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. Intent of AOP.1.4.1 The initial medical and nursing assessments are completed within 24 hours of admission to the organization and available for use by all those caring for the patient. When the patient’s condition indicates, the initial medical and/or nursing assessment is conducted and available earlier. Thus, emergency patients are assessed immediately, and policy may define that certain other patient groups are assessed sooner than 24 hours. When the initial medical assessment is conducted in a physician’s private office or other outpatient setting prior to care in the organization as an inpatient, it must be within the previous 30 days. If at the time of admission as an inpatient the medical assessment is more than 30 days old, the medical history must be updated and the physical examination repeated. For medical assessments conducted within 30 days prior to admission, any significant changes in the patient’s condition since the assessment are noted at admission. This updating and/or re-examination can be accomplished by any qualified individual (also see intent statement of AOP.4). Measurable Elements of AOP.1.4.1 1. The initial medical assessment is conducted within the first 24 hours of admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy. 2. The initial nursing assessment is conducted within the first 24 hours of admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy. 3. Initial medical assessments conducted prior to admission to inpatient status, or prior to an outpatient procedure in the organization, are no older than 30 days or the medical history has been updated and the physical exam repeated. 4. For any assessment less than 30 days old, any significant changes in the patient’s condition since the assessment are noted in the patient’s record (also see Glossary) at the time of admission to inpatient status. Standard AOP.1.5 Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care. Intent of AOP.1.5 Assessment findings are used throughout the care process to evaluate patient progress and understand the need for reassessment. It is therefore essential that the medical, nursing, and other meaningful assessments be documented well and can be quickly and easily retrieved from the patient’s record or other standardized location and used by those caring for the patient. In particular, the patient’s medical and nursing assessments are documented in the record within the first 24 hours of admission as an inpatient. This does not preclude the placement of additional, more detailed assessments in separate locations from the patient’s record as long as they remain accessible to those caring for the patient. Measurable Elements of AOP.1.5 1. Assessment findings are documented in the patient’s record. 2. Those caring for the patient can find and retrieve assessments as needed from the patient’s record or other standardized accessible location. (Also see MCI.7, ME 2) 3. Medical assessments are documented in the patient’s record within 24 hours of admission. 4. Nursing assessments are documented in the patient’s record within 24 hours of admission. Standard AOP.1.5.1 The initial medical assessment is documented before anesthesia or surgical treatment. Intent of AOP.1.5.1 Results of the medical assessment and any diagnostic tests are recorded in the patient’s record before anesthesia or surgery. Measurable Elements of AOP.1.5.1 1. Patients for which surgery is planned have a medical assessment performed before the surgery. (Also see ASC.7, ME 2) 2. The medical assessment of surgical patients is documented before surgery. Standard AOP.1.6 Patients are screened for nutritional status and functional needs and are referred for further assessment and treatment when necessary. Intent of AOP.1.6 The information gathered at the initial medical and/or nursing assessment, through the application of screening criteria (also see Glossary), may indicate that the patient needs further or more in-depth assessment of nutritional status or functional status (also see Glossary) including a fall-risk assessment. The more in-depth assessment may be necessary to identify those patients in need of nutritional interventions, and patients in need of rehabilitation services (also see Glossary) or other services related to their ability to function independently or at their greatest potential. The most effective way to identify patients with nutritional (also see Glossary) or functional needs is through screening criteria. For example, the nursing initial assessment form may contain the criteria. In each case, the screening criteria are developed by qualified individuals able to further assess and, if necessary, provide any required patient treatment. For example, screening criteria for nutritional risk may be developed by nurses who will apply the criteria, dietitians who will supply the recommended dietary intervention, and nutritionists able to integrate nutritional needs with the other needs of the patient. (Also see COP.5) Measurable Elements of AOP.1.6 1. Qualified individuals develop criteria to identify patients who require further nutritional assessment. 2. Patients are screened for nutritional risk as part of the initial assessment. 3. Patients at risk for nutritional problems according to the criteria receive a nutritional assessment. 4. Qualified individuals develop criteria to identify patients who require further functional assessment. (Also see International Patient Safety Goal 6, ME 1, related to fall-risk assessment) 5. Patients are screened for their need for further functional assessment as part of the initial assessment. (Also see International Patient Safety Goal 6, ME 2) 6. Patients in need of a functional assessment according to the criteria are referred for such an assessment. Standard AOP.1.7 The organization conducts individualized initial assessments for special populations cared for by the organization. Intent of AOP.1.7 The initial assessment of certain patient populations in the organization’s community requires that the assessment process be modified. Such modification is based on the characteristics of each patient population or on the special situation. Each organization identifies those special populations and situations represented among its patients and appropriately modified the assessment process. In particular, when within the population served by the organization, the organization conducts such individualized assessments for very young patients; frail elderly; terminally ill and others in pain; women in labor; patients with emotional or psychiatric disorders; patients suspected of drug and/or alcohol dependency; and victims of abuse and neglect. The assessment of patients suspected of drug and/or alcohol dependency and the assessment of victims of abuse and neglect are shaped by the culture of the patient population. These assessments are not intended to be a proactive case-finding process. Rather, the assessment of these patients responds to their needs and condition in a culturally acceptable and confidential manner. The assessment process is modified consistent with local laws and regulations and professional standards related to such populations and situations and involve the family when appropriate or necessary. Measurable Elements of AOP.1.7 1. The organization identifies those patient populations and special situations for which the initial assessment process is modified. 2. These special patient populations, including those relevant populations noted in the intent statement, receive individualized assessments. Standard AOP.1.8 The initial assessment includes determining the need for additional specialized assessments. Intent of AOP.1.8 The initial assessment process may identify a need for other assessments such as dental, hearing and language, and so on. The organization refers the patient for such assessments when available within the organization or the community. Measurable Elements of AOP.1.8 1. When the need for additional specialized assessments is identified, patients are referred within the organization or outside the organization. (Also see ACC.3, ME 2) 2. Specialized assessments conducted within the organization are completed and documented in the patient’s record. Standard AOP.1.8.1 The initial assessment includes determining the need for discharge planning. Intent of AOP.1.8.1 Continuity of care (also see Glossary) requires special preparation and considerations for some patients, such as for discharge planning. The organization develops a mechanism, such as a list of criteria, to identify those patients for whom discharge planning is critical due to age, lack of mobility, continuing medical and nursing needs, assistance with activities of daily living, etc. As arrangements for discharge may take some time, the Joint Commission International Accreditation Standards for Hospitals, Third Edition   assessment process and planning process are initiated as soon as possible after admission as an inpatient. Measurable Elements of AOP.1.8.1 1. There is a process to identify those patients for whom discharge planning is critical. (Also see ACC.3, ME 2) 2. Planning for discharge for these patients begins soon after admission as an inpatient. (Also see ACC.3, ME 4) Standard AOP.1.8.2 All patients are screened for pain and assessed when pain is present. Intent of AOP.1.8.2 During the initial assessment and reassessments, the organization identifies patients with pain. When pain is identified, the patient can be treated in the organization or referred for treatment. The scope of treatment is based on the care setting and services provided. When the patient is treated in the organization, a more comprehensive assessment is performed. This assessment is appropriate to the patient’s age and measures pain intensity and quality such as pain character, frequency, location, and duration. This assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the organization and the patient’s needs. Measurable Elements of AOP.1.8.2 1. Patients are screened for pain. (Also see COP.6, ME 1) 2. When pain is identified, the patient is referred or a comprehensive assessment is performed, appropriate to the patient’s age and measuring pain intensity and quality such as pain character, frequency, location, and duration. 3. The assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the organization and the patient’s needs. Standard AOP.2 All patients are reassessed at appropriate intervals to determine their response to treatment and to plan for continued treatment or discharge. Intent of AOP.2 Reassessment by all of the patient’s care providers is key to understanding whether care decisions are appropriate and effective. Patients are reassessed throughout the care process at intervals appropriate to their needs and plan of care or as defined in organization policies and procedures. The results of these reassessments are noted in the patient’s record for the information and use of all those caring for the patient. Reassessment by a physician is integral to ongoing patient care. A physician assesses acute care patients daily, including weekends. An organization may use physiologic-based criteria (also see Glossary), identify unique circumstances, or identify types of patients or patient populations for which a reassessment period is less frequently than daily. Thus, less frequent reassessment may be appropriate for patients in rehabilitation units, following a normal vaginal delivery, patients with minor oral and maxillofacial surgery or patients in long-term psychiatric units, or other similar units, in which the standard of care is less intensive medical and nursing services. The criteria, circumstances, types of patients or patient populations, and the appropriate reassessment period are defined in policy. Reassessments are conducted and results are entered in the patient’s record at regular intervals during care (for example, nursing staff periodically records vital signs as needed based on the patient’s condition); daily by a physician for acute care patients or less frequently as described in organization policy; in response to a significant change in the patient’s condition; if the patient’s diagnosis has changed and the care needs require revised planning; and to determine if medications and other treatments have been successful and the patient can be transferred or discharged. Measurable Elements of AOP.2 1. Patients are reassessed to determine their response to treatment. (Also see ASC.5.3, ME 1; MMU.7, ME 1; COP.5, ME 3; and ASC.7.3, MEs 1 and 2) 2. Patients are reassessed to plan for continued treatment or discharge. (Also see ACC.3, MEs 2 and 3; and COP.7.1, ME 2) 3. Patients are reassessed at intervals appropriate to their condition, plan of care, and individual needs or according to organization policies and procedures. (Also see ASC.3, ME 1) 4. A physician reassesses patients daily, including weekends, during the acute phase of their care and treatment. 5. Organization policy defines the circumstances, types of patients or patient populations for which a physician’s assessment may be less than daily and identifies the reassessment interval for these patients. 6. Reassessments are documented in the patient’s record. Standard AOP.3 Qualified individuals conduct the assessments and reassessments. Intent of AOP.3 The assessment and reassessment of patients are critical processes that require special education, training, knowledge and skills. Thus, for each type of assessment, those individuals qualified to perform the assessment are identified and their responsibilities defined in writing. In particular, those individuals qualified to conduct emergency assessments or assessments of nursing needs are clearly identified. Assessments are performed by each discipline within its scope of practice (also see Glossary), licensure (also see Glossary), applicable laws and regulations, or certification (also see Glossary). Measurable Elements of AOP.3 1. Individuals qualified to conduct patient assessments and reassessments are identified by the organization. 2. Only those individuals permitted by licensure, applicable laws and regulations, or certification perform patient assessments. 3. Emergency assessments are conducted by individuals qualified to do so. 4. Nursing assessments are conducted by individuals qualified to do so. 5. Those qualified to conduct patient assessments and reassessments have their responsibilities defined in writing. (Also see SQE.1.1, MEs 1 and 2 and SQE.10, ME 1) Standards AOP.4 Medical, nursing, 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. Intent of AOP.4 and AOP.4.1 A patient may undergo many kinds of assessments outside and inside the organization by many different departments and services. As a result, there may be a variety of information, test results, and other data (also see Glossary) in the patient’s record. (Also see intent statement of AOP.1.4.1) A patient benefits most when the staff responsible for the patient work together to analyze the assessment findings and combine this information into a comprehensive picture of the patient’s condition. From this collaboration, the patient’s needs are identified, the order of their importance is established, and care decisions are made. Integration of finding at this point will facilitate the coordination of care provision. (Also see COP.2) The process for working together is simple and informal when the patient’s needs are not complex. Formal treatment team meetings, patient conferences, and clinical rounds may be appropriate for patients with complex or unclear needs. The patient, his or her family, and others who make decisions on the patient’s behalf are appropriately included in the decision process. Measurable Elements of AOP.4 1. Patient assessment data and information are analyzed and integrated. (Also see COP.1, ME 1) 2. Those responsible for the patient’s care participate in the process. Measurable Elements of AOP.4.1 1. Patient needs are prioritized based on assessment results. 2. The patient and his or her family are informed of the outcomes of the assessment process and any confirmed diagnosis when appropriate. (Also see PFR.2.1, ME 1) 3. The patient and his or her family are informed of the planned care and treatment and participate in the decisions about the priority needs to be met. (Also see PFR.2.1, MEs 2 and 4 and ACC.1.2, ME 5) Laboratory Services Standard AOP.5 Laboratory services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations. Intent of AOP.5 The organization has a system for providing laboratory services, including clinical pathology services (also see Glossary), required by its patient population, clinical services offered, and health care provider needs. The laboratory services are organized and provided in a manner that meets applicable local and national standards, laws, and regulations. Laboratory services, including those required for emergencies, may be provided within the organization, by agreement with another organization, or both. Laboratory services are available after normal hours for emergencies. Outside sources are convenient for the patient to access. The organization selects outside sources based on the recommendation of the director or other individual responsible for laboratory services. Outside sources of laboratory services meet applicable laws and regulations and have an acceptable record of accurate, timely services. Patients are informed when an outside source of laboratory services is owned by the referring physician. Measurable Elements of AOP.5 1. Laboratory services meet applicable local and national standards, laws, and regulations. 2. Adequate, regular, and convenient laboratory services are available to meet needs. 3. Emergency laboratory services are available, including after normal hours. 4. Outside sources are selected based on an acceptable record and compliance with laws and regulations. 5. Patients are informed about any relationships between the referring physician and outside sources of laboratory services. (Also see GLD.6.1, ME 1) Standard AOP.5.1 A laboratory safety program is in place, followed, and documented. Intent of AOP.5.1 The laboratory has an active safety program to the degree required by the risks and hazards encountered in the laboratory. The program addresses safety practices and prevention measures for laboratory staff, other staff, and patients when present. The laboratory program is coordinated with the organization’s safety management program. The laboratory safety management program includes written policies and procedures that support compliance with applicable standards and regulations; written policies and procedures for the handling and disposal of infectious and hazardous materials; availability of safety devices appropriate to the laboratory’s practices and hazards encountered; the orientation of all laboratory staff to safety procedures and practices; and in-service education (also see Glossary) for new procedures and newly acquired or recognized hazardous materials. Measurable Elements of AOP.5.1 1. A laboratory safety program is in place and is appropriate to the risks and hazards encountered. (Also see FMS.4 and FMS.5) 2. The program is coordinated with the organization’s safety management program. (Also see FMS.4, ME 2) 3. Written policies and procedures address the handling and disposal of infectious and hazardous materials. (Also see FMS.5, ME 2) 4. Appropriate safety devices are available. (Also see FMS.5, ME 5) 5. Laboratory staff are oriented to safety procedures and practices. (Also see FMS.11, ME 1 and GLD.5.4, MEs 1 and 2) 6. Laboratory staff receive education for new procedures and newly acquired or recognized hazardous materials. (Also see SQE.8, MEs 3 and 4) Standard AOP.5.2 Individuals with adequate training, skills, orientation, and experience administer the tests and interpret the results. Intent of AOP.5.2 The organization identifies which laboratory staff members perform testing, including those who perform screening tests at the bedside, and staff which direct or supervise testing. Supervisory staff and technical staff have appropriate and adequate training, experience, and skills and are oriented to their work. Technical staff are given work assignments consistent with their training and experience. In addition, there is a sufficient number of staff to perform tests promptly and provide necessary laboratory staffing during all hours of operation and for emergencies. Measurable Elements of AOP.5.2 1. Those individuals who perform testing and those who direct or supervise testing are identified. 2. Appropriately trained and experienced staff administer tests. (Also see SQE.4, ME 1) 3. Appropriately trained and experienced staff interpret tests. (Also see SQE.4, ME 1) 4. There is an adequate number of staff to meet patient needs. 5. Supervisory staff have appropriate training and experience. Standard AOP.5.3 Laboratory results are available in a timely way as defined by the organization. Intent of AOP.5.3 The organization defines the time period for reporting laboratory test results. Results are reported within a time frame based on patient needs, services offered, and clinical staff needs. Emergency tests and after-hours and weekend testing needs are included. Results from urgent tests, such as those from the emergency department, operating theatres, and intensive care units, are given special attention in the planning and monitoring (also see Glossary) process. In addition, when laboratory services are by contract (also see “contracted services” in Glossary) with an outside organization, the reports are also timely as set forth by organization policy or the contract. (Also see International Patient Safety Goal 2, ME 1) Measurable Elements of AOP.5.3 1. The organization has established the expected report time for results. 2. The timeliness of reporting of urgent/emergency tests is monitored. 3. Laboratory results are reported within a time frame to meet patient needs. (Also see ASC.7.2) Standard AOP.5.4 All equipment used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. Intent of AOP.5.4 Laboratory staff work to ensure that all equipment functions at acceptable levels and in a manner that is safe to the operator(s). A laboratory equipment management program provides for selecting and acquiring equipment; identifying and taking inventory of equipment; assessing equipment use through inspection, testing, calibration, and maintenance; monitoring and acting on equipment hazard notices, recalls, reportable incidents, problems, and failures; and documenting the management program. Testing, maintenance, and calibration frequency are related to the laboratory’s use of the equipment and its documented history of service. Measurable Elements of AOP.5.4 1. There is a laboratory equipment management program and it is implemented. (Also see FMS.8, ME 1) 2. The program includes selecting and acquiring equipment. 3. The program includes inventorying equipment. (Also see FMS.8, ME 2) 4. The program includes inspecting and testing equipment. (Also see FMS.8, ME 3) 5. The program includes calibrating and maintaining equipment. (Also see FMS.8, ME 4) 6. The program includes monitoring and follow-up. (Also see FMS.8, ME 5) 7. All testing, maintenance, and calibration of equipment are adequately documented. (Also see FMS.8.1, ME 1) Standard AOP.5.5 Essential reagents and other supplies are regularly available. Intent of AOP.5.5 The organization has identified those reagents and supplies necessary to regularly provide laboratory services to its patients. A process to order or secure those essential reagents and other supplies is effective. All reagents are stored and dispensed according to defined procedures. The periodic evaluation of all reagents ensures accuracy and precision of results. Written guidelines ensure the complete and accurate labeling of reagents and solutions. Measurable Elements of AOP.5.5 1. Essential reagents and supplies are identified. (Also see FMS.5, ME 1) 2. Essential reagents and supplies are available. 3. All reagents are stored and dispensed according to guidelines. (Also see FMS.5, ME 2) 4. All reagents are periodically evaluated for accuracy and results. 5. All reagents and solutions are completely and accurately labeled according to guidelines. (Also see FMS.5, ME 7) Standard AOP.5.6 Procedures for collecting, identifying, handling, safely transporting, and disposing of specimens are followed. Intent of AOP.5.6 Procedures are developed and implemented for • ordering tests; collecting and identifying specimens; transporting, storing, and preserving specimens; and receiving, logging-in, and tracking specimens. These procedures are observed for specimens sent to outside sources for testing. Measurable Elements of AOP.5.6 1. Procedures guide the ordering of tests. 2. Procedures guide the collection and identification of specimens. (Also see International Patient Safety Goal 1, ME 4) 3. Procedures guide the transport, storage, and preservation of specimens. Joint Commission International Accreditation Standards for Hospitals, Third Edition 4. Procedures guide the receipt and tracking of specimens. 5. The procedures are implemented. 6. The procedures are observed when outside sources or services are used. Standard AOP.5.7 Established norms and ranges are used to interpret and report clinical laboratory results. Intent of AOP.5.7 The laboratory establishes reference intervals or “normal” ranges for each test performed. The range is included in the clinical record (also see Glossary), either as part of the report or by including a current listing of such values approved by the laboratory director. Ranges are furnished when an outside source performs the test. The reference ranges are appropriate to the organization’s geography and demographics and are reviewed and updated when methods change. Measurable Elements of AOP.5.7 1. The laboratory has established reference ranges for each test performed. 2. The range is included in the clinical record at the time test results are reported. 3. Ranges are furnished when tests are performed by outside sources. 4. Ranges are appropriate to the organization’s geography and demographics. 5. Ranges are reviewed and updated as needed. Standard AOP.5.8 A qualified individual(s) is responsible for managing the clinical laboratory service or pathology service. Intent of AOP.5.8 Clinical laboratory services are under the direction of an individual who is qualified by virtue of documented training, expertise, and experience, consistent with applicable law and regulation. This individual assumes professional responsibility for the laboratory facility and the services provided in the laboratory as well as tests performed outside the laboratory such as the testing performed at bedside (point of care testing). The oversight of services outside of the laboratory include ensuring consistent organizationwide policies and practices, such as training, supply management, etc., and not daily supervision of those activities. Daily supervision remains the responsibility of the leaders of the department or unit in which the testing is conducted. When this individual provides clinical consultation or medical opinion, he or she is a physician, preferably a pathologist. Specialty and subspecialty laboratory services are under the direction of appropriately qualified individuals. Responsibilities of the laboratory director include developing, implementing, and maintaining policies and procedures; administrative oversight; maintaining any necessary quality control program; recommending outside sources of laboratory services; and monitoring and reviewing all laboratory services. Measurable Elements of AOP.5.8 ❒ 1. The clinical laboratory, and other laboratory services throughout the organization, are under the direction and oversight of one or more qualified individuals responsible for carrying out the responsibilities identified in the intent statement. (Also see GLD.5, ME 1) 2. Responsibilities include developing, implementing, and maintaining policies and procedures. 3. Responsibilities include administrative oversight. 4. Responsibilities include maintaining quality control programs. 5. Responsibilities include recommending outside sources of laboratory services. (Also see GLD.3.3, ME 4) 6. Responsibilities include monitoring and reviewing all laboratory services within and outside of the laboratory. (Also see GLD.3.3, ME 3) Standards AOP.5.9 Quality control procedures are in place, followed, and documented. AOP.5.9.1 There is a process for proficiency testing. Intent of AOP.5.9 and AOP.5.9.1 Sound quality control systems are essential to providing excellent pathology and clinical laboratory services. Quality control procedures include a) validation of the test methods used for accuracy, precision, and reportable range; b) daily surveillance of results by qualified laboratory staff; c) rapid corrective action when a deficiency is identified; d) testing of reagents (also see AOP.5.5); and e) documentation of results and corrective actions. Proficiency testing determines how well an individual laboratory’s results compare with other laboratories that use the same methodologies. Such testing can identify performance problems not recognized by internal mechanisms. Thus, the laboratory participates in an approved proficiency testing program when available. Alternatively, when approved programs are not available, the laboratory exchanges samples with a laboratory in another organization for purposes of peer comparison testing. The laboratory maintains a cumulative record of participation in a proficiency testing process. Proficiency testing, or an alternative, is carried out for all specialty laboratory programs (also see Glossary) when available. Measurable Elements of AOP.5.9 1. There is a quality control program for the clinical laboratory. 2. The program includes the validation of test methods. 3. The program includes the daily surveillance of test results. 4. The program includes rapid correction of deficiencies. 5. The program includes the documentation of results and corrective actions. 6. Program elements a) through e) identified in the intent statement are implemented. Measurable Elements of AOP.5.9.1 1. The laboratory participates in a proficiency testing program, or an alternative, for all specialty laboratory services and tests. 2. A cumulative record of participation is maintained. Standard AOP.5.10 The organization regularly reviews quality control results for all outside sources of laboratory services. Joint Commission International Accreditation Standards for Hospitals, Third Edition Intent of AOP.5.10 When the organization uses outside sources of laboratory services, they regularly receive and review the quality control results of that outside source. Qualified individuals review the quality control results. Measurable Elements of AOP.5.10 1. Quality control results from outside sources are regularly reviewed. 2. Qualified individuals review the quality control results. Standard AOP.5.11 The organization has access to experts in specialized diagnostic areas when necessary. Intent of AOP.5.11 The organization is able to identify and contact experts in specialized diagnostic areas such as parasitology, virology, or toxicology, when needed. The organization maintains a roster of such experts. Measurable Elements of AOP.5.11 1. A roster of experts for specialized diagnostic areas is maintained. 2. Experts in specialized diagnostic areas are contacted when needed.  Radiology and Diagnostic Imaging Services Standards 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. Intent of AOP.6 and AOP.6.1 The organization has a system for providing radiology and diagnostic imaging services required by its patient population, clinical services offered, and health care provider needs. Radiology and diagnostic imaging services meet all applicable local and national standards, laws, and regulations. Radiology and diagnostic imaging services, including those required for emergencies, may be provided within the organization, by agreement with another organization, or both. Radiology and diagnostic imaging services are available after normal hours for emergencies. Outside sources are convenient for the patient to access, and reports are received in a timely way that supports continuity of care. The organization selects outside sources based on the recommendation of the director or other individual responsible for radiology and diagnostic imaging services. Outside sources of radiology and diagnostic imaging services meet applicable laws and regulations and have an acceptable record of accurate, timely services. Patients are informed when an outside source of services is owned by the referring physician. Measurable Elements of AOP.6 1. Radiology and diagnostic imaging services meet applicable local and national standards, laws, and regulations. 2. Adequate, regular and convenient radiology and diagnostic imaging services are available to meet patient needs. 3. Radiology and diagnostic imaging services are available for emergencies after normal hours of operation. Measurable Elements of AOP.6.1 1. Outside sources are selected based on recommendations of the director and an acceptable record of timely performance and compliance with applicable laws and regulations. 2. Patients are informed about any relationships between the referring physician and outside sources of radiology and/or diagnostic imaging services. (Also see GLD.6.1, ME 1) Standard AOP.6.2 A radiation safety program is in place, followed, and documented. Intent of AOP.6.2 The organization has an active radiation safety program that includes all components of the organization’s radiology and diagnostic imaging services including radiation oncology and the cardiac catheterization laboratory. The radiation safety program reflects the risks and hazards encountered. The program addresses safety practices and prevention measures for radiology and diagnostic imaging staff, other staff, and patients. The program is coordinated with the organization’s safety management program. The radiation safety management program includes written policies and procedures that support compliance with applicable standards, laws and regulations; written policies and procedures for handling and disposal of infectious and hazardous materials; availability of safety protective devices appropriate to the practices and hazards encountered; the orientation of all radiology and diagnostic imaging staff to safety procedures and practices; and in-service education for new procedures and newly acquired or recognized hazardous materials. Measurable Elements of AOP.6.2 1. A radiation safety program is in place and appropriate to the risks and hazards encountered. (Also see FMS.4 and FMS.5) 2. The program is coordinated with the organization’s safety management program. 3. Written policies and procedures address compliance with applicable standards, laws, and regulations. 4. Written policies and procedures address handling and disposal of infectious and hazardous materials. (Also see FMS.5, ME 2) 5. Appropriate radiation safety devices are available. (Also see FMS.5, ME 5) 6. Radiology and diagnostic imaging staff are oriented to safety procedures and practices. (Also see FMS.11, ME 1 and GLD.5.4, MEs 1 and 2) 7. Radiology and diagnostic imaging staff receive education for new procedures and hazardous materials. (Also see SQE.8, MEs 3 and 4) Standard AOP.6.3 Individuals with adequate training, skills, orientation, and experience perform diagnostic imaging studies, interpret the results and report the results. Intent of AOP.6.3 The organization identifies which radiology and diagnostic imaging staff members perform diagnostic and imaging studies, interpret the results or verify and report results, as well as those who direct or supervise the processes. Supervisory staff and technical staff have appropriate and adequate training, experience, and skills and are oriented to their work. Technical staff members are given work assignments consistent with their training and experience. In addition, there is a sufficient number of staff to perform, interpret and report studies promptly and provide necessary staffing during all hours of operation and for emergencies. Measurable Elements of AOP.6.3 1. Those individuals who perform diagnostic and imaging studies or direct or supervise the studies are identified. 2. Appropriately trained and experienced staff perform diagnostic and imaging studies. (Also see SQE.4, ME 1) 3. Appropriately trained and experienced staff interpret study results. (Also see SQE.4, ME 1) 4. Appropriate staff verify and report the results of studies. 5. There is an adequate number of staff to meet patient needs. 6. Supervisory staff have appropriate training and experience. Standard AOP.6.4 Radiology and diagnostic imaging study results are available in a timely way as defined by the organization. Intent of AOP.6.4 The organization defines the time period for reporting diagnostic radiology and diagnostic imaging study results. Results are reported within a time frame based on patient needs, services offered, and the clinical staff ’s needs. Emergency tests and after-hours and weekend testing needs are included. Results from urgent radiology and diagnostic imaging studies, such as those from the emergency department, operating theatres, and intensive care units, are given special attention in the planning and monitoring process. Radiology and diagnostic imaging studies performed by outside contractors of services are reported according to organization policy or contract requirement. (Also see International Patient Safety Goal 2, ME 1) Measurable Elements of AOP.6.4 1. The organization has established the expected report time for results. 2. The timeliness of reporting of urgent/emergency studies is monitored. 3. Radiology and diagnostic imaging study results are reported within a time frame to meet patient needs. (Also see ASC.7, ME 2) Standard 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. Intent of AOP.6.5 Radiology and diagnostic imaging staff work to ensure that all equipment functions at acceptable levels and in a manner that is safe to the operator(s). A radiology and diagnostic imaging equipment management program provides for selecting and acquiring equipment; identifying and inventorying equipment; assessing equipment use through inspection, testing, calibration, and maintenance; monitoring and acting on equipment hazard notices, recalls, reportable incidents, problems, and failures; and documenting the management program. Testing, maintenance, and calibration frequency are related to the use of the equipment and its documented history of service. (Also see FMS.7) Measurable Elements of AOP.6.5 1. There is a radiology and diagnostic imaging equipment management program and it is implemented. (Also see FMS.8, ME 1) 2. The program includes selecting and acquiring equipment. 3. The program includes inventorying equipment. (Also see FMS.8, ME 2) 4. The program includes inspecting and testing equipment. (Also see FMS.8, ME 3) 5. The program includes calibrating and maintaining equipment. (Also see FMS.8, ME 4) 6. The program includes monitoring and follow-up. (Also see FMS.8, ME 5) 7. There is adequate documentation of all testing, maintenance, and calibration of equipment. (Also see FME.8.1, ME 1) Standard AOP.6.6 X-ray film and other supplies are regularly available. Intent of AOP.6.6 The organization has identified the film, reagents, and supplies necessary to regularly provide radiology and diagnostic imaging services to its patients. A process to order or secure essential film, reagents, and other supplies is effective. All supplies are stored and dispensed according to defined procedures. The periodic evaluation of reagents ensures accuracy and precision of results. Measurable Elements of AOP.6.6 1. Essential x-ray film, reagents and supplies are identified. (Also see FMS.5, ME 1) 2. Essential x-ray film, reagents and supplies are available. 3. All supplies are stored and dispensed according to guidelines. (Also see FMS.5, ME 2) 4. All supplies are periodically evaluated for accuracy and results. 5. All supplies are completely and accurately labeled. (Also see FMS.5, ME 7) Standard AOP.6.7 A qualified individual(s) is responsible for managing the radiology and diagnostic imaging services. Intent of AOP.6.7 Radiology and diagnostic imaging services are under the direction of an individual who is qualified by documented training, expertise, and experience, consistent with applicable law and regulation. This individual assumes professional responsibility for the radiology and diagnostic imaging facility and the services provided. When this individual provides clinical consultation or medical opinion, he or she is a physician, preferably a radiologist. When radiation therapy or other special services are provided, they are under the direction of appropriately qualified individuals. The radiology and diagnostic imaging director’s responsibilities include developing, implementing, and maintaining policies and procedures; administrative oversight; maintaining any necessary quality control program; recommending outside sources of radiology and diagnostic imaging services; and monitoring and reviewing of all radiology and diagnostic imaging services. Measurable Elements of AOP.6.7 1. Radiology and diagnostic imaging services are under the direction of one or more qualified individuals. (Also see GLD.5, ME 1) 2. Responsibilities include developing, implementing, and maintaining policies and procedures. 3. Responsibilities include administrative oversight. 4. Responsibilities include maintaining quality control programs. 5. Responsibilities include recommending outside sources of radiology and diagnostic imaging services. (Also see GLD.3.3, ME 4) 6. Responsibilities include monitoring and reviewing all radiology and diagnostic imaging services. (Also see GLD.3.3, ME 3) 7. The individual(s) carries out the responsibilities. Standard AOP.6.8 Quality control procedures are in place, followed, and documented. Intent of AOP.6.8 Sound quality control systems are essential to providing excellent radiology and diagnostic imaging services. Quality control procedures include validation of the test methods used for accuracy and precision; daily surveillance of imaging results by qualified laboratory staff; rapid corrective action when a deficiency is identified; testing of reagents and solutions (also see AOP.6.6); and documentation of results and corrective actions. Measurable Elements of AOP.6.8 1. There is a quality control program for the radiology and diagnostic imaging service, and it is implemented. 2. Quality control includes validating test methods. 3. Quality control includes daily surveillance of imaging results. 4. Quality control includes rapid correction when a deficiency is identified. 5. Quality control includes testing reagents and solutions. 6. Quality control includes documenting results and corrective actions. Standard AOP.6.9 The organization regularly reviews quality control results for all outside sources of diagnostic services. Intent of AOP.6.9 When the organization uses outside sources of radiology and diagnostic imaging services, it regularly receives and reviews the quality control results of that outside source. Qualified individuals review the quality control results. When diagnostic imaging quality control of outside sources is difficult to obtain, the director develops an alternative approach for quality oversight. Measurable Elements of AOP.6.9 1. Quality control results from outside sources are reviewed regularly. 2. Qualified individuals review the quality control results. Standard AOP.6.10 The organization has access to experts in specialized diagnostic areas when needed. Intent of AOP.6.10 The organization can identify and contact experts in specialized diagnostic areas such as radiation physics, radiation oncology, or nuclear medicine, when necessary. The organization maintains a roster of such experts. Measurable Elements of AOP.6.10 1. The organization maintains a roster of experts for specialized diagnostic areas. 2. The organization contacts experts in specialized diagnostic areas when needed. Care of Patients (COP) Overview A health care organization’s main purpose is patient care. Providing the most appropriate care in a setting that supports and responds to each patient’s unique needs requires a high level of planning and coordination. Certain activities are basic to patient care. For all disciplines that care for patients, these activities include planning and delivering care to each patient; monitoring (also see Glossary) the patient to understand the results of the care; modifying care when necessary; completing the care; and planning the follow-up. Many physicians, nurses, pharmacists, rehabilitation therapists, and other types of health care providers may carry out these activities. Each provider has a clear role in patient care. That role is determined by licensure (also see Glossary); credentials (also see Glossary); certification (also see Glossary); law and regulation; an individual’s particular skills, knowledge and experience; and organization policies or job descriptions. Some care may be carried out by the patient, his or her family, or other trained caregivers. The Assessment of Patients (AOP) standards (also see pages 71-93) describe the basis for care delivery—a plan for each patient based on an assessment of his or her needs. That care may be preventive (also see Glossary), palliative (also see Glossary), curative, or rehabilitative and may include anesthesia, surgery, medication, supportive therapies, or a combination of these. A plan of care (also see Glossary) is not sufficient to achieve optimal outcomes (also see Glossary). The delivery of the services must be coordinated and integrated by all individuals caring for the patient. 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. COP.1 Policies and procedures and applicable laws and regulations guide the uniform care of all patients. COP.2 There is a process to integrate and coordinate the care provided to each patient. COP.2.1 The care provided to each patient is planned and written in the patient’s record. COP.2.2 Those permitted to write patient orders write the order in the patient record in a uniform location. COP.2.3 Procedures performed are written into the patient’s record. COP.2.4 Patients and families are informed about the outcomes of care and treatment including unanticipated outcomes. COP.3 Policies and procedures guide the care of high-risk patients and the provision of high-risk services. COP.3.1 Policies and procedures guide the care of emergency patients. COP.3.2 Policies and procedures guide the use of resuscitation services throughout the organization. COP.3.3 Policies and procedures guide the handling, use, and administration of blood and blood products. COP.3.4 Policies and procedures guide the care of patients on life support or who are comatose. COP.3.5 Policies and procedures guide the care of patients with a communicable disease and immune- suppressed patients. COP.3.6 Policies and procedures guide the care of patients on dialysis. COP.3.7 Policies and procedures guide use of restraint and the care of patients in restraint. COP.3.8 Policies and procedures guide the care of elderly patients, disabled individuals, children and populations at risk for abuse. COP.3.9 Policies and procedures guide the care of patients receiving chemotherapy or other high-risk medications. COP.4 A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical care, are regularly available. COP.4.1 Food preparation, handling, storage, and distribution are safe and comply with laws, regulations, and current acceptable practices. COP.5 Patients at nutrition risk receive nutrition therapy. COP.6 Patients are supported in managing pain effectively. COP.7 The organization addresses end-of-life care. COP.7.1 As appropriate to the care and services provided, assessments and reassessments of the dying patient and their family are designed to meet individualized needs. COP.7.2 Care of the dying patient optimizes his or her comfort and dignity. Standards, Intents, and Measurable Elements Care Delivery for All Patients Standard COP.1 Policies and procedures and applicable laws and regulations guide the uniform care of all patients. Intent of COP.1 Patients with the same health problems and care needs have a right to receive the same quality of care throughout the organization. To carry out the principle of “one level of quality of care” requires that the leaders plan and coordinate patient care. In particular, services provided to similar patient populations in multiple departments or settings are guided by policies and procedures that result in their uniform delivery. In addition, the leaders ensure that the same level of care is available each day of the week and all work shifts each day. Those policies and procedures respect applicable laws and regulations that shape the care process and are best developed collaboratively. Uniform patient care is reflected in the following: 1.Access to and appropriateness of care and treatment do not depend on the patient’s ability to pay or the source of payment. 2.Access to appropriate care and treatment by qualified practitioners does not depend on the day of the week or time of day. 3.Acuity of the patient’s condition determines the resources allocated to meet the patient’s needs. 4.The level of care provided to patients (for example, anesthesia care) is the same throughout the organization. 5.Patients with the same nursing care needs receive comparable levels of nursing care throughout the   organization. Uniform patient care results in the efficient use of resources and permits the evaluation of outcomes of similar care throughout the organization. Measurable Elements of COP.1 1. The organization’s leaders collaborate to provide uniform care processes. (Also see ACC.1.1 and AOP.4, ME 1) 2. Policies and procedures guide uniform care and reflect relevant laws and regulations. 3. Uniform care is provided that meets requirements #1 through #5 in the intent statement. (Also see ASC.3, ME 1) Standard COP.2 There is a process to integrate and coordinate the care provided to each patient. Intent of COP.2 The patient care process (also see Glossary) is dynamic and involves many care providers and can involve multiple care settings and departments and services. The integration and coordination of patient care activities are goals that result in efficient care processes, more effective use of human and other resources, and the likelihood of better patient outcomes. Thus, leaders use tools and techniques to better integrate and coordinate care for their patients (for example, team-delivered care, multi-departmental patient rounds, combined care planning forms, integrated patient record [also see Glossary], case managers). (Also see intent statement of AOP.4) The patient’s record facilitates and reflects the integration and coordination of care. In particular, each provider records observations and treatments in the patient’s record. Also, any results or conclusions from collaborative patient care team meetings or similar patient discussions are written in the patient’s record. (Also see COP.5, ME 2) Measurable Elements of COP.2 1. Care planning is integrated and coordinated among settings, departments, and services. (Also see ACC.2, ME 3) 2. Care delivery is integrated and coordinated among settings, departments, and services. 3. The results or conclusions of any patient care team meetings or other collaborative discussions are written in the patient’s record. Standard COP.2.1 The care provided to each patient is planned and written in the patient’s record. Intent of COP.2.1 Patient care processes are carefully planned to achieve optimal outcomes. The planning process uses the data (also see Glossary) from the initial assessment and from periodic reassessments to identify and prioritize the treatments, procedures, nursing care, and other care to meet the patient’s needs. The patient and family are involved in the planning process. The plan is recorded in the patient’s record. The plan of care is developed within 24 hours of admission as an inpatient (also see Glossary). Based on the reassessment of the patient performed by the patient’s care providers, the plan is updated as appropriate to reflect the evolving condition of the patient. The care planned for a patient must be related to his or her identified needs. Those needs may change as the result of clinical improvement, new information from a routine reassessment (for example, abnormal laboratory or radiography results), or may be evident from a sudden change in the patient’s condition (for example, loss of consciousness). As needs change, the plan for the patient’s care also changes. Changes are written in the record as notes to the initial plan, as revised or new care goals, or may result in a new plan. Note: A single, integrated plan is preferable to the entry of a separate care plan by each provider. The plan of care for each patient should also reflect individualized, objective and realistic care goals to facilitate reassessment and revision of the care plan. Measurable Elements of COP.2.1 1. The care for each patient is planned by the responsible physician, nurse, and other health professionals within 24 hours of admission as an inpatient. 2. The planned care is individualized and based on the patient’s initial assessment data. 3. The plan is updated or revised, as appropriate, based on the reassessment of the patient by the care providers. 4. The care planned for each patient is written in the patient’s record. 5. The planned care is provided. 6. The care provided for each patient is written in the patient’s record by the health professional providing the care. (Also see ASC.7.2; ASC.5.2, ME 1; and COP.2.3, ME 1) Standard COP.2.2 Those permitted to write patient orders write the order in the patient record in a uniform location. Intent of COP.2.2 Patient care activities include orders, for example, for laboratory testing, administration of medications, nursing care, and nutrition therapy (also see Glossary). Diagnostic, surgical, and other procedures are ordered by individuals qualified to do so. Such orders must be easily accessible if they are to be acted on in a timely manner. Locating orders on a common sheet or in a uniform location in patient records facilitates the carrying out of orders. Written orders help staff understand the specifics of an order, when the order is to be carried out, and who is to carry out the order. Orders can be written on an order sheet that is transferred to the patient’s record periodically or at discharge. Each organization decides which orders must be written rather than verbal; which diagnostic imaging and clinical laboratory test orders must provide a clinical indication/rationale; any exceptions in specialized settings such as emergency departments and intensive care units; who is permitted to write orders; and where orders are to be located in the patient record. Measurable Elements of COP.2.2 1. Orders are written when required and follow organization policy. (Also see MMU.4) 2. Diagnostic imaging and clinical laboratory test orders include a clinical indication/rationale when required for interpretation. 3. Only those permitted to write orders do so. 4. Orders are found in a uniform location in patient records. Standard COP.2.3 Procedures performed are written into the patient’s record. Intent of COP.2.3 Diagnostic and other procedures performed and the results are written in the patient’s record. Such procedures include endoscopies, cardiac catheterization and other invasive (also see Glossary) and noninvasive diagnostic and treatment procedures. (For surgical procedures, see ASC.7.2, ME 2, and COP.2.1, ME 6) Measurable Elements of COP.2.3 1. Procedures performed are written into the patient’s record. 2. The results of procedures performed are written into the patient’s record. Standard COP.2.4 Patients and families are informed about the outcomes of care and treatment including unanticipated outcomes. Intent of COP.2.4 The care and treatment process is an ongoing cycle of assessments and reassessments, planning and delivering care, and assessing outcomes. Patients and their families are informed of the results of the assessment process, are informed of the planned care and treatment and participate in care decisions. Thus, to complete the cycle of information with patients, they need to be informed of the outcome(s) of care and treatment. This includes being informed of any unanticipated outcomes of care. Joint Commission International Accreditation Standards for Hospitals, Third Edition Measurable Elements of COP.2.4 1. Patients and families are informed about the outcomes of their care and treatment. (Also see PFR.2.1.1, ME 1) 2. Patients and families are informed about any unanticipated outcomes of their care and treatment. (Also see PFR.2.1.1, ME 2) Care of High-Risk Patients and Provision of High-Risk Services Standard COP.3 Policies and procedures guide the care of high-risk patients and the provision of high-risk services. Intent of COP.3 Health care organizations care for a variety of patients with a variety of health care needs. Some patients are considered high risk because of their age, condition, or critical nature of their needs. Children and the elderly are commonly placed in this group as they frequently cannot speak for themselves, do not understand the care process, and cannot participate in decisions regarding their care. Similarly, the frightened, confused, or comatose emergency (also see Glossary) patient is unable to understand the care process when care needs to be provided efficiently and rapidly. Health care organizations also provide a variety of services, some of which are considered high risk because of the complex equipment needed to treat a life-threatening condition (dialysis patients), the nature of the treatment (use of blood and blood products), the potential for harm to the patient (restraint) or toxic effects of certain high-risk medications (for example, chemotherapy; also see Glossary). Policies and procedures are important tools for staff to understand these patients and services and to respond in a thorough, competent, and uniform manner. The leaders are responsible for identifying the patients and services considered high risk in the organization; using a collaborative process to develop relevant policies and procedures; and training staff in implementing the policies and procedures. The patients and services identified in COP.3.1 through COP.3.9, when present in the organization, are included in the process. Additional patients and services are included when represented in the organization’s patient population and services. Organizations may also wish to identify collateral risk as the result of any procedures or plan of care (for example, the need to prevent deep vein thrombosis, decubitus ulcers, and falls). Such risks, when present, may be prevented by educating staff and developing appropriate policies and procedures. (Also see PFR.1.5, MEs 1 and 2) Measurable Elements of COP.3 1. The organization’s leaders have identified the high-risk patients and services. 2. The leaders use a collaborative process to develop applicable policies and procedures. 3. Staff have been trained and use the policies and procedures to guide care. Standards COP.3.1 Policies and procedures guide the care of emergency patients. COP.3.2 Policies and procedures guide the use of resuscitation services throughout the organization. COP.3.3 Policies and procedures guide the handling, use, and administration of blood and blood products. COP.3.4 Policies and procedures guide the care of patients on life support or who are comatose. (Also see PFR.1.5) COP.3.5 Policies and procedures guide the care of patients with a communicable disease and immune-suppressed patients. COP.3.6 Policies and procedures guide the care of patients on dialysis. COP.3.7 Policies and procedures guide use of restraint and the care of patients in restraint. COP.3.8 Policies and procedures guide the care of elderly patients, disabled individuals, children and populations at risk for abuse. COP.3.9 Policies and procedures guide the care of patients receiving chemotherapy or other high-risk medications. Intent of COP.3.1 through COP.3.9 Policies and procedures must be tailored to the particular at-risk patient population or high-risk service to be appropriate and effective in reducing the related risk. It is particularly important that the policy or procedure identify a) how planning will occur, including the identification of differences between adult and pediatric populations, or other special considerations; b) the documentation required for the care team to work and communicate effectively; c) special consent considerations, if appropriate; d) patient monitoring requirements; e) special qualifications or skills of staff involved in the care process; and f) the availability and use of specialized equipment. Clinical guidelines (also see Glossary) and clinical pathways (also see Glossary) are frequently helpful in developing the policies and procedures and may be incorporated into them. (Also see PFR.1.4, ME 2; PFR.1.5, ME 2; and AOP.1.7) Note: For standards COP.3.1 through COP.3.9, elements a) through f) of the intent statement must be reflected in the required policies and procedures. Measurable Elements of COP.3.1 1. The care of emergency patients is guided by appropriate policies and procedures. 2. Patients receive care consistent with the policies and procedures. Measurable Elements of COP.3.2 1. The uniform use of resuscitation services throughout the organization is guided by appropriate policies and procedures. 2. Resuscitation is provided according to policies and procedures. Measurable Elements of COP.3.3 1. The handling, use, and administration of blood and blood products is guided by appropriate policies and procedures. 2. Blood and blood products are administered according to policies and procedures. Measurable Elements of COP.3.4 1. The care of comatose patients is guided by appropriate policies and procedures. 2. The care of patients who are on life support is guided by policies and procedures. 3. Comatose patients and patients on life support receive care according to the policies and procedures. Measurable Elements of COP.3.5 1. The care of patients with a communicable disease is guided by appropriate policies and procedures. 2. The care of immune-suppressed patients is guided by appropriate policies and procedures. 3. Immune-suppressed patients and patients with communicable diseases receive care according to the policies and procedures. Measurable Elements of COP.3.6 1. The care of patients on dialysis is guided by appropriate policies and procedures. 2. Dialysis patients receive care according to the policies and procedures. Measurable Elements of COP.3.7 1. The use of restraint is guided by appropriate policies and procedures. 2. Patients in restraint receive care according to the policies and procedures. Measurable Elements of COP.3.8 1. The care of frail, dependent elderly patients is guided by appropriate policies and procedures. 2. Frail, dependent elderly patients receive care according to the policies and procedures. 3. The care of young, dependent children is guided by appropriate policies and procedures. 4. Young, dependent children receive care according to the policies and procedures. 5. Patient populations at risk for abuse are identified and their care is guided by appropriate policies and procedures. 6. Identified populations at risk for abuse receive care according to the policies and procedures. Measurable Elements of COP.3.9 1. The care of patients receiving chemotherapy or other high-risk medications is guided by appropriate policies and procedures. 2. Patients receiving chemotherapy or other high-risk medications receive care according to the policies and procedures. Food and Nutrition Therapy Standard COP.4 A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical care, are regularly available. Intent of COP.4 Appropriate food and nutrition are important to patients’ well-being and recovery. Food appropriate for the patient’s age, cultural and dietary preferences, and planned care is available on a regular basis. The patient participates in planning and selecting foods, and the patient’s family may, when appropriate, participate in providing food, consistent with cultural, religious, and other traditions and practices. Based on the patient’s assessed needs and plan of care, the patient’s physician or other qualified caregiver orders appropriate food or other nutrients for the patient. When the patient’s family or others provide food to the patient, they are educated about foods that are contraindicated according to the patient’s care needs and plans, including information about any medications associated with food interactions. When possible, patients are offered a variety of food choices consistent with their nutritional (also see Glossary) status. Measurable Elements of COP.4 1. Food or nutrition, appropriate to the patient, is regularly available. 2. All patients have an order for food in their record. 3. The order is based on the patient’s nutritional status and needs. 4. Patients have a variety of food choices consistent with their condition and care. 5. When families provide food, they are educated about the patient’s diet limitations. Standard COP.4.1 Food preparation, handling, storage, and distribution are safe and comply with laws, regulations, and current acceptable practices. Intent of COP.4.1 Food preparation, storage, and distribution are monitored to ensure safety and compliance with laws, regulations, and current acceptable practices. Food preparation and storage practices reduce the risk of contamination (also see Glossary) and spoilage. Food is distributed to patients at specified times. Food and nutritional products, including enteral nutrition products, are available to meet special patient needs. Measurable Elements of COP.4.1 1. Food is prepared in a manner that reduces risk of contamination and spoilage. 2. Food is stored in a manner that reduces risk of contamination and spoilage. 3. Enteral nutrition products are stored according to manufacturer recommendations and organization policy. 4. The distribution of food is timely, and special requests are met. 5. Practices meet applicable laws, regulations, and acceptable practices. Standard COP.5 Patients at nutrition risk receive nutrition therapy. Intent of COP.5 On initial assessment, patients are screened to identify those at nutritional risk. These patients are referred to a nutritionist for further assessment. When it is determined that a patient is at nutrition risk, a plan for nutrition therapy (also see Glossary) is carried out. The patient’s progress is monitored and recorded in their record. Physicians, nurses, the dietetics service, and, when appropriate, the patient’s family, collaborate to plan and provide nutrition therapy. (Also see AOP.1.6) Joint Commission International Accreditation Standards for Hospitals, Third Edition Measurable Elements of COP.5 1. Patients assessed at nutrition risk receive nutrition therapy. 2. A collaborative process is used to plan, deliver, and monitor nutrition therapy. (Also see COP.2) 3. The patient’s response to nutrition therapy is monitored. (Also see AOP.2, ME 1) 4. The patient’s response to nutrition therapy is recorded in his or her record. (Also see MCI.19.2, ME 4) Pain Management and End-of-Life Care Patients who are in pain or approaching the end of life and their families require care focused on their unique needs. Patients may experience pain associated with treatments or procedures such as postoperative pain or pain during a physical therapy session, or pain associated with chronic disease or acute illness. Dying patients may also experience other symptoms (also see Glossary) related to the disease process or curative treatments or may need help in dealing with psychosocial, spiritual, and cultural issues associated with death and dying. Families and caregivers may require respite from caring for a terminally ill family member or help in coping with grief and loss. The organization’s goal for managing pain or providing care at the end of life considers the settings in which care or service is provided (such as a hospice or palliative care unit), the type of services provided, and the patient population served. The organization develops processes to manage pain and end-of-life care. These processes assure patients that pain and symptoms will be assessed and appropriately managed; ensure that patients in pain or terminally ill will be treated with dignity and respect; assess patients as frequently as necessary to identify pain and other symptoms; plan preventive and therapeutic approaches to manage pain and other symptoms; and educate patients and staff about managing pain and other symptoms. Standard COP.6 Patients are supported in managing pain effectively. Intent of COP.6 Pain can be a common part of the patient experience; unrelieved pain has adverse physical and psychological effects. The patient’s right to appropriate assessment and management of pain is respected and supported. Based on the scope of services (also see Glossary) provided, the organization has processes to assess and manage pain appropriately, including a) identifying patients with pain during initial assessment and reassessments; b) providing management of pain according to guidelines or protocols (also see Glossary); c) communicating with and educating patients and families about pain and symptom management in the context of their personal, cultural, and religious beliefs (Also see PFR.1.1, ME 1); and d) educating health care providers about pain assessment and management. (Also see PFR.2.4) Measurable Elements of COP.6 1. Based on the scope of services provided, the organization has processes to identify patients in pain. (Also see AOP.1.8.2, ME 1) 2. Patients in pain receive care according to pain management guidelines. 3. Based on the scope of services provided, the organization has processes to communicate with and educate patients and families about pain. (Also see PFE.4, ME 5)
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