2013 Hospital Accreditation Standards

The Joint Commission Mission

The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. 2013 The Joint Commission Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. JCR educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at JCR educational programs and purchasers of JCR publications receive no special consideration or treatment in, or confidential information about, the accreditation process. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A. 5 4 3 2 1 Requests for permission to make copies of any part of this work should be mailed to the following: Permissions Editor Department of Publications and Education Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 permissions@jcrinc.com ISBN: 978-1-59940-636-7 ISSN: Pending For more information about The Joint Commission, please visit http://www.jointcommission.org.

Contents

Introduction (INTRO) ...................................................................INTRO-1

Requirements for Accreditation Accreditation Participation Requirements (APR)..................................APR-1 Environment of Care (EC) .....................................................................EC-1 Emergency Management (EM) ..............................................................EM-1 Human Resources (HR).........................................................................HR-1 Infection Prevention and Control (IC) ....................................................IC-1 Information Management (IM) ..............................................................IM-1 Leadership (LD) .....................................................................................LD-1 Life Safety (LS) ........................................................................................LS-1 Medication Management (MM)...........................................................MM-1 Medical Staff (MS).................................................................................MS-1 National Patient Safety Goals (NPSG) ..............................................NPSG-1 Nursing (NR) ........................................................................................NR-1 Provision of Care, Treatment, and Services (PC) ....................................PC-1 Performance Improvement (PI)................................................................PI-1 Record of Care, Treatment, and Services (RC) .......................................RC-1 Rights and Responsibilities of the Individual (RI) ....................................RI-1 Transplant Safety (TS) ............................................................................TS-1 Waived Testing (WT) ...........................................................................WT-1 Other Information Appendix A: Medicare Requirements for Hospitals (AXA) ...................AXA-1 Index (IX) ................................................................................................IX-1

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Introduction (INTRO)
The 2013 Hospital Accreditation Standards (HAS) aims to keep accreditation leaders, managers, and frontline staff up to date with the requirements necessary to achieve and maintain Joint Commission hospital accreditation. This abridged version of the Comprehensive Accreditation Manual for Hospitals (CAMH) provides all hospital standards, elements of performance (EPs), National Patient Safety Goals (NPSGs), and Accreditation Participation Requirements (APRs) effective January 1, 2013. In addition, a spring update will provide updates to accreditation standards and deemed status requirements in the form of replacement pages. The CAMH and the E-dition available on your organizations Joint Commission Connect extranet site include policies, procedures, and other information about the hospital accreditation process. These are not provided in this book.

Chapter Structure
The HAS includes the information your hospital needs for continuous performance improvement. Each chapter in this manual is set up as follows: Q An overview explains the chapters purpose and the principles on which the requirements were built. Q The chapter outline shows you exactly how the chapter is laid out and provides a frame of reference for the numbering of requirements. Q Introductions at the beginning of some requirements (or cluster of requirements) provide information about the requirements origin and any issues that surround it. Q The standards are statements that define the performance expectations and/or structures or processes that must be in place for your hospital to provide safe, quality care, treatment, and services. Q A rationale is additional background, justification, or information about a requirement to explain its purpose. In some cases, the rationale for a requirement is self-evident. Therefore, not every requirement has a written rationale. Rationales are not scored. Q References (placed in parentheses following the requirement) identify related requirements, whether they are in the same chapter or a different chapter. These references should help you more quickly find related requirements on a particular topic.
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Q

EPs, or elements of performance, are statements that detail the specific performance expectations and/or structures or processes that must be in place in order for a hospital to provide quality care, treatment, and services. EPs are scored and determine a hospitals overall compliance with a requirement. Notes provide additional or clarifying information about a specific EP. Notes are not scored.

The HAS also includes an appendix with explanatory text from the Code of Federal Regulations on Medicare certification as well as an Index.

Description of Icons
The following icons can be found in this manual: Q Scoring categories are indicated by the icons A or C. Category A EPs usually relate to structural requirements (for example, policies, programs, or plans). Such EPs address an issue that must be fully compliant. Category C EPs are frequency-based requirements and are scored based on the number of times a hospital is found not to be compliant with a particular EP. Q The documentation icon indicates when written documentation is required to demonstrate compliance with an EP. A documentation icon is used to identify data collection and documentation requirements that are beyond information required to be included in the medical record. For example, an EP that requires a written procedure will have a , but the icon is not applied to an EP that contains the required list of components of the medical record. Other examples in which the documentation icon is used are for EPs that require a policy, a written plan, bylaws, a license, evidence of testing, data, performance improvement reports, medication labels, Material Safety Data Sheets, or meeting minutes. Q Patient care impact icons ( ) indicate scoring criticality, that is, the immediacy of risk to the quality of care and patient safety. The Joint Commission has identified four levels of scoring criticality: 1. Immediate Threat to Health or Safety situations, identified with a , have or may potentially have serious adverse effects on the health or safety of patients. 2. EPs tagged with a icon identify issues that, when found out of compliance, indicate a situation exists that could pose a significant threat to patient safety or quality of care. These situational decision rules will automatically trigger a recommendation for Preliminary Denial of Accreditation, Contingent Accreditation, or Accreditation with Follow-up Survey if the EP is found out of compliance.
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Introduction

Figure 1. Components (including icons) of a requirements chapter.

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3. Noncompliance with direct impact requirements marked by a icon indicate situations that could directly impact patients by creating an immediate risk to safety or quality of care, treatment, and services. 4. Indirect impact requirements pose a less immediate risk to patient care or safety than direct impact requirements; however, noncompliance can increase risk to safety or quality of care, treatment, or services over time. Any requirements considered to have an indirect impact will not show a criticality icon in this manual.
Q

The Measure of Success (MOS) icon identifies which EPs, if found to be noncompliant, would require a quantifiable measure to determine whether the corrective action a hospital takes in response to a Requirement for Improvement (RFI) was effective and sustained. The risk icon identifies specific risks, as assessed by a systems proximity to patient, probability of harm, severity of harm, and number of patients at risk. Risk categories identified by The Joint Commission are related to NPSGs, selected direct and indirect impact requirements, accreditation programspecific risk areas, and RFIs identified during current accreditation cycle survey events. This manual will show a single icon at the EP level for the three categories related to NPSGs, selected direct and indirect impact requirements, and program-specific risk areas.

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