment process and in the reappointment process. The clinical privileges, once determined or redetermined, are made available by hard copy, electronic or other means to those individuals or locations (for example, operating room, emergency department) in the organization in which the medical staff member will provide services. This information will help ensure that medical staff members practice within the bounds of their competency and authorized privileges. The information is periodically updated as appropriate. Measurable Elements of SQE.10 1. There is a standardized procedure to grant privileges to practitioners on initial appointment and on reappointment. (Also see AOP.3, ME 5 and MMU.4.2, ME 2) 2. The procedure is documented in policies, is followed, and can be demonstrated as to how privileging decisions are reached. 3. The procedure considers sources of information as identified in the intent as relevant to the practitioner and also considers the findings of the annual performance review of the practitioner. 4. The privileges authorized for each medical staff member are made known to appropriate individuals and units of the organization and are updated as appropriate. Standard SQE.11 There is an ongoing professional practice evaluation of the quality and safety of the clinical care provided by each medical staff member. Intent of SQE.11 There is a standardized process to, at least annually, gather relevant data on each practitioner for review by the relevant department head or medical staff review body. Such a review allows the organization to identify professional practice trends that impact on quality of care (also see Glossary) and patient safety. Criteria used in the ongoing professional practice evaluation include, but are not limited to, the following: Review of operative and other clinical procedures performed and their outcomes Pattern of blood and pharmaceutical usage Requests for tests and procedures Length-of-stay patterns Morbidity and mortality data Practitioner’s use of consultation and specialists Other relevant criteria as determined by the organization This information may be acquired through the following: Periodic chart review Direct observation (also see Glossary) Monitoring of diagnostic and treatment techniques Clinical quality monitoring Discussion with peers and other staff The appraisal of the activities of senior medical staff and department heads is conducted by an appropriate internal or external authority. The ongoing professional practice evaluation process is objective and evidence based. The result of the review process can be no change in the medical staff member’s responsibilities, expansion of responsibilities, limitation of responsibilities, a period of counseling and oversight or other appropriate action. At any time during the year, when evidence of questionable or poor performance arises, there is a review and appropriate actions are taken. The results of reviews, actions taken, and any impact on privileges are documented in the medical staff member’s credentials or other file. Measurable Elements of SQE.11 1. There is an ongoing professional practice evaluation of each medical staff member that includes evaluation when indicated by the findings of quality improvement activities. (Also see QPS.1.1, ME 1) 2. The ongoing professional practice evaluation of each medical staff member considers available evidence at least annually through a standardized procedure established by the organization. 3. Appropriate information from the professional practice evaluation process is documented in the medical staff member’s credentials or other file. Nursing Staff Standard SQE.12 The organization has an effective process to gather, verify, and evaluate the nursing staff ’s credentials (license, education, training, and experience). Intent of SQE.12 The organization needs to ensure that it has a qualified nursing staff that appropriately matches its mission, resources, and patient needs. The nursing staff are responsible for providing direct patient care. In addition, nursing care contributes to the overall patient outcomes. The organization must ensure that nurses are qualified to provide nursing care and must specify the types of care they are permitted to provide if not identified in laws or regulations. The organization ensures that each nurse is qualified to provide safe and effective care and treatment to patients by understanding the applicable laws and regulations that apply to nurses and nursing practice; gathering all available credentials on each nurse, including at least evidence of education and training; evidence of current licensure; evidence of current competence through information from other sources in which the nurse was employed; and also letters of recommendation and/or other information the organization may require such as health history, pictures, etc.; and • verification of the essential information such as current registry or licensure, especially when such documents are periodically renewed, and any certifications and evidence of completion of specialized or advanced education. The organization needs to make every effort to verify essential information, even when the education took place in another country and a significant time ago. Secure Web sites, documented phone confirmation from the source, written confirmation, and third parties, such as a designated, official governmental or non-governmental agency, can be used. The situations described for medical staff in the intent statement of SQE.9 are considered acceptable substitutes for an organization performing primary source verification of nurse credentials. Standards compliance requires that primary source verification is carried out for new nurse applicants beginning four months prior to initial accreditation survey; and current employed nurses during a period of three (3) years to ensure that verification has been accomplished by the organization’s triennial accreditation survey. This is accomplished according to a plan that places priority on the verification of the credentials of nurses providing high-risk services such as in the operating theater, emergency department, or intensive care unit. When verification is not possible, such as with the loss of records in a disaster, this is documented. The organization has a process that ensures that the credentials of each contract nurse have also been gathered, verified, and reviewed to ensure current clinical competence prior to assignment. The organization gathers and maintains a file of each nurse’s credentials. The files contain current licenses when regulations require periodic renewal. There is documentation of training related to any additional competencies. Measurable Elements of SQE.12 1. The organization has a standardized procedure to gather the credentials of each nursing staff member. 2. Licensure, education, training, and experience are documented. 3. Such information is verified from the original source according to the parameters found in the intent statement of SQE.9. 4. There is a record maintained of the credentials of every nursing staff member. 5. The organization has a process to ensure that the credentials of contract nurses are valid and complete prior to assignment. Standard SQE.13 The organization has a standardized procedure to identify job responsibilities and make clinical work assignments based on the nursing staff member’s credentials and any regulatory requirements. Intent of SQE.13 Review of the qualifications of the nurse staff member provides the basis for assigning job responsibilities and clinical care activities. This assignment may be described in a job description or described in other ways or documents. Assignments made by the organization are consistent with any applicable law and regulation regarding nursing responsibilities and clinical care. (Also see MMU.6, ME 3) Measurable Elements of SQE.13 1. Licensure, education, training, and experience of a nursing staff member are used to make clinical work assignments. 2. The process takes into account relevant laws and regulations. Standard SQE.14 The organization has a standardized procedure for nursing staff participation in the organization’s quality improvement activities, including evaluating individual performance when indicated. Intent of SQE.14 The nursing staff’s essential clinical role requires them to actively participate in the organization’s clinical quality improvement program. If at any point during clinical quality monitoring, evaluation, and improvement, a nursing staff member’s performance is in question, the organization has a process to evaluate that individual’s performance. The results of reviews, actions taken, and any impact on privileges are documented in the medical staff member’s credentials or other file. Measurable Elements of SQE.14 1. Nursing staff participate in the organization’s quality improvement activities. (Also see QPS.1.1, ME 1) 2. The performance of individual nursing staff members is reviewed when indicated by the findings of quality improvement activities. 3. Appropriate information from the review process is documented in the nurse’s credentials or other file. Other Health Professional Staff Standard SQE.15 The organization has a standardized procedure to gather, verify, and evaluate other health professional staff members’ credentials (license, education, training, and experience). Intent of SQE.15 Health care organizations employ or may permit a variety of other health professionals to provide care and services to their patients or participate in patient care processes (also see Glossary). For example, these professionals include nurse midwives, surgical assistants, emergency medical care specialists, pharmacists, and pharmacy technicians. In some countries or cultures, this group also includes traditional healers or those considered to provide services that complement or provide alternatives to traditional medical practice (for example, acupuncture, herbal medicine). Often, these individuals do not actually practice in the organization; instead, they refer to the organization or provide continuing or follow-up care for patients in the community. Many of these professionals complete formal training programs and receive a license or certificate or are registered with local or national authorities. Others may complete less formal apprentice programs or other supervised experiences. For those other health professionals permitted to work or practice in the health care organization, the organization is responsible for gathering and verifying their credentials. The organization must ensure that other health professional staff are qualified to provide care and treatments and must specify the types of care and treatment they are permitted to provide if not identified in laws or regulations. The organization ensures that other health professionals are qualified to provide safe and effective care and treatment to patients by understanding the applicable laws and regulations that apply to such practitioners; gathering all available credentials on each individual including at least evidence of education and training, evidence of current licensure or certification when required; and verification of the essential information such as current registry, licensure, or certification. The organization needs to make every effort to verify essential information relevant to the individual’s intended responsibilities, even when the education took place in another country and a significant time ago. Secure Web sites, documented phone confirmation from the source, written confirmation, and third parties, such as a designated, official governmental or non-governmental agency, can be used. The situations described for medical staff in the intent statement of SQE.9 are considered acceptable substitutes for an organization performing primary source verification for the credentials of other health professional staff. Standards compliance requires that primary source verification is carried out for new applicants beginning four months prior to initial accreditation survey; and current employed health professionals during a period of three (3) years to ensure that verification has been accomplished by the organization’s triennial accreditation survey. When there is no required formal education process, licensure, or registry process or other credential or evidence of competency, this is documented in the individual’s record. When verification is not possible, such as with the loss of records in a disaster, this is documented in the individual’s record. The organization gathers and maintains a file of each health professional’s credentials. The files contain current licenses or registry when regulations require periodic renewal. Measurable Elements of SQE.15 1.The organization has a standardized procedure to gather the credentials of each health professional staff member. 2. Licensure, education, training, and experience are documented when relevant. 3. Such information is verified from the original source according to the parameters found in the intent statement of SQE.9. 4. There is a record maintained on other health professional staff members. 5. The record contains copies of any required license, certification, or registration. Standards SQE.16 The organization has a standardized procedure to identify job responsibilities and make clinical work assignments based on other health professional staff members’ credentials and any regulatory requirements. SQE.17 The organization has an effective process for other health professional staff members’ participation in the organization’s quality improvement activities. Intent of SQE.16 and SQE.17 The organization is responsible for identifying the types of activities or range of services these individuals will provide in the organization. This can be accomplished through agreements, job assignments, job descriptions, or other methods. In addition, the organization defines the level of supervision (consistent with existing law and regulation), if any, for these professionals. Other health professionals are included in the organization’s quality management and improvement program. Measurable Elements of SQE.16 1. Licensure, education, training, and experience of other health professional staff members are used to make clinical work assignments. 2. The process takes into account relevant laws and regulations. Joint Commission International Accreditation Standards for Hospitals, Third Edition Measurable Elements of SQE.17 1. Other health professional staff participate in the organization’s quality improvement activities. (Also see QPS.1.1, ME 1) 2. The performance of other health professional staff members is reviewed when indicated by the findings of quality improvement activities. 3. Appropriate information from the review process is documented in the health professional’s file. Management of Communication and Information (MCI) Overview Providing patient care is a complex endeavor that is highly dependent on the communication of information. This communication is to and with the community, patients and their families, and to other health professionals. Failures in communication are one of the most common root causes of patient safety incidents. To provide, coordinate, and integrate services, health care organizations rely on information about the science of care, individual patients, care provided, results of care, and their own performance. Like human, material, and financial resources, information is a resource that must be managed effectively by the organization’s leaders. Every organization seeks to obtain, manage, and use information to improve patient outcomes (also see Glossary), as well as individual and overall organization performance. Over time, organizations become more effective in identifying information needs; designing an information management system; defining and capturing data (also see Glossary) and information; analyzing data and transforming it into information; transmitting and reporting data and information; and integrating and using information. Although computerization and other technologies improve efficiency (also see Glossary), the principles of good information management (also see Glossary) apply to all methods, whether paper based or electronic. These standards are designed to be equally compatible with non-computerized systems and future technologies. Standards MCI.1 The organization communicates with its community to facilitate access to care and access to information about its patient care services. MCI.2 The organization informs patients and families about its care and services and how to access those services. MCI.3 Patient and family communication and education are provided in an understandable format and language. MCI.4 Communication is effective throughout the organization. MCI.5 The leaders ensure that there is effective communication and coordination among those individuals and departments responsible for providing clinical services. MCI.6 Information about the patient’s care and response to care is communicated among medical, nursing, and other care providers during each staffing shift, and between shifts. MCI.7 The patient’s record(s) is available to the care providers to facilitate the communication of essential information. MCI.8 Information related to the patient’s care is transferred with the patient. MCI.9 The organization plans and designs information management processes to meet internal and external information needs. MCI.10 Information privacy and confidentiality are maintained. MCI.11 Information security, including data integrity, is maintained. MCI.12 The organization has a policy on the retention time of records, data, and information. MCI.13 The organization uses standardized diagnosis codes, procedure codes, symbols, abbreviations and definitions. MCI.14 The data and information needs of those in and outside the organization are met on a timely basis in a format that meets user expectations and with the desired frequency. MCI.15 Appropriate clinical and managerial staff participate in selecting, integrating, and using information management technology. MCI.16 Records and information are protected from loss, destruction, tampering, and unauthorized access or use. MCI.17 Decision makers and other appropriate staff members are educated and trained in the principles of information management. MCI.18 A written policy or protocol defines the requirements for developing and maintaining policies and procedures. MCI.19 The organization initiates and maintains a clinical record for every patient assessed or treated. MCI.19.1 The clinical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results of treatment, and promote continuity of care among health care providers. MCI.19.1.1 The clinical record of every patient receiving emergency care includes the time of arrival, the conclusions at termination of treatment, the patient’s condition at discharge, and follow-up care instructions. MCI.19.2 Organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format. MCI.19.3 Every patient clinical record entry identifies its author and when the entry was made in the record. MCI.19.4 As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records. MCI.20 Aggregate data and information support patient care, organization management, and the quality management program. MCI.20.1 The organization has a process to aggregate data and has determined what data and information are to be regularly aggregated to meet the needs of clinical and managerial staff in the organization and agencies outside the organization. MCI.20.2 The organization supports patient care, education, research, and management with timely information from current sources. MCI.20.3 The organization has a process for using or participating in external databases. Joint Commission International Accreditation Standards for Hospitals, Third Edition Standards, Intents, and Measurable Elements Communication with the Community Standard MCI.1 The organization communicates with its community to facilitate access to care and access to information about its patient care services. Intent of MCI.1 Health care organizations define their communities and patient populations and plan ongoing communication with those key groups. The communications may be directly to individuals or through public media, and through agencies within the community or third parties. The types of information communicated include information on services, hours of operation and the process to obtain care; and information on the quality of services is provided to the public and to referral (also see Glossary) sources. Measurable Elements of MCI.1 1. The organization has identified its communities and populations of interest. 2. The organization has implemented a communication strategy with these populations. 3. The organization provides information on its services, hours of operation, and the process to obtain care. (Also see GLD.3.1) 4. The organization provides information on the quality of its services. Communication with Patients and Families Standard MCI.2 The organization informs patients and families about its care and services and how to access those services. Intent of MCI.2 Patients and families need complete information on the care and services offered by the organization as well as how to access those services. Providing this information is essential to building open and trusting communication among patients, families, and the organization. This information helps match the patient’s expectations with the organization’s ability to meet those expectations. Information on alternative sources of care and services is provided when the needed care is beyond the organization’s mission (also see “mission statement” in Glossary) and capabilities. (Also see ACC.1.2, ME 1) Measurable Elements of MCI.2 1. Patients and families are provided information on the care and services provided by the organization. (Also see ACC.1.2, ME 2) 2. Patients and families are provided information on how to access services in the organization. (Also see ACC.1.2, ME 2) 3. Information on alternative sources of care and services is provided when the organization cannot provide the care or services. Standard MCI.3 Patient and family communication and education are provided in an understandable format and language. Intent of MCI.3 Patients can only make informed decisions and participate in the care process if they understand the information provided to them. Thus, particular attention is given to the format and language used in communicating with and providing education to patients and families. Patients respond differently to spoken instructions, printed materials, videotapes, demonstrations, and so on. Also, it is important to understand the language preferred. On occasion, family members (also see Glossary) or interpreters may need to assist with the education or translate materials. It is important to recognize the limitations of children to serve as translators to communicate important clinical and other information and education. Thus, child translators should be used only as a last resort. When nonfamily members are used to translate or interpret, they are aware of any patient barriers to communication and understanding. (Also see ACC.1.3; PFE.3, ME 1; PFE.5, MEs 1 and 2; and PFR.5) Measurable Elements of MCI.3 1. Patient and family communication and education are in an understandable format. 2. Patient and family communication and education are provided in an understandable language. Communication Between Providers Within and Outside of the Organization Standard MCI.4 Communication is effective throughout the organization. Intent of MCI.4 Effective communication within an organization is a leadership issue. Thus, the organization’s leaders understand the dynamics of communication among and between professional groups, structural units such as departments, between professional and non professional groups, and between health professionals and management, between health professionals and families and with outside organizations, to name a few. The organization’s leaders not only set the parameters of effective communication but also serve as role models with the effective communication of the organization’s mission, strategies, plans, and other relevant information. The leaders pay attention to the accuracy and timeliness of information in the organization. Measurable Elements of MCI.4 1. The leaders ensure processes are in place for communicating relevant information throughout the organization in a timely manner. (Also see ACC.2, ME 1 and MMU.5.1, ME 1) 2. Effective communication occurs in the organization among the organization’s programs. (Also see ACC.2, ME 1) 3. Effective communication occurs with outside organizations. (Also see ACC.3.1, MEs 2 and 3 and MMU.5.1, ME 1) 4. Effective communication occurs with patients and families. (Also see ACC.2, ME 4) 5. The leaders communicate the organization’s mission and appropriate policies, plans, and goals to all staff. Standard MCI.5 The leaders ensure that there is effective communication and coordination among those individuals and departments responsible for providing clinical services. Intent of MCI.5 To coordinate and integrate patient care, the leaders develop a culture that emphasizes cooperation and communication. The leaders develop formal (for example, standing committees, joint teams) and informal (for example, newsletters and posters) methods for promoting communication among services and individual staff members. Coordination of clinical services comes from an understanding of each department’s mission and services of each department and collaboration in developing common policies and procedures. As appropriate to the services, the communication is both clinical and nonclinical in nature. Measurable Elements of MCI.5 1. Leaders ensure effective and efficient communication among clinical and nonclinical departments, services, and individual staff members. (Also see ACC.2.1, ME 1) 2. Leaders foster communication in the delivery of clinical services. Standard MCI.6 Information about the patient’s care and response to care is communicated among medical, nursing, and other care providers during each staffing shift, and between shifts. Intent of MCI.6 Communicating and exchanging information between and among health care professionals is essential to a smooth care process. Essential information can be communicated through verbal, written, or electronic means. Each organization decides what information needs to be communicated, by what means, and with what frequency. The information communicated from one care provider to another includes the patient’s health status; a summary of the care provided; and the patient’s response to care. Measurable Elements of MCI.6 1. There is a process to communicate patient information between the care providers on an ongoing basis ❒ or at key times in the care process. (Also see AOP.1.4, ME 3) 2. Information communicated includes the patient’s health status. 3. Information communicated includes a summary of the care provided. 4. Information communicated includes the patient’s progress. Standard MCI.7 The patient’s record(s) is available to the care providers to facilitate the communication of essential information. Intent of MCI.7 The patient’s record(s) (also see Glossary) is a primary source of information on the care process and the patient’s progress and thus is an essential communication tool. For this information to be useful and support the continuity of the patient’s care, it needs to be available during inpatient care, for outpatient visits, and at other times as needed and kept up to date. Medical nursing and other patient care notes are available to all of the patient’s care providers. Organization policy identifies those care providers who have access to the patient’s record to ensure confidentiality (also see Glossary) of patient information. Measurable Elements of MCI.7 1. Policy establishes those care providers who have access to the patient’s record(s). 2. The record(s) is available to those providers. (Also see AOP.1.5, ME 2) 3. The record(s) is up to date to ensure communication of the latest information. Standard MCI.8 Information related to the patient’s care is transferred with the patient. Intent of MCI.8 Patients are frequently transferred (also see Glossary) within the organization during their care. When the care team changes as a result of the transfer, continuity of patient care requires that essential information related to the patient be transferred with him or her. Thus, medications and other treatments can continue uninterrupted, and the patient’s status can be appropriately monitored (also see Glossary). To accomplish this information transfer, the patient’s record(s) is transferred or information from the patient’s record is summarized at transfer. Such a summary includes the reason for admission, significant findings, diagnosis, procedures performed, medications and other treatments, and the patient’s condition at transfer. Measurable Elements of MCI.8 1. The patient’s record or a summary of patient care information is transferred with the patient to another service or unit in the organization. 2. The summary contains the reason for admission. 3. The summary contains the significant findings. 4. The summary contains any diagnosis made. 5. The summary contains any procedures performed. 6. The summary contains any medications and other treatments. 7. The summary contains the patient’s condition at transfer. Leadership and Planning Standard MCI.9 The organization plans and designs information management processes to meet internal and external information needs. Intent of MCI.9 Information is generated and used during patient care and for managing a safe and effective organization. The ability to capture and provide information requires effective planning. Planning incorporates input from a variety of sources: The care providers; The organization’s managers and leaders; and Those outside the organization who need or require data (also see Glossary) or information about the organization’s operation and care processes. The planning also considers the organization’s mission, services provided, resources, access to affordable technology, and support for effective communication among caregivers. The priority information needs of these sources influence the organization’s information management strategies and ability to implement those strategies. The strategies are appropriate for the organization’s size, complexity of services, availability of trained staff and other human and technical resources. The plan is comprehensive and includes all of the departments and services of the organization. Planning for the management of information does not require a formal written information plan, but does require evidence of a planned approach that identifies the organization’s information needs. Measurable Elements of MCI.9 1. The information needs of those who provide clinical services are considered in the planning process. 2. The information needs of those who manage the organization are considered in the planning process. 3. The information needs and requirements of individuals and agencies outside the organization are considered in the planning process. 4. The planning is appropriate to the organization’s size and complexity. Standard MCI.10 Information privacy and confidentiality are maintained. Intent of MCI.10 The organization maintains the privacy and confidentiality of data and information and is especially careful about preserving the confidentiality of sensitive data and information. The balance between data sharing and data confidentiality is addressed. The organization determines the level of privacy and confidentiality maintained for different categories of information (for example, the patient’s record, research data). Measurable Elements of MCI.10 1. There is a written policy for addressing the privacy and confidentiality of information that is based on and consistent with law and regulation. 2. The policy is implemented. 3. Compliance with the policy is monitored. 4. The organization has a policy that indicates if patients have access to their health information and the process to gain access when permitted. (Also see PFR.1.6 Intent) Standard MCI.11 Information security, including data integrity, is maintained. Intent of MCI.11 Policies and procedures address security procedures that allow only authorized staff to gain access to data and information. Access to different categories of information is based on need and defined by job title and function, including students in academic settings. An effective process defines who has access to information; the information to which an individual has access; the user’s obligation to keep information confidential; and the process followed when confidentiality and security are violated. One aspect of maintaining security of patient information is to determine who is authorized to obtain a patient clinical record (also see Glossary) and make entries into the patient clinical record. The organization develops a policy to authorize such individuals and identifies the content and format for entries into patient clinical records. There is a process to ensure that only authorized individuals make entries in patient clinical records. Measurable Elements of MCI.11 1. The organization has a written policy for addressing information security, including data integrity, that is based on or consistent with law or regulation. 2. The policy includes levels of security for each category of data and information are identified. 3. Those who have the need or job position that permits access to each category of data and information are identified. 4. The policy is implemented. 5. Compliance with the policy is monitored. Standard MCI.12 The organization has a policy on the retention time of records, data, and information. Intent of MCI.12 The organization develops and implements a policy that guides the retention of patient clinical records and other data and information. Patient clinical records and other data and information are retained for sufficient periods to comply with law and regulation and support patient care, management, legal documentation, research, and education. The retention policy is consistent with the confidentiality and security of such information. When the retention period is complete, patient clinical records and other records, data, and information are destroyed appropriately. Measurable Elements of MCI.12 1. The organization has a policy on retaining patient clinical records and other data and information. 2. The retention process provides expected confidentiality and security. 3. Records, data, and information are destroyed appropriately. Standard MCI.13 The organization uses standardized diagnosis codes, procedure codes, symbols, abbreviations and definitions. Intent of MCI.13 Standardized terminology, definitions, vocabulary, and nomenclature facilitate comparison of data and information within and among organizations. Uniform use of diagnosis and procedure codes supports data aggregation and analysis. Abbreviations and symbols are also standardized and include a “do not use” listing (also see Glossary). Such standardization is consistent with recognized local and national standards. Measurable Elements of MCI.13 1. Standardized diagnosis codes are used and use monitored. 2. Standardized procedure codes are used and use monitored. 3. Standardized definitions are used. 4. Standardized symbols are used, and those not to be used are identified and monitored. Joint Commission International Accreditation Standards for Hospitals, Third Edition ❒ 5. Standardized abbreviations are used, and those not to be used are identified and monitored. Standard MCI.14 The data and information needs of those in and outside the organization are met on a timely basis in a format that meets user expectations and with the desired frequency. Intent of MCI.14 The format and methods of disseminating data and information to the intended user are tailored to meet the user’s expectations. Dissemination strategies include providing only the data and information the user requests or needs; formatting the report to aid use in the decision process; providing reports with the frequency needed by the user; linking sources of data and information; and providing interpretation or clarification of data. Measurable Elements of MCI.14 1. Data and information dissemination meet user needs. 2. Users receive data and information on a timely basis. 3. Users receive data and information in a format that aids its intended use. 4. Staff have access to the data and information needed to carry out their job responsibilities. Standard MCI.15 Appropriate clinical and managerial staff participate in selecting, integrating, and using information management technology. Intent of MCI.15 Information management technology represents a major investment of resources for a health care organization. For this reason, technology is carefully matched to the organization’s current and future needs and its resources. Available technology needs to be integrated with existing information management processes and helps integrate the activities of all of the organization’s departments and services. This level of coordination requires that key clinical and managerial staff participate in the selection process. Measurable Elements of MCI.15 1. Clinical staff participate in information technology decisions. 2. Managerial staff participate in information technology decisions. Standard MCI.16 Records and information are protected from loss, destruction, tampering, and unauthorized access or use. Intent of MCI.16 Patient records and other data and information are secure and protected at all times. For example, active patient records are kept in areas where only authorized health professional staff have access, and records are stored in locations where heat, water, fire, or other damage is not likely to occur. The organization also considers unauthorized access to electronically stored information and implements processes to prevent such access. (Also see PFR.1.6 related to the confidentiality of patient information.) Measurable Elements of MCI.16 1. Records and information are protected from loss or destruction. 2. Records and information are protected from tampering and unauthorized access or use. Standard MCI.17 Decision makers and other appropriate staff members are educated and trained in the principles of information management. Intent of MCI.17 Individuals in the organization who generate, collect, analyze, and use data and information are educated and trained to effectively participate in managing information. This education and training enable these individuals to understand security and confidentiality of data and information; use measurement instruments, statistical tools, and data analysis methods; assist in interpreting data; use data and information to help in decision making; educate and support the participation of patients and families in care processes; and use indicators (also see Glossary) to assess and improve care and work processes. Individuals are educated and trained as appropriate to their responsibilities, job descriptions (also see Glossary), and data and information needs. The information management process makes it possible to combine information from various sources and generate reports to support decision making. In particular, the combination of clinical and managerial information helps organization leaders to plan collaboratively. The information management process supports leaders with integrated longitudinal data and comparative data. Measurable Elements of MCI.17 1. Decision makers and others are provided education on the principles of information management. 2. The education is appropriate to needs and job responsibilities. 3. Clinical and managerial data and information are integrated as needed to support decision making. Standard MCI.18 A written policy or protocol defines the requirements for developing and maintaining policies and procedures. Intent of MCI.18 The policy or protocol (also see Glossary) outlines how the following will be carried out: a) Review and approval of all policies and procedures by an authorized person before issue; b) The process and frequency of review and continued approval of policies and procedures; c) The controls for ensuring that only current, relevant versions of policies and procedures are available wherever they are used; d) Identification of changes in policies and procedures; e) Maintenance of document identity and legibility; f) Control of policies and procedures that originated outside the organization; g) Retention of obsolete policies and procedures for at least the time required by law and regulation, while ensuring that they will not be mistakenly used; and h) Identification and tracking of all policies and procedures in circulation. The tracking system allows each document to be identified by title, date of issue, edition and/or current revision date, number of pages, who authorized issue and/or reviewed the document, and database identification (if applicable). There is a process to ensure that staff members have read and are familiar with policies and procedures relevant to their work. The processes for developing and maintaining policies and procedures are implemented. Measurable Elements of MCI.18 1. There is a written policy or protocol that defines the requirements for developing and maintaining policies and procedures including at least items a) through h) in the intent, and it is implemented. 2. There is a written protocol that outlines how policies and procedures that originated outside the organization will be controlled, and it is implemented. 3. There is a written policy or protocol that defines retention of obsolete policies and procedures for at least the time required by law and regulation, while ensuring that they will not be mistakenly used, and it is implemented. 4. There is a written policy or protocol that outlines how all policies and procedures in circulation will be identified and tracked, and it is implemented. Patient Clinical Record Standard MCI.19 The organization initiates and maintains a clinical record for every patient assessed or treated. Intent of MCI.19 Every patient assessed or treated in a health care organization (also see Glossary) as an inpatient, outpatient, or urgent care patient has a clinical record. The record is assigned an identifier unique to the patient, or some other mechanism is used to link the patient with his or her clinical record. A single record and a single identifier enable the organization to easily locate patient clinical records and document the care of patients over time. Measurable Elements of MCI.19 1. A clinical record is initiated for every patient assessed or treated by the organization. 2. Patient clinical records are maintained through the use of an identifier unique to the patient or some other effective method. Standards MCI.19.1 The clinical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results of treatment, and promote continuity of care among health care providers. MCI.19.1.1 The clinical record of every patient receiving emergency care includes the time of arrival, the conclusions at termination of treatment, the patient’s condition at discharge, and follow-up care instructions. Intent of MCI.19.1 and MCI.19.1.1 The clinical record of each patient needs to present sufficient information to support the diagnosis, justify the treatment provided, and document the course and results of the treatment. A standardized format and content of a patient’s clinical record help promote the integration and continuity of care (also see Glossary) among the various providers of care to the patient. The organization determines the specific data and information recorded in the clinical record of each patient assessed or treated on an outpatient, emergency, or inpatient basis. The record of each patient receiving emergency care includes the specific information identified in standard MCI.20.1.1. Measurable Elements of MCI.19.1 1. Patient clinical records contain adequate information to identify the patient. 2. Patient clinical records contain adequate information to support the diagnosis. (Also see ASC.7, ME 3) 3. Patient clinical records contain adequate information to justify the care and treatment. 4. Patient clinical records contain adequate information to document the course and results of treatment. (Also see AOP.1.5, ME 1; AOP.2, COP.5, ME 2; ASC.5.2, ME 1; ASC.5.3, ME 2; ASC.6, ME 2; ASC.7.3, ME 3; and MMU.4.3, ME 1) 5. The specific content of patient clinical records has been determined by the organization. Measurable Elements of MCI.19.1.1 1. The clinical records of emergency patients include arrival time. 2. The clinical records of emergency patients include conclusions at the termination of treatment. 3. The clinical records of emergency patients include the patient’s condition at discharge. 4. The clinical records of emergency patients include any follow-up care instructions. Standards MCI.19.2 Organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format. MCI.19.3 Every patient clinical record entry identifies its author and when the entry was made in the record. Intent of MCI.19.2 and MCI.19.3 Access to each category of information is based on need and defined by job title and function, including students in academic settings. An effective process defines who has access to information; the information to which an individual has access; the user’s obligation to keep information confidential; and the process followed when confidentiality and security are violated. One aspect of maintaining the security of patient information is to determine who is authorized to obtain a patient clinical record and make entries into the patient clinical record. The organization develops a policy to authorize such individuals and identifies the content and format for entries into patient clinical records. There is a process to ensure that only authorized individuals make entries in patient clinical records, and that each entry identifies the author of the entry and the date. If required by the organization, the time of the entry is also noted, such as for timed treatments or medication orders. Measurable Elements of MCI.19.2 1. Those authorized to make entries in the patient clinical record are identified in organization policy. (Also see International Patient Safety Goal 2, ME 2) 2. The format and location of entries are determined by organization policy. 3. There is a process to ensure that only authorized individuals make entries in patient clinical records. Measurable Elements of MCI.19.3 1. The author can be identified for each patient clinical record entry. 2. The date of each patient clinical record entry can be identified. 3. When required by the organization, the time of an entry can be identified. Standard MCI.19.4 As part of its performance improvement activities, the organization regularly assesses patient clinical record content and the completeness of patient clinical records. Intent of MCI.19.4 Each organization determines the content and format of the patient clinical record and has a process to assess record content and the completeness of records. That process is a part of the organization’s performance improvement activities and is carried out regularly. Patient clinical record review is based on a sample representing the practitioners providing care and the types of care provided. The review process is conducted by the medical staff, nursing staff, and other relevant clinical professionals who are authorized to make entries in the patient record. The review focuses on the timeliness, completeness, legibility, and so forth of the record and clinical information. Clinical record content required by law or regulation is included in the review process. The organization’s clinical record review process includes records of patients currently receiving care as well as records of discharged patients. Measurable Elements of MCI.19.4 1. Patient clinical records are reviewed regularly. 2. The review uses a representative sample. 3. The review is conducted by physicians, nurses, and others authorized to make entries in patient records or manage patient records. 4. The review focuses on the timeliness, legibility, and completeness of the clinical record. 5. Record contents required by law or regulation are included in the review process. 6. Records of active and discharged patients are included in the review process. 7. The results of the review process are incorporated into the organization’s quality oversight mechanism. Aggregate Data and Information Standards MCI.20 Aggregate data and information support patient care, organization management, and the quality management program. MCI.20.1 The organization has a process to aggregate data and has determined what data and information are to be regularly aggregated to meet the needs of clinical and managerial staff in the organization and agencies outside the organization. MCI.20.2 The organization supports patient care, education, research, and management with timely information from current sources. MCI.20.3 The organization has a process for using or participating in external databases. Intent of MCI.20 through MCI.20.3 The organization collects and analyzes aggregate data to support patient care and organization management. Aggregate data provides a profile of the organization over time and allows the comparison of the organization’s performance with other organizations. Thus, aggregate data are an important part of the organization’s performance improvement activities. In particular, aggregate data from risk management, utility system (also see Glossary) management, infection prevention and control, and utilization review can help the organization understand its current performance and identify opportunities for improvement. Clinical care providers, researchers, educators, and managers often need information to assist with their responsibilities. Such information may include scientific and management literature, clinical practice guidelines (also see Glossary), research findings, and educational methodologies. The Internet, print materials in a library, on-line search sources, and personal materials are all valuable sources of current information. By participating in external performance databases, an organization can compare its performance to that of other similar organizations locally, nationally, and internationally. Performance comparison is an effective tool for identifying opportunities for improvement and documenting the organization’s performance level. Health care networks and those purchasing or paying for health care often ask for such information. External databases vary widely from insurance databases to those maintained by professional societies. Organizations may be required by law or regulation to contribute to some external databases (also see QPS.4.2). In all cases, the security and confidentiality of data and information are maintained. Measurable Elements of MCI.20 1. Aggregate data and information support patient care. 2. Aggregate data and information support organization management. 3. Aggregate data and information support the quality management program. Measurable Elements of MCI.20.1 1. The organization has a process to aggregate data in response to identified user needs. 2. The organization provides needed data to agencies outside the organization. Measurable Elements of MCI.20.2 1. Current scientific and other information supports patient care. 2. Current scientific and other information supports clinical education. 3. Current scientific and other information supports research. 4. Current professional and other information supports management. 5. Information is provided in a time frame that meets user expectations. Measurable Elements of MCI.20.3 1. The organization has a process to participate in or use information from external databases. 2. The organization contributes data or information to external databases in accordance with law or regulation.   3. The organization compares its performance using external reference databases. (Also see QPS.4.2, ME 2; MCI.20.3, ME 3; and PCI.10.4, ME 1) 4. Security and confidentiality are maintained when contributing to or using external databases. Glossary accreditation Determination by the Joint Commission International (JCI) accrediting body that an eligible health care organization complies with applicable JCI standards. accreditation decisions Categories of accreditation that an organization can achieve based on a JCI survey. These decision categories are: accredited The organization demonstrates acceptable compliance with all standards and International Patient Safety Goals. accreditation denied The organization is consistently not in compliance with JCI standards and International Patient Safety Goals, when JCI withdraws its accreditation for other reasons, or when the organization voluntarily withdraws from the accreditation process. accreditation process A continuous process whereby health care organizations are required to demonstrate to JCI that they are providing safe, high-quality care, as determined by compliance with JCI standards and International Patient Safety Goals recommendations. The key component of this process is an on-site evaluation of an organization by JCI surveyors. accreditation survey An evaluation of an organization to assess its compliance with applicable standards and to determine its accreditation status. Also known as a “triennial survey” (also see below), the JCI accreditation survey includes the following: Evaluation of documents provided by organization staff that show compliance Verbal information about the implementation of standards or examples of their implementation that enables compliance to be determined On-site observations by surveyors Tracking of patients through the care process by the tracer methodology Education about standards compliance and performance improvement initial survey Evaluation of an organization that is seeking JCI accreditation for the first time or has not been unaccredited by JCI during the previous six months. for-cause survey An organizational evaluation undertaken when JCI becomes aware of potentially serious issues involving standards compliance, patient care, or patient safety. validation survey An evaluation of the survey process subsequent to an organization’s initial or triennial re-survey, assessing standards compliance in health care organizations, as part of JCI’s internal quality improvement efforts. Similar in scope to an initial triennial survey, the validation survey is voluntary and in no way affects the results of an organization’s triennial survey. focused survey Narrow, limited evaluation of an organization subsequent to a triennial survey, which concentrates solely on issues deemed noncompliant during the triennial survey. extension survey An organizational evaluation made necessary by any of the following factors: An organization has offered at least 25% of its services at a new location or in a significantly altered physical plan. An organization has expanded its capacity to provide services by 25% or greater, as measured by patient volume or other relevant measures. An organization has merged with, consolidated with, or acquired an unaccredited site, service, or program for which there are applicable JCI standards. adverse event An unanticipated, undesirable, or potentially dangerous occurrence in a health care organization. Also see sentinel event. ambulatory care Types of health services provided to individuals on an outpatient basis. Ambulatory care services are provided in many settings ranging from freestanding surgical facilities to cardiac catheterization centers. Also see outpatient programs. anesthesia and sedation The administration to an individual, in any setting, for any purpose, by any route, medication to induce a partial or total loss of sensation for the purpose of conducting an operative or other procedure. Definitions of four levels of sedation and anesthesia include the following: minimal sedation (anxiolysis) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. procedural (or moderate) sedation (formerly “conscious sedation”) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. deep sedation/analgesia A drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. anesthesia Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. best practice Clinical, scientific, or professional technique, method, or process that is recognized by a majority of professionals in a particular field as more effective at delivering a particular outcome than any other practice. These practices, also sometimes referred to as “good practice” or “better practice,” are typically evidence based and consensus driven. care plan See plan of care certification 1.The procedure and action by which an authorized organization evaluates and certifies that an individual, institution, or program meets requirements, such as standards. Certification differs from accreditation in that certification can also be applied to individuals (for example, a medical specialist). 2.The process by which a non-government agency or association certifies that an individual has met predetermined qualifications specified by that agency or association. clinical pathology Services relating to solving clinical problems, especially using laboratory methods in clinical diagnosis. Includes clinical chemistry, bacteriology and mycology, parasitology, virology, clinical microscopy, hematology, coagulation immunohematology, immunology, serology, and radiobioassay. clinical pathways An agreed-upon treatment regime that includes all elements of care. clinical practice guidelines Statements that help practitioners and patients choose appropriate health care for specific clinical conditions (for example, recommendations on the case management of diarrhea in children under the age of five years). The practitioner is guided through all steps of consultation (questions to ask, physical signs to look for, lab exams to prescribe, assessment of the situation, and treatment to prescribe). clinical record See patient record/medical record/clinical record clinical staff See staff clinical trial Therapy testing in three or sometimes four stages depending on the purpose, size, and scope of the test. “Phase I” trials evaluate the safety of diagnostic, therapeutic, or prophylactic drugs, devices, or techniques to determine the safe dosage range (if appropriate). They involve a small number of healthy subjects. The trial usually lasts about one year. “Phase II” trials are usually controlled to assess the effectiveness and dosage (if appropriate) of the drugs, devices, or techniques. These studies involve several hundred volunteers, including a limited number of patients with the target disease or disorder. The trial usually lasts about two years. “Phase III” trials verify the effectiveness of the drugs, devices, or techniques determined in Phase II studies. Phase II patients are monitored to identify any adverse reactions from long-term use. These studies involve groups of patients large enough to identify clinically significant responses. The trial usually lasts about three years. “Phase IV” trials study the drugs, devices, or techniques that have been approved for general sale. These studies are often conducted to obtain more data about a product’s safety and efficacy. competence A determination of an individual’s skills, knowledge, and capability to meet defined expectations, as frequently described in a job description. confidentiality The restricted access to data and information to individuals who have a need, a reason, and permission for such access. An individual’s right to personal and informational privacy, including for his or her health care records. contamination The presence of an infectious agent on an animate or inanimate surface. continuum of care Matching the individual’s ongoing needs with the appropriate level and type of care, treatment, and service within an organization or across multiple organizations. continuity of care The degree to which the care of individuals is coordinated among practitioners, among organizations, and over time. contracted services Services provided through a written agreement with another organization, agency, or individual. The agreement specifies the services or personnel to be provided on behalf of the applicant organization and the fees to provide these services or personnel. credentialing The process of obtaining, verifying, and assessing the qualifications of a health care practitioner to provide patient care services in or for a health care organization. The process of periodically checking staff qualifications is called recredentialing. credentials Evidence of competence, current and relevant licensure, education, training, and experience. Other criteria may be added by a health care organization. Also see competence; credentialing. data Facts, clinical observations, or measurements collected during an assessment activity. Data before they are analyzed are called “raw data.” disaster See emergency discharge The point at which an individual’s active involvement with an organization or program is terminated and the organization or program no longer maintains active responsibility for the care of the individual. discharge summary A section of a patient record that summarizes the reasons for admittance, the significant findings, the procedures performed, the treatment rendered, the patient’s condition on discharge, and any specific instructions given to the patient or family (for example, follow-up, medications). “do not use” list A written catalog of abbreviations, acronyms, and symbols that are not to be used throughout an organization—whether handwritten or entered as free text into a computer—due to their potentially confusing nature. efficiency The relationship between the outcomes (results of care) and the resources used to deliver care. For example, when two programs use the same amount of resources, the one that achieves a higher immunization coverage rate is the more efficient. Increasing efficiency involves achieving the same outputs with fewer resources or more outputs with the same amount of resources. emergency An unanticipated or sudden occasion, as in emergency surgery needed to prevent death or serious disability. A natural or man-made event that significantly disrupts the environment of care (for example, damage to the organization’s building(s) and grounds due to severe winds, storms, or earthquakes); that significantly disrupts care and treatment (for example, loss of utilities such as power, water, or telephones due to floods, civil disturbances, accidents, or emergencies in the organization or its community); or that results in sudden, significantly changed or increased demands for the organization’s services (for example, bioterrorist attack, building collapse, or plane crash in the organization’s community). Some emergencies are called “disasters” or “potential injury creating events” (PICEs). environmental management plan(s) The organization’s written document describing the process it has in place for the following areas of its operations: safety and security, hazardous materials, emergencies, fire safety, medical equipment, and utility systems. The plan identifies specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities. evidence- (or scientific-) based guidelines Making medical decisions based on empirical evidence or in the absence of empirical evidence, expert consensus (such as consensus statements promoted by professional societies). The approach requires understanding conflicting results and assessing the quality and strength of evidence. Finally, physicians must know how this applies to patients and health care policy. failure mode and effects analysis (FMEA) A systematic way of examining a design prospectively for possible ways in which failure can occur. It assumes that no matter how knowledgeable or careful people are, errors will occur in some situations and may even be likely to occur. family The person(s) with a significant role in the patient’s life. This may include a person(s) not legally related to the patient. This person(s) is often referred to as a surrogate decision maker if authorized to make care decisions for a patient if the patient loses decision-making ability. functional status The ability of individuals to take care of themselves physically and emotionally as appropriate to their age group. Functional status may be divided into “social,” “physical,” and “psychological” functions. Functional status may be assessed by asking questions during periodic health examinations or using formal screening instruments. Also see measure. governance The individual(s), group, or agency that has ultimate authority and responsibility for establishing policy, maintaining quality of care, and providing for organization management and planning. Other names for this group include “board,” “board of trustees,” “board of governors,” “board of commissioners,” and “governing body.” harvesting, of organs Removal of an organ for means of transplantation. hazard vulnerability analysis The identification of potential emergencies and the direct and indirect effects these emergencies may have on the health care organization’s operations and the demand for its services. hazardous materials and waste Materials whose handling, use, and storage are guided or defined by local, regional, or national regulation, hazardous vapors, and hazardous energy sources. Although JCI considers infectious waste as falling into this category of materials, not all laws and regulations define infectious or medical waste as hazardous waste. health care–associated infection(s) (HAI) Any infection(s) acquired by an individual while receiving care or services in a health care organization. Common HAIs are urinary infections, surgical wound infections, pneumonia, and blood stream infections. health care organization A generic term used to describe many types of organizations that provide health care services. This includes ambulatory care centers, behavioral/mental health institutions, home care organizations, hospitals, laboratories, and long term care organizations. Also known as a “health care institution.” health care organization management standards For purposes of JCI Accreditation, standards that are organized according to what is done directly or indirectly to provide for a safe, effective, and well-managed organization and facility (for example, prevention and control of infection, facility management, staff qualifications). health care professional Any person who has completed a course of study and is skilled in a field of health. This includes a physician, dentist, nurse, or allied health professional. Health care professionals are often licensed by a government agency or certified by a professional organization. indicator A measure used to determine, over time, an organization’s performance of functions, processes, and outcomes. infectious waste See hazardous materials and waste information management The creation, use, sharing, and disposal of data or information across an organization. This practice is critical to the effective and efficient operation of organization activities. It includes the role of management to produce and control the use of data and information in work activities, information resources management, information technology, and information services. informed consent Agreement or permission accompanied by full information on the nature, risks, and alternatives of a medical procedure or treatment before the physician or other health care professional begins the procedure or treatment. After receiving this information, the patient then either consents to or refuses such a procedure or treatment. in-service education Organized education, usually provided in the workplace, designed to enhance the skills of staff members or teach them new skills relevant to their jobs and disciplines. inpatient Generally, persons who are admitted to and housed in a health care organization at least overnight. intent statement A brief explanation of a standard’s rationale, meaning, and significance, noted in this manual under the heading Intent. Intent statements may contain detailed expectations of the standard that are evaluated in the on-site survey process. invasive procedure A procedure involving puncture or incision of the skin, or insertion of an instrument or foreign material into the body. job description Explanation of an employment position including duties, responsibilities, and conditions required to perform the job. leader An individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization’s governance, management, clinical, and support functions and processes. The leaders described in the JCI standards include at least the leaders of the governing body; the chief executive officer and other senior managers; departmental leaders; the elected and the appointed leaders of the medical staff and the clinical departments and other medical staff members in organizational administrative positions; and the nurse executive and other senior nursing leaders. licensure A legal right that is granted by a government agency in compliance with a statute governing an occupation (such as physicians, nurses, psychiatry, or clinical social work, or the operation of a health care facility). measure To collect quantifiable data about a function, system, or process (one “measures”). A quantitative tool. Also see “indicator” medical equipment Fixed and portable equipment used for the diagnosis, treatment, monitoring, and direct care of individuals. medical record See patient record/medical record/clinical record medical waste See hazardous materials and waste medication Any prescription medications; sample medications; herbal remedies; vitamins; nutriceuticals; overthe-counter drugs; vaccines; diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications; respiratory therapy treatments; parenteral nutrition; blood derivatives; and intravenous solutions (plain, with electrolytes and/or drugs). medication, high-risk or high-alert Those drugs that carry a risk for errors that can lead to significant adverse outcomes. medication error Any preventable event that may cause inappropriate medication use or jeopardize patient safety. Also see sentinel event. mission statement A written expression that sets forth the purpose, or “mission,” of an organization or one of its components. The generation of a mission statement usually precedes the formation of goals and objectives. monitoring The review of information on a regular basis. The purpose of monitoring is to identify the changes in a situation. For example, the health information specialist of the district health management team reports every month the cases of meningitis occurring in villages at risk. multidisciplinary Including representatives of a range of professions, disciplines, or service areas. near miss Any process variation that did not affect an outcome but for which a recurrence carries a significant chance of a serious adverse outcome. Such a “near miss” falls within the scope of the definition of an adverse event. Also see adverse event. nonclinical staff See staff nosocomial infection(s) See health care–associated infection(s) nutritional care Interventions and counseling to promote appropriate nutrition intake. This activity is based on nutrition assessment and information about food, other sources of nutrients, and meal preparation. It considers the patient’s cultural background and socioeconomic status. nutrition therapy Medical treatment that includes enteral and parenteral nutrition. observation The time during which a patient is watched closely by a caregiver (or caregivers). organizational chart A graphic representation of titles and reporting relationships in an organization, sometimes referred to as an “organogram” or “organization table.” outcome The effect(s) that an intervention has on a specific health problem. It reflects the purpose of the intervention. For example, the outcome(s) of a rural health education program on safe drinking water could be fewer diarrhea episodes in children under five or decreased child mortality by diarrhea. outpatient Generally, persons who do not need the level of care associated with the more structured environment of an inpatient or a residential program. In many countries, outpatient care is also known as “ambulatory care.” In some countries, outpatients are considered “admitted” to a health care organization; in others, outpatients are considered “registered.” Also see ambulatory care. palliative services Treatments and support services intended to alleviate pain and suffering rather than to cure illness. Palliative therapy may include surgery or radiotherapy undertaken to reduce or shrink tumors compressing vital structures and thereby improve the quality of life. Palliative services include attending to the patient’s psychological and spiritual needs and supporting the dying patient and his or her family. patient An individual who receives care, treatment, and services. For JCI standards, the patient and family are considered a single unit of care. patient care process The act of providing accommodations, comfort, and treatment to an individual. This implies responsibility for safety, including treatment, services, habilitation, rehabilitation, or other programs requested by the organization or network for the individual. patient-centered standards For purposes of JCI Accreditation, standards that are organized according to what is done directly or indirectly for or to patients (for example, patient education, creation of patient records, patient assessment). patient record/medical record/clinical record A written account of a variety of patient health information, such as assessment findings, treatment details, progress notes, and discharge summary. This record is created by physicians and other health care professionals. physiologic-based criteria Criteria centered on the branch of biology dealing with the functions of the living organism and its parts of the physical and chemical factors and processes involved. plan A detailed method, formulated beforehand, that identifies needs, lists strategies to meet those needs, and sets goals and objectives. The format of the plan may include narratives, policies and procedures, protocols, practice guidelines, clinical paths, care maps, or a combination of these. plan of care A plan that identifies the patient’s care needs, lists the strategy to meet those needs, documents treatment goals and objectives, outlines the criteria for ending interventions, and documents the individual’s progress in meeting specified goals and objectives. It is based on data gathered during patient assessment. The format of the plan in some organizations may be guided by specific policies and procedures, protocols, practice guidelines, clinical paths, or a combination of these. The plan of care may include prevention, care, treatment, habilitation, and rehabilitation. Also see plan. point-of-care testing Analytical testing performed at sites outside the traditional laboratory environment, usually at or near where care is delivered to individuals. practice guidelines Tools that describe processes found by clinical trials or by consensus opinion of experts to be the most effective in evaluating and/or treating a patient who has a specific symptom, condition, or diagnosis, or describe a specific procedure. Synonyms include practice parameter, protocol, preferred practice pattern, and guideline. Also see evidence- (scientific)- based guidelines and clinical practice guidelines preventive services Interventions to promote health and prevent disease. This includes identification of and counseling on risk factors (for example, smoking, lack of physical activity), screening to detect disease (for example, breast cancer, sexually transmitted diseases), immunizations, and chemoprophylaxis (for example, hormone replacement therapy). primary source verification Verification of an individual health care practitioner’s reported qualifications by the original source or an approved agent of that source. Methods for conducting primary source verification of credentials include direct correspondence, documented telephone verification, or secure electronic verification from the original qualification source or reports from credentials verification organizations that meet JCI requirements. privileging The process whereby a specific scope and content of patient care services (that is, clinical privileges) are authorized for a health care practitioner by a health care organization, based on evaluation of the individual’s credentials and performance. process A series of actions (or activities) that transform the inputs (resources) into outputs (services). For example, a rural health education program will require that staff develop an education strategy, develop educational materials, and deliver the education sessions. protocol Scientific treatment plan or study outline—including types of trial participants, schedule, procedures, medications and dosages, etc.—for using an experimental procedure or a new treatment with the intent of measuring human applications. qualified individual An individual or staff member who can participate in one or all of the organization’s care activities or services. Qualification is determined by the following: education, training, experience, competence, applicable licensure, law or regulation, registration, or certification. quality of care The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Dimensions of performance include the following: patient perspective issues; safety of the care environment; and accessibility, appropriateness, continuity, effectiveness, efficacy, efficiency, and timeliness of care. recruiting Seeking; normally new employees or other members of an organization. referral The sending of an individual (1) from one clinician to another clinician or specialist; or (2) from one setting or service to another or other resource, either for consultation or care that the referring source is not prepared or qualified to provide. rehabilitation services The use of medical, social, educational, and vocational measures together for training or retraining individuals disabled by disease or injury. The goal is to enable patients to achieve their highest possible level of functional ability. risk management program Clinical and administrative activities that organizations undertake to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself. root cause analysis A process for identifying the basic or causal factor(s) that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. Also see sentinel event. safety The degree that the organization’s buildings, grounds, and equipment do not pose a hazard or risk to patients, staff, or visitors. scope of practice The range of activities performed by a practitioner in a health care organization. The scope is determined by training, tradition, law or regulation, or the organization. scope of services The range of activities performed by governance, managerial, clinical, and support personnel. screening criteria A set of standardized rules or tests applied to patient groups on which to base a preliminary judgment that further evaluation is warranted, such as the need for a nutritional evaluation based on nutritional screening. security Protection from loss, destruction, tampering, or unauthorized access or use. sedation See anesthesia and sedation. sentinel event An unanticipated occurrence involving death or major permanent loss of function. side effect Pharmacological effect of a drug, normally adverse, other than the one(s) for which the drug is prescribed. specialty laboratory programs Programs that include laboratory disciplines such as chemistry (including toxicology, therapeutic drug testing, and drugs of abuse testing); clinical cytogenetics-immunogenetics; diagnostic immunology; embryology; hematology (including coagulation testing); histocompatibility; immunohematology; microbiology (including bacteriology, mycobacteriology, mycology, virolology, and parasitology); molecular biology; pathology (including surgical pathology, cytopathology, and necropsy); and radiobioassay. staff As appropriate to their roles and responsibilities, all people who provide care, treatment, and services in the hospital (e.g., medical staff and nursing staff), including those receiving pay (e.g., permanent, temporary, and part-time personnel, as well as contract employees), volunteers, and health profession students. clinical staff Those who provide direct patient care (physicians, nurses, etc.) nonclinical staff Those who provide indirect patient care (admissions, food service, etc.) standard A statement that defines the performance expectations, structures, or processes that must be in place for an organization to provide safe and high-quality care, treatment, and service. standards-based evaluation An assessment process that determines a health care organization’s or practitioner’s compliance with pre-established standards. Also see accreditation. survivor risk factors Chances for surviving family members or other loved ones experiencing difficulties with the death of a loved one. symptom, primary First or most prominent indication of an illness, disease, or other disorder. symptom, secondary An indication of illness, disease, or other disorder that appears after or because of a primary symptom. therapeutic duplication One person using two drugs, usually unnecessarily, from the same therapeutic category at the same time. time-out A pause, just prior to performing a surgical or other procedure, during which any unanswered questions or confusion about patient, procedure, or site are resolved by the entire surgical or procedural team. Even when there is only one person doing the procedure, a brief pause to confirm the correct patient, procedure, and site is appropriate. tracer methodology A process that JCI surveyors use during the on-site survey to analyze an organization’s systems by following individual patients through the organization’s health care process in the sequence experienced by the patients. Depending on the health care setting, this may require surveyors to visit multiple care units, departments or areas within an organization or a single care unit to “trace” the care rendered to a patient. patient tracer The process used by JCI to evaluate an individual patient’s total care experience within a health care organization. system tracer A session during the on-site survey devoted to evaluating high-priority safety and quality of care issues on a systemwide basis throughout the organization. Examples of such issues may include infection prevention and control, medication management, staffing effectiveness and the use of data. transfer The formal shifting of responsibility for the care of a patient from (1) one care unit to another, (2) one clinical service to another, (3) one qualified practitioner to another, or (4) one organization to another organization. utility system Organizationwide system and equipment that support the following: electrical distribution; emergency power; water; vertical and horizontal transport; heating, ventilating, and air conditioning; plumbing, boiler, and steam; piped gases; vacuum systems; or communication systems, including data-exchange systems. May also include systems for life support; surveillance, prevention, and control of infection; and environment support. utilization The use, patterns of use, or rates of use of a specified health care service. “Overuse” occurs when a health care service is provided under circumstances in which its potential for harm exceeds the possible benefits. “Underuse” is the failure to use a necessary health care service when it would have produced a favorable outcome for a patient. “Misuse” occurs when an appropriate service has been selected but a preventable complication occurs. All three reflect a problem in quality of health care. They can increase mortality risk and diminish quality of life. Also see utilization management. utilization management The planning, organization, direction, and control of resources. How this relates to patient care by a health care organization is significant. variation The differences in results obtained in measuring the same event more than once. The sources of variations can be grouped into two major classes: common causes and special causes. Too much variation often leads to waste and loss, such as the occurrence of undesirable patient health outcomes and increased cost of health services. Index A Abbreviations, standardized (MCI.13), 221–222 Abuse or neglect victims care of (COP.3.8), 101, 102 initial assessments (AOP.1.7), 78–79 Academic training programs (SQE.8.3), 203 Access to Care and Continuity of Care (ACC) standards, 39 admission to care admission or transfer criteria (ACC.1.4), 43–44 barriers to access and delivery of services (ACC.1.3), 43 delays-in-treatment policy (ACC.1), 41 emergency care assessment and treatment (ACC.1.1.1), 42 information available during admission process (ACC.1.2), 43 needs of patient match organization’s mission (ACC.1), 41 registration and admission process (ACC.1.1), 41–42 screening for admission to care (ACC.1), 41 screening for preventative, palliative, curative, and rehabilitative services (ACC.1.1.2), 42–43 changes to chapter, 22 continuity of care identification of individual responsible for care (ACC.2.1), 45 processes for continuity and coordination of care (ACC.2), 44–45 discharge, referral, and follow-up care discharge planning process (ACC.3.1), 46 discharge summary (ACC.3.2), 47 follow-up instructions (ACC.3.3), 47–48 policy and criteria for (ACC.3), 45–46 referrals for care and support services (ACC.3.1), 46 list of standards, 39–40 transfer of patients clinical summary from referring organization (ACC.4.2), 49 documentation of transfer (ACC.4.4), 50 monitoring patient during transfer (ACC.4.3), 49 patient information transfers with patient (ACC.4.2), 49 policy for (ACC.4), 48 referring organization’s responsibilities (ACC.4.1), 48–49 transportation laws, regulations, and licensing requirements for medical transport services (ACC.6), 50–51 management of transport services (ACC.6.1), 51 transportation needs of patients (ACC.5.), 50 Accreditation application for survey, 6–7 benefits of, 1 characteristics of programs, 2 country-specific nature of, 2 eligibility requirements, 5 goal of, 2 programs offered by JCI, 2 purpose of, 1, 2 renewal of, 9–10 reporting requirements between surveys, 20 voluntary nature of, 1 withdrawal from accreditation process, 11 Accreditation awards. See also Accreditation status additional certificates, 20 basis for, 6 display and use of, 20 duration of, 6, 9 effective date for, 9 ownership, structure, or service changes and, 6, 10 renewal of, 6, 9–10 withdrawal of accreditation, 10–11 Accreditation Committee (JCI), 10, 11, 12 Accreditation decisions. See also Accreditation status Accreditation Denied, 5–6, 10–11 Accredited, 5, 9 appeal process, 10–11 basis for, 2, 3, 9 focused surveys, 12 validation surveys, 13 Accreditation Denied appeal process, 10–11 basis for, 5–6 Accreditation service specialists, 7 Accreditation status accuracy of reporting of, 9, 20 focused surveys and, 12 ownership, structure, or service changes and, 6, 10, 20 publicly disclosed information, 9, 19 standards compliance and, 6, 10 validation surveys and, 13 Accreditation surveys agenda for, 7 cancellation of, 7, 8 compliance evaluation through, 5 cultural sensitivity of, 5 failure to permit, 12 focused surveys, 8, 9, 10, 11–12, 19 follow-up improvements, 10 length of, 2 organization-specific nature of, 2 postponement of, 7, 8 purpose of, 5 report on (see Official Accreditation Survey Findings Report) scheduling of, 7, 10, 12 scope of, 5 surveyors qualifications of, 7 survey team composition, 8 travel costs for, 8–9 validation surveys, 7, 12–13 Accredited, 5, 9 Accuracy of information. See Information accuracy and truthfulness Action plan, 17, 18–19 Administration of medications (MMU.6), 127 documentation of (MMU.6.1), 127–128 patient-provided medications (MMU.6.2), 128 sample medications (MMU.6.2), 128 self-administration of medications (MMU.6.2), 128 timely administration (MMU.6.1), 127–128 verification with order or prescription (MMU.6.1), 127–128 Admission to care admission or transfer criteria (ACC.1.4), 43–44 barriers to access and delivery of services (ACC.1.3), 43 delays-in-treatment policy (ACC.1), 41 emergency care assessment and treatment (ACC.1.1.1), 42 information available during admission process (ACC.1.2), 43 needs of patient match organization’s mission (ACC.1), 41 policies for (GLD.6.1), 180 registration and admission process (ACC.1.1), 41–42 screening for admission to care (ACC.1), 41 screening for preventative, palliative, curative, and rehabilitative services (ACC.1.1.2), 42–43 Adverse drug events data analysis for (QPS.6), 152 documentation of (MMU.7), 128–129 Agenda for surveys, 7, 8 Aggregate data and information. See Data, aggregated Alcohol-dependent patients, initial assessments (AOP.1.7), 78–79 Anesthesia and sedation. See also Anesthesia and Surgical Care (ASC) standards; Surgical procedures continuum of, 107 data analysis for adverse events (QPS.6), 152 data collection for monitoring (QPS.3.7), 148–149 informed consent for (PFR.6.4), 66 medical assessment before surgery or anesthesia (AOP.1.5.1), 77–78 Anesthesia and Surgical Care (ASC) standards, 107 anesthesia, continuum of, 107 anesthesia services anesthesia care planning (ASC.5), 111–112 anesthesia services director (ASC.2), 109–110 availability of anesthesia services (ASC.1), 109 discharge from postanesthesia recovery area (ASC.6), 113 documentation of anesthesia (ASC.5.2), 112 documentation of physiological status monitoring (ASC.5.3), 112–113 laws and regulations for (ASC.1), 109 outside anesthesia services (ASC.1), 109 patient education on risks, benefits, and alternatives (ASC.5.1), 112 physiological status monitoring during anesthesia administration (ASC.5.3), 112–113 postanesthesia monitoring (ASC.6), 113 preanesthesia assessment (ASC.4), 111 preinduction assessment (ASC.4), 111 sedation policies and procedures (ASC.3), 110–111 applicability of standards, 107 changes to chapter, 4, 25 list of standards, 107–108 surgical care documentation of physiological status monitoring (ASC.7.3), 115 documentation of postsurgical diagnosis (ASC.7.2), 114–115 documentation of preoperative diagnosis (ASC.7), 113–114 documentation of surgical planning (ASC.7), 113–114 documentation of surgical procedure (ASC.7.2), 114–115 patient education on risks, benefits, and alternatives (ASC.7.1), 114 physiological status monitoring during and after surgery (ASC.7.3), 115 postsurgical care planning (ASC.7.4), 115 surgical care planning (ASC.7), 113–114 Antibiotics and other medication use, data collection for monitoring (QPS.3.5), 147, 148–149 Appeal process, 10–11 Application for survey, 6–7 Assault protection (PFR.1.4), 58 Assessment of Patients (AOP) standards, 71 analysis and integration of assessment data (AOP.4), 81–82 care based on assesses needs (AOP.4, AOP.4.1), 81–82 changes to chapter, 23–24 content of assessment (AOP.1.1), 74, 75 functional assessments (AOP.1.6), 78 initial assessments abuse or neglect victims (AOP.1.7), 78–79 alcohol-dependent patients (AOP.1.7), 78–79 care based on initial assessment (AOP.1.3), 75–76 discharge planning needs (AOP.1.8.1), 79–80 documentation of (AOP.1.5), 75, 77 drug-dependent patients (AOP.1.7), 78–79 elderly patients (AOP.1.7), 78–79 emergency care assessment (AOP.1.3.1, AOP.1.4.1), 75–77 functional assessments (AOP.1.6), 78 nutritional assessments (AOP.1.6), 78 pain assessments (AOP.1.8.2), 80 patient population-specific assessments (AOP.1.7), 78–79 pediatric patients (AOP.1.7), 78–79 policies and procedures for (AOP.1.2), 74–75 pregnant women (AOP.1.7), 78–79 psychological assessment (AOP.1.2), 74–75 qualifications of staff for (AOP.3), 81 social and economic assessment (AOP.1.2), 74–75 specialized assessments, determination of need for (AOP.1.8), 75, 79 time frame for completion (AOP.1.4, AOP.1.4.1), 75, 76–77 time limits before updating assessment (AOP.1.4.1), 76–77 laboratory services availability of (AOP.5), 82–83 emergency laboratory services (AOP.5), 82–83 equipment testing, maintenance, and calibration (AOP.5.4), 84–85 experts for specialized diagnostic areas (AOP.5.11), 88 hazardous materials, handling of (AOP.5.1), 83 infectious materials, handling of (AOP.5.1), 83 laboratory director (AOP.5.8), 86–87 outside sources for (AOP.5), 82–83 proficiency testing program (AOP.5.9.1), 87 quality control program (AOP.5.9), 87 quality control results, review of (AOP.5.10), 87–88 reagents and other supplies (AOP.5.5), 85 reference ranges, establishment of (AOP.5.7), 86 safety program (AOP.5.1), 83 specimen collection, identification, and tracking (AOP.5.6), 85–86 staff, adequacy of (AOP.5.2), 83–84 staff, training and experience of (AOP.5.2), 83–84 supervisory staff (AOP.5.2), 83–84 time frame for results reporting (AOP.5.3), 84 list of standards, 71–73 medical assessment before surgery or anesthesia (AOP.1.5.1), 77–78 nutritional assessments (AOP.1.6), 78 process for (AOP.1), 74 qualifications of staff for (AOP.3), 81 radiology and diagnostic imaging services availability of (AOP.6), 88–89 emergency radiology and diagnostic imaging services (AOP.6), 88–89 equipment management program (AOP.6.5), 90–91 experts for specialized diagnostic areas (AOP.6.10), 93 outside sources for (AOP.6.1), 88–89 quality control program (AOP.6.8), 92 quality control results, review of (AOP.6.9), 92–93 radiology and diagnostic imaging director (AOP.6.7), 91–92 safety program (AOP.6.2), 89 staff, training and experience of (AOP.6.3), 89–90 supervisory staff (AOP.6.3), 89–90 time frame for results reporting (AOP.6.4), 90 x-ray film and other supplies (AOP.6.6), 91 reassessment pain assessments (AOP.1.8.2), 80 policies and procedures for (AOP.2), 80–81 qualifications of staff for (AOP.3), 81 scope of assessment (AOP.1.1), 74, 75 B Barriers to access and delivery of services (ACC.1.3), 43 Barriers to communication (MCI.3), 217 Belief- and value-sensitive care (PFR.1.1, COP.7.1), 56–57, 105–106 Billing practices (GLD.6.1), 180 Blood and blood products data collection for monitoring (QPS.3.8), 148–149 infection risks (PCI.7.2), 161–162 informed consent for (PFR.6.4), 66 policies and procedures (COP.3.3), 101, 102 transfusion reactions, data analysis of (QPS.6), 152 Budget and resource allocation for continued operation (FMS.4.2), 186–187 Budget approval (GLD.1.3), 170–171 Bylaws, policies and procedures (GLD.1), 170
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