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❒ 4. Based on the scope of services provided, the organization has processes to educate staff about pain. (Also see SQE.3, ME 1)

Standard

COP.7 The organization addresses end-of-life care.

Intent of COP.7

Patients who are in pain or dying have unique needs for respectful, compassionate care. To accomplish this, all staff are made aware of the unique needs of patients in pain or at the end of life. Concern for the patient’s comfort and dignity should guide all aspects of care during the final stages of life. End-of-life care provided by the organization includes a) providing appropriate treatment for any symptoms according to the wishes of the patient and family; b) sensitively addressing issues such as autopsy and organ donation; c) respecting the patient’s values, religion, and cultural preferences (Also see PFR.1.1, ME 1); d) involving the patient and family in all aspects of care; and e) responding to the psychological, emotional, spiritual, and cultural concerns of the patient and family.

To accomplish these goals, all staff are made aware of patients’ unique needs at the end of life. (Also see PFR.2.5)

Measurable Elements of COP.7

1. Staff are made aware of patients’ unique needs at the end of life.

2. End-of-life care provided by the organization addresses dying patients’ needs at least including elements a) through e) in the intent statement as appropriate to the patient and family.

Standard

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.

Intent of COP.7.1

Assessments and reassessments need to be individualized to meet patients’ and families’ needs when a patient is

at the end of life. Assessments and reassessments should evaluate, as appropriate

a) symptoms such as nausea and respiratory distress;

b) factors that alleviate or exacerbate physical symptoms;

c) current symptom management and the patient’s response;

d) patient and family spiritual orientation and, as appropriate, any involvement in a religious group;

e) patient and family spiritual concerns or needs such as despair, suffering, guilt, or forgiveness;

f) patient and family psychosocial status such as family relationships, the adequacy of the home environment if care is provided there, coping mechanisms, and the patient’s and family’s reactions to illness;

g) the need for support or respite services for the patient, family, or other caregivers;

h) the need for an alternative setting or level of care; and

i) survivor risk factors (also see Glossary) such as family coping mechanisms and the potential for pathological grief reactions.

Joint Commission International Accreditation Standards for Hospitals, Third Edition

Measurable Elements of COP.7.1

1. Patients and families are assessed and reassessed at least for those elements identified in a) through i) in the intent statement, as appropriate.

2. Assessment findings guide the care and services provided. (Also see AOP.2, ME 2)

Standard

COP.7.2 Care of the dying patient optimizes his or her comfort and dignity.

Intent of COP.7.2

The organization ensures appropriate care of those in pain or dying by

taking interventions to manage pain and primary or secondary symptoms;

preventing symptoms to the extent reasonably possible;

taking interventions that address patient and family psychosocial, emotional, and spiritual needs regarding dying and grieving;

taking interventions that address patient and family religious and cultural concerns; and

involving the patient and family in care decisions.

Measurable Elements of COP.7.2

1. Interventions are taken to manage pain and primary or secondary symptoms. (Also see PFR.2.4, ME 1)

2. Symptoms are prevented to the extent reasonably possible.

3. Interventions address patient and family psychosocial, emotional, and spiritual needs regarding dying and grieving.

4. Interventions address patient and family religious and cultural concerns.

5. The patient and family are involved in care decisions. (Also see PFR.2, ME 1 and PFR.2.1, ME 4)

Anesthesia and Surgical Care (ASC)

Overview

The use of anesthesia, sedation, and surgical interventions are common and complex processes in a health care organization. They require complete and comprehensive patient assessment, integrated care planning, continued patient monitoring (also see Glossary), and criteria-determined transfer (also see Glossary) for continuing care, rehabilitation, and eventual transfer and discharge.

Anesthesia and sedation (also see Glossary) are commonly viewed as a continuum from minimal sedation (also see Glossary) to full anesthesia. As patient response may move along that continuum, anesthesia and sedation use are organized in an integrated manner. Thus, this chapter includes anesthesia and moderate and deep sedation, during which the patient’s protective reflexes needed for ventilatory functions are at risk. This chapter does not address the use of minimal sedation (anxiolysis). Thus, the use of the term “anesthesia” includes moderate and deep sedation.

Note: The anesthesia and surgery standards are applicable in what ever setting anesthesia and/or moderate or deep sedation are used and surgical and other invasive procedures (also see Glossary) that require consent (also see PFR.6.4) are performed. Such settings include hospital operating theaters, day surgery or day hospital units, dental and other outpatient (also see Glossary) clinics, emergency services, intensive care areas, or elsewhere.

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.

ASC.1 Anesthesia services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations and professional standards. ASC.2 A qualified individual(s) is responsible for managing the anesthesia services. ASC.3 Policies and procedures guide the care of patients undergoing moderate and deep sedation. ASC.4 A qualified individual conducts a preanesthesia assessment and preinduction assessment.

ASC.5 Each patient’s anesthesia care is planned and documented. ASC.5.1 The risks, benefits, and alternatives are discussed with the patient, his or her family, or those who make decisions for the patient.

ASC.5.2 The anesthesia used and anesthetic technique are written in the patient record. ASC.5.3 Each patient’s physiological status during anesthesia administration is continuously monitored and written in the patient’s record.

ASC.6 Each patient’s postanesthesia status is monitored and documented, and the patient is discharged from the recovery area by a qualified individual or by using established criteria.

ASC.7 Each patient’s surgical care is planned and documented based on the results of the assessment. ASC.7.1 The risks, benefits, and alternatives are discussed with the patient and his or her family or those who make decisions for the patient.

ASC.7.2 The surgery performed is written in the patient record.

ASC.7.3 Each patient’s physiological status is continuously monitored during and immediately after surgery and written in the patient’s record. ASC.7.4 Patient care after surgery is planned and documented.

Standards, Intents, and Measurable Elements

Organization and Management

Standard

ASC.1 Anesthesia services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations and professional standards.

Intent of ASC.1

The organization has a system for providing anesthesia services (including moderate and deep sedation) required by its patient population, clinical services offered, and health care provider needs. Anesthesia services meet all applicable local and national standards, laws, and regulations.

Anesthesia services, including those required for emergencies, may be provided within the organization, by agreement with another organization, or both. Anesthesia services are available after normal hours for emergencies.

Any use of outside anesthesia sources is based on the recommendation of the director and other individuals responsible for anesthesia services. Outside sources meet applicable laws and regulations and have an acceptable quality and patient safety record.

Measurable Elements of ASC.1

1. Anesthesia services meet applicable local and national standards, laws, and regulations.

2. Adequate, regular and convenient anesthesia services are available to meet patient needs.

3. Anesthesia services are available for emergencies after normal hours of operation.

4. Outside sources are selected based on recommendations of the director, an acceptable record of performance, and compliance with applicable laws and regulations.

Standard

ASC.2 A qualified individual(s) is responsible for managing the anesthesia services.

Intent of ASC.2

Anesthesia services are under the direction of one or more individuals who are qualified by documented training, expertise, and experience, consistent with applicable law and regulation. This individual(s) assumes professional responsibility for the anesthesia services provided. Responsibilities include

developing, implementing, and maintaining policies and procedures;

administrative oversight;

maintaining any necessary quality control program;

recommending outside sources of anesthesia services; and

monitoring and reviewing of all anesthesia services.

Measurable Elements of ASC.2

1. Anesthesia services are under the direction of one or more qualified individuals. (Also see Glossary; GLD.5)

2. Responsibilities include developing, implementing, and maintaining policies and procedures.

3. Responsibilities include administrative oversight.

4. Responsibilities include maintaining quality control programs.

Joint Commission International Accreditation Standards for Hospitals, Third Edition

5. Responsibilities include recommending outside sources of anesthesia services. (Also see GLD.3.3, ME 1)

6. Responsibilities include monitoring and reviewing all anesthesia services.

7. The individual(s) carries out the responsibilities. (Also see GLD.5.5)

Sedation Care

Standard

ASC.3 Policies and procedures guide the care of patients undergoing moderate and deep sedation.

Intent of ASC.3

Sedation—in particular, moderate and deep sedation—poses risks to patients and thus needs to be provided using clear definitions, policies, and procedures. The degrees of sedation occur on a continuum, and a patient may progress from one degree to another, based on the medications administered, route, and dosages. Important considerations include the patient’s ability to maintain protective reflexes; an independent, continuous patent airway; and to respond to physical stimulation or verbal commands.

Sedation policies and procedures identify a) how planning will occur including the identification of differences between adult and pediatric populations,

or other special considerations; b) 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 sedation process; and f) availability and use of specialized equipment.

The qualifications of the physician, dentist, or other qualified individual responsible for the patient receiving moderate and deep sedation are also important. The individual should be competent in g) techniques of various modes of sedation; h) appropriate monitoring; i) response to complications; j) use of reversal agents; and k) at least basic life support.

The responsible qualified individual conducts a presedation assessment of the patient to ensure the planned sedation and level of sedation is appropriate for the patient. Organization policy defines the scope and content of this assessment.

In addition to the physician or dentist, a qualified individual is responsible for providing uninterrupted monitoring of the patient’s physiological parameters and assistance in supportive or resuscitation measures. The qualifications of the individual providing the monitoring and the monitoring equipment and supplies are the same as for sedation provided in other settings within the organization, for example in the operating theatre and the ambulatory dental clinic. Thus, one level of care is maintained. (Also see COP.1, ME 3 and GLD.3.2.1, ME 3)

Definitions of the levels of sedation can be found in the Glossary of this manual.

Measurable Elements of ASC.3

1. Appropriate policies and procedures, addressing at least elements a) through f) found in the intent statement, guide the care of patients undergoing moderate and deep sedation. (Also see AOP.2, ME 2 and MMU.4, ME 1)

2. The qualified individual(s) identified in ASC.2 participates in the development of the policies and procedures.

3. There is a presedation assessment, according to organization policy, to evaluate risk and appropriateness of the sedation for the patient.

4. The qualified practitioner responsible for the sedation is qualified in at least elements g) through k) in the intent statement.

5. A qualified individual monitors the patient during sedation and during the period of recovery from sedation and documents the monitoring.

6. Moderate and deep sedation are administered according to hospital policy.

Anesthesia Care

Standard

ASC.4 A qualified individual conducts a preanesthesia assessment and preinduction assessment.

Intent of ASC.4

Because anesthesia carries a high level of risk, its administration is carefully planned. The patient’s preanesthesia assessment is the basis for that plan and for the use of postoperative analgesia (also see “anesthesis and sedation” in Glossary). The preanesthesia assessment provides information needed to

select the anesthesia and plan anesthesia care;

safely administer an appropriate anesthetic; and

interpret findings of patient monitoring.

An anesthesiologist or another qualified individual conducts the preanesthesia assessment.

The preanesthesia assessment process is carried out in a shortened time frame when an emergency (also see Glossary) or obstetric patient requires anesthesia. As the preanesthesia assessment may be carried out some time prior to admission or prior to the surgical procedure, patients are re-evaluated immediately before the induction of anesthesia.

Measurable Elements of ASC.4

1. A preanesthesia assessment is performed for each patient. (Also see AOP.1.1, ME 1)

2. Patients are re-evaluated immediately before the induction of anesthesia.

3. The two assessments are performed by individual(s) qualified to do so.

4. The two assessments are documented in the clinical record (also see Glossary).

Standard

ASC.5 Each patient’s anesthesia care is planned and documented.

Intent of ASC.5

Anesthesia care is carefully planned and documented in the anesthesia record. The plan considers information

Joint Commission International Accreditation Standards for Hospitals, Third Edition

from other patient assessments and identifies the anesthesia to be used, the method of administration, other medications and fluids, monitoring procedures, and anticipated postanesthesia care.

Measurable Elements of ASC.5

1. The anesthesia care of each patient is planned.

2. The plan is documented.

Standard

ASC.5.1 The risks, benefits, and alternatives are discussed with the patient, his or her family, or those who make decisions for the patient.

Intent of ASC.5.1

The anesthesia planning process includes educating the patient, his or her family, or decision maker on the risks, benefits, and alternatives related to the planned anesthesia and postoperative analgesia. This discussion occurs as part of the process to obtain consent for anesthesia (including moderate and deep sedation) as required in PFR.6.4, ME 2. An anesthesiologist or a qualified individual provides this education.

Measurable Elements of ASC.5.1

1. The patient, family, and decision makers are educated on the risks, benefits, and alternatives of anesthesia. (Also see PFR.6.4, ME 2)

2. The anesthesiologist or another qualified individual provides the education.

Standard

ASC.5.2 The anesthesia used and anesthetic technique are written in the patient record.

Intent of ASC.5.2

The anesthesia used and the anesthetic technique are written in the patient’s anesthesia record.

Measurable Elements of ASC.5.2

1. The anesthesia used is written into the patient’s anesthesia record. (Also see COP.2.1, ME 6 and MCI.19.1, ME 4)

2. The anesthetic technique used is written into the patient’s anesthesia record.

Standard

ASC.5.3 Each patient’s physiological status during anesthesia administration is continuously monitored and written in the patient’s record.

Intent of ASC.5.3

Physiological monitoring provides reliable information about the patient’s status during the administration of anesthesia and the recovery period. Monitoring methods depend on the patient’s preanesthesia status, anesthesia choice, and complexity of the surgical or other procedure performed during anesthesia. In all cases, however, the monitoring process is continuous, and the results are written into the patient’s record.

Measurable Elements of ASC.5.3

1. Physiological status is continuously monitored during anesthesia administration. (Also see AOP.2, ME 1)

2. The results of monitoring are written into the patient’s anesthesia record. (Also see MCI.19.1, ME 4)

Standard

ASC.6 Each patient’s postanesthesia status is monitored and documented, and the patient is discharged from the recovery area by a qualified individual or by using established criteria.

Intent of ASC.6

Monitoring during anesthesia is the basis for monitoring during the postanesthesia recovery period. The ongoing, systematic collection and analysis of data (also see Glossary) on the patient’s status in recovery support decisions about moving the patient to other settings and less intensive services. Recording of monitoring data provides the documentation to support discharge decisions.

Discharge from the postanesthesia recovery areas is by one of the following alternative ways: a) The patient is discharged by a fully qualified anesthesiologist or other individual authorized by the individual(s) responsible for managing the anesthesia services. b) The patient is discharged by a nurse or similarly qualified individual in accordance with postanesthesia criteria developed by the hospital’s leaders, and the discharge is documented in the patient’s record.

c) The patient is discharged to a unit which has been designated as appropriate for postanesthesia or postsedation care of selected patients, such as a cardiovascular intensive care unit, neurosurgical intensive care unit, among others.

The time of arrival and discharge from the recovery area are recorded.

Measurable Elements of ASC.6

1. Patients are monitored appropriate to their condition during the postanesthesia recovery period. (Also see AOP.2, ME 3)

2. Monitoring findings are entered into the patient’s record. (Also see MCI.19.1, ME 4)

3. Patients are discharged from the postanesthesia unit in accordance with the alternatives described in a) through c) found in the intent statement.

4. Recovery area arrival and discharge times are recorded.

Surgical Care

Standard

ASC.7 Each patient’s surgical care is planned and documented based on the results of the assessment.

Intent of ASC.7

Because surgery carries a high level of risk, its use is carefully planned. The patient’s assessment(s) is the basis

for selecting the appropriate surgical procedure. Assessment(s) provide information necessary to

select the appropriate procedure and the optimal time;

perform procedures safely; and

interpret findings of patient monitoring.

Procedure selection depends on the patient’s history, physical status, and diagnostic data as well as the risks and benefits of the procedure for the patient. Procedure selection considers the information from the admitting assessment, diagnostic test, and other available sources. The assessment process is carried out in a shortened time frame when an emergency patient needs surgery.

The surgical care planned for the patient is documented in the patient’s record, including a preoperative diagnosis. The name of the surgical procedure alone does not constitute a diagnosis.

Measurable Elements of ASC.7

1. Each patient’s surgical care is planned.

2. The planning process considers all available assessment information. (Also see AOP.1.5.1, ME 1; AOP.5.3, ME 3; and AOP.6.4, ME 3)

3. Prior to the procedure, a preoperative diagnosis is documented. (Also see MCI.19.1, ME 2)

4. Prior to the procedure, the planned surgical care is documented.

Standard

ASC.7.1 The risks, benefits, and alternatives are discussed with the patient and his or her family or those who make decisions for the patient.

Intent of ASC.7.1

Patients and their families or decision makers receive adequate information to participate in care decisions and provide the informed consent (also see Glossary) required in PFR.6.4. The information includes

the risks of the planned procedure;

the benefits of the planned procedure;

the potential complications; and

the surgical and nonsurgical options (alternatives) available to treat the patient.

In addition, when blood or blood products may be needed, information on the risks and alternatives are discussed. The patient’s surgeon or other qualified individual provides this information.

Measurable Elements of ASC.7.1

1.The patient, family, and decision makers are educated on the risks, benefits, potential complications and alternatives related to the planned surgical procedure. (Also see PFR.6.4, ME 1)

2.The education includes the need for, risk and benefits of, and alternatives to blood and blood product use.

3.The patient’s surgeon or other qualified individual provides the education. (Also see PFR.6.1, ME 2)

Standard

ASC.7.2 The surgery performed is written in the patient record.

Intent of ASC.7.2

A patient’s postsurgical care depends on the events and findings of the surgical procedure. Thus, the patient’s record includes a postoperative diagnosis, a description of the surgical procedure and findings (including surgical specimens sent for examination), and the names of the surgeon and surgical assistants. To support a continuum of postsurgical supportive care, the written surgical report or note is available prior to the patient leaving the postanesthesia recovery area. (Also see COP.2.1, ME 6)

Measurable Elements of ASC.7.2

1. A postoperative diagnosis is documented.

2. A description of the surgical procedure, findings, and any surgical specimens is documented. (Also see COP.2.3, MEs 1 and 2)

3. The names of the surgeon and surgical assistants are documented.

4. The written surgical report, or a brief note in the patient’s record, is available before the patient leaves the postanesthesia recovery area.

Standard

ASC.7.3 Each patient’s physiological status is continuously monitored during and immediately after surgery and written in the patient’s record.

Intent of ASC.7.3

The patient’s physiological status is monitored during surgery and immediately after. The monitoring is appropriate to the patient’s condition and the procedure performed.

Results of monitoring trigger key intraoperative decisions as well as postoperative decisions such as return to surgery, transfer to another level of care, or discharge. Monitoring information guides medical and nursing care and identifies the need for diagnostic and other services. Monitoring findings are entered into the patient’s record. This requirement is related to the same requirement for physiological monitoring during anesthesia (also see ASC.5.3). It will be scored here only if the procedure was performed under a local anesthetic with no general or regional anesthesia or sedation.

Measurable Elements of ASC.7.3

1. The patient’s physiological status is monitored continuously during surgery. (Also see AOP.2, ME 1)

2. The patient’s physiological status is monitored during the immediate postsurgery period. (Also see AOP.2, ME 1)

3. Findings are entered into the patient’s record. (Also see MCI.19.1, ME 4)

Standard

ASC.7.4 Patient care after surgery is planned and documented.

Intent of ASC.7.4

Each patient’s postsurgical medical and nursing care needs differ. Therefore, it is necessary to plan for that care, including the level of care, care setting, follow-up monitoring or treatment, and need for medication. Postsurgical care planning can begin before surgery based on the patient’s assessed needs and condition. The planned care is documented in the patient’s record to ensure continuity of services during the recovery or rehabilitative period.

Measurable Elements of ASC.7.4

1. Each patient’s medical, nursing, and other postsurgical care is planned.

2. The plan(s) is documented in the patient’s record.

Medication Management and Use (MMU)

Overview

Medication management is an important component in palliative (also see Glossary), symptomatic, preventive (also see Glossary), and curative treatment of diseases and conditions. Medication management encompasses the system and processes an organization uses to provide pharmacotherapies to its patients. This is usually a multidisciplinary (also see Glossary), coordinated effort of staff of a health care organization, applying the principles of effective process design, implementation, and improvement to the selecting, procuring, storing, ordering/prescribing, transcribing, distribution, preparing, dispensing, administering, documenting, and monitoring (also see Glossary) of medication therapies. While health care providers’ roles in medication management vary greatly from one country to another, sound medication management processes for patient safety are universal.

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.

MMU.1 Medication use in the organization complies with applicable laws and regulations and is efficiently

organized to meet patient needs. MMU.1.1 An appropriately licensed pharmacist, technician, or other trained professional supervises the pharmacy or pharmaceutical service.

MMU.2 An appropriate selection of medications for prescribing or ordering is stocked or readily available. MMU.2.1 There is a method for overseeing the organization’s medication list and medication use. MMU.2.2 The organization can readily obtain medications not stocked or normally available to the

organization or for times when the pharmacy is closed. MMU.3 Medications are properly and safely stored.

MMU.3.1 Organization policy supports appropriate storage of medications and applicable nutrition products. MMU.3.2 Emergency medications are available, monitored, and safe when stored out of the pharmacy. MMU.3.3 The organization has a medication recall system.

MMU.4 Prescribing, ordering and transcribing are guided by policies and procedures. MMU.4.1 The organization defines the elements of a complete order or prescription and the types of orders that are acceptable for use.

MMU.4.2 The organization identifies those qualified individuals permitted to prescribe or order medications. MMU.4.3 Medications prescribed and administered are written in the patient’s record. MMU.5 Medications are prepared and dispensed in a safe and clean environment.

MMU.5.1 Medication prescriptions or orders are reviewed for appropriateness. MMU.5.2 A system is used to dispense medications in the right dose to the right patient at the right time.

MMU.6 The organization identifies those qualified individuals permitted to administer medications.

MMU.6.1 Medication administration includes a process to verify the medication is correct based on the medication order. MMU.6.2 Policies and procedures govern medications brought into the organization for patient self-

administration or as samples. MMU.7 Medication effects on patients are monitored. MMU.7.1 Medication errors are reported through a process and time frame defined by the organization.

Standards, Intents, and Measurable Elements

Organization and Management

Standard

MMU.1 Medication use in the organization complies with applicable laws and regulations and is efficiently organized to meet patient needs.

Intent of MMU.1

Medications, as an important resource in patient care, must be organized effectively and efficiently. Medication management is not only the responsibility of the pharmaceutical service but also of managers and clinical care providers. How this responsibility is shared depends on the organization’s structure and staffing. In those cases where a pharmacy is not present, medications may be managed on each clinical unit according to organization policy. In other cases, where a large central pharmacy is present, the pharmacy may organize and control medications throughout the organization. Effective medication management includes all parts of the organization, inpatient (also see Glossary), outpatient (also see Glossary), and specialized units. Applicable laws and regulations are incorporated into the organizational structure and the operations of the medication management system used in the organization. To ensure efficient and effective medication management and use, the organization conducts a systems review at least once a year. The review includes the selection and procurement of medications, storage, ordering and transcribing, preparing and dispensing, administration and monitoring. The review considers evidence-based practices (also see Glossary), internal quality data (also see Glossary), and documented improvements to understand the need and priority of continued system improvements in quality and safety.

Measurable Elements of MMU.1

1. There is a plan or policy or other document that identifies how medication use is organized and managed throughout the organization.

2. All settings, services and individuals who manage medication processes are included in the organizational structure.

3. Policies guide all phases of medication management and medication use in the organization.

4. There is at least one documented review of the medication management system within the previous 12 months.

5. The pharmacy or pharmaceutical service and medication use comply with applicable laws and regulations.

6. Appropriate sources of drug information are readily available to those involved in medication use.

Standard

MMU.1.1 An appropriately licensed pharmacist, technician, or other trained professional supervises the pharmacy or pharmaceutical service.

Intent of MMU.1.1

A qualified individual (also see Glossary) directly supervises the activities of the pharmacy or pharmaceutical service. The individual is appropriately licensed, certified, and trained. Supervision includes all of the processes described in MMU.2 through MMU.5, and participation in MMU.7 through MMU.7.1.

Joint Commission International Accreditation Standards for Hospitals, Third Edition

Measurable Elements of MMU.1.1

1. An appropriately licensed, certified, and trained individual supervises all activities. (Also see GLD.5, ME 1)

2. The individual provides supervision for the processes described in MMU.2 through MMU.5.

Selection and Procurement

Standard

MMU.2 An appropriate selection of medications for prescribing or ordering is stocked or readily available.

Intent of MMU.2

Every organization must decide which medications to make available for prescribing and ordering by the care providers. This decision is based on the organization’s mission, patient needs, and types of services provided. The organization develops a list (often referred to as a formulary) of all of the medications it stocks or that are readily available from outside sources. In some cases, laws or regulations may determine the medications on the list or the source of those medications. Medication selection is a collaborative process that considers patient need and safety as well as economics.

Medications are occasionally out of stock due to delayed delivery, national shortages or other reasons not anticipated through normal inventory control. There is a process to notify prescribers of the shortage and suggested substitutes.

Measurable Elements of MMU.2

1. Medications available for prescribing and ordering are appropriate to the organization’s mission, patient needs, and services provided.

2. There is a list of medications stocked in the organization or readily available from outside sources.

3. A collaborative process was used to develop the list (unless determined by regulation or an authority outside the organization).

4. There is a process established for when medications are not available that includes a notification to prescribers and suggested substitutions.

Standard

MMU.2.1 There is a method for overseeing the organization’s medication list and medication use.

Intent of MMU.2.1

The organization has a method, such as designating a committee, to maintain and monitor the medication list and to monitor the use of medications in the organization. Those involved in the oversight of the list include health care practitioners involved in the ordering, dispensing, administering, and monitoring process for medications. Decisions to add or remove medications from the list are guided by criteria that include the indication for use, effectiveness, risks, and costs. There is a process or mechanism to monitor patient response to newly added medications. For example, when the decision is made to add a new type of medication or a new class of drugs to the list, there is a process to monitor appropriateness of indication, how the drug is prescribed (dosage or route, for example) and any unanticipated adverse events (also see Glossary) or conditions associated with the new drug during the introductory period.

The list is reviewed at least annually based on emerging safety and efficacy information and information on usage and adverse events. Associated with the overall management of medications is the need to ensure that medications are protected from loss or theft from the pharmacy or any other location where medications are stored or dispensed.

Measurable Elements of MMU.2.1

1.There is a method for overseeing medication use in the organization.

2.Medications are protected from loss or theft throughout the organization.

3. Health care practitioners involved in ordering, dispensing, administering, and monitoring processes are involved in monitoring and maintaining the medication list.

4. Decisions to add or remove medications from the list are guided by criteria.

5. There is a process or mechanism to monitor patient response to medications newly added to the list.

6. The list is reviewed at least annually based on safety and efficacy information.

Standard

MMU.2.2 The organization can readily obtain medications not stocked or normally available to the organization or for times when the pharmacy is closed.

Intent of MMU.2.2

On occasion, medications not stocked or readily available to the organization are needed. There is a process to approve and procure such medications. Also, there are occasions when medications are needed during the night or when the pharmacy is closed or medication supply locked. Each organization needs to plan for these occurrences and educate staff on procedures to follow in the event they occur. (Also see GLD.3.2.1, ME 2)

Measurable Elements of MMU.2.2

1. There is a process to approve and procure required medications not stocked or normally available to the organization. (Also see GLD.3.2.1, ME 1)

2. There is a process to obtain medications at times the pharmacy is closed or medication supply locked. (Also see GLD.3.2.1, ME 2)

3. Staff understand the processes.

Storage

Standard

MMU.3 Medications are properly and safely stored.

Intent of MMU.3

Medications may be stored within a storage area, in a pharmacy or pharmaceutical service, or on the patient care units in unit pharmacies or the nursing station in the clinical unit. Standard MMU.1 provides the oversight mechanism for all locations that medications are stored. In all locations that medications are stored, the following is evident: a) Medications are stored under conditions suitable for product stability; b) Controlled substances are accurately accounted for according to applicable law and regulation; c) Medications and chemicals used to prepare medications are accurately labeled with contents, expiration

dates, and warnings;

d) Concentrated electrolytes are not stored in care units unless clinically necessary, and when stored in care units there are safeguards in place to prevent inadvertent administration (scored at International Patient Safety Goal 3, MEs 1 and 2);

e) All medication storage areas are periodically inspected according to hospital policy to ensure medications are stored properly; and

f) Organization policy defines how medications brought in by the patient are identified and stored.

Measurable Elements of MMU.3

Each element a) through f) found in the intent statement is scored separately as they represent critical or high-risk areas.

1. Medications are stored under conditions suitable for product stability.

2. Controlled substances are accurately accounted for according to applicable law and regulation.

3. Medications and chemicals used to prepare medications are accurately labeled with contents, expiration dates, and warnings.

4. All medication storage areas are periodically inspected according to hospital policy to ensure medications are stored properly.

5. Organization policy defines how medications brought in by the patient are identified and stored.

Standard

MMU.3.1 Organization policy supports appropriate storage of medications and applicable nutrition products.

Intent of MMU.3.1

There are some types of medications that because of their high risk (radioactive medications), unusual circumstances (brought in by the patient), opportunity for abuse or misuse (sample medications and emergency medications) or their special nature (applicable nutritional products) are best supported by policies that guide storage and control of use. The policies address the receipt process, the identification of the medication, if necessary, the storage and any distribution.

Measurable Elements of MMU.3.1

1. Organization policy defines how appropriate nutrition products are stored.

2. Organization policy defines how radioactive, investigational and similar medications are stored.

3. Organization policy defines how sample medications are stored and controlled.

4. Organization policy defines how emergency medications are stored and maintained.

5. All storage is according to organization policy.

Standard

MMU.3.2 Emergency medications are available, monitored, and safe when stored out of the pharmacy.

Intent of MMU.3.2

When patient emergencies occur, quick access to appropriate emergency medications is critical. Each organization plans the location of emergency medications and the medications to be supplied in these locations. For example, agents to reverse anesthesia are found in the operating theatres. Emergency cabinets, carts, bags, or boxes can be used for this purpose. To ensure access to emergency medications when needed, the organization establishes a procedure or process to prevent abuse, theft, or loss of the medications. The process ensures that medications are replaced when used, damaged, or out-of-date. Thus, the organization understands the balance between ready access and security for locations where emergency medications are stored.

Measurable Elements of MMU.3.2

1. Emergency medications are available in the units they will be needed or readily accessible within the organization to meet emergency needs. (Also see GLD.3.2.1, ME 1 and MMU.2.2, ME 1)

2. Emergency medications are protected from loss or theft.

3. Emergency medications are monitored and replaced in a timely manner after use or when expired or damaged.

Standard

MMU.3.3 The organization has a medication recall system.

Intent of MMU.3.3

The organization has a process for identifying, retrieving, and returning or destroying medications recalled by the manufacturer or supplier. There is a policy or procedure that addresses any use of or the destruction of medications known to be expired or outdated.

Measurable Elements of MMU.3.3

1. There is a medication recall system in place.

2. Policies and procedures address any use of medications known to be expired or outdated.

3. Policies and procedures address the destruction of medications known to be expired or outdated.

4. Policies and procedures are implemented.

Ordering and Transcribing

Standard

MMU.4 Prescribing, ordering, and transcribing are guided by policies and procedures.

Intent of MMU.4

Safe prescribing, ordering, and transcribing are guided by organization policies and procedures. Medical, nursing, pharmacy, and administrative staff collaborate to develop and monitor the policies and procedures. Relevant staff are trained in correct prescribing, ordering, and transcribing practices. As illegible medication prescriptions or orders jeopardize patient safety and may delay treatment, organization policy addresses actions to reduce illegibility.

A listing of all current medications is recorded in the patient’s record (also see Glossary) and is available to the pharmacy, nurses, and physicians.

Measurable Elements of MMU.4

1. Policies and procedures guide the safe prescribing, ordering and transcribing of medications in the organization. (Also see COP.2.2, ME 1; AOP.3, ME 1; and International Patient Safety Goal 2, ME 1)

2. Policies and procedures address actions related to illegible prescriptions and orders.

3. There is a collaborative process to develop the policies and procedures.

4. Relevant staff is trained in correct prescribing, ordering, and transcribing practices.

5. Patient records contain a list of current medications taken prior to admission and this information is

made available to the pharmacy and the patient’s care providers.

Standard

MMU.4.1 The organization defines the elements of a complete order or prescription and the types of orders that are acceptable for use.

Intent of MMU.4.1

To reduce the variation (also see Glossary) and improve patient safety, the organization defines in policy the acceptable elements of a complete order or prescription. The elements addressed in the policy(s) include at least the following: a) The data necessary to accurately identify the patient. b) The elements of the order or prescription. c) When generic or brand names are acceptable or required. d) Whether or when indications for use are required on a PRN (pro re nata, or “as needed”) or other medication

order. e) Special precautions or procedures for ordering drugs with look-alike or sound-alike names. f) Actions to be taken when medication orders are incomplete, illegible, or unclear. g) The permitted additional types of orders such as emergency, standing, automatic stop, etc., orders and any

elements required in such orders. h) The use of verbal and telephone medication orders and the process to verify such orders. (Also see International Patient Safety Goal 2, ME 1) i) The types of orders that are weight based, such as for pediatric populations.

Thus, this standard sets organization-wide expectations for medication orders. The implemented policy will be reflected in complete orders entered in the patient record, the pharmacy or dispensing unit receiving the information needed for dispensing, and the administration of the medication based on a complete order.

Measurable Elements of MMU.4.1

Elements a) through i) found in the intent statement are scored together as they represent aspects of the organization’s policy on complete orders.

1. Acceptable medication orders or prescriptions are defined in policy(s) and at least elements a) through i) are addressed in the policy(s).

2. Medication orders or prescriptions are complete per organization policy.

Standard

MMU.4.2 The organization identifies those qualified individuals permitted to prescribe or order medications.

Intent of MMU.4.2

Selecting a medication to treat a patient requires specific knowledge and experience. Each organization is responsible for identifying those individuals with the requisite knowledge and experience and who are also permitted by licensure (also see Glossary), certification (also see Glossary), laws, or regulations to prescribe or order medications. An organization may place limits on prescribing or ordering by an individual, such as for controlled substances, chemotherapy agents, or radioactive and investigational medications. Individuals permitted to prescribe and order medications are known to the pharmaceutical service or others who dispense

medications. In emergency situations, the organization identifies any additional individuals permitted to

prescribe or order medications.

Measurable Elements of MMU.4.2

1. Only those permitted by the organization and by relevant licensure, laws and regulations prescribe or order medications.

2. There is a process to place limits, when appropriate, on the prescribing or ordering practices of individuals. (Also see SQE.10, ME 1)

3. Individuals permitted to prescribe and order medications are known to the pharmaceutical service or others who dispense medications.

Standard

MMU.4.3 Medications prescribed and administered are written in the patient’s record.

Intent of MMU.4.3

The record of each patient who receives medication contains a list of the medications prescribed or ordered for the patient and the dosage and times the medication was administered. Included are medications administered “as needed.” If this information is recorded on a separate medication form, the form is inserted in the patient’s record at discharge or transfer (also see Glossary).

Measurable Elements of MMU.4.3

1. Medications prescribed or ordered are recorded for each patient.

2. Medication administration is recorded for each dose.

3. Medication information is kept in the patient’s record or inserted into his or her record at discharge or transfer.

Preparing and Dispensing

Standard

MMU.5 Medications are prepared and dispensed in a safe and clean environment.

Intent of MMU.5

The pharmacy or pharmaceutical service prepares and dispenses medications in a clean and safe environment that complies with law, regulation, and professional practice standards. The organization identifies the standards of practice for a safe and clean preparation and dispensing environment. Medications stored and dispensed from areas outside the pharmacy, for example, patient care units, comply with the same safety and cleanliness measures. Staff preparing compounded sterile products (such as IVs and epidurals) are trained in the principles of aseptic technique. Similarly, hooded vents are available and used when indicated by professional practices, for example, cytotoxic medications.

Measurable Elements of MMU.5

1. Medications are prepared and dispensed in clean and safe areas with appropriate equipment and supplies. (Also see PCI.7, MEs 1 and 2)

2. Medications preparation and dispensing adhere to law, regulation, and professional standards of practice.

Joint Commission International Accreditation Standards for Hospitals, Third Edition

❒ 3. Staff preparing sterile products are trained in aseptic techniques.

Standard

MMU.5.1 Medication prescriptions or orders are reviewed for appropriateness.

Intent of MMU.5.1

The licensed pharmacist, technician, or trained professional reviews each prescription or order, newly prescribed or ordered, for appropriateness or when the dosage or other appropriateness factors change. The organization defines what patient-specific information is required for the effective review of the order or prescription. This occurs prior to dispensing or prior to administration when medications are dispensed from locations other than the pharmacy. When questions arise, the individual who prescribed or ordered the medication is contacted.

The process to review an order or prescription includes evaluation of a) the appropriateness of the drug, dose, frequency, and route of administration; b) therapeutic duplication (also see Glossary); c) real or potential allergies or sensitivities; d) real or potential interactions between the medication and other medications or food; e) variation (also see Glossary) from organization criteria for use; f) patient’s weight and other physiological information; and g) other contraindications.

Those who review medication orders or prescriptions are competent to do so by virtue of education and training, as specified by privileging (also see Glossary), or have demonstrated competency in the review process. In addition, the review for appropriateness may not be necessary or appropriate in an emergency or when the ordering physician is present (for example, the operating room or the emergency department), or in interventional radiology or diagnostic imaging where the medication is part of the procedure.

To facilitate review, there is a record (profile) for all medication administered to a patient except emergency medications and those administered as part of a procedure. When computer software programs are used to cross-check drug/drug interactions and drug allergies, the software is updated on an appropriate schedule.

Measurable Elements of MMU.5.1

1. The organization defines the patient-specific information required for an effective review process. (Also see MCI.4, MEs 1 and 3)

2. Each prescription or order is reviewed for appropriateness and includes elements a) through g) in the intent. Thus, each prescription or order is evaluated for appropriateness review.

3. Each prescription or order is reviewed for appropriateness prior to dispensing.

4. There is a process to contact the individual who prescribed or ordered the medication when questions arise.

5. Individuals permitted to review orders or prescriptions are judged competent to do so.

6. Review is facilitated by a record (profile) for all patients receiving medications.

7. Computer software, when used to cross-check drugs for drug/drug interactions and allergies, is periodically updated.

Standard

MMU.5.2 A system is used to dispense medications in the right dose to the right patient at the right time.

Intent of MMU.5.2

The organization dispenses medications in the most ready-to-administer form possible to minimize opportunities for error during distribution and administration. The central pharmacy and other medication-distribution points throughout the organization use the same system. The system supports accurate dispensing of medications in a timely manner.

Measurable Elements of MMU.5.2

1. There is a uniform medication dispensing and distribution system in the organization.

2. Medications are appropriately labeled after preparation.

3. Medications are dispensed in the most ready to administer form.

4. The system supports accurate dispensing.

5. The system supports timely dispensing.

Administration

Standard

MMU.6 The organization identifies those qualified individuals permitted to administer medications.

Intent of MMU.6

Administering a medication to treat a patient requires specific knowledge and experience. Each organization is responsible for identifying those individuals with the requisite knowledge and experience and who are also permitted by licensure, certification, laws or regulations to administer medications. An organization may place limits on medication administration by an individual, such as for controlled substances or radioactive and investigational medications. In emergency situations, the organization identifies any additional individuals permitted to administer medications.

Measurable Elements of MMU.6

1. The organization identifies those individuals, by job description (also see Glossary) or the privileging process, authorized to administer medications.

2. Only those permitted by the organization and by relevant licensure, laws and regulations administer medications.

3. There is a process to place limits, when appropriate, on the medication administration of individuals. (Also see SQE.13, MEs 1 and 2)

Standard

MMU.6.1 Medication administration includes a process to verify the medication is correct based on the medication order.

Intent of MMU.6.1

The safe administration of medications includes verifying the a) medication with the prescription or order; b) time and frequency of administration with the prescription or order; c) dosage amount with the prescription or order; d) route of administration with the prescription or order; and

e) identity of the patient. (Scored at International Patient Safety Goal 1, ME 3)

The organization defines the verification process to be used in administering medications.

When the medication is prepared and dispensed on the patient care unit, then the process of appropriateness review described in MMU.5.1 must also be carried out by a qualified individual.

Measurable Elements of MMU.6.1

1. Medications are verified with the prescription or order.

2. The dosage amount of the medication is verified with the prescription or order.

3. The route of administration is verified with the prescription or order.

4. Medications are administered on a timely basis.

5. Medications are administered as prescribed and noted in the patient’s record.

Standard

MMU.6.2 Policies and procedures govern medications brought into the organization for patient self-administration or as samples.

Intent of MMU.6.2

Overseeing medication use in an organization requires an understanding of the sources and uses of medications that are not prescribed or ordered in the organization. Medications brought into the organization by the patient or his or her family are known to the patient’s physician and noted in the patient’s record. The self-administration of medications—either those brought into the organization or those prescribed or ordered within the organization—is known to the patient’s physician and noted in the patient’s record.

The organization controls the availability and use of medication samples.

Measurable Elements of MMU.6.2

1. Policies and procedures are implemented to govern patient self-administration of medications.

2. Policies and procedures are implemented to govern the documentation and management of any medications brought into the organization for or by the patient.

3. Policies and procedures are implemented to govern the availability and use of medication samples.

Monitoring

Standard

MMU.7 Medication effects on patients are monitored.

Intent of MMU.7

The patient, his or her physician, nurse, and other care providers work together to monitor patients on medications. The purposes of monitoring are to evaluate the medication’s effect on the patient’s symptoms or illness, as well as blood count, renal function, liver function and other monitoring with select medications, and to evaluate the patient for adverse effects. Based on monitoring, the dosage or type of medication can be adjusted when needed. It is appropriate to closely monitor the patient’s response to the first dose(s) of a medication new to the patient. Such monitoring is intended to identify the anticipated therapeutic response as well as allergic responses, unanticipated drug/drug interactions, a change in the patient’s equilibrium raising the risk of falls, etc.

Monitoring medication effects includes observing and documenting any adverse effects. The organization has a policy that identifies all adverse effects that are to be recorded and those that must be reported. The organization establishes a mechanism for reporting adverse events when required and the time frame for reporting.

Measurable Elements of MMU.7

1. Medication effects on patients are monitored, including adverse effects. (Also see AOP.2, ME 1)

2. The monitoring process is collaborative.

3. The organization has a policy that identifies those adverse effects that are to be recorded in the patient’s record and those that must be reported to the organization. (Also see QPS.6, ME 3)

4. Adverse effects are documented in the patient’s record as required by policy.

5. Adverse effects are reported in the time frame required by policy.

Standard

MMU.7.1 Medication errors are reported through a process and time frame defined by the organization.

Intent of MMU.7.1

The organization has a process to identify and report medication errors (also see Glossary) and near misses (also see Glossary). The process includes defining a medication error (also see Glossary) and near miss, using a standardized format for reporting, and educating staff on the process and importance of reporting. The reporting process is part of the organization’s quality and patient safety program. (Also see QPS.7) The program focuses on preventing medication errors through understanding the types of errors that occur in the organization and in other organizations, and why near misses occur. Improvements in medication processes and staff training are used to prevent errors in the future. The pharmacy participates in such staff training.

Measurable Elements of MMU.7.1

1. A medication error and near miss are defined. (Also see QPS.6, ME 4 and QPS.7, ME 1)

2. Medication errors and near misses are reported in a timely manner using an established process. (Also see QPS.7, ME 2)

3. The organization uses medication errors and near misses reporting information to improve medication use processes. (Also see QPS.7, ME 3)

Patient and Family Education (PFE)

Overview

Patient and family education helps patients better participate in their care and make informed care decisions. Many different staff in the organization educate patients and families. Education takes place when the patient interacts with his or her physician(s) or the nurse(s). Others provide education as they provide specific services such as rehabilitation or nutrition therapy (also see Glossary) or prepare the patient for discharge and continuing care. Because many staff help educate patients and families, it is important that staff members coordinate their activities and focus on what patients need to learn.

Effective education thus begins with an assessment of the patient and family’s learning needs. This assessment determines not only what needs to be learned, but how the learning can best occur. Learning is most effective when it suits an individual’s learning preferences, religious and cultural values, and reading and language skills, as well as when it occurs at appropriate points in the care process.

Education includes both the knowledge needed during the care process and the knowledge needed after the patient is discharged to another care site or home. Thus, education can include information on community resources for additional care and required follow-up care and how to access emergency services if necessary. Effective education in an organization employs available electronic and visual formats and a variety of distance learning and other techniques.

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.

PFE.1 The organization provides education that supports patient and family participation in care decisions and care processes. PFE.2 Each patient’s educational needs are assessed and recorded in his or her record. PFE.2.1 The patient’s and family’s ability to learn and willingness to learn are assessed.

PFE.3 Education and training help meet patients’ ongoing health needs. PFE.4 Patient and family education include the following topics, as appropriate to the patient’s care: the safe use of medications, the safe use of medical equipment, potential interactions between medications and food, nutritional guidance, pain management, and rehabilitation techniques.

PFE.5 Education methods consider the patient’s and family’s values and preferences and allow sufficient interaction among the patient, family, and staff for learning to occur. PFE.6 Health professionals caring for the patient collaborate to provide education.

Joint Commission International Accreditation Standards for Hospitals, Third Edition

Standards, Intents, and Measurable Elements

Standard

PFE.1 The organization provides education that supports patient and family participation in care decisions and care processes.

Intent of PFE.1

Health care organizations educate patients and families so that they have the knowledge and skills to participate in the patient care processes (also see Glossary) and care decisions. Each organization builds education into care processes based upon its mission, services provided, and patient population. Education is planned to ensure that every patient is offered the education he or she requires. The organization chooses how it organizes its educational resources in an efficient and effective manner. Thus, organizations may choose to appoint an education coordinator or education committee, create an education service, or simply work with all staff to provide education in a coordinated manner.

Measurable Elements of PFE.1

1. The organization plans education consistent with its mission, services, and patient population.

2. There is an appropriate structure or mechanism for education throughout the organization.

3. Education resources are organized in an efficient and effective manner.

Standard

PFE.2 Each patient’s educational needs are assessed and recorded in his or her record.

Intent of PFE.2

Education focuses on the specific knowledge and skills the patient and family will need to make care decisions, participate in their care, and continue care at home. This is in contrast to the general flow of information between staff and the patient that is informative but not of an educational nature. To understand the educational needs of each patient and their family, there is an assessment process that identifies the types of surgeries, other invasive procedures (also see Glossary) and treatments planned, the accompanying nursing needs, and the continuing care needs following discharge. This assessment permits the patient’s care givers to plan and deliver the needed education.

Organization staff inform and educate patients and families at appropriate times in the care process. Education provided as part of the process of obtaining informed consent (also see Glossary) for treatment (for example, for surgery and anesthesia) is documented in the patient’s record (also see Glossary). Education is also provided to support other care decisions of patients and families. In addition, when a patient or family directly participates in providing care (for example, changing dressings, feeding the patient, administering medications and treatments), they need to be educated.

Once the educational needs are identified, they are recorded in the patient’s record. This helps all the patient’s caregivers participate in the education process. Each organization decides the location and format for educational assessment, planning, and delivery of information in the patient’s record.

Measurable Elements of PFE.2

1. The educational needs of the patient and family are assessed.

2. Educational needs assessment findings are recorded in the patient’s record.

3. There is uniform recording of patient education by all staff.

4. Patients and families learn about how to grant informed consent if appropriate. (Also see PFR.2.1,

ME 3 and MCI.3, MEs 1 and 2)

5. Patients and families learn about how to participate in care decisions. (Also see PFR.2, ME 1)

6. Patients and families learn about their condition and any confirmed diagnosis. (Also see PFR.2.1, ME 1)

7. Patients and families learn about their right to participate in the care process as appropriate. (Also see PFR.2.1, ME 4)

Standard

PFE.2.1 The patient’s and family’s ability to learn and willingness to learn are assessed.

Intent of PFE.2.1

Knowledge and skills strengths and deficits are identified and used to plan the education. There are many patient variables that determine if the patient and family are willing and capable to learn. Thus, to plan the education, the organization must assess a) the patient’s and family’s beliefs and values; b) their literacy, educational level, and language; c) emotional barriers and motivations; d) physical and cognitive limitations; and e) the patient’s willingness to receive information.

Measurable Elements of PFE.2.1

1.The patient and family are assessed on elements a) through e) of the intent. (Also see PFR.1.1, ME 1)

2.The assessment findings are used to plan the education.

Standard

PFE.3 Education and training help meet patients’ ongoing health needs.

Intent of PFE.3

Patients frequently require follow-up care to meet ongoing health needs or achieve their health goals. General health information provided by the organization, or from community resources, may include when to resume daily activities postdischarge, preventive (also see Glossary) practices relevant to the patient’s condition or health goals, and, when appropriate, information on coping with disease or disability.

The organization identifies educational and training resources available in the community. In particular, community organizations that support health promotion and disease prevention are identified and, when possible, ongoing relationships are established.

Measurable Elements of PFE.3

1.Patients and families receive education and training to meet their ongoing health needs or achieve their health goals. (Also see MCI.3, MEs 1 and 2)

2.The organization identifies and establishes relationships with community resources that support continuing health promotion and disease prevention education. (Also see ACC.3.1, ME 2 and GLD.3.1, ME 2)

3.Patients are referred to these sources when appropriate and available. (Also see GLD.3.1, ME 2)

Standard

PFE.4 Patient and family education include the following topics, as appropriate to the patient’s care: the safe use of medications, the safe use of medical equipment, potential interactions between medications and food, nutritional guidance, pain management, and rehabilitation techniques.

Intent of PFE.4

The organization routinely provides education in areas that carry high risk to patients. Education supports the return to previous functional levels and maintenance of optimal health.

The organization uses standardized materials and processes in educating patients on at least the following topics:

Safe and effective use of all medications taken by the patient (not just discharge medications), including potential medication side effects (also see Glossary);

Safe and effective use of medical equipment (also see Glossary);

Potential interactions between prescribed medications and other medications (including over-the-counter preparations) and food;

Diet and nutrition;

Pain management; and

Rehabilitation techniques.

Measurable Elements of PFE.4

1. When appropriate, patients and families are educated about the safe and effective use of all medications and potential side effects of medications.

2. When appropriate, patients and families are educated about safely and effectively using medical equipment.

3. When appropriate, patients and families are educated about preventing interactions between prescribed medications and other medications (including over-the-counter preparations) and food.

4. When appropriate, patients and families are educated about appropriate diet and nutrition.

5. When appropriate, patients and families are educated about pain management. (Also see COP.6, ME 3)

6. When appropriate, patients and families are educated about rehabilitation techniques.

Standard

PFE.5 Education methods consider the patient’s and family’s values and preferences and allow sufficient interaction among the patient, family, and staff for learning to occur.

Intent of PFE.5

Learning occurs when attention is paid to the methods used to educate patients and families. Understanding patients and families helps the organization to select appropriate educational methods and educators and to identify the family’s role and the instruction method.

Patients and their families are encouraged to participate in the care process by speaking up and asking staff questions to ensure correct understanding and anticipated participation. Staff recognize the important role patients play in the provision of safe, quality care.

The opportunity for interaction among staff, the patient, and his or her family permits feedback to ensure that the information is understood and that it is appropriate, useful, and usable. (Also see MCI.3, MEs 1 and 2) The organization decides when and how verbal education is reinforced with written materials to enhance understanding, and to provide a future educational reference.

Measurable Elements of PFE.5

1. Interaction among staff, the patient, and family confirms that the information was understood. (Also see MCI.3, MEs 1 and 2)

2. Those who provide education encourage patients and their families to ask questions and speak up as active participants. (Also see PFR.2, ME 1)

3. Verbal information is reinforced with written material as appropriate to the patient’s needs and learning preferences. (Also see PFR.2.1 and MCI.3)

Standard

PFE.6 Health professionals caring for the patient collaborate to provide education.

Intent of PFE.6

When health care professionals understand one another’s contributions to patient education, they can collaborate more effectively. Collaboration, in turn, helps to ensure that the information patients and families receive is comprehensive, consistent, and as effective as possible. Collaboration is based on the patient’s needs and may not always be necessary or appropriate.

Knowledge of the subject matter, available adequate time and ability to communicate effectively are important considerations in effective education.

Measurable Elements of PFE.6

1. Patient and family education is provided collaboratively when appropriate.

2. Those who provide education have the subject knowledge to do so.

3. Those who provide education have adequate time to do so.

4. Those who provide education have the communication skills to do so. (Also see ASC.5.1, ME 2)

Functional Section II: Health Care Organization Management Standards

Quality Improvement and Patient Safety (QPS)

Overview

This chapter describes a comprehensive approach to quality improvement and patient safety. Integral to overall improvement in quality is the ongoing reduction in risks to patients and staff. Such risks may be found in clinical processes as well as in the physical environment. This approach includes

leading and planning the quality improvement and patient safety program;

designing new clinical and managerial processes well;

monitoring (also see Glossary) how well processes work through indicator (also see Glossary) data collection;

analyzing the data; and

implementing and sustaining changes that result in improvement.

Both quality improvement and patient safety programs

are leadership driven;

seek to change the culture of an organization;

proactively identify and reduce risk and variation (also see Glossary);

use data (also see Glossary) to focus on priority issues; and

seek to demonstrate sustainable improvements.

Quality and safety are rooted in the daily work of individual health care professionals and other staff. As physicians and nurses assess patient needs and provide care, this chapter can help them understand how to make real improvements to help their patients and reduce risks. Similarly, managers, support staff, and others can apply the standards to their daily work to understand how processes can be more efficient, resources can be used more wisely, and physical risks can be reduced.

This chapter emphasizes that continuously planning, designing, monitoring, analyzing, and improving clinical and managerial processes must be well-organized and have clear leadership to achieve maximum benefit. This approach takes into account that most clinical care processes involve more than one department or unit and may involve many individual jobs. This approach also takes into account that most clinical and managerial quality issues are interrelated. Thus, efforts to improve those processes must be guided by an overall framework for quality management and improvement activities in the organization, overseen by a quality improvement and patient safety oversight group or committee.

These international accreditation standards address the full spectrum of clinical and managerial activities of a health care organization, including the framework for improving those activities and reducing the risks associated with variation in processes.

Thus, the framework presented in these standards is suitable for a wide variety of structured programs and less formal approaches to quality improvement and patient safety. This framework can also incorporate traditional monitoring programs such as those related to unanticipated events (risk management) and resource use (utilization management; also see Glossary).

Over time, organizations that follow this framework will

develop greater leadership support for an organizationwide program;

train and involve more staff;

set clearer priorities for what to monitor;

base decisions on indicator data; and

make improvements based on comparison to other organizations, nationally and internationally.

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.

QPS.1 Those responsible for governing and managing the organization participate in planning and monitoring

a quality improvement and patient safety program. QPS.1.1 The organization’s leaders collaborate to carry out the quality improvement and patient safety program.

QPS.1.2 The leaders prioritize which processes should be monitored and which improvement and patient

safety activities should be carried out. QPS.1.3 The leaders provide technological and other support to the quality improvement and patient safety program.

QPS.1.4 Quality improvement and patient safety information is communicated to staff. QPS.1.5 Staff are trained to participate in the program. QPS.2 The organization designs new and modified systems and processes according to quality improvement principles. QPS.2.1 Clinical practice guidelines and clinical pathways are used to guide clinical care. QPS.3 The organization’s leaders identify key measures (indicators) to monitor the organization’s clinical and

managerial structures, processes, and outcomes and the International Patient Safety Goals. QPS.3.1 Clinical monitoring includes those aspects of patient assessment selected by the leaders. QPS.3.2 Clinical monitoring includes those aspects of laboratory services selected by the leaders. QPS.3.3 Clinical monitoring includes those aspects of radiology and diagnostic imaging services selected

by the leaders. QPS.3.4 Clinical monitoring includes those aspects of surgical procedures selected by the leaders. QPS.3.5 Clinical monitoring includes those aspects of antibiotic and other medication use selected by the

leaders. QPS.3.6 Clinical monitoring includes the monitoring of medication errors and near misses. QPS.3.7 Clinical monitoring includes those aspects of anesthesia and sedation use selected by the leaders. QPS.3.8 Clinical monitoring includes those aspects of the use of blood and blood products selected by the

leaders.

QPS.3.9 Clinical monitoring includes those aspects of availability, content, and use of patient records

selected by the leaders.

QPS.3.10 Clinical monitoring includes those aspects of infection control, surveillance, and reporting selected by the leaders. QPS.3.11 Clinical monitoring includes those aspects of clinical research selected by the leaders. QPS.3.12 Managerial monitoring includes those aspects of the procurement of routinely required supplies

and medications essential to meet patient needs selected by the leaders.

QPS.3.13 Managerial monitoring includes those aspects of reporting of activities as required by law and regulation and selected by the leaders. QPS.3.14 Managerial monitoring includes those aspects of risk management selected by the leaders. QPS.3.15 Managerial monitoring includes those aspects of utilization management selected by the leaders. QPS.3.16 Managerial monitoring includes those aspects of patient and family expectations and satisfaction

selected by the leaders.

QPS.3.17 Managerial monitoring includes those aspects of staff expectations and satisfaction selected by the leaders. QPS.3.18 Managerial monitoring includes those aspects of patient demographics and clinical diagnoses

selected by the leaders. QPS.3.19 Managerial monitoring includes those aspects of financial management selected by the leaders. QPS.3.20 Managerial monitoring includes those aspects of the prevention and control of events that

jeopardize the safety of patients, families, and staff selected by the leaders, including the International

Patient Safety Goals. QPS.4 Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the organization.

QPS.4.1 The frequency of data analysis is appropriate to the process being studied and meets organization

requirements. QPS.4.2 The analysis process includes comparisons internally, with other organizations when available, and with scientific standards and desirable practices.

QPS.5 The organization uses a defined process for identifying and managing sentinel events. QPS.6 Data are analyzed when undesirable trends and variation are evident from the data. QPS.7 The organization uses a defined process for the identification and analysis of near-miss events.

QPS.8 Improvement in quality and safety is achieved and sustained.

QPS.9 Improvement and safety activities are undertaken for the priority areas identified by the organization’s leaders.

QPS.10 An ongoing program of identifying and reducing unanticipated adverse events and safety risks to patients and staff is defined and implemented.

Standards, Intents, and Measurable Elements

Leadership and Planning

Standard

QPS.1 Those responsible for governing and managing the organization participate in planning and monitoring a quality improvement and patient safety program.

Intent of QPS.1

If an organization is to initiate and maintain improvement and reduce risks to patients and staff, leadership and planning are essential. This leadership and planning come from the governing body of the organization along with those who manage the clinical and managerial activities of the organization on a daily basis. Collectively they represent the leadership of the organization. The leadership is responsible for establishing the organization’s commitment, approach to improvement and safety, and program management and oversight. The leadership develops the quality and patient safety plan and through their vision and support, shapes the quality culture of the organization.

The governing body holds ultimate accountability for quality and patient safety in the organization and thus, they approve the quality and patient safety plan (also see GLD.1.6) and, on a regular basis, they receive and act on reports related to the organization’s program to improve quality and patient safety (also see GLD.1.6).

Measurable Elements of QPS.1

1. The organization’s leadership participates in developing the plan for the quality improvement and patient safety program.

2. The organization’s leadership participates in monitoring the quality improvement and patient safety program.

3. The organization’s leadership establishes the oversight process or mechanism for the organization’s quality improvement and patient safety program.

4. The organization’s leadership reports on the quality and patient safety program to governance.

Standard

QPS.1.1 The organization’s leaders collaborate to carry out the quality improvement and patient safety program.

Intent of QPS.1.1

The organization’s leaders have a key role in ensuring that the quality and patient safety plan shapes the organization’s culture and makes an impact on every aspect of operations. This takes collaboration and commitment through a multidisciplinary (also see Glossary) approach. Leaders ensure the program addresses

the role of system design and redesign in the improvement process;

a multidisciplinary approach with all departments and services in the organization included in the program;

coordination among the multiple organizational units concerned with quality and safety such as the clinical laboratory quality control program, a risk management program (also see Glossary), a facility risk management program, a patient safety office, or other types of offices or programs. An inclusive program is necessary to improving patient outcomes (also see Glossary) because patients receive care from many different departments and services and/or types of clinical staff; and,

• a systematic approach in that it employs similar or uniform quality processes and knowledge to carry out all improvement and patient safety activities.

Measurable Elements of QPS.1.1

1. The organization’s leaders collaborate to carry out the quality improvement and patient safety program. (also see GLD.3.4, ME 2; SQE.11, ME 1; SQE.14, ME 1; and SQE.17, ME 1)

2. The quality improvement and patient safety program is organizationwide.

3. The program addresses the systems of the organization and the role of system design and redesign in quality and safety improvement.

4. The program addresses coordination among all components of the organization’s quality monitoring and control activities. (Also see GLD.3.4, ME 2 and PCI.10, ME 2)

5. The program employs a systematic approach to quality improvement and patient safety.

Standard

QPS.1.2 The leaders prioritize which processes should be monitored and which improvement and patient safety activities should be carried out.

Intent of QPS.1.2

A primary responsibility of leaders is to set priorities. Organizations typically find more opportunities for quality monitoring and improvement than they have human and other resources to accomplish. Therefore, the leaders provide focus for the organization’s quality monitoring and improvement activities. The leaders prioritize those critical, high-risk, problem-prone, primary processes that most directly relate to quality of care (also see Glossary) and safety of the environment. The leaders include the International Patient Safety Goals (also see pages 31–35). The leaders use available data (also see Glossary) and information to identify priority areas.

Measurable Elements of QPS.1.2

1. The leaders set priorities for monitoring activities.

2. The leaders set priorities for improvement and patient safety activities.

3. The priorities include the implementation of the International Patient Safety Goals.

Standard

QPS.1.3 The leaders provide technological and other support to the quality improvement and patient safety program.

Intent of QPS.1.3

Monitoring clinical and management functions in a health care organization (also see Glossary) results in the accumulation of data and information. Understanding how well the organization is doing depends on the analysis of the data and information over time and comparison with other organizations. For large or complex organizations, this tracking and comparison may require technology and/or staff members with data management experience. An organization’s leaders understand the monitoring and improvement priorities in terms of this necessary support. They provide the support consistent with the organization’s resources and quality improvement.

Measurable Elements of QPS.1.3

1. The leaders understand the technology and other support requirements for tracking and comparing monitoring results.

2. The leaders provide technology and support, consistent with the organization’s resources, for tracking and comparing monitoring results.

Standard

QPS.1.4 Quality improvement and patient safety information is communicated to staff.

Intent of QPS.1.4

The regular communication of information about the quality improvement and patient safety program to staff is essential. The communication is on a regular basis through effective channels such as newsletters, storyboards, staff meetings, and human resource processes. The information can be about new or recently completed improvement projects, progress in meeting the International Patient Safety Goals, the results of the analysis of sentinel and other adverse events (also see Glossary), recent research or benchmark programs, etc.

Measurable Elements of QPS.1.4

1. Information on the quality improvement and patient safety program is communicated to staff.

2. The communications are on a regular basis through effective channels. (Also see GLD.1.6, ME 2)

3. The communications include progress on compliance with the International Patient Safety Goals.

Standard

QPS.1.5 Staff are trained to participate in the program.

Intent of QPS.1.5

Participating in data collection and analysis and planning and implementing quality improvements require knowledge and skill that most staff do not have or do not use regularly. Thus, when asked to participate in the program, staff members receive training consistent with their role in the planned activity. Staff schedules may need to be adjusted to accommodate sufficient time to fully participate in training and improvement activities as part of regular work assignments. The organization identifies or provides a knowledgeable trainer for this education.

Measurable Elements of QPS.1.5

1. There is a training program for staff that is consistent with their role in the quality improvement and patient safety program.

2. A knowledgeable individual provides the training.

3. Staff members participate in the training as part of their regular work assignment.

Design of Clinical and Managerial Processes

Standard

QPS.2 The organization designs new and modified systems and processes according to quality improvement principles.

Intent of QPS.2

Organizations frequently have the opportunity to design new processes or have a need to modify existing processes. The new or modified process uses design elements from authoritative sources, including law and regulations as applicable. Such authoritative sources include clinical practice guidelines (also see standard QPS.2.1 and Glossary) when available for clinical processes, national standards and norms and other sources of information.

The design of new or modified processes may also be informed by the experiences of others considered to be best/better/good practices. Such practices are evaluated by the organization and relevant practices may be used and tested.

When processes or services are designed well, they draw on a variety of information sources. Good process design a) is consistent with the organization’s mission and plans; b) meets the needs of patients, families, staff, and others; c) uses current practice guidelines, clinical standards, scientific literature, and other relevant evidence-based

information (also see Glossary) on clinical practice design; d) is consistent with sound business practices; e) considers relevant risk management information; f) builds on available knowledge and skills in the organization; g) builds on the best/better/good practices of other organizations; h) uses information from related improvement activities; and i) integrates and connects processes and systems.

When an organization designs new processes, it selects suitable measures (indicators) for the process. Once an organization implements a new process, it collects data to see if the process is actually operating as expected.

Measurable Elements of QPS.2

1. Quality improvement principles and tools are applied to the design of new or modified processes.

2. Design elements a) through i) are considered when relevant to the process being designed or modified.

3. Indicators are selected to measure how well the newly designed or redesigned process operates.

4. Indicator data are used to evaluate the ongoing operation of the process.

Standard

QPS.2.1 Clinical practice guidelines and clinical pathways are used to guide clinical care.

Intent of QPS.2.1

The goals of health care organizations include

standardizing clinical care processes;

reducing risks within care processes, particularly those associated with critical decision steps; and

providing clinical care in a timely, effective manner using available resources efficiently.

Organizations use a variety of tools to reach these and other goals. For example, care providers seek to develop clinical care processes and make clinical care decisions based on the best available scientific evidence (also see “evidence- [scientific-] based guidelines” in Glossary). Clinical practice guidelines are useful tools in this effort to understand and apply the best science to a particular diagnosis or condition.

In addition, care providers seek to standardize care processes. Clinical care pathways are useful tools in this effort to ensure effective integration and coordination of care and efficient use of available resources.

organization’s patient population and mission are a) selected from among those applicable to the services and patients of the organization (mandatory national

guidelines are included in this process, if present); b) evaluated for their applicability and science; c) adapted when needed to the technology, drugs, and other resources of the organization or to accepted

national professional norms; d) formally approved or adopted by the organization; e) implemented and monitored for consistent use and effectiveness; f) supported by staff trained to apply the guidelines or pathways; and g) periodically updated.

Organizations are expected to have gone through the process described in a) through f) for at least one clinical practice guideline and one clinical pathway per year.

Measurable Elements of QPS.2.1

1. Leaders use clinical practice guidelines to guide patient care processes (also see Glossary).

2. Leaders use clinical pathways to standardize care processes.

3. The organization follows the process described in a) through f) of the intent in implementing clinical practice guidelines and clinical pathways.

4. The process is used to adapt, adopt or update at lease one guideline and one pathway per 12-month period.

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