International Patient Safety Goals Overview This chapter addresses the International Patient Safety Goals, as required for implementation as of 1 January 2008 in all organizations accredited by Joint Commission International (JCI) under the International Standards for Hospitals. The purpose of the International Patient Safety Goals is to promote specific improvements in patient safety. The goals highlight problematic areas in health care and describe evidence- and expert-based consensus solutions to these problems. Recognizing that sound system design is intrinsic to the delivery of safe, high-quality health care, the goals generally focus on system-wide solutions, wherever possible. The goals are structured in the same manner as the other standards, including a standard (goal statement), an intent statement, and measurable elements. The goals are scored similar to other standards as “met,” “partially met” or “not met.” The Accreditation Decision Rules consider compliance with the International Patient Safety Goals as a separate decision rule. Goals The following is a list of all goals. They are presented here for your convenience without their requirements, intent statements, or measurable elements. For more information about these goals, please see the next section in this chapter, Goals, Requirements, Intents, and Measurable Elements. Goal 1 Identify Patients Correctly Goal 2 Improve Effective Communication Goal 3 Improve the Safety of High-Alert Medications Goal 4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery Goal 5 Reduce the Risk of Health Care–Associated Infections Goal 6 Reduce the Risk of Patient Harm Resulting from Falls Goals, Requirements, Intents, and Measurable Elements Goal 1 Identify Patients Correctly Requirement of Goal 1 The organization develops an approach to improve accuracy of patient identifications. Intent of Goal 1 Wrong-patient errors occur in virtually all aspects of diagnosis and treatment. Patients may be sedated, disoriented, or not fully alert; may change beds, rooms, or locations within the hospital; may have sensory disabilities; or may be subject to other situations that may lead to errors in correct identification. The intent of this goal is twofold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Policies and/or procedures are collaboratively developed to improve identification processes, in particular, the processes used to identify a patient when giving medications, blood, or blood products; taking blood and other specimens for clinical testing; or providing any other treatments or procedures. The policies and/or procedures require at least two ways to identify a patient, such as the patient’s name, identification number, birth date, a bar-coded wristband, or other ways. The patient’s room number or location cannot be used for identification. The policies and/or procedures clarify the use of two different identifiers in different locations within the organization, such as in ambulatory care (also see Glossary) or other outpatient (also see Glossary) services, the emergency department, or operating theatre. Identification of the comatose patient with no identification is also included. A collaborative process is used to develop the policies and/or procedures to ensure they address all possible identification situations. Measurable Elements of Goal 1 1. A collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification. 2. The policies and/or procedures require the use of two patient identifiers, not including the use of the patient’s room number or location. 3. Patients are identified before administering medications, blood, or blood products. 4. Patients are identified before taking blood and other specimens for clinical testing. (Also see AOP.5.7, ME 2) 5. Patients are identified before providing treatments and procedures. Goal 2 Improve Effective Communication Requirement of Goal 2 The organization develops an approach to improve the effectiveness of communication among caregivers. Intent of Goal 2 Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors, and results in improved patient safety. Communication can be electronic, verbal, or written. The most error-prone communications are patient care orders given verbally and those given over the telephone, when permitted under local laws or regulations. Another error-prone communication is the report back of critical test results, such as the clinical laboratory telephoning the patient care unit to report the results of a STAT test. The organization collaboratively develops a policy and/or procedure for verbal and telephone orders that includes: the writing down (or entering into a computer) of the complete order or test result by the receiver of the information; the receiver reading back the order or test result; and the confirmation that what has been written down and read back is accurate. The policy and/or procedure identify permissible alternatives when the read-back process may not always be possible such as in the operating theatre and in emergency (also see Glossary) situations in the emergency department or intensive care unit. Measurable Elements of Goal 2 1. A collaborative process is used to develop policies and/or procedures that address the accuracy of verbal and telephone communications. (Also see AOP.5.4, AOP.6.4, MMU.4, ME 1, and MMU.4.3, ME 1) 2. The complete verbal and telephone order or test result is written down by the receiver of the order or test result. (Also see MCI.19.2, ME 2) 3. The complete verbal and telephone order or test result is read back by the receiver of the order or test result. 4. The order or test result is confirmed by the individual who gave the order or test result. Goal 3 Improve the Safety of High-Alert Medications Requirement of Goal 3 The organization develops an approach to improve the safety of high-alert medications. Intent of Goal 3 When medications are part of the patient treatment plan, appropriate management is critical to ensuring patient safety. A frequently cited medication safety issue is the unintentional administration of concentrated electrolytes (for example, potassium chloride [2mEq/ml or more concentrated], potassium phosphate, sodium chloride [0.9% or more concentrated], and magnesium sulfate [50% or more concentrated]). This error can occur when a staff member has not been properly oriented to the patient care unit, when contract nurses (also see “contracted services” in Glossary) are used and not properly oriented, or during emergencies. The most effective means to reduce or eliminate this occurrence is to remove the concentrated electrolytes from the patient care unit to the pharmacy. The organization collaboratively develops a policy and/or procedure that prevents the location of concentrated electrolytes in patient care areas where misadministration can occur. The policy and/or procedure identifies any areas where concentrated electrolytes are clinically necessary, such as the emergency department or operating theatre, and identifies how they are clearly labeled and how they are stored in those areas in a manner that restricts access to prevent inadvertent administration. Measurable Elements of Goal 3 1. A collaborative process is used to develop policies and/or procedures that address the location, labeling, and storage of concentrated electrolytes. 2. Concentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration in those areas where permitted by policy. (Also see intent statement of MMU.3) Goal 4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery Requirement of Goal 4 The organization develops an approach to ensuring correct-site, correct-procedure, and correct-patient surgery. Intent of Goal 4 Wrong-site, wrong-procedure, wrong-patient surgery is a disturbingly common occurrence in health care organizations. These errors are the result of ineffective or inadequate communication between members of the surgical team, lack of patient involvement in site marking, and lack of procedures for verifying the operative site. In addition, inadequate patient assessment, inadequate medical record review (also see Glossary), a culture that does not support open communication among surgical team members, problems related to illegible handwriting and the use of abbreviations are frequent contributing factors. Organizations need to collaboratively develop a policy and/or procedure that is effective in eliminating this disturbing problem. Evidence-based practices, such as those described in The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery ™ (also see http://www.jointcommission.org/PatientSafety/UniversalProtocol), are used. The essential processes found in the Universal Protocol are marking the surgical site; a preoperative verification process; and a time-out (also see Glossary) that is held immediately before the start of a procedure. Marking the surgical site involves the patient and is done with an unambiguous mark. The mark should be consistent throughout the organization, should be made by the person performing the procedure, should take place with the patient awake and aware, if possible, and must be visible after the patient is prepped and draped. The surgical site is marked in all cases involving laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine). The purpose of the preoperative verification process is to verify the correct site, procedure, and patient; ensure that all relevant documents, images, and studies are available, properly labeled, and displayed; and verify any required special equipment and/or implants are present. The time-out permits any unanswered questions or confusion to be resolved. The time-out is conducted in the location the procedure will be done, just before starting the procedure, and involves the entire operative team. The organization determines how the process is to be briefly documented, such as in a checklist. Measurable Elements of Goal 4 1. A collaborative process is used to develop policies and/or procedures that will establish uniform processes to ensure the correct site, correct procedure, and correct patient, including procedures done in settings other than the operating theatre. 2. The organization uses a clearly understood mark for surgical site identification and involves the patient in the marking process. 3. The organization uses a process to verify that all documents and equipment needed are on hand, correct, and functional. 4. The organization uses a checklist and time-out procedure just before starting a surgical procedure. Goal 5 Reduce the Risk of Health Care–Associated Infections Requirement of Goal 5 The organization develops an approach to reduce the risk of health care–associated infections. Intent of Goal 5 Infection prevention and control are challenging in most health care settings, and rising rates of health care–associated infections (also see Glossary) are a major concern for patients and health care professionals (also see Glossary). Infections common to all health care settings include catheter-associated urinary tract infections, blood stream infections and pneumonia (often associated with mechanical ventilation). Central to the elimination of these and other infections is proper hand hygiene. Internationally acceptable hand hygiene guidelines are available from the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (US CDC) and various other national and international organizations. The organization has a collaborative process to develop policies and/or procedures that adapt or adopt currently published and generally accepted hand hygiene guidelines and for the implementation of those guidelines with the organization. Measurable Elements of Goal 5 1. A collaborative process is used to develop policies and/or procedures that address reducing the risk of health care–associated infections. (Also see PCI.5) 2. The organization has adopted or adapted currently published and generally accepted hand hygiene guidelines. 3. The organization implements an effective hand hygiene program. Goal 6 Reduce the Risk of Patient Harm Resulting from Falls Requirement of Goal 6 The organization develops an approach to reduce the risk of patient harm resulting from falls. Intent of Goal 6 Falls account for a significant portion of injuries in hospitalized patients. In the context of the population it serves, the services it provides, and its facilities, the organization should evaluate its patients’ risk for falls and take action to reduce the risk of falling and to reduce the risk of injury should a fall occur. The evaluation could include fall history, medications and alcohol consumption review, gait and balance screening, and walking aids used by the patient. The organization establishes a fall-risk reduction program based on appropriate policies and/or procedures. The program is implemented. Measurable Elements of Goal 6 1. A collaborative process is used to develop policies and/or procedures that address reducing the risk of patient harm resulting from falls in the organization. 2. The organization implements a process for the initial assessment of patients for fall risk and reassessment of patients when indicated by a change in condition, medications, etc. 3. Measures are implemented to reduce fall risk for those assessed to be at risk.     Functional Section I: Patient-Centered Standards Access to Care and Continuity of Care (ACC) Overview A health care organization (also see Glossary) should consider the care it provides as part of an integrated system of services, health care professionals, and levels of care, which make up a continuum of care. The goal is to correctly match the patient’s health care needs with the services available, coordinate the services provided to the patient in the organization, and then plan for discharge (also see Glossary) and follow-up. The result is improved patient care outcomes (also see Glossary) and more efficient use of available resources. Information is essential for making correct decisions about which patient needs can be met by the health care organization; the efficient flow of services to the patient; and the appropriate transfer or discharge of the patient to his or her home or another care setting. 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. ACC.1 Patients are admitted to receive inpatient care or registered for outpatient services based on their identified health care needs and the organization’s mission and resources. ACC.1.1 The organization has a process for admitting inpatients and for registering outpatients. ACC.1.1.1 Patients with emergency or immediate needs are given priority for assessment and treatment. ACC.1.1.2 Patient needs for preventive, palliative, curative, and rehabilitative services are prioritized based on the patient’s condition at the time of admission as an inpatient to the organization. ACC.1.2 At admission as an inpatient, patients and families receive information on the proposed care, the expected outcomes of that care, and any expected cost to the patient for the care. ACC.1.3 The organization seeks to reduce physical, language, cultural, and other barriers to access and delivery of services. ACC.1.4 Admission or transfer to or from units providing intensive or specialized services is determined by established criteria. ACC.2 The organization designs and carries out processes to provide continuity of patient care services in the organization and coordination among health professionals. ACC.2.1 During all phases of care, there is a qualified individual identified as responsible for the patient’s care. ACC.3 There is a policy guiding the appropriate referral or discharge of patients. ACC.3.1 The organization cooperates with health care practitioners and outside agencies to ensure timely and appropriate referrals. ACC.3.2 Patient records contain a copy of the discharge summary. ACC.3.3 Patients and, as appropriate, their families are given understandable follow-up instructions at referral or discharge. ACC.4 There is a policy guiding the appropriate transfer of patients to another organization to meet their continuing care needs. ACC.4.1 The referring organization determines that the receiving organization can meet the patient’s continuing care needs. ACC.4.2 The receiving organization is given a written summary of the patient’s clinical condition and the interventions provided by the referring organization. ACC.4.3 During direct transfer, a qualified staff member monitors the patient’s condition. ACC.4.4 The transfer process is documented in the patient’s record. ACC.5 The process for referring, transferring, or discharging the patient considers transportation needs. ACC.6 Medical transport services meet relevant laws and regulations and licensing requirements. ACC.6.1 The medical transport services are provided through a well managed process that ensures patient and staff safety and quality transport services. Standards, Intents, and Measurable Elements Admission to the Organization Standard ACC.1 Patients are admitted to receive inpatient care or registered for outpatient services based on their identified health care needs and the organization’s mission and resources. Intent of ACC.1 Matching patient needs with the health care organization’s mission and resources depends on obtaining information on the patient’s needs and condition through screening, usually at the point of first contact. The screening may be through triage criteria, visual evaluation, a physical examination, or the results of previously conducted physical, psychological, clinical laboratory or diagnostic imaging evaluations. The screening can occur at a referring source, during emergency (also see Glossary) transport, or when the patient arrives at the organization. It is important that decisions to treat, transfer (also see Glossary) or refer are made only after the results of screening evaluations are available. Only those patients for whom the organization has the clinical capability to provide the needed services, consistent with its mission, are considered for inpatient (also see Glossary) admission or registered for outpatient services (also see Glossary). When the organization requires particular screening tests or evaluations prior to admission or registration, this is stated in a written policy. Patients are informed when obtaining the planned care may require placement on a waiting list or other delay in care or treatment. Patients are informed of the associated reasons for the delay or wait. This requirement applies to inpatient care and outpatient diagnostic services, not to minor waits in providing outpatient care or inpatient care such as when a physician is behind schedule. Measurable Elements of ACC.1 1. Screening is initiated at the point of first contact within or outside the organization. 2. Based on the results of screening, it is determined if the needs of the patient match the organization’s mission and resources. 3. Patients are accepted only if the organization can provide the necessary services and the appropriate outpatient or inpatient setting for care. 4. There is a process to provide the results of diagnostic tests to those responsible for determining if the patient is to be admitted, transferred, or referred. 5. Policies identify which screening and diagnostic tests are standard before admission. 6. Patients are not admitted, transferred, or referred before the test results required for these decisions are available. 7. Policies define how patients are informed when there will be a wait or delay in care and treatment and the reasons for the delay or wait, and how the information will be documented. Standard ACC.1. The organization has a process for admitting inpatients and for registering outpatients. Intent of ACC.1.1 The process for admitting inpatients to the organization for care, and for registering outpatients for services is standardized through written policies and procedures. Staff responsible for the process are familiar with and follow the standardized procedures. The policies and procedures address registration for outpatient services or admission for inpatient services; admission directly from the emergency service to an inpatient unit; and the process for holding patients for observation (also see Glossary). The policies also address how patients are managed when inpatient facilities are limited or no space is available to admit patients or admit patients to the appropriate unit. Measurable Elements of ACC.1.1 1.Policies and procedures are used to standardize the outpatient registration process. 2.Policies and procedures are used to standardize the inpatient admitting process. 3.Staff are familiar with the policies and procedures and follow them. 4.The policies and procedures address admitting emergency patients to inpatient units. 5.The policies and procedures address holding patients for observation. 6.The policies and procedures address managing patients when bed space is not available on the desired service or unit or elsewhere in the facility. Standard ACC.1.1.1 Patients with emergency or immediate needs are given priority for assessment and treatment. Intent of ACC.1.1.1   Patients with emergency or immediate needs are assessed and receive care as quickly as necessary. Such patients may be assessed by a physician or other qualified individual (also see Glossary) before other patients, receive diagnostic services as rapidly as possible, and begin treatment to meet their needs. The organization establishes physiologic-based (also see Glossary) criteria, where possible and appropriate, and trains staff to determine those patients with immediate needs and how their care is given priority. Measurable Elements of ACC.1.1.1 1.The organization has established criteria to prioritize patients with immediate needs. 2.The criteria are physiologic-based, where possible and appropriate. 3.Staff are trained to use the criteria. 4.Patients are prioritized based on the urgency of their needs. Standard ACC.1.1.2 Patient needs for preventive, palliative, curative, and rehabilitative services are prioritized based on the patient’s condition at the time of admission as an inpatient to the organization. Intent of ACC.1.1.2 When patients are considered for admission as an inpatient to the organization, the screening assessment helps staff understand and prioritize the preventive (also see Glossary), palliative (also see Glossary), curative, and rehabilitative services needed by the patient and select the most appropriate service or unit to meet the patient’s most urgent or priority needs. Measurable Elements of ACC.1.1.2 1. The screening assessment helps staff understand and prioritize the preventive, palliative, curative, and rehabilitative services needed by the patient. 2. The service or unit selected to meet these needs is appropriate. Standard ACC.1.2 At admission as an inpatient, patients and families receive information on the proposed care, the expected outcomes of that care, and any expected cost to the patient for the care. Intent of ACC.1.2 During the admission process, patients and their families receive sufficient information to make knowledgeable decisions. Information is provided about the proposed care, the expected outcomes, and any expected cost to the patient or family for the care when not paid for by a public or private source. When financial constraints related to the cost of care are present, the organization seeks ways to overcome those constraints. Such information can be in written form or provided verbally noting such in the patient’s record. Measurable Elements of ACC.1.2 1.There is a process to provide the patient/family with information at admission. (Also see MCI.2, ME 1) 2.The process includes information on the proposed care. 3.The process includes information on the expected outcomes of care. 4.The process includes information on any expected costs to the patient or family. 5.Patients receive sufficient information to make knowledgeable decisions. (Also see AOP.4.1, ME 3) Standard ACC.1.3 The organization seeks to reduce physical, language, cultural, and other barriers to access and delivery of services. Intent of ACC.1.3 Organizations frequently serve communities with a diverse population. Patients may be aged, have disabilities, speak multiple languages or dialects, be culturally diverse, or present other barriers that make the process of accessing and receiving care very difficult. The organization is familiar with those barriers and has implemented processes to eliminate or reduce these barriers during the admission process. The organization also seeks to reduce the impact of these barriers on the delivery of services. Measurable Elements of ACC.1.3 1. The leaders and staff of the organization understand the most common barriers in its patient population. 2. There is a process to overcome or limit barriers during the admission process. 3. There is a process to limit the impact of barriers on the delivery of services. 4. These processes are implemented. Standard ACC.1.4 Admission or transfer to or from units providing intensive or specialized services is determined by established criteria. Intent of ACC.1.4 Units or services that provide intensive care (for example, a post-surgical intensive care unit) or that provide specialized services (for example, the care of burn patients or organ transplant units) are costly and usually are limited in space and staffing. Also, when present, emergency departments with observation beds, and clinical research units, must ensure appropriate patient selection for the unit or beds. Each organization must establish criteria for determining those patients who require the level of care provided in such units. To ensure consistency, the criteria should be physiologic-based where possible and appropriate. Appropriate individuals from the emergency, intensive or specialized services participate in developing the criteria. The criteria are used to determine direct entry to the unit, for example, directly from the emergency service. The criteria are also used to determine transfer into the unit from within the organization or outside the organization. The criteria are also used to determine when a patient no longer requires the services of the unit and can be transferred to another level of care. When the organization conducts research or provides specialized patient care services or programs, admission or transfer into such programs is through established criteria or an established protocol (also see Glossary). Appropriate individuals from the research or other programs are involved in developing the criteria or protocol. Admission to such programs is documented in the patient’s record and includes the criteria or protocol conditions under which the patient was admitted or transferred. Measurable Elements of ACC.1.4 1. The organization has established entry and/or transfer criteria for its intensive and specialized services or units, including research and other programs to meet special patient needs. 2. The criteria are physiologic-based where possible and appropriate. 3. Appropriate individuals are involved in developing the criteria. 4. Staff are trained to apply the criteria. 5. Patients transferred or admitted to intensive and specialized units/services meet the criteria and this is documented in the patient’s record. 6. Patients who no longer meet criteria to remain in the unit are transferred or discharged. Continuity of Care Standard ACC.2 The organization designs and carries out processes to provide continuity of patient care services in the organization and coordination among health professionals. Intent of ACC.2 As patients move through a health care organization from admission to discharge or transfer, several departments and services and many different health care providers may be involved in providing care. Throughout all phases of care, patient needs are matched with appropriate resources in and, when necessary, outside the organization. This is usually accomplished by using established criteria or policies that determine the appropriateness of transfers within the organization. (Also see ACC.1.4 related to criteria for admission to or from intensive and specialized units) For patient care to appear seamless, the organization needs to design and implement processes for continuity and coordination of care among physicians, nurses, and other health care providers in emergency services and inpatient admission; diagnostic services and treatment services; surgical and non-surgical treatment services; among outpatient care programs; and • other organizations and other care settings. The leaders of the various settings and services work together to design and implement the processes. The processes may be supported with explicit transfer criteria or by policies, procedures, or guidelines. The organization identifies individuals responsible for coordinating services. These individuals may coordinate all patient care (for example, between departments) or may be responsible for coordinating the care of individual patients (for example, case manager). Measurable Elements of ACC.2 1. The leaders of services and settings design and implement processes that support continuity and coordination of care, including those identified in the intent statement. 2. Established criteria or policies determine the appropriateness of transfers within the organization. 3. Continuity and coordination are evident throughout all phases of patient care. 4. Continuity and coordination are evident to the patient. Standard ACC.2.1 During all phases of care, there is a qualified individual identified as responsible for the patient’s care. Intent of ACC.2.1 To maintain continuity of care (also see Glossary) throughout the patient’s stay in the organization, the individual with overall responsibility for the patient’s care or particular phase of the patient’s care is clearly identified. This individual may be a physician or other qualified individual. The responsible individual is identified in the patient’s record or in another manner made known to the organization’s staff. A single individual providing the oversight of care during the entire hospital stay will improve continuity, coordination, patient satisfaction, quality, and potentially the outcomes, and thus is desirable for certain complex patients and others the organization may identify. This individual would need to collaborate and communicate with the other care providers. When a patient moves from one phase of care to another (for example, from surgical to rehabilitation), the individual responsible for the patient’s care may change or the same individual may continue overseeing all of the patient’s care. Measurable Elements of ACC.2.1 1. The individual responsible for the patient’s care is identified. (Also see PFR.6.1, ME 6) 2. The individual is qualified to assume responsibility for the patient’s care. 3. The individual is identified to the organization’s staff. Discharge, Referral, and Follow-Up Standard ACC.3 There is a policy guiding the appropriate referral or discharge of patients. Intent of ACC.3 Referring or discharging a patient to a health care professional outside the organization, another care setting, home, or family is based on the patient’s health status and need for continuing care or services. The patient’s physician or individual responsible for his or her care determines readiness for discharge. Criteria may also be used to indicate when a patient is ready for discharge. Continuing needs may mean referral (also see Glossary) to a medical specialist, rehabilitation therapist, or even preventive health needs coordinated in the home by the family. An organized process is required to ensure that any continuing needs are met by appropriate health care professionals or outside organizations. The process includes referring patients to sources of care outside the region when required. When indicated, the organization begins to plan for the continuing needs as early in the care process as possible. The family is included in the discharge planning process as appropriate to the patient and his or her needs. When the organization permits patients to leave the hospital for a period of time, for example, on a weekend “pass,” there is a policy and procedure to guide this process. Measurable Elements of ACC.3 1. There is a policy guiding the appropriate referral and/or discharge of patients. 2. The referral and/or discharge is based on the patient’s needs for continuing care. (Also see AOP.1.8.1, ME 1, and GLD.6.1, ME 3) 3. The patient’s readiness for discharge is determined. 4. When indicated, planning for referral and/or discharge begins early in the care process and, when appropriate, includes the family. (Also see AOP.1.8.1, ME 2) 5. Patients are appropriately referred and/or discharged. 6. Organization policy guides the process of patients “on pass” for a defined period of time. Standard ACC.3.1 The organization cooperates with health care practitioners and outside agencies to ensure timely and appropriate referrals. Intent of ACC.3.1 Timely referral to the practitioner, organization, or agency that can best meet the patient’s continuing needs takes planning. The organization becomes familiar with the health care providers in its community to understand the types of patients treated and services provided, and to build formal or informal relationships with those providers. When patients come from a different community, the organization attempts to make a referral to a qualified individual or agency in the patient’s home community. Also, patients may need support services and medical services at discharge. For example, patients may need social, nutritional (also see Glossary), financial, psychological, or other support at discharge. The availability and actual use of these support services may, to a large degree, determine the need for continuing medical services. The discharge planning process considers the type of support service needed and the availability of such services. Measurable Elements of ACC.3.1 1. The discharge planning process considers the need for both support services and continuing medical services. 2. The organization identifies the health care providers, organizations, and individuals in its community that are most associated with the organization’s services and patient population. (Also see PFE.3, ME 2) 3. Referrals outside the organization are to specific individuals and agencies in the patient’s home community whenever possible. 4. Referrals are made, when possible, for support services. Standard ACC.3.2 Patient records contain a copy of the discharge summary. Intent of ACC.3.2 A summary of the patient’s care is prepared at discharge from the organization. Any qualified individual can compile the discharge summary (also see Glossary) such as the patient’s physician, a house medical officer or a clerk. The summary includes the following: a) Reason for admission b) Significant physical and other findings c) Significant diagnoses and co-morbidities d) Diagnostic and therapeutic procedures performed e) Significant medications and other treatments f) The patient’s condition at the time of discharge g) Discharge medications, all of the medications to be taken at home h) Follow-up instructions As these items are to be found in each patient discharge summary, they are scored together for each record as Measurable Element 2. The copy of the discharge summary is placed in the patient’s record (also see Glossary). A copy is given to the patient and, as appropriate, the patient’s family, when indicated by organization policy or common practice consistent with law and culture. A copy of the discharge summary is also provided to the practitioner who will be responsible for the continuing care of the patient or their follow-up. Measurable Elements of ACC.3.2 1. A discharge summary is prepared at discharge by a qualified individual. 2. All discharge summaries contain the items a) through h) identified in the intent. 3. The summary contains follow-up instructions. 4. A copy of the discharge summary is placed in the patient record. 5. Unless contrary to organization policy, laws, or culture, patients are given a copy of the discharge summary. 6. A copy of the discharge summary is provided to the practitioner responsible for the patient’s continuing or follow-up care. Standard ACC.3.3 Patients and, as appropriate, their families are given understandable follow-up instructions at referral or discharge. Intent of ACC.3.3 For patients not directly referred or transferred to another health care provider, clear instructions on where and how to receive continuing care are essential to ensure optimal outcomes of care and that all care needs are met. The instructions include the name and location of sites for continuing care, any return to the organization for follow-up, and when urgent care should be obtained. Families are included in the process when a patient’s condition or abilities prevent him or her from understanding the follow-up instructions. Families are also included when they play a role in the continuing care process. The organization provides the instructions to the patient and, as appropriate, their family in a simple, understandable manner. The instructions are provided in writing or in the form most understandable to the patient. Measurable Elements of ACC.3.3 1. Follow-up instructions are provided in an understandable form and manner. 2. The instructions include any return for follow-up care. 3. The instructions include when to obtain urgent care. 4. Families are also provided the instructions as appropriate to the patient’s condition. Transfer of Patients Standard ACC.4 There is a policy guiding the appropriate transfer of patients to another organization to meet their continuing care needs. Intent of ACC.4 Transferring a patient to an outside organization is based on the patient’s status and need for continuing health care services. Transfer may be in response to a patient’s need for specialized consultation and treatment, urgent services, or less intensive services such as sub-acute care or longer term rehabilitation. A referral process is required to ensure that outside organizations meet any continuing needs. Such a process addresses how responsibility is transferred between providers and settings; criteria for when transfer is appropriate; who is responsible for the patient during transfer; and what is to be done when transfer to another source of care is not possible. Measurable Elements of ACC.4 1. There is policy guiding the appropriate transfer of patients. 2. The transfers are based on the patient’s needs for continuing care. 3. The process addresses the transfer of responsibility to another provider or setting. 4. The process addresses criteria that define when transfer is appropriate. (Also see GLD.6.1, ME 3) 5. The process addresses who is responsible during transfer. 6. The process addresses the situation in which transfer is not possible. 7. Patients are appropriately transferred to other organizations. Standard ACC.4.1 The referring organization determines that the receiving organization can meet the patient’s continuing care needs. Intent of ACC.4.1 When referring a patient to another organization, the referring organization must determine if the receiving organization provides services to meet the patient’s needs and has the capacity to receive the patient. This determination is usually made well in advance, and the willingness to receive patients and transfer conditions are described in formal or informal affiliations or agreements. This advance determination ensures continuity of care and that the patient’s care needs will be met. Measurable Elements of ACC.4.1 1. The referring organization determines that the receiving organization can meet the needs of the patient to be transferred. 2. Formal or informal arrangements are in place with receiving organizations when patients are frequently transferred to the receiving organization. Standard ACC.4.2 The receiving organization is given a written summary of the patient’s clinical condition and the interventions provided by the referring organization. Intent of ACC.4.2 To ensure continuity of care, patient information is transferred with the patient. A copy of the discharge summary or other written clinical summary is provided to the receiving organization with the patient. The summary includes the patient’s clinical condition or status, the procedures and other interventions provided, and the continuing patient needs. Measurable Elements of ACC.4.2 1. Patient clinical information or a clinical summary is transferred with the patient. 2. The clinical summary includes patient status. 3. The clinical summary includes procedures and other interventions provided. 4. The clinical summary includes the patient’s continuing care needs. Standard ACC.4.3 During direct transfer, a qualified staff member monitors the patient’s condition. Intent of ACC.4.3 Transferring a patient directly to another health care organization may be a brief process with an alert and talking patient, or it may involve moving a comatose patient who needs continuous nursing or medical oversight. In either case, the patient requires monitoring (also see Glossary), but the qualifications of the individual doing the monitoring are significantly different. Thus, the condition and status of the patient determine the appropriate qualifications of the staff member monitoring the patient during transfer. Measurable Elements of ACC.4.3 1. All patients are monitored during direct transfer. 2. The qualifications of the staff member are appropriate for the patient’s condition. Standard ACC.4.4 The transfer process is documented in the patient’s record. Intent of ACC.4.4 The record of each patient transferred to another health care organization contains documentation of the transfer. The documentation includes the name of the organization and the name of the individual agreeing to receive the patient, the reason(s) for the transfer, and any special conditions for transfer (such as when space at the receiving organization is available, or the patient’s status). Also, it is noted if the patient’s condition or status changed during transfer (for example, the patient dies or requires resuscitation). Any other documentation required by organization policy (for example, a signature of the receiving nurse or physician, the name of the individual who monitored the patient during transport) is included in the record. Measurable Elements of ACC.4.4 1. The records of transferred patients note the name of the health care organization and name of the individual agreeing to receive the patient. 2. The records of transferred patients contain other notes as required by the policy of the transferring organization. 3. The records of transferred patients note the reason(s) for transfer. 4. The records of transferred patients note any special conditions related to transfer. 5. The records of transferred patients note any change of patient condition or status during transfer. Transportation Standard ACC.5 The process for referring, transferring, or discharging the patient considers transportation needs. Note: Standard ACC.5 applies to all organizations. Intent of ACC.5 The organization’s process for referring, transferring, or discharging the patient considers transportation needs. The organization’s need to provide or arrange for transportation, or to contact the patient’s family or friends for transportation, depends on the patient’s condition and status. Measurable Elements of ACC.5 1. The process for referring patients considers transportation needs. 2. The process for transferring patients considers transportation needs. 3. The process for discharging patients considers transportation needs. 4. Transportation is appropriate to the patient’s needs. Standard ACC.6 Medical transport services meet relevant laws and regulations and licensing requirements. Note: Standards ACC.6 and ACC.6.1 apply only to organizations that own and operate a medical transport service. Intent of ACC.6 Organizations that own or operate transport services, both urgent and non-urgent, meet relevant laws, regulations, and licensure (also see Glossary) requirements. These laws and regulations may relate to the level of staffing for different types of urgent transport, for example, the requirement for a physician to be present during the transport of certain types of medical patients. The laws may relate to maintenance of vehicles, qualifications of drivers and emergency medical technicians, etc. When there is a licensing process for medical transport services, the organization’s operation is licensed. Measurable Elements of ACC.6 1. The medical transport service meets relevant laws and regulations. 2. The medical transport service is licensed when required. Standard ACC.6.1 The medical transport services are provided through a well-managed process that ensures patient and staff safety and quality transport services. Intent of ACC.6.1 The organization ensures that medical transport services are integrated into the quality and safety program and appropriately integrated into the management structure of the organization. This is evidenced by the following: A qualified individual directs the operation of the transport services. There is medical oversight of any patient assessment and medical services provided during transport. The quality and safety of transport services are monitored and included in the organization’s quality and safety monitoring and improvement process. Qualified individuals triage patients and ensure the dispatch of appropriate transport that meets patient needs. There is a regular inspection and preventive maintenance program for all transport vehicles. The transport program is included in the scope of the organization’s infection prevention and control program, including as relevant, exposure of staff and patients to biologic and chemical agents. The patient’s rights are respected during transport. Measurable Elements of ACC.6.1 1. A qualified individual directs the operation of the transport services; 2. There is medical oversight of any patient assessment and medical services provided during transport; 3. The quality and safety of transport services are monitored and included in the organization’s quality and safety monitoring and improvement process; 4. Qualified individuals triage patients and ensure the dispatch of appropriate transport that meets patient needs; 5. There is a regular inspection and preventive maintenance program for all transport vehicles; 6. The transport program is included in the scope of the organization’s infection control program, including, as relevant, exposure of staff and patients to biologic and chemical agents; and 7. The patient’s rights are respected during transport. Patient and Family Rights (PFR) Overview Each patient is unique, with his or her own needs, strengths, values and beliefs. Health care organizations work to establish trust and open communication with patients and to understand and protect each patient’s cultural, psychosocial, and spiritual values. Patient care outcomes (also see Glossary) are improved when patients and, as appropriate, their families or those who make decisions on their behalf, are involved in care decisions and processes in a way that matches cultural expectations. To promote patient rights in a health care organization, one starts by defining those rights, then educating patients and staff about those rights. Patients are informed of their rights and how to act on them. Staff are taught to understand and respect patients’ beliefs and values and to provide considerate and respectful care that protects patients’ dignity. This chapter addresses processes to identify, protect and promote patient rights; inform patients of their rights; include the patient’s family, when appropriate, in decisions about the patient’s care; • obtain informed consent; educate staff about patient rights; and establish the organization’s ethical framework. How these processes are carried out in an organization depends on its country’s laws and regulations and any international conventions, treaties, or agreements on human rights endorsed by its country. These processes are related to how an organization provides health care in an equitable manner, given the structure of the health care delivery system and the health care financing mechanisms of the country. This chapter also addresses the rights of patients and families related to research and to the donation and transplantation of organs and tissues. 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. PFR.1 The organization is responsible for providing processes that support patients’ and families’ rights during care. PFR.1.1 Care is considerate and respectful of the patient’s personal values and beliefs. PFR.1.1.1 The organization has a process to respond to patient and family requests for pastoral services or similar requests related to the patient’s spiritual and religious beliefs. PFR.1.2 Care is respectful of the patient’s need for privacy. PFR.1.3 The organization takes measures to protect patients’ possessions from theft or loss. PFR.1.4 Patients are protected from physical assault. PFR.1.5 Children, disabled individuals, the elderly and other populations at risk receive appropriate protection. PFR.1.6 Patient information is confidential. PFR.2 The organization supports patients’ and families’ rights to participate in the care process. PFR.2.1 The organization informs patients and families about the process of how they will be told of medical conditions and any confirmed diagnosis, how they will be told of planned care and treatment, and how they can participate in care decisions, to the extent they wish to participate. PFR.2.1.1 The organization informs patients and families about how they will be told about the outcomes of care and treatment, including unanticipated outcomes, and who will tell them. PFR.2.2 The organization informs patients and families about their rights and responsibilities related to refusing or discontinuing treatment. PFR.2.3 The organization respects patient wishes and preferences to withhold resuscitative services and forgo or withdraw life-sustaining treatments. PFR.2.4 The organization supports the patient’s right to appropriate assessment and management of pain. PFR.2.5 The organization supports the patient’s right to respectful and compassionate care at the end of life. PFR.3 The organization informs patients and families about its process to receive and act on complaints, conflicts, and differences of opinion about patient care and the patient’s right to participate in these processes. PFR.4 Staff members are educated about their role in identifying patients’ values and beliefs and protecting patients’ rights. PFR.5 All patients are informed about their rights in a manner they can understand. PFR.6 Patient informed consent is obtained through a process defined by the organization and carried out by trained staff. PFR.6.1 Patients and families receive adequate information about the illness, proposed treatment(s), and care providers so that they can make care decisions. PFR.6.2 The organization establishes a process, within the context of existing law and culture, for when others can grant consent. PFR.6.3 General consent for treatment, if obtained when a patient is admitted as an inpatient or is registered for the first time as an outpatient, is clear in its scope and limits. PFR.6.4 Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures. PFR.6.4.1 The organization lists those categories or types of treatments and procedures that require specific informed consent. PFR.7 The organization informs patients and families about how to gain access to clinical research, investigation, or clinical trials involving human subjects. PFR.7.1 The organization informs patients and families about how patients who choose to participate in clinical research, investigation, or clinical trials are protected. PFR.8 Informed consent is obtained before a patient participates in clinical research, investigation, and trials. PFR.9 The organization has a committee or another way to oversee all research in the organization involving human subjects. PFR.10 The organization informs patients and families about how to choose to donate organs and other tissues. PFR.11 The organization provides oversight of the harvesting and transplantation of organs and tissues. Joint Commission International Accreditation Standards for Hospitals, Third Edition Standards, Intents, and Measurable Elements Standard PFR.1 The organization is responsible for providing processes that support patients’ and families’ rights during care. Intent of PFR.1 An organization’s leaders are primarily responsible for how an organization will treat its patients. Thus, the leaders need to know and understand patient and family rights and their organization’s responsibilities as identified in laws and regulations. The leaders then provide direction to ensure that staff throughout the organization assume responsibility for protecting these rights. To effectively protect and advance patient rights, the leaders work collaboratively and seek to understand their responsibilities in relation to the community served by the organization. The organization respects the right of patients, and in some circumstances the right of the patient’s family, to have the prerogative to determine what information regarding their care would be provided to family or others, and under what circumstances. For example, the patient may not wish to have a diagnosis shared with family. Patient and family rights are a fundamental element of all contacts among an organization, its staff, and patients and families. Thus, policies and procedures are developed and implemented to ensure that all staff members are aware of and respond to patient and family rights issues when they interact with and care for patients throughout the organization. The organization uses a collaborative and inclusive process to develop the policies and procedures, and, when appropriate, include patients and families in the process. (Also see ACC.6.1, ME 7) Measurable Elements of PFR.1 1. The organization’s leaders work collaboratively to protect and advance patient and family rights. 2. The leaders understand patient and family rights as identified in laws and regulations and in relation to the community served. 3. The organization respects the right of patients, and in some circumstances the right of the patient’s family, to have the prerogative to determine what information regarding their care would be provided to family or others, and under what circumstances. 4. Staff members are knowledgeable about the policies and procedures related to patient rights and can explain their responsibilities in protecting patient rights. 5. Policies and procedures guide and support patient and family rights in the organization. Standards PFR.1.1 Care is considerate and respectful of the patient’s personal values and beliefs. PFR.1.1.1 The organization has a process to respond to patient and family requests for pastoral services or similar requests related to the patient’s spiritual and religious beliefs. Intent of PFR.1.1 and PFR.1.1.1 Each patient brings his or her own set of values and beliefs to the care process. Some values and beliefs are commonly held by all patients and are frequently cultural and religious in origin. Other values and beliefs are those of the patient alone. All patients are encouraged to express their beliefs in ways that respect the beliefs of others. Strongly held values and beliefs can shape the care process and how patients respond to care. Thus, each care provider seeks to understand the care and services they provide within the context of the patient’s values and beliefs. When a patient or family wishes to speak with someone related to religious or spiritual needs, the organization has a process to respond to the request. The process may be carried out through on-site religious staff, local sources or family referred sources. The process to respond is more complex, for example, when the organization or country does not officially “recognize” and/or have sources related to a religion or belief for which there may be a request. Measurable Elements of PFR.1.1 1. There is a process to identify and respect patient values and beliefs, and when applicable, those of the patient’s family. (Also see PFE.2.1, ME 1 and COP.7, ME 1) 2. Staff use the process and provide care that is respectful of the patient’s values and beliefs. Measurable Elements of PFR.1.1.1 1. The organization has a process designed to respond to routine as well as complex requests related to religious or spiritual support. 2. The organization responds to requests for religious or spiritual support. Standard PFR.1.2 Care is respectful of the patient’s need for privacy. Intent of PFR.1.2 Patient privacy, especially during clinical interviews, examinations, procedures/treatments, and transport, is important. Patients may desire privacy from other staff, other patients, and even from family members. Also, patients may not wish to be photographed, recorded, or participate in accreditation survey (also see Glossary) interviews. Although there are some common approaches to providing privacy for all patients, individual patients may have different or additional privacy expectations and needs according to the situation and these expectations and needs may change over time. Thus, as staff members provide care and services to patients, they inquire about the patient’s privacy needs and expectations related to the care or service. This communication between a staff member and his or her patient builds trust and open communication and does not need to be documented. Measurable Elements of PFR.1.2 1. Staff members identify patient expectations and needs for privacy during care and treatment. (Also see PFR.2.5) 2. A patient’s expressed need for privacy is respected for all clinical interviews, examinations, procedures/treatments, and transport. Standard PFR.1.3 The organization takes measures to protect patients’ possessions from theft or loss. Intent of PFR.1.3 The organization communicates its responsibility, if any, for the patient’s possessions to patients and families. When the organization takes responsibility for any or all of the patient’s personal possessions brought into the organization, there is a process to account for the possessions and ensure they will not be lost or stolen. This process considers the possessions of emergency patients, same-day surgery patients, inpatients (also see Glossary), and those patients unable to make alternative safekeeping arrangements and those incapable of making decisions regarding their possessions. Measurable Elements of PFR.1.3 1. The organization has determined its level of responsibility for patients’ possessions. 2. Patients receive information about the organization’s responsibility for protecting personal belongings. 3. Patients’ possessions are safeguarded when the organization assumes responsibility or when the patient is unable to assume responsibility. Standard PFR.1.4 Patients are protected from physical assault. Intent of PFR.1.4 The organization is responsible for protecting patients from physical assault by visitors, other patients, and staff. This responsibility is particularly relevant to infants and children, the elderly, and others unable to protect themselves or signal for help. The organization seeks to prevent assault through processes such as investigating individuals in the facility without identification, monitoring (also see Glossary) remote or isolated areas of the facility, and quickly responding to those thought to be in danger of assault. Measurable Elements of PFR.1.4 1. The organization has a process to protect patients from assault. 2. Infants, children, the elderly, and others less able or unable to protect themselves are addressed in the process. 3. Individuals without identification are investigated. 4. Remote or isolated areas of the facility are monitored. Standard PFR.1.5 Children, disabled individuals, the elderly, and other populations at risk receive appropriate protection. Intent of PFR.1.5 Each organization identifies its vulnerable and at-risk patient groups and establishes processes to protect the rights of individuals in these groups. Vulnerable patient groups and the organization’s responsibility may be identified in laws or regulations. Staff members understand their responsibilities in these processes. At least children, disabled individuals, the elderly and other identified populations at risk are protected. Comatose patients and individuals with mental or emotional disabilities, when present in the organization, are also included. Such protection extends beyond physical assault to other areas of safety such as protection from abuse, negligent care, withholding of services, or assistance in the event of a fire. Measurable Elements of PFR.1.5 1. The organization identifies its vulnerable patient groups. (Also see COP.3.1 through COP.3.9) 2. Children, disabled individuals, the elderly, and others identified by the organization are protected. (Also see COP.3.8) 3. Staff members understand their responsibilities in the protection processes. Standard PFR.1.6 Patient information is confidential. Intent of PFR.1.6 Medical and other health information, when documented and collected, is important for understanding the patient and his or her needs and for providing care and services over time. This information may be in paper or electronic form or a combination of the two. The organization respects such information as confidential and has implemented policies and procedures that protect such information from loss or misuse. The policies and procedures reflect information that is released as required by laws and regulations. Staff respects patient confidentiality (also see Glossary) by not posting confidential information on the  patient’s door or at the nursing station and by not holding patient-related discussions in public places. Staff are aware of laws and regulations governing the confidentiality of information and inform the patient about how the organization respects the confidentiality of information. Patients are also informed about when and under what circumstances information may be released and how their permission will be obtained. 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 MCI.10, ME 4 and MCI.16) Measurable Elements of PFR.1.6 1. Patients are informed about how their information will be kept confidential and about laws and regulations that require the release of and/or require confidentiality of patient information. 2. Patients are requested to grant permission for the release of information not covered by law and regulation. 3. The organization respects patient health information as confidential. Standard PFR.2 The organization supports patients’ and families’ rights to participate in the care process. Intent of PFR.2 Patients and families participate in the care process by making decisions about care, asking questions about care, and even refusing diagnostic procedures and treatment. The organization supports and promotes patient and family involvement in all aspects of care by developing and implementing related policies and procedures. Management, clinical staff, and others participate in developing such policies and procedures. All staff members are trained on the policies and procedures and on their role in supporting patients’ and families’ rights to participate in the care process. Measurable Elements of PFR.2 1. Policies and procedures are developed to support and promote patient and family participation in care processes. (Also see COP.7.2, ME 5; PFE.2, ME 5; PFE.5, ME 2; ACC.2, ME 4; and ACC.3, ME 3) 2. Developing policies and procedures is a collaborative effort and includes management and clinical staff. 3. Staff members are trained on the policies and procedures and their role in supporting patient and family participation in care processes. Standard PFR.2.1 The organization informs patients and families about the process of how they will be told of medical conditions and any confirmed diagnosis, how they will be told of planned care and treatment, and how they can participate in care decisions, to the extent they wish to participate. Intent of PFR.2.1 For patients and families to participate in care decisions, they need basic information about the medical conditions found during assessment, including any confirmed diagnosis when appropriate, and on the proposed care and treatment. Patients and families understand when they will be told this information and who is responsible for telling them. Patients and families understand the type of decisions that must be made about care and how to participate in those decisions. In addition, patients and families need to understand the organization’s process to obtain consent and which care processes, tests, procedures, and treatments require their consent. Although some patients may not wish to personally know a confirmed diagnosis or participate in the decisions regarding their care, they are given the opportunity and can choose to participate through a family member, friend, or a surrogate decision maker. Measurable Elements of PFR.2.1 1. Patients and families understand how and when they will be told of medical conditions and any confirmed diagnosis when appropriate. (Also see AOP.4.1, ME 2 and PFE.2, ME 6) 2. Patients and families understand how and when they will be told of planned care and treatment(s). (Also see AOP.4.1, ME 3 and ACC.2, ME 4) 3. Patients and families understand when consent will be requested and the process used to give consent. (Also see PFE.2, ME 4) 4. Patients and families understand their right to participate in care decisions to the extent they wish. (Also see PFR.2, ME 1; AOP.4.1, ME 3; COP.7.2, ME 5; ACC.3, ME 4; and PFE.2, ME 7) Standard PFR.2.1.1 The organization informs patients and families about how they will be told about the outcomes of care and treatment, including unanticipated outcomes, and who will tell them. Intent of PFR.2.1.1 During the care process, patients, and when appropriate, their families, have a right to be told of the outcomes of the planned care and treatment. It is also important that they be told of any unanticipated outcome of the care and treatment, such as unanticipated events during surgery or with prescribed medications or other treatments. It should be clear to the patient how they will be told and who will tell them of the expected and any unanticipated outcomes. Measurable Elements of PFR.2.1.1 1. Patients and families understand how they will be told and who will tell them of the outcomes of care and treatment. (Also see COP.2.4, ME 1) 2. Patients and families understand how they will be told and who will tell them of any unanticipated outcomes of care and treatment. (Also see COP.2.4, ME 2) Standard PFR.2.2 The organization informs patients and families about their rights and responsibilities related to refusing or discontinuing treatment. Intent of PFR.2.2 Patients, or those making decisions on their behalf, may decide not to proceed with the planned care or treatment or continue care or treatment after it has been initiated. The organization informs patients and families about their right to make these decisions, the potential outcomes of these decisions, and their responsibilities related to such decisions. Patients and families are informed about any care and treatment alternatives. Measurable Elements of PFR.2.2 1. The organization informs patients and families about their rights to refuse or discontinue treatment. 2. The organization informs patients about the consequences of their decisions. 3. The organization informs patients and families about their responsibilities related to such decisions. 4. The organization informs patients about available care and treatment alternatives. Standard PFR.2.3 The organization respects patient wishes and preferences to withhold resuscitative services and forgo or withdraw life-sustaining treatments. Intent of PFR.2.3 Decisions about withholding resuscitative services or forgoing or withdrawing life-sustaining treatment are among the most difficult choices facing patients, families, health care professionals, and organizations. No single process can anticipate all of the situations in which such decisions must be made. For this reason, it is important for the organization to develop a framework for making these difficult decisions. The framework helps the organization identify its position on these issues; ensures that the organization’s position conforms to its community’s religious and cultural norms and to any legal or regulatory requirements, in particular when legal requirements for resuscitation are not consistent with the patient’s wishes; addresses situations in which these decisions are modified during care; and guides health professionals through the ethical and legal issues in carrying out such patient wishes. To ensure that the decision-making process related to carrying out the patient’s wishes is applied consistently, the organization develops policies and procedures through a process that includes many professionals and viewpoints. The policies and procedures identify lines of accountability and responsibility and how the process is documented in the patient’s record (also see Glossary). Measurable Elements of PFR.2.3 1. The organization has identified its position on withholding resuscitative services and forgoing or withdrawing life-sustaining treatments. 2. The organization’s position conforms to its community’s religious and cultural norms and any legal or regulatory requirements. 3. Policies and procedures are implemented to guide the process for patients to make their decisions known to the organization and for modifying decisions during the course of care. Joint Commission International Accreditation Standards for Hospitals, Third Edition 4. Policies and procedures are implemented to guide the organization’s response to patient decisions. 5. The policies and procedures were developed through a collaborative and inclusive process. 6. Documentation about decisions follows organization policy. 7. The organization guides health professionals on the ethical and legal issues in carrying out such patient wishes. Standard PFR.2.4 The organization supports the patient’s right to appropriate assessment and management of pain. Intent of PFR.2.4 Pain is a common part of the patient experience and unrelieved pain has adverse physical and psychological effects. A patient’s response to pain is frequently within the context of societal norms and traditions. Thus, patients are encouraged and supported in their reporting of pain. The organization’s care processes recognize and reflect the right of all patients to appropriate assessment and management of pain. (Also see COP.6) Measurable Elements of PFR.2.4 1. The organization respects and supports the patient’s right to appropriate assessment and management of pain. (Also see COP.7.2, ME 1) 2. The organization’s staff understand the personal, cultural, and societal influences on the patient’s right to report pain, and accurately assess and manage pain. Standard PFR.2.5 The organization supports the patient’s right to respectful and compassionate care at the end of life. Intent of PFR.2.5 Dying patients have unique needs for respectful, compassionate care. Concern for the patient’s comfort and dignity guides all aspects of care during the final stages of life. To accomplish this, all staff members are made aware of patients’ unique needs at the end of life. These needs include treatment of primary and secondary symptoms (also see Glossary); pain management (also see COP.6); response to the patient’s and family’s psychological, social, emotional, religious and cultural concerns (also see PFR.1.1 and PFR.1.1.1); and involvement in care decisions (also see COP.7). Measurable Elements of PFR.2.5 1. The organization recognizes that dying patients have unique needs. 2. The organization’s staff respects the right of dying patients to have those unique needs addressed in the care process. Standard PFR.3 The organization informs patients and families about its process to receive and act on complaints, conflicts, and differences of opinion about patient care and the patient’s right to participate in these processes. Intent of PFR.3 Patients have a right to voice complaints about their care and to have those complaints reviewed and, when possible, resolved. Also, decisions regarding care sometimes present questions, conflicts, or other dilemmas for the organization and the patient, family, or other decision makers. These dilemmas may arise from issues of access, treatment, or discharge (also see Glossary). They can be especially difficult to resolve when the issues involve, for example, withholding resuscitative services or forgoing or withdrawing life-sustaining treatment. The organization has established processes for seeking resolution of such dilemmas and complaints. The organization identifies in policies and procedures those who need to be involved in the processes and how the patient and family participate. Measurable Elements of PFR.3 1. Patients are aware of their right to voice a complaint and the process to do so. 2. Complaints are reviewed according to the organization’s mechanism. 3. Dilemmas that arise during the care process are reviewed according to the organization’s mechanism. 4. Policies and procedures identify participants in the process. 5. Policies and procedures identify how the patient and family participate. Standard PFR.4 Staff members are educated about their role in identifying patients’ values and beliefs and protecting patients’ rights. Intent of PFR.4 The organization educates all staff about patient and family rights. The education recognizes that staff members may hold values and beliefs that differ from those of the patients in their care. The education includes how each staff member participates in identifying patient values and beliefs and how they respect those values and beliefs in the care process. Measurable Elements of PFR.4 1. Staff members understand their role in identifying patient and family values and beliefs and how such values and beliefs can be respected in the care process. 2. Staff members understand their role in protecting patient and family rights. Standard PFR.5 All patients are informed about their rights in a manner they can understand. Intent of PFR.5 Admission as an inpatient or registration as an outpatient (also see Glossary) to a health care organization (also see Glossary) can be frightening and confusing for patients, making it difficult for them to understand and act on their rights. Thus, the organization prepares a written statement of patient and family rights that is given to patients when they are admitted as an inpatient or registered as an outpatient to the organization and is available each visit or throughout their stay. For example, the statement may be posted in the facility. The statement is appropriate to the patient’s age, understanding, and language. When written communication is not effective or appropriate, the patient and family are informed of their rights in a manner they can understand. (Also see MCI.3, MEs 1 and 2) Measurable Elements of PFR.5 ❒ 1. Each patient receives information about his or her rights in writing. Joint Commission International Accreditation Standards for Hospitals, Third Edition ❒ 2. The organization has a process to inform patients of their rights when written communication is not effective or appropriate. Informed Consent Standard PFR.6 Patient informed consent is obtained through a process defined by the organization and carried out by trained staff. Intent of PFR.6 One of the main ways that patients are involved in their care decisions is by granting informed consent. To consent, a patient must be informed of those factors related to the planned care required for an informed decision. Informed consent (also see Glossary) may be obtained at several points in the care process. For example, informed consent can be obtained when the patient is admitted for inpatient care in the organization and before certain procedures or treatments for which the risk is high. The consent process is clearly defined by the organization in policies and procedures. Relevant laws and regulations are incorporated into the policies and procedures. Patients and families are informed as to what tests, procedures, and treatments require consent and how they can give consent (for example; given verbally, by signing a consent form, or through some other means). Patients and families understand who may, in addition to the patient, give consent. Designated staff members are trained to inform patients and obtain and document patient consent. Measurable Elements of PFR.6 1. The organization has a clearly defined informed consent process described in policies and procedures. 2. Designated staff are trained to implement the policies and procedures. 3. Patients give informed consent consistent with the policies and procedures. Standard PFR.6.1 Patients and families receive adequate information about the illness, proposed treatment(s), and care providers so that they can make care decisions. Intent of PFR.6.1 Staff members clearly explain any proposed treatment(s) or procedures to the patient and, when appropriate, the family. The information provided includes the patient’s condition; the proposed treatment(s); potential benefits and drawbacks; possible alternatives; the likelihood of success; possible problems related to recovery; and possible results of non-treatment. Staff members also inform the patient of the name of the physician or other practitioner who has primary responsibility for the patient’s care or who is authorized to perform procedures or treatment(s). Measurable Elements of PFR.6.1 1. Patients are informed of their condition. 2. Patients are informed about the proposed procedures and treatment(s) and who is authorized to perform the procedure or treatment. 3. Patients are informed about potential benefits and drawbacks to the proposed treatment(s) and possible problems related to recovery. 4. Patients are informed about possible alternatives to the proposed treatment(s) and possible results of non-treatment. 5. Patients are informed about the likelihood of successful treatment(s). 6. Patients know the identity of the physician or other practitioner responsible for their care. (Also see ACC.2.1, ME 1) Standard PFR.6.2 The organization establishes a process, within the context of existing law and culture, for when others can grant consent. Intent of PFR.6.2 Informed consent for care sometimes requires that people other than (or in addition to) the patient be involved in decisions about the patient’s care. This is especially true when the patient does not have the mental or physical capacity to make care decisions, when culture or custom requires that others make care decisions, or when the patient is a child. When the patient cannot make decisions about his or her care, a surrogate decision maker is identified. When someone other than the patient gives consent, that individual is noted in the patient’s record. Measurable Elements of PFR.6.2 1. The organization has a process for when others can grant informed consent. 2. The process respects law, culture, and custom. 3. Individuals, other than the patient, granting consent are noted in the patient’s record Standard PFR6.3 General consent for treatment, if obtained when a patient is admitted as an inpatient or is registered for the first time as an outpatient, is clear in its scope and limits. Intent of PFR.6.3 Many organizations obtain a general consent (rather than rely on implied consent) for treatment when the patient is admitted as an inpatient to the organization or when the patient is registered for the first time as an outpatient. When a general consent is obtained, patients are given information on the scope of the general consent, such as which tests and treatments are included under the general consent. Patients are also given information about those tests and treatments for which a separate informed consent will be obtained. The general consent notes if it is likely that students and other trainees will participate in care processes. The organization defines how a general consent is documented in the patient’s record. Measurable Elements of PFR.6.3 1. Patients and families are informed as to the scope of a general consent, when used by the organization. 2. The organization has defined how a general consent, when used, is documented in the patient’s record. Standard PFR.6.4 Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures. Intent of PFR.6.4 When the planned care includes surgical or invasive procedures (also see Glossary), anesthesia (including moderate and deep sedation; also see Glossary), use of blood and blood products, or other high-risk treatments or procedures, a separate consent is obtained. This consent process provides the information identified in PFR.6.1 and documents the identity of the individual providing the information. Measurable Elements of PFR.6.4 1. Consent is obtained before surgical or invasive procedures. (Also see ASC.7.1 Intent) 2. Consent is obtained before anesthesia (including moderate and deep sedation). (Also see ASC.5.1 Intent and ME 1) 3. Consent is obtained before the use of blood and blood products. 4. Consent is obtained before other high-risk procedures and treatments. 5. The identity of the individual providing the information to the patient and family is noted in the patient’s record. (Also see PFR.8, ME 2) 6. Consent is documented in the patient’s record by signature or record of verbal consent. (Also see PFR.8, ME 2) Standard PFR.6.4.1 The organization lists those categories or types of treatments and procedures that require specific informed consent. Intent of PFR.6.4.1 Not all treatments and procedures require a specific, separate consent. Each organization identifies those high-risk, problem-prone, or other procedures and treatments for which consent must be obtained. The organization lists these procedures and treatments and educates staff to ensure the process to obtain consent is consistent. The list is developed collaboratively by those physicians and others who provide the treatments or perform the procedures. The list includes procedures and treatments provided on an outpatient basis and inpatient basis. Measurable Elements of PFR.6.4.1 1. The organization has listed those procedures and treatments that require separate consent. 2. The list is developed collaboratively by those physicians and others who provide the treatments and perform the procedures. Research Standard PFR.7 The organization informs patients and families about how to gain access to clinical research, investigation, or clinical trials involving human subjects. Intent of PFR.7 An organization that conducts research, investigations, or clinical trials involving human subjects provides information to patients and families about how to gain access to those activities when relevant to the patient’s treatment needs. When patients are asked to participate, they need information upon which to base their decision. That information includes expected benefits; potential discomforts and risks; alternatives that might also help them; and procedures that must be followed. Patients are informed that they can refuse to participate or withdraw participation and that their refusal or withdrawal will not compromise their access to the organization’s services. The organization has policies and procedures for providing patients and families with this information. Measurable Elements of PFR.7 1. Appropriate patients and families are identified and informed about how to gain access to those research, investigations, or clinical trials relevant to their treatment needs. 2. Patients asked to participate are informed about expected benefits. 3. Patients asked to participate are informed about potential discomforts and risks. 4. Patients asked to participate are informed about alternatives that might also help them. 5. Patients asked to participate are informed about the procedures that must be followed. 6. Patients are assured that their refusal to participate or withdraw from participation will not compromise their access to the organization’s services. 7. Policies and procedures guide the information and decision process. Standard PFR.7.1 The organization informs patients and families about how patients who choose to participate in clinical research, investigation, or clinical trials are protected. Intent of PFR.7.1 An organization that conducts research, investigations, or clinical trials involving human subjects knows that its first responsibility is to the patient’s health and well-being. The organization informs patients and families in advance about established processes to review research protocols (also see Glossary); weigh the relative risks and benefits to the subjects; • obtain subject consent; and withdraw from participation. This information is communicated to patients and families to assist with decisions regarding participation. Measurable Elements of PFR.7.1 1. Patients and families are informed about the organization’s process for reviewing research protocols. 2. Patients and families are informed about the organization’s process for weighing the benefits and risks to the subjects. 3. Patients and families are informed about the organization’s process for obtaining consent. 4. Patients and families are informed about the organization’s process for withdrawing from participation. Standard PFR.8 Informed consent is obtained before a patient participates in clinical research, investigation, and trials. Intent of PFR.8 When patients and families decide to participate in clinical research, investigations, or clinical trials, informed consent is granted. The information provided at the time the decision to participate was made serves as the basis for the informed consent (also see intent statement of PFR.6). The individual(s) providing the information and obtaining the consent is noted in the patient’s record. Measurable Elements of PFR.8 1. Informed consent is obtained when a patient decides to participate in clinical research, investigations, or clinical trials. 2. Consent decisions are documented, dated, and based on the information identified in PFR.6.4, MEs 5 and 6. 3. The identity of the individual(s) providing the information and obtaining the consent is noted in the patient’s record. 4. Consent is documented in the patient’s record by signature or record of verbal consent. Standard PFR.9 The organization has a committee or another way to oversee all research in the organization involving human subjects. Intent of PFR.9 When the organization conducts clinical research, investigations, or trials that involve human subjects, a committee or other mechanism to provide oversight for all such activities in the organization is established. The organization develops a statement of purpose for the oversight activities. Oversight activities include the review process for all research protocols, a process to weigh the relative risks and benefits to the subjects, and processes related to the confidentiality and security of the research information. Measurable Elements of PFR.9 1. The organization has a committee or other mechanism to oversee all research within the organization. 2. The organization develops a clear statement of purpose for the oversight activities. 3. Oversight activities include a review process. 4. Oversight activities include a process to weigh relative risks and benefits to subjects. 5. Oversight activities include processes to provide confidentiality and security of research information. Organ Donation Standard PFR.10 The organization informs patients and families about how to choose to donate organs and other tissues. Intent of PFR.10 The organization supports the choice of patients and families to donate organs and other tissues for research or transplantation. Information is provided on the donation process and if the organization is a procurement site for a community, regional, or national organ procurement agency or network. Measurable Elements of PFR.10 1. The organization supports patient and family choices to donate organs and other tissues. 2. The organization provides information to support the choice. Standard PFR.11 The organization provides oversight of the harvesting and transplantation of organs and tissues. Intent of PFR.11 Policies and procedures are developed to guide the procurement and donation process and the transplantation process. The policies are consistent with law and regulation and respect the community’s religious and cultural values. Organization staff are trained in implementing the policies and procedures to support patient and family choices. Staff are also trained in the contemporary concerns and issues related to organ donation and availability of transplants, for example information on organ and tissue shortages, the buying and selling of organs over black market trade, the harvesting (also see Glossary) of organs without consent from executed prisoners or dead patients. The organization cooperates with other organizations and agencies in the community responsible for all or a portion of the procurement, banking, transportation, or transplantation process. Measurable Elements of PFR.11 1. Policies and procedures guide the procurement and donation process. 2. Policies and procedures guide the transplantation process. 3. Staff are trained in the policies and procedures. 4. Staff are trained in the issues and concerns related to organ donation and the availability of transplants. 5. The organization cooperates with relevant organizations and agencies in the community to respect and implement choices to donate. Assessment of Patients (AOP) Overview An effective patient assessment process results in decisions about the patient’s immediate and continuing treatment needs for emergency (also see Glossary), elective or planned care, even when the patient’s condition changes. Patient assessment is an ongoing, dynamic process that takes place in many inpatient (also see Glossary) and outpatient (also see Glossary) settings and departments and clinics. Patient assessment consists of three primary processes: Collecting information and data on the patient’s physical, psychological, social status, and health history Analyzing the data (also see Glossary) and information, including the results of laboratory and imaging diagnostic tests, to identify the patient’s health care needs Developing a plan of care (also see Glossary) to meet the patient’s identified needs Patient assessment is appropriate when it considers the patient’s condition, age, health needs, and his or her requests or preferences. These processes are most effectively carried out when the various health professionals responsible for the patient work together. 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. AOP.1 All patients cared for by the organization have their health care needs identified through an established assessment process. AOP.1.1 The organization has determined the scope and content of assessments, based on applicable laws and regulations and professional standards. AOP.1.2 Each patient’s initial assessment(s) include an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history. AOP.1.3 The patient’s medical and nursing needs are identified from the initial assessments. AOP.1.3.1 The initial medical and nursing assessment of emergency patients is appropriate to their needs and conditions. AOP.1.4 Assessments are completed in the time frame prescribed by the organization. AOP.1.4.1 The initial medical and nursing assessments are completed within the first 24 hours after the patient’s admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy. AOP.1.5 Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care. AOP.1.5.1 The initial medical assessment is documented before anesthesia or surgical treatment. AOP.1.6 Patients are screened for nutritional status and functional needs and are referred for further assessment and treatment when necessary. AOP.1.7 The organization conducts individualized initial assessments for special populations cared for by the organization. AOP.1.8 The initial assessment includes determining the need for additional specialized assessments. AOP.1.8.1 The initial assessment includes determining the need for discharge planning. AOP.1.8.2 All patients are screened for pain and assessed when pain is present. AOP.2 All patients are reassessed at appropriate intervals to determine their response to treatment and to plan for continued treatment or discharge. AOP.3 Qualified individuals conduct the assessments and reassessments. AOP.4 Physicians, nurses, and other individuals and services responsible for patient care collaborate to analyze and integrate patient assessments. AOP.4.1 The most urgent or important care needs are identified. AOP.5 Laboratory services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations. AOP.5.1 A laboratory safety program is in place, followed, and documented. AOP.5.2 Individuals with adequate training, skills, orientation, and experience administer the tests and interpret the results. AOP.5.3 Laboratory results are available in a timely way as defined by the organization. AOP.5.4 All equipment used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. AOP.5.5 Essential reagents and other supplies are regularly available. AOP.5.6 Procedures for collecting, identifying, handling, safely transporting and disposing of specimens are followed. AOP.5.7 Established norms and ranges are used to interpret and report clinical laboratory results. AOP.5.8 A qualified individual(s) is responsible for managing the clinical laboratory service or pathology service. AOP.5.9 Quality control procedures are in place, followed, and documented. AOP.5.9.1 There is a process for proficiency testing. AOP.5.10 The organization regularly reviews quality control results for all outside sources of laboratory services. AOP.5.11 The organization has access to experts in specialized diagnostic areas when necessary. AOP.6 Radiology and diagnostic imaging services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations. AOP.6.1 Radiology and diagnostic imaging services are provided by the organization or are readily available through arrangements with outside sources. AOP.6.2 A radiation safety program is in place, followed, and documented. AOP.6.3 Individuals with adequate training, skills, orientation, and experience perform diagnostic imaging studies, interpret the results and report the results. AOP.6.4 Radiology and diagnostic imaging study results are available in a timely way as defined by the organization. AOP.6.5 All equipment used to conduct radiology and diagnostic imaging studies are regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. AOP.6.6 X-ray film and other supplies are regularly available. AOP.6.7 A qualified individual(s) is responsible for managing the diagnostic radiology and imaging services. AOP.6.8 Quality control procedures are in place, followed, and documented. AOP.6.9 The organization regularly reviews quality control results for all outside sources of diagnostic services. AOP.6.10 The organization has access to experts in specialized diagnostic areas when needed. Joint Commission International Accreditation Standards for Hospitals, Third Edition Standards, Intents, and Measurable Elements Standard AOP.1 All patients cared for by the organization have their health care needs identified through an established assessment process. Intent of AOP.1 When a patient is admitted to an organization for care (ACC.1), staff members then need to completely assess the patient to establish the reason the patient is there. The specific information the organization requires at this stage, and the procedures for getting it, depend on the patient’s needs and the setting in which care is being provided, for example, inpatient or outpatient care. Organization policy and procedures define how this process functions and what information needs to be gathered and documented. Measurable Elements of AOP.1 1. Organization policy and procedure define the assessment information to be obtained for inpatients. 2. Organization policy and procedure define the assessment information to be obtained for outpatients. 3. Organization policy identifies the information to be documented for the assessments. Standard AOP.1.1 The organization has determined the scope and content of assessments, based on applicable laws and regulations and professional standards. Intent of AOP.1.1 To consistently assess patient needs, the organization defines, in policies, the scope and content of assessments to be performed by physicians, nurses and other clinical disciplines. Any assessment forms used for assessments reflect this policy. The organization defines assessment activities in both inpatient and outpatient settings in which care is provided. The organization defines those elements common to all assessments, and defines any differences, when permitted, in the scope of general medical and specialty services assessments. The assessment defined in policy may be completed by more than one qualified individual (also see Glossary) and at different points in time. All the content must be available when treatment is initiated. Measurable Elements of AOP.1.1 1. The scope and content of assessments by each clinical discipline are defined in policies. (Also see ASC.4, ME 1) 2. The scope and content of assessments performed in inpatient and outpatient settings are defined in policies. Standard AOP.1.2 Each patient’s initial assessment(s) include an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history. Intent of AOP.1.2 The initial assessment(s) of a patient, outpatient or inpatient, is critical to identifying his or her needs and starting the care process. The initial assessment(s) provides information to • understand the care the patient is seeking; select the best care setting for the patient; form an initial diagnosis; and understand the patient’s response to any previous care. To provide this information, the initial assessment includes an evaluation of the patient’s medical status through a physical examination and health history. The psychological assessment determines the patient’s emotional status (for example, if he or she is depressed, fearful, or belligerent, and may harm themselves or others). Gathering social information on a patient is not intended to “classify” patients. Rather, a patient’s social, cultural, family, and economic contexts are important factors that can influence his or her response to illness and treatment. Families can be very helpful in these areas of assessment and in understanding the patient’s wishes and preferences in the assessment process. Economic factors are assessed as part of the social assessment or assessed separately when the patient and their family will be responsible for the cost of all or a portion of the care while an inpatient or following discharge (also see Glossary). Many different qualified individuals may be involved in the assessment of a patient. The most important factors are that the assessments are complete and available (also see MCI.7, ME 2) to those caring for the patient. (Also see AOP.1.8.2, ME 1 regarding pain assessments.) Measurable Elements of AOP.1.2 1. All inpatients and outpatients have an initial assessment(s) that meets organization policy. 2. The medical assessment includes a health history and a physical examination consistent with the scope and content defined in hospital policy. 3. Each patient receives an initial psychological assessment as appropriate to their needs. 4. Each patient receives an initial social and economic assessment as appropriate to their needs. 5. The initial assessment(s) results in understanding any previous care and the care the patient is currently seeking. 6. The initial assessment(s) results in selecting the best setting for the care. 7. The initial assessment(s) results in an initial diagnosis. Standards AOP.1.3 The patient’s medical and nursing needs are identified from the initial assessments. AOP.1.3.1 The initial medical and nursing assessment of emergency patients is appropriate to their needs and conditions. Intent of AOP.1.3 and AOP.1.3.1 The primary outcome (also see Glossary) from the patient’s initial assessments is an understanding of the patient’s medical and nursing needs so care and treatment can begin. To accomplish this, the organization determines the scope and content of the initial medical and nursing and other assessments (AOP.1.1), the time frame for completion of assessments (AOP.1.4) and the documentation requirements for assessments (AOP.1.5). While the medical and nursing assessments are primary to the initiation of care, there may be additional assessments by other care providers including special assessments (AOP.1.8), and individualized assessments (AOP.1.7). These assessments must be integrated (AOP.4) and the most urgent care needs identified (AOP.4.1). In an emergency, the initial medical and nursing assessments may be limited to the patient’s apparent needs and condition. Also, when there is no time to record the complete history and physical examination of an emergency patient requiring surgery, a note on the preoperative diagnosis is recorded before surgery. Measurable Elements of AOP.1.3 1. The initial assessment results in the identification of patients’ medical needs. 2. Medical needs are identified based on the documented health history and physical examination as well as other assessments required in accordance with hospital policy. 3. The initial assessment results in the identification of patients’ nursing needs. 4. The nursing care needs of the patient are identified based on the nurse’s documented assessment, the medical assessment, as well as other assessments required in accordance with hospital policy. Measurable Elements of AOP.1.3.1 1. For emergency patients, the medical assessment is appropriate to their needs and condition. 2. For emergency patients, the nursing assessment is appropriate to their needs and condition. 3. If surgery is performed, there is at least a brief note and preoperative diagnosis recorded before surgery. Standard AOP.1.4 Assessments are completed in the time frame prescribed by the organization. Intent of AOP.1.4 To begin correct treatment for the patient as quickly as possible, the initial assessments must be completed as rapidly as possible. The health care organization (also see Glossary) determines the time frame for completing assessments, in particular the medical and nursing assessments. The precise time frame depends on a variety of factors, including the types of patients cared for by the organization, the complexity and duration of their care, and the dynamics of conditions surrounding their care. With this in mind, an organization may establish different time frames for assessment in different areas or services. When an assessment is partially or entirely completed outside the organization (for example, in a consultant surgeon’s office), the findings are reviewed and/or verified at admission as an inpatient, as appropriate to the time between the outside assessment and admission (also see AOP.1.4.1), the critical nature of the findings, the complexity of the patient, and the planned care and treatment (for example, the review confirms the clarity of the diagnosis and any planned procedures or treatments, the presence of radiographs needed in surgery, any change(s) in the patient’s condition such as control of blood sugar, and identifies any critical lab tests that may need repeating). Measurable Elements of AOP.1.4 1. Appropriate time frames for performing assessments are established for all settings and services. 2. Assessments are completed within the time frames established by the organization. 3. The findings of all assessments performed outside the organization are reviewed and/or verified at the time of admission to inpatient status. (Also see AOP.1.4.1 for the updating or repeating of portions of medical assessments older than 30 days; also see MCI.6, ME 1) Standard
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