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Effective 1 January 2014

About Joint Commission International


Joint Commission International (JCI) is a client-focused, results-oriented, premier source of knowledge for health care organizations,

JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR HOSPITALS, 5TH EDITION


government agencies, and third-party payers throughout the world. It provides educational services, consulting services, and publications
to assist in improving the quality, safety, and efficiency of health care services. JCI offers international and country-specific accreditation
programs and other assessment tools to provide objective evaluations of the quality and safety of health care organizations. JCI is a
division of Joint Commission Resources, Inc., a wholly controlled, not-for-profit affiliate formed by The Joint Commission to provide lead-
ership in health care accreditation and quality improvement.

Joint
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Accreditation
Standards
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Hospitals
Bar Code

Field Review
March 2013
For review only. Do not distribute.
2013 Joint Commission International

IAS500 5th Edition


Hospital Accreditation Standards, 5th Edition Field Review

1 International Patient Safety Goals


2 (IPSG)
3 Goal 1: Identify Patients Correctly

4 Standard IPSG.1
5 The hospital develops an approach to improve accuracy of patient identifications.

6 Intent of IPSG.1
7 Wrong-patient errors occur in virtually all aspects of diagnosis and treatment. Patients may be sedated, disoriented, or not
8 fully alert, or comatose; may change beds, rooms, or locations within the hospital; may have sensory disabilities; may not
9 remember his/her identity; or may be subject to other situations that may lead to errors in correct identification. The
10 intent of this goal is twofold: first, to reliably identify the individual as the person for whom the service or treatment is
11 intended; second, to match the service or treatment to that individual.
12 The identification process used throughout the hospital requires at least two ways in which to identify a patient, such as
13 the patients name, identification number, birth date, a bar-coded wristband, or other ways. The patients room number
14 or location cannot be used for identification. These two different identifiers are utilized in all locations within the
15 hospital; for example, in the ambulatory care or other outpatient location, the emergency department, operating theatre,
16 diagnostic departments, and the like.
17 Two different patient identifiers are required in any circumstance involving patient interventions. For example, patients
18 are identified before providing treatments (such as administering medications, blood, or blood products, serving a
19 restricted diet tray, or providing radiation therapy); performing procedures (such as insertion of an intravenous line or
20 hemodialysis); and before any diagnostic procedures (such as taking blood and other specimens for clinical testing,
21 performing a cardiac catheterization or diagnostic radiology procedure.). Identification of the comatose patient with no
22 identification is also included.

23 Measurable Elements of IPSG.1


24 1. Patients are identified using two patient identifiers, not including the use of the patients room number or
25 location.
26 2. Patients are identified before providing treatments and procedures.
27 3. Patients are identified before any diagnostic procedures.
28 4. Patients are identified before providing treatments and procedures.
29 5. Policies and procedures support consistent practice in all situations and locations.

30

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Hospital Accreditation Standards, 5th Edition Field Review

31 Goal 2: Improve Effective Communication

32 Standard IPSG.2
33 The hospital develops an approach to improve the effectiveness of verbal and/or telephone communication among
34 caregivers.

35 Standard IPSG.2.1 (formerly standard AOP.5.3.1)


36 There is a process for reporting critical results of diagnostic tests.

37 Standard IPSG.2.2 (new standard)


38 The hospital implements a standardized approach to handoff communication between staff, during change of shift, and
39 between different patient care units in the course of a patient transfer.

40 Intent of IPSG.2 through IPSG.2.2


41 Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces
42 errors and results in improved patient safety. Communication can be electronic, verbal, or written. Three patient care
43 circumstances that can be critically impacted by poor communication include verbal or telephone patient care orders,
44 verbal or telephone communication of critical test results, and hand-off communications. The most error-prone
45 communications are patient care orders given verbally and those given over the telephone, when permitted under local
46 laws and regulations. Different accents, dialects, and pronunciations can make it difficult for the receiver to understand
47 the order being given. For example, drug names and numbers that sound alike, such as erythromycin instead of
48 azithromycin or fifteen instead of fifty can affect the accuracy of the order. Background noise, interruptions, and
49 unfamiliar drug names and terminology often compound the problem. Once received, a verbal order must be transcribed
50 as a written order, which adds complexity and risk to the ordering process.
51 The reporting of critical results of diagnostic tests is also a patient safety issue. Diagnostic tests include, but are not
52 limited to; laboratory tests, radiology exams, nuclear medicine exams, ultrasound procedures, magnetic resonance
53 imaging, and the like. Results that are significantly outside the normal range may indicate a high risk or life-threatening
54 condition. A formal reporting system that clearly identifies how critical results of diagnostic tests are communicated to
55 health care practitioners and how the information is documented reduces patient risks.
56 Safe practices for verbal or telephone communications include the following:
57 Limiting verbal communication of prescription or medication orders to urgent situations in which
58 immediate written or electronic communication is not feasible. For example, verbal orders can be disallowed
59 when the prescriber is present and the patients chart is available. Verbal orders can be restricted to
60 situations where it is difficult or impossible for hard copy or electronic order transmission, such as during a
61 sterile procedure.
62 The development of guidelines for requesting and receiving test results on an emergency or STAT basis, the
63 identification and definitions of critical tests and critical values, to whom and by whom critical test results
64 are reported, and monitoring compliance.

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65 Writing down (or entering into a computer) the complete order or test result by the receiver of the
66 information; the receiver reading back the order or test result; and confirming that what has been written
67 down and read back is accurate. Permissible alternatives for when the read-back process may not always be
68 possible may be identified, such as in the operating theatre and in emergency situations in the emergency
69 department or intensive care unit.
70 Handoffs of patient care within a hospital occur
71 between health care providers, such as between physicians and other physician or healthcare providers, or
72 from one provider to another provider during shift changes;
73 between different levels of care in the same hospital such as when the patient is moved from an intensive
74 care unit to a medical unit or from an emergency department to the operating theatre; and
75 from inpatient units to diagnostic or other treatment departments, such as radiology or physical therapy.
76 Breakdowns in communication can occur during any of these handoffs and can result in adverse events. Background
77 noises, interruptions, and other distractions from unit activities can inhibit clear communication of important patient
78 information. Standardized, critical content for communication between the patient, family, caregiver, and health care
79 providers can significantly improve the outcomes related to these handoffs.

80 Measurable Elements of IPSG.2


81 1. The complete verbal order is written down and read back by the receiver and confirmed by the individual giving
82 the order.
83 2. The complete telephone order is written down and read back by the receiver and confirmed by the individual
84 giving the order.
85 3. The complete test result is written down and read back by the receiver and confirmed by the individual giving the
86 result.

87 Measurable Elements of IPSG.2.1


88 1. The hospital has defined critical values for each type of diagnostic test.
89 2. The hospital has identified by whom and to whom critical results of diagnostic test are reported.
90 3. The hospital has identified what information is documented in the patient record.

91 Measurable Elements of IPSG.2.2


92 1. The hospital develops standardized critical content for communications with the health care provider.
93 2. The hospital develops standardized forms tools and methods, such as checklists, to assist in making the handoff
94 successful.
95 3. Evidence within the hospital supports the implementation of a safe handoff process.

96

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Hospital Accreditation Standards, 5th Edition Field Review

97 Goal 3: Improve the Safety of High-Alert Medications

98 Standard IPSG.3
99 The hospital develops an approach to improve the safety of high-alert medications.

100 Standard IPSG.3.1 (new standard)


101 The hospital develops an approach to manage the safe use of concentrated electrolytes.

102 Intent of IPSG.3


103 When medications are part of the patient treatment plan, appropriate management is critical to ensuring patient safety.
104 Any medication, even those that can be purchased without a prescription, if used improperly can cause injury. However,
105 high-alert medications cause harm more frequently and the harm they produce is likely to be more serious when they are
106 given in error. This can lead to increased patient suffering and potentially additional costs associated with caring for these
107 patients.
108 High-alert medications include
109 medications that are involved in a high percentage of errors and/or sentinel events or high-risk medications
110 (that carry a higher risk for adverse outcomes), such as insulin, heparin, or chemotherapeutics; and
111 medications whose names, packaging and labeling, or clinical use, look alike and/or sound alike, such as
112 Xanax and Zantac or naloxone and lanoxin.
113 There are many medication names that sound or look like other medication names. Confusing names is a common cause
114 of medication errors throughout the world. Contributing to this confusion are
115 incomplete knowledge of drug names;
116 newly available products;
117 similar packaging or labeling; similar clinical use;
118 similar strengths, dosage forms, and frequency of administration; and
119 illegible prescriptions or misunderstanding during issuing of verbal orders.
120 Lists of high-alert medications and look-alike/sound-alike medications are available from organizations such as the World
121 Health Organization (WHO), the Institute for Safe Medication Practices (ISMP), as well as in the literature.
122 A frequently cited medication safety issue is the incorrect or unintentional administration of concentrated electrolytes (for
123 example, potassium chloride [equal to or greater than 2 mEq/ml concentration], potassium phosphate [equal to or greater
124 than 3 mmol/ml], sodium chloride [greater than 0.9% concentrated], and magnesium sulfate [equal to or greater than
125 50% concentration]). Errors can occur when staff are not properly oriented to the patient care unit, when contract nurses
126 are used and not properly oriented, or during emergencies. The most effective means to reduce or to eliminate these
127 occurrences is to develop a process for managing high-alert medications that includes removing the concentrated
128 electrolytes from the patient care units to the pharmacy.

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129 The hospital identifies the list of high-risk medications and look-alike/sound-alike medications based on data from
130 multiple sources, such as medication use within the hospital, data from adverse and near-miss events, and other relevant
131 data. Information from the literature and/or a Ministry of Health may also be useful in helping to identify what
132 medications should be included. These medications are stored in a way that reduces the likelihood of inadvertent mis-
133 administration or ideally directs on the proper use of the medication. Strategies to improve the safety of high-alert
134 medications may be tailored to the specific risk of each medication and should include consideration of prescribing,
135 preparation, administration and monitoring processes, in addition to safe storage strategies. The hospital also identifies
136 any areas where concentrated electrolytes are clinically necessary as determined by evidence and professional practice,
137 such as the emergency department or operating theatre, and identifies how they are clearly labeled and how they are
138 stored in those areas in a manner that restricts access to prevent inadvertent administration.

139 Measurable Elements of IPSG.3


140 1. The hospital identifies a list of high-risk medications and look-alike/sound-alike medications.
141 2. The hospital identifies strategies to improve the safety of high-risk medications, which may include specific
142 storage, prescribing, preparation, administration, or monitoring processes.
143 3. The hospital identifies the location, labeling, and storage of look-alike/sound-alike medications.
144 4. Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that
145 restricts access.
146

147 Measurable Elements of IPSG.3.1


148 1. The hospital has a process that prevents inadvertent administration of concentrated electrolytes.
149 2. Concentrated electrolytes are only present in patient care units identified as clinically necessary.
150 3. Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that
151 restricts access promotes safe use.
152

153 Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery


154 Standard IPSG.4
155 The hospital develops an approach to ensuring correct-site, correct-procedure, and correct-patient surgery.

156 Standard IPSG.4.1 (new standard)


157 The hospital develops an approach for the time-out that is performed in the operating theatre immediately prior to the
158 start of surgery to ensure correct-site, correct-procedure, and correct-patient surgery.

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159 Intent of IPSG.4 and IPSG.4.1


160 Wrong-site, wrong-procedure, wrong-patient surgery is an alarmingly common occurrence in health care hospitals. These
161 errors are the result of ineffective or inadequate communication between members of the surgical team, lack of patient
162 involvement in site marking, and lack of procedures for verifying the operative site. In addition, inadequate patient
163 assessment, inadequate medical record review, a culture that does not support open communication among surgical team
164 members, problems related to illegible handwriting, and the use of abbreviations are frequent contributing factors.
165 Surgery and invasive procedures include all procedures that incorporate at least those procedures that investigate and/or
166 treat diseases and disorders of the human body through cutting, removing, altering, or insertion of diagnostic/therapeutic
167 scopes. Organizations need to identify all areas within the hospital where surgical and invasive procedures take place; for
168 example, the cardiac catheterization lab, interventional radiology department, gastrointestinal lab, and the like. The
169 approach the hospital takes to ensuring correct-site, correct-procedure, and correct-patient surgery applies to all areas of
170 the hospital in which surgical and invasive procedures occur.
171 Evidence-based practices are described in The (U.S..) Joint Commissions Universal Protocol for Preventing Wrong Site,
172 Wrong Procedure, Wrong Person Surgery.
173 The essential processes found in the Universal Protocol are
174 marking the surgical site;
175 a preoperative verification process; and
176 a time-out that is held immediately before the start of a procedure.
177 Marking the surgical site involves the patient and is done with an instantly recognizable mark. The mark must be
178 consistent throughout the hospital; must be made by the person performing the procedure; should take place with the
179 patient awake and aware; if possible, and must be visible after the patient is prepped and draped. The surgical site is
180 marked in all cases involving laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine).
181 The purpose of the preoperative verification process is to
182 verify the correct site, procedure, and patient;
183 ensure that all relevant documents, images, and studies are available, properly labeled, and displayed; and
184 verify any required special equipment and/or implants are present.
185 There are various elements of the preoperative verification process that can be completed before the patient arrives to
186 the preoperative areasuch as ensuring that documents, imaging and test results, and paperwork are properly labeled and
187 available; and marking the surgical site. In fact, waiting until the time-out to complete the preoperative verification
188 process may unnecessarily delay surgery if paperwork or imaging isnt labeled and available when surgery is about to
189 begin. It is more likely that portions of the preoperative verification may occur more than once and in more than one place. For
190 example, the surgical consent may be obtained in the surgeons office and then verified that it is completed in the
191 preoperative holding area; marking the surgical site may occur in the preoperative holding area, and verifying that the
192 right equipment is available may occur in the operating theatre.
193 The time-out, held immediately before the start of the procedure with all team members present, permits any unanswered
194 questions or confusion to be resolved. The time-out is conducted in the location the procedure will be done, just before

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195 starting the procedure, and involves the entire operative team. The hospital determines how the time-out process is to be
196 documented.

197 Measurable Elements of IPSG.4


198 1. The hospital uses an instantly recognizable mark for surgical-site identification that is consistent throughout the
199 hospital.
200 2. Surgical site marking is done by the person performing the procedure and involves the patient in the marking
201 process.
202 3. The hospital uses a checklist or other process to verify preoperatively the correct site, correct procedure, and
203 correct patient and that all documents and equipment needed are on hand, correct, and functional.
204 4. When surgery is performed, including medical and dental procedures done in settings other than the operating
205 theatre, the organization uses uniform processes to ensure the correct site, correct procedure, and correct patient.

206 Measurable Elements of IPSG.4.1


207 1. The full surgical team conducts and documents a time-out procedure in the area in which the surgery/invasive
208 procedure will be performed, just before starting a surgical/invasive procedure.
209 2. The components of the time-out include correct patient identification, correct side and site, agreement of the
210 procedure to be done, and confirmation that the verification process has been completed.
211 3. When surgery is performed, including medical and dental procedures done in settings other than the operating
212 theatre, the hospital uses uniform processes to ensure the correct site, correct procedure, and correct patient.
213

214 Goal 5: Reduce the Risk of Health CareAssociated Infections

215 Standard IPSG.5


216 The hospital adopts and implements evidence-based hand-hygiene guidelines to reduce the risk of health careassociated
217 infections.

218 Intent of IPSG.5


219 Infection prevention and control are challenging in most health care settings, and rising rates of health careassociated
220 infections are a major concern for patients and health care practitioners. Infections common to all health care settings
221 include catheter-associated urinary tract infections, blood stream infections, and pneumonia (often associated with
222 mechanical ventilation).
223 Central to the elimination of these and other infections is proper hand hygiene. Internationally acceptable hand-hygiene
224 guidelines are available from the World Health Organization (WHO), the United States Centers for Disease Control and
225 Prevention (US CDC) and various other national and international organizations.

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226 The hospital adopts and implements currently published evidence-based hand-hygiene guidelines. Hand hygiene
227 guidelines are posted in appropriate areas and staff are educated in proper handwashing and hand-disinfection
228 procedures. Soap, disinfectants, and towels or other means of drying are located in those areas where handwashing and
229 disinfecting procedures are required.

230 Measurable Elements of IPSG.5


231 1. The hospital has adopted currently published, evidence-based hand-hygiene guidelines.
232 2. The hospital implements an effective hand-hygiene program throughout the hospital.
233 3. Handwashing and hand-disinfection procedures are used in accordance with hand hygiene guidelines
234 throughout the hospital.

235 Goal 6: Reduce the Risk of Patient Harm Resulting from Falls
236 Standard IPSG.6
237 The hospital develops an approach to reduce the risk of patient harm resulting from falls.

238 Intent of IPSG.6


239 Many injuries in hospitals to both inpatients and outpatients are a result of falls. The risk for falls are related to the
240 patient, the situation, and/or the location. Risks associated with patients might include patient history of falls,
241 medications use, alcohol consumption, gait or balance disturbances, visual impairments, altered mental status, and the
242 like. Documented criteria identifies the types of patients that are considered at high risk for falls. An example of a
243 situational risk is the patient who arrives to the outpatient department from a long term care facility via ambulance for a
244 radiologic examination. The patient may be at risk for falls in that situation when transferring from ambulance cart to
245 exam table, or when changing positions while lying on the narrow exam table. Specific locations may present higher fall
246 risks because of the services the hospital provides. For example, a physical therapy department (inpatient or outpatient)
247 has many types of specialized equipment used by patients that may increase the risk of fall, such as parallel bars,
248 freestanding stair cases, and exercise equipment.
249 In the context of the population it serves, the services it provides, and its facilities, the hospital should evaluate patient
250 falls and take action to reduce the risk of falling and to reduce the risk of injury should a fall occur. A fall reduction
251 program may include risk assessment and periodic reassessment of a particular patient population and/or of the
252 environment in which care and services are provided (such as those conducted during periodic safety tours). The hospital
253 has a responsibility to identify the locations (such as the physical therapy department), situations (such as patients arriving
254 by ambulance, patient transfers from wheelchairs or carts, or the use of patient-lifting devices), and types of patients
255 (such as patients with gait or balance disturbances, visual impairments, altered mental status, and the like) that may be at
256 high risk for falls.
257 The hospital establishes a fall-risk reduction program based on appropriate policies and/or procedures. The program
258 monitors both the intended and unintended consequences of measures taken to reduce falls. For example, the
259 inappropriate use of physical restraints or fluid intake restriction may result in injury, impaired circulation, or
260 compromised skin integrity. The program is implemented.

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261 Measurable Elements of IPSG.6


262 1. The hospital implements a process for assessing inpatient and outpatient situations and locations identified as
263 high risk for falls.
264 2. The hospital implements a process for the initial and ongoing assessment and intervention of inpatients and
265 outpatients identified as at risk for falls based on documented criteria.
266 3. Measures are implemented to reduce fall risk for those identified patients, situations and locations assessed to be
267 at risk.
268
269 Reference
270 1. World Health Organization. Look-Alike, Sound-Alike Medication Names. Accessed Nov 29, 2012.
271 http://www.ccforpatientsafety.org/common/pdfs/fpdf/Presskit/PS-Solution1.pdf.

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Hospital Accreditation Standards, 5th Edition Field Review

1 Access to Care and Continuity of


2 Care (ACC)
3

4 Screening for Admission to the Hospital

5 Standard ACC.1
6 Patients who may be admitted to the hospital or who seek outpatient services are screened to identify if their health care
7 needs match the hospitals mission and resources.

8 Intent of ACC.1
9 Matching patient needs with the hospitals mission and resources depends on obtaining information on the patients needs
10 and condition through screening, usually at the point of first contact. The screening may be through triage criteria, visual
11 evaluation, a physical examination, or the results of previously conducted physical, psychological, clinical laboratory, or
12 diagnostic imaging evaluations. The screening can occur at a referring source, during emergency transport, or when the
13 patient arrives at the hospital. It is important that decisions to treat, to transfer, or to refer are made only after the results of
14 screening evaluations are available. Only those patients for whom the hospital has the clinical capability to provide the needed
15 services, consistent with its mission, are considered for inpatient admission or registered for outpatient services. Certain screening exams or
16 diagnostic tests may be required for every patient being admitted, or the hospital may identify specific screenings and tests for
17 particular patient populations. For example, all patients with active diarrhea must have a screen for Clostridium difficile, or
18 certain types of patients require screening for methicillin-resistant Staphylococcus aureus, such as all patients coming from long
19 term care facilities.
20 Specific screening tests or evaluations are identified when the hospital requires them prior to admission or registration.

21 Measurable Elements of ACC.1


22 1. Based on the results of screening, it is determined if the needs of the patient match the hospitals mission and
23 resources.
24 2. Patients are accepted only if the hospital can provide the necessary services and the appropriate outpatient or
25 inpatient setting for care.
26 3. There is a process to provide the results of diagnostic tests to those responsible for determining if the patient is to be
27 admitted, transferred, or referred.
28 4. Specific screening tests or evaluations are identified when the hospital requires them prior to admission or
29 registration.
30 5. Patients are not admitted, transferred, or referred before the test results required for these decisions are available.

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31

32 Standard ACC.1.1 (formerly ACC.1.1.1)


33 Patients with emergent, urgent, or immediate needs are given priority for assessment and treatment.

34 Intent of ACC.1.1
35 Patients with emergent, urgent, or immediate needs (such as airborne infections) are identified by an evidence-based triage
36 process. Once identified as emergent, urgent, or requiring immediate needs, these patients are assessed and receive care as
37 quickly as necessary. Such patients may be assessed by a physician or other qualified individual before other patients, receive
38 diagnostic services as rapidly as possible, and begin treatment to meet their needs. The triage process may include physiologic-
39 based criteria, where possible and appropriate. The hospital trains staff to determine which patients need immediate care and
40 how their care is given priority.
41 When the hospital is not able to meet the needs of the patient with an emergency condition and the patient requires transfer
42 to a higher level of care, the transferring hospital must provide and document stabilizing treatment within its capacity prior to
43 transport.

44 Measurable Elements of ACC.1.1


45 1. The hospital uses an evidence-based triage process to prioritize patients with immediate needs.
46 2. Staff are trained to use the criteria.
47 3. Patients are prioritized based on the urgency of their needs.
48 4. Emergency patients are assessed and stabilized within the capacity of the hospital prior to transfer.
49 5. Stabilizing treatment provided prior to transport is documented in a record maintained by the transferring hospital.

50 Standard ACC.1.2 (formerly ACC.1.1.3)


51 The hospital considers the clinical needs of patients and informs patients when there are waiting periods or delays for
52 diagnostic and/or treatment services.

53 Intent of ACC.1.2
54 Patients are informed when there are known long waiting periods for diagnostic and/or treatment services or when obtaining
55 the planned care may require placement on a waiting list. Patients are informed of the associated reasons for the delay or wait
56 and are informed of available alternatives. This requirement applies to inpatient and outpatient care and/or diagnostic
57 services; not to minor waits in providing outpatient care or inpatient care, such as when a physician is behind schedule. For
58 some services, such as oncology or transplant, delays may be consistent with national norms for those services and thus
59 different than the delays for such services as diagnostic.

60 Measurable Elements of ACC. 1.2


61 1. Inpatients and outpatients are informed when there will be a delay in care and/or treatment.
62 2. Patients are informed of the reasons for the delay or wait and provided with information on available alternatives

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63 consistent with their clinical needs.


64 3. The information is documented in the patients record.
65

66 Admission to the Hospital

67 Standard ACC.2 (formerly ACC.1.1)


68 The hospital has a process for admitting inpatients and for registering outpatients.

69 Intent of ACC.2
70 The process for admitting inpatients to the hospital for care and for registering outpatients for services is standardized. Staff
71 are familiar with and follow the standardized process.
72 The process addresses
73 registration for outpatient services or admission for inpatient services;
74 admission directly from the emergency service to an inpatient unit; and
75 the process for holding patients for observation.
76 The process also addresses how patients are managed when inpatient facilities are limited or no space is available to admit
77 patients or to admit patients to the appropriate unit.

78 Measurable Elements of ACC.2


79 1. The outpatient registration process is standardized.
80 2. The inpatient admitting process is standardized.
81 3. There is a process for admitting emergency patients to inpatient units.
82 4. There is a process for holding patients for observation.
83 5. There is a process for managing patients when bed space is not available on the desired service or unit or elsewhere in
84 the facility.
85 6. Staff are familiar with and follow all of the admission and registration processes.
86

87 Standard ACC.2.1 (formerly ACC.1.1.2)


88 Patient needs for preventive, palliative, curative, and rehabilitative services are prioritized based on the patients condition at
89 the time of admission as an inpatient to the hospital.

90 Intent of ACC.2.1
91 When patients are considered for admission as an inpatient to the hospital, the screening assessment helps staff identify and

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92 prioritize the preventive, curative, rehabilitative, and palliative services needed by the patient and select the most appropriate
93 service or unit to meet the patients most urgent or priority needs.

94 Measurable Elements of ACC.2.1


95 1. The screening assessment helps staff identify the patients needs.
96 2. The service or unit selected to meet these needs is based on the screening assessment findings.
97 3. Patients needs related to preventive, curative, rehabilitative, and palliative services are prioritized.

98 Standard ACC.2.2 (formerly ACC.1.2)


99 At admission as an inpatient, patients and families receive information on the proposed care, the expected outcomes of care,
100 and any expected cost to the patient for care.

101 Intent of ACC.2.2


102 During the admission process, patients and their families receive sufficient information to make knowledgeable decisions.
103 Information is provided about the proposed care, the expected outcomes, and any expected cost to the patient or family for
104 the care when not paid for by a public or private source. When financial constraints related to the cost of care are present, the
105 hospital seeks ways to overcome those constraints. Such information can be in written form or provided verbally, noting such
106 in the patients record.

107 Measurable Elements of ACC.2.2


108 1. The patient and family are provided with information at admission.
109 2. The information includes proposed care.
110 3. The information includes expected outcomes of care.
111 4. The information includes any expected costs to the patient or family.
112

113 Standard ACC.2.2.1 (new standard)


114 The hospital develops a process to manage the flow of patients throughout the hospital.
115
116 Intent of ACC.2.2.1
117 Emergency department (ED) crowding and high hospital occupancy rates can lead to boarding patients in the ED or creating
118 temporary inpatient holding areas. Managing the flow of patients throughout their care is essential to prevent crowding,
119 which can undermine the timeliness of care and, ultimately, patient safety. Effective management of system-wide processes
120 that support patient flow (such as admitting, assessment and treatment, patient transfer, and discharge) can minimize delays in
121 the delivery of care. The components of the patient flow process address the following topics:
122 a) The available supply of inpatient beds
123 b) Facility plans for allocation of space, utilities, equipment, and supplies to support temporary patient locations
124 c) Staffing plans to support the addition of temporary patient locations and/or boarding in the ED

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125 d) The patient flow of areas where patients receive care, treatment, and services (such as inpatient units, laboratory,
126 operating rooms, telemetry, radiology, and the post-anesthesia care unit)
127 e) The efficiency of the nonclinical services that support patient care and treatment (such as housekeeping and
128 transportation)
129 f) Access to support services (such as social work, religious or spiritual support, and the like).
130 Monitoring and improving these processes are useful strategies to reduce patient flow problems. Staff from throughout the
131 hospitalinpatient units, emergency department, medical staff, nursing, administration, environmental services, risk
132 managementcan make a significant contribution to understanding and resolving problems in patient flow. Measures and
133 goals help identify impacts across units, reveal cycles and trends over time, and support accountability at all levels of the
134 organization.
135
136 Patients who come to a hospital ED for care are especially vulnerable to boarding. Boarding in the ED must be used as a
137 temporary solution to hospital crowding. Hospital plans should identify a time frame by which boarded patients will be
138 transferred from the ED to a standard or temporary inpatient area. The expectations here are intended to guide hospitals in
139 providing for a safe location, the orientation and training of staff, and the assessment, reassessment, and care (within its
140 capabilities) of patients who are subject to boarding.
141
142 Measurable Elements of ACC.2.2.1
143 1. The hospital has processes that support the flow of patients throughout the hospital.
144 2. The hospital plans for the care of patients needing admission who are boarded in the ED, including identifying a time
145 limit for boarding. .
146 3. The hospital plans for care to patients placed in temporary, overflow locations.
147 4. The components of the patient flow process address at least a) through e) of the intent statement.
148 5. The individuals who manage patient flow processes review the effectiveness to identify and implement process
149 improvements.
150

151 Standard ACC.2.3 (formerly ACC.1.4)


152 Admission to units providing intensive or specialized services is determined by established criteria.

153 Standard ACC.2.3.1 (also formerly ACC.1.4)


154 Discharge from units providing intensive or specialized services is determined by established criteria.

155 Intent of ACC.2.3 and ACC.2.3.1


156 Units or services that provide intensive care (for example, a postsurgical intensive care unit) or that provide specialized
157 services (for example, the care of burn patients or organ transplant units) are costly and usually are limited in space and
158 staffing. Each hospital must establish criteria for determining those patients who require the level of care provided in such
159 units.
160 When considering admission to specialized units that utilize expensive resources, hospitals may restrict admission to only

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161 those patients with reversible medical conditions, and not provide admission to patients whose conditions are terminal. To
162 ensure consistency, the criteria should utilize prioritization, and diagnostic and/or objective parameters, including physiologic-
163 based criteria. Individuals from the emergency, intensive, or specialized services participate in developing the criteria. The
164 criteria are used to determine direct entry to the unit, for example, directly from the emergency department. The criteria are
165 also used to determine admission into the unit from within the hospital or from outside the hospital (such as when a patient is
166 transferred from another hospital).
167 Patients admitted to a specialized unit require reassessment and re-evaluation to identify when the patients condition has
168 changed, such that specialized care may no longer be required. For example, when the patients physiological status has
169 stabilized and intensive monitoring and treatment are no longer necessary, or when the patients status has deteriorated to the
170 point that specialized care and services will no longer be provided, the patient may be discharged from the specialized unit or
171 moved to a unit that provides a lower level of care (such as a medical/surgical unit, hospice, or palliative care unit). The
172 criteria used for transfer from a specialized unit to a lower level of care should be the criteria that are used for admitting
173 patients to the next level of care. For example, when the patients condition has deteriorated such that intensive treatment is
174 no longer considered helpful, the patients admission to hospice or palliative care must be according to criteria for admission
175 to those services.
176 When the hospital conducts research or provides specialized patient care services or programs, admission into such programs
177 is through established criteria or an established protocol. Individuals from the research or other programs are involved in
178 developing the criteria or protocol. Admission to such programs is documented in the patients record and includes the
179 criteria or protocol conditions under which the patient was admitted.

180 Measurable Elements of ACC.2.3


181 1. The hospital has established entry and/or transfer criteria for admission to intensive and specialized services or units,
182 including research and other programs to meet special patient needs.
183 2. The criteria utilize prioritization, diagnostic, and/or objective parameters, including physiologic-based criteria.
184 3. Individuals from intensive/specialty units are involved in developing the criteria.
185 4. Staff are trained to apply the criteria.
186 5. The records of patients who are admitted to units providing intensive/specialized services contain evidence that they
187 meet the criteria for services.

188 Measurable Elements of ACC.2.3.1


189 1. The hospital has established discharge and/or transfer criteria from intensive and specialized services or units to a
190 different level of care, including research and other programs.
191 2. The criteria used for discharge or transfer should include the criteria used for admission to the next level of care.
192 3. Individuals from intensive or specialty units are involved in developing the criteria.
193 4. Staff are trained to apply the criteria.
194 5. The records of patients who are transferred or discharged from units providing intensive or specialized services
195 contain evidence that they no longer meet the criteria for services.
196

197 Continuity of Care


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198 Standard ACC.3 (formerly ACC.2)


199 The hospital designs and carries out processes to provide continuity of patient care services in the hospital and coordination
200 among health care practitioners.

201 Intent of ACC.3


202 As patients move through the hospital from admission to discharge or transfer, several departments and services and many
203 different health care practitioners may be involved in providing care. Throughout all phases of care, patient needs are matched
204 with the required resources within and, when necessary, outside the hospital. Continuity is enhanced when all patient-care
205 providers have the information needed from the patients current and past medical experiences to help in decision making,
206 and, when multiple decision makers are providing care, these decision makers agree on the care and services to be provided.
207 For patient care to appear seamless, the hospital needs to design and to implement processes for continuity and coordination
208 of care among physicians, nurses, and other health care practitioners in
209 a) emergency services and inpatient admission;
210 b) diagnostic services and treatment services;
211 c) surgical and nonsurgical treatment services;
212 d) outpatient care programs; and
213 e) other organizations and other care settings.
214 The leaders of the various settings and services work together to design and to implement the processes of care coordination
215 and continuity. These processes may be supported with the use of tools such as guidelines, clinical pathways, care plans,
216 referral forms, checklists, and the like. The hospital identifies individuals responsible for coordinating services. These
217 individuals may coordinate all patient care (for example, between departments) or may be responsible for coordinating the
218 care of individual patients (for example, case manager).
219 This care coordination is best accomplished by using established criteria or policies that determine the appropriateness of
220 transfers within the hospital. (Also see ACC.1.4 related to criteria for admission to or transfer from intensive and specialized
221 units)

222 Measurable Elements of ACC.3


223 1. The leaders of services and settings design and implement processes that support continuity and coordination of care,
224 including at least a) through e) identified in the intent statement.
225 2. Continuity and coordination of care processes are supported by the use of tools, such as care plans, guidelines, or
226 other such tools.
227 3. Continuity and coordination are evident throughout all phases of patient care.

228 Standard ACC.3.1 (formerly ACC.2.1)


229 During all phases of inpatient care, there is a qualified individual identified as responsible for the patients care.

230 Intent of ACC.3.1


231 To maintain continuity of care throughout the patients stay in the hospital, the individual with overall responsibility for

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232 coordination and continuity of the patients care or particular phase of the patients care is clearly identified. This individual
233 may be a physician or other qualified individual. The responsible individual is identified in the patients record. A single
234 individual providing the oversight of care during the entire hospital stay will improve continuity, coordination, patient
235 satisfaction, quality, and potentially the outcomes and thus is desirable for certain complex patients and others the hospital
236 may identify. This individual would need to collaborate and to communicate with the other health care practitioners. In addition,
237 hospital policy identifies the process for the transfer of responsibility from the responsible individual to another individual during
238 vacations, holidays, and other periods. The policy identifies those consultants, on-call physicians, locum tenens, or others who
239 take responsibility and how they are to assume that responsibility and to document their participation or coverage.
240 When a patient moves from one phase of care to another (for example, from surgical to rehabilitation), the individual
241 responsible for the patients care may change or the same individual may continue overseeing the entire patients care.

242

243 Measurable Elements of ACC.3.1


244 1. The individual(s) responsible for the coordination of the patients care is identified in the patient record and available
245 through all phases of inpatient care.
246 2. The individual(s) is qualified to assume responsibility for the patients care.
247 3. There is a process for transferring the responsibility for coordination of care from individual to individual.
248 4. The process identifies how these individuals assume the transferred responsibility and document their participation or
249 coverage.
250

251 Discharge, Referral, and Follow-Up

252 Standard ACC.4 (formerly ACC.3)


253 There is a process for the referral or discharge of patients that is based on the patients health status and the need for
254 continuing care or services.

255 Intent of ACC.4


256 Referring or discharging a patient to a health care practitioner outside the hospital, another care setting, home, or family is
257 based on the patients health status and need for continuing care or services. The patients physician or individual responsible
258 for his or her care must determine readiness for discharge based on the policies and relevant criteria or indications of referral
259 and discharge established by the hospital. Criteria may also be used to indicate when a patient is ready for discharge.
260 Continuing needs may mean referral to a medical specialist, rehabilitation therapist, or even preventive health needs
261 coordinated in the home by the family. An organized process is required to ensure that any continuing needs are met by
262 appropriate health care practitioners or outside organizations. The process includes referring patients to sources of care
263 outside the region when required. When indicated, the hospital begins to plan for the continuing needs as early in the care
264 process as possible. The family is included in the discharge planning process as appropriate to the patient and his or her
265 needs.
266 There is process to guide when the hospital permits patients to leave the hospital for a period of time (such as on a weekend
267 pass).

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268 Measurable Elements of ACC.4


269 1. Patients are referred and/or discharged based on their health status and needs for continuing care.
270 2. The patients readiness for discharge is determined by the use of relevant criteria or indications that ensure patient
271 safety.
272 3. Planning for referral and/or discharge begins early in the care process.
273 4. There is a process for patients being permitted to leave the hospital during the planned course of treatment on an
274 approved pass for a defined period of time.

275 Standard ACC.4.1 (formerly PFE.4)


276 Patient and family education and instruction are related to the patients continuing care needs.

277 Intent of ACC.4.1


278 The hospital routinely provides education in areas that carry high risk to patients. Education supports the return to previous
279 functional levels and maintenance of optimal health.
280 The hospital uses standardized materials and processes in educating patients on at least the following topics:
281 a) Safe and effective use of all medications taken by the patient (not just discharge medications), including potential
282 medication side effects
283 b) Safe and effective use of medical equipment
284 c) Potential interactions between prescribed medications and other medications (including over-the-counter
285 preparations) and food
286 d) Diet and nutrition
287 e) Pain management
288 f) Rehabilitation techniques

289 Measurable Elements of ACC.4.1


290 1. Patients and families are educated about the safe and effective use of all medications, potential side effects of
291 medications, and prevention of potential interactions with over-the-counter medications and/or food.
292 2. Patients and families are educated about safe and effective use of medical equipment.
293 3. Patients and families are educated about proper diet and nutrition.
294 4. Patients and families are educated about pain management.
295 5. Patients and families are educated about rehabilitation techniques.

296 Standard ACC.4.2 (formerly ACC.3.1)


297 The hospital cooperates with health care practitioners and outside agencies to ensure timely referrals.

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298 Intent of ACC.4.2


299 Timely referral to the practitioner, organization, or agency that can best meet the patients continuing needs takes planning.
300 The hospital becomes familiar with the health care practitioners in its community to understand the types of patients treated
301 and services provided and to build formal or informal relationships with those practitioners. When patients come from a
302 different community, the hospital attempts to make a referral to a qualified individual or agency in the patients home
303 community.
304 Also, patients may need support services and medical services at discharge. For example, patients may need social, nutritional,
305 financial, psychological, or other support at discharge. The availability and actual use of these support services may, to a large
306 degree, determine the need for continuing medical services. The discharge planning process includes the type of support
307 service needed and the availability of such services.

308 Measurable Elements of ACC.4.2


309 1. The discharge planning process includes the need for both support services and continuing medical services.
310 2. Referrals outside the hospital are to specific individuals and agencies in the patients home community whenever
311 possible.
312 3. Referrals are made for support services.

313 Standard ACC.4.3 (formerly ACC.3.2.1)


314 The complete discharge summary is prepared for all inpatients.

315 Intent of ACC.4.3


316 The discharge summary provides an overview of the patients stay within the hospital. The summary can be used by the
317 practitioner responsible for providing follow-up care. The summary includes the following:
318 a) Reason for admission, diagnoses, and comorbidities
319 b) Significant physical and other findings
320 c) Diagnostic and therapeutic procedures performed
321 d) Significant* medications administered during hospitalization and all the medications to be taken at home
322 e) The patients condition/status at the time of discharge (examples include; condition improved, condition
323 unchanged, and the like)
324 f) Follow-up instructions
325 *Note: Significant medications includes those medications that may have a residual effect

326 Measurable Elements of ACC.4.3


327 1. The discharge summary contains reason for admission, diagnoses, and comorbidities.
328 2. The discharge summary contains significant physical and other findings.
329 3. The discharge summary contains diagnostic and therapeutic procedures performed.
330 4. The discharge summary contains significant medications, including discharge medications.

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331 5. The discharge summary contains the patients condition/status at the time of discharge.
332 6. The discharge summary contains follow-up instructions.
333

334 Standard ACC.4.3.1 (formerly ACC.3.4)


335 Patient education and follow up instructions are given in a form and language the patient can understand.

336 Intent of ACC.4.3.1


337 For patients not directly referred or transferred to another health care practitioner, clear instructions on where and how to
338 receive continuing care are essential to ensure optimal outcomes of care and that all care needs are met.
339 The instructions include the name and location of sites for continuing care, any return to the hospital for follow-up, and when
340 urgent care should be obtained. Families are included in the process when a patients condition or abilities prevent him or her
341 from understanding the follow-up instructions. Families are also included when they play a role in the continuing care
342 process.
343 The hospital provides the instructions to the patient and, as appropriate, his or her family in a simple, understandable manner.
344 The instructions are provided in writing or in the form most understandable to the patient.

345 Measurable Elements of ACC.4.3.1


346 1. Follow-up instructions are provided in a form and manner the patient and/or family understands.
347 2. The instructions include any return for follow-up care.
348 3. The instructions include when to obtain urgent care.
349

350 Standard ACC.4.3.2 (formerly ACC.3.2)


351 The clinical records of inpatients contain a copy of the discharge summary.

352 Intent of ACC.4.3.2


353 A summary of the patients care is prepared at discharge from the hospital. Any qualified individual can compile the discharge
354 summary, such as the patients physician, a house medical officer, or a clerk.
355 The copy of the discharge summary is placed in the patients record. A copy is given to the patient when indicated by hospital
356 or by common practice consistent with laws and culture. A copy of the discharge summary is also provided to the practitioner
357 who will be responsible for the continuing care of the patient or his or her follow-up.

358 Measurable Elements of ACC.4.3.2


359 1. A discharge summary is prepared by a qualified individual.
360 2. Unless contrary to hospital policy, laws, or culture, the patient is given a copy of the discharge summary.
361 3. A copy of the discharge summary is provided to the practitioner responsible for the patients continuing or follow-up

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362 care.
363 4. A copy of the completed discharge summary is placed in the patient record in a time frame identified by the hospital.
364

365 Standard ACC.4.4 (formerly ACC.3.3)


366 The hospital has a process for ensuring that summaries of the medical care of outpatients requiring complex care or with
367 complex diagnoses are available to health care professionals providing care to that patient.

368 Intent of ACC.4.4


369 When the hospital provides ongoing care and treatment for outpatients with complex diagnoses and/or who need complex
370 care (for example, patients seen frequently over a longer period of time for multiple problems, multiple visits, multiple clinics,
371 and the like), there may be an accumulated number of diagnoses and medications, and an evolving clinical history and physical
372 exam findings. It is important for any health care professional in the hospital providing care to that outpatient to have access
373 to summary information about the care being provided.
374 The process for providing this information to healthcare professionals includes
375 identifying the types of patients receiving complex care and/or with complex diagnoses (such as
376 patients seen in the cardiac clinic with multiple comorbidities, or patients with end stage renal failure);
377 identifying the information needed by the clinicians who treat those patients;
378 determining what process will be used to ensure that the medical information needed by the clinicians is
379 available in an easy-to-retrieve and easy-to-review format; and
380 evaluating the implementation results to verify the information and process meet the needs of the
381 clinicians and improve the quality and safety of outpatient clinical services.

382 Measurable Elements of ACC.4.4


383 1. The hospital identifies the types of outpatients receiving complex care and/or with complex diagnoses.
384 2. The hospital identifies the information needed by the clinicians who treat those patients.
385 3. The hospital develops a process that will be used to ensure the medical information needed by clinicians is available
386 in an easy to retrieve and review format.
387 4. The process is evaluated to see if it meets the needs of the clinicians and improves the quality and safety of outpatient
388 clinical visits.
389

390 Standard ACC.4.6 (formerly ACC.3.5)


391 The hospital has a process for the management and follow-up of patients who notify hospital staff that they intend to leave
392 against medical advice.

393 Standard ACC.4.6.1

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394 The hospital has a process for the management of patients who leave the hospital against medical advice without notifying
395 hospital staff.

396 Intent of ACC.4.6 and ACC.4.6.1


397 When a patient decides to leave the hospital after an examination has been completed and a treatment plan recommended,
398 whether it is an inpatient or an outpatient, this is identified as leaving against medical advice. Inpatients and outpatients
399 (including patients from the emergency department) have the right to refuse medical treatment and/or leave the hospital
400 against medical advice. However, these patients may be at risk of inadequate treatment that may result in permanent harm or
401 death. When a competent inpatient or outpatient requests to leave the hospital without medical approval, the medical risks
402 must be explained by the physician providing the treatment plan or his/her designee prior to discharge. Also, normal
403 discharge procedures should be followed, if the patient allows. If the patient has a family physician that has not been involved,
404 but is known to the hospital, the family physician must be notified of the patients decision. Efforts should be made to
405 identify the reason the patient is choosing to leave against medical advice. Hospitals need to understand these reasons in
406 order to be able to provide better communication to patients and/or families and identify potential process improvements.
407 When a patient leaves the hospital against medical advice without notifying anyone in the hospital, or an outpatient receiving
408 complex or life-saving treatment, such as chemotherapy or radiation therapy does not return for treatment, the hospital must
409 make an effort to contact the patient to inform the patient of potential risks. If the patient has a family physician who is
410 known to the hospital, the hospital, in order to reduce the risk of harm, should notify that physician.
411 The hospital designs this process to be consistent with applicable laws and regulations.

412 Measurable Elements of ACC.4.6


413 1. There is a process for managing inpatients and outpatients who notify staff that they are leaving against medical
414 advice.
415 2. The process includes informing the patient of the medical risks of inadequate treatment.
416 3. The patient should be discharged according to the hospital discharge process.
417 4. If the family physician of a patient leaving against medical advice is known and has not been involved in the process,
418 the physician is notified.
419 5. The hospital has a process to try to identify the reasons for patients leaving against medical advice.
420 6. The process is consistent with applicable laws and regulations.

421 Measurable Elements of ACC.4.6.1


422 1. There is a process for the management of inpatients and outpatients who leave the hospital against medical advice
423 without notifying hospital staff.
424 2. There is a process for the management of outpatients receiving complex treatment who do not return for treatment.
425 3. If the family physician is known and has not been involved in the process, the physician is notified.
426 4. The process is consistent with applicable laws and regulations.
427

428

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429 Transfer of Patients

430 Standard ACC.5 (formerly ACC.4)


431 Patients are transferred to other organizations based on status, the need to meet their continuing care needs, and the ability of
432 the receiving organization to meet the patients needs.

433 Intent of ACC.5


434 Transferring a patient to an outside organization is based on the patients status and need for continuing health care services.
435 Transfer may be in response to a patients need for specialized consultation and treatment, urgent services, or less-intensive
436 services, such as sub-acute care or longer term rehabilitation. Criteria help to identify when a transfer is necessary in order to
437 assure that the patients needs are met.
438 When referring a patient to another organization, the referring hospital must determine if the receiving organization provides
439 services to meet the patients needs and has the capacity to receive the patient. This determination is usually made well in
440 advance and the willingness to receive patients and the transfer conditions are described in formal or informal affiliations or
441 agreements. This advance determination ensures continuity of care and that the patients care needs will be met. Transfers
442 may occur to other sources of specialized treatment or services without formal or informal transfer agreements.

443 Measurable Elements of ACC.5


444 1. Transfers of patients are based on criteria developed by the hospital to address the patients needs for continuing
445 care.
446 2. The referring hospital determines that the receiving organization can meet the needs of the patient to be transferred.
447 3. Formal or informal arrangements are in place with receiving organizations when patients are frequently transferred to
448 the same organization(s).

449 Standard ACC.5.1 (formerly ACC.4.1)


450 The referring hospital develops a transfer process to ensure that patients are transferred safely.

451 Intent of ACC.5.1


452 Transferring a patient directly to another health care organization may be a brief process with an alert and talking patient, or it
453 may involve moving a comatose patient who needs continuous nursing or medical oversight. In either case, the patient
454 requires monitoring and may need specialized equipment, but the qualifications of the individual doing the monitoring and
455 the type of equipment needed are significantly different. Thus, the condition and status of the patient determine the
456 qualifications of the staff member monitoring the patient and the type of equipment needed during transfer.
457 A consistent process for how patients are transferred from one organization to another is required to ensure that patients are
458 transferred safely. Such a process addresses
459 how responsibility is transferred between practitioners and settings;
460 criteria for when transfer is necessary to meet the patients needs;
461 who is responsible for the patient during transfer;

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462 what supplies and equipment are required during transfer;


463 a follow-up mechanism that provides the condition of the patient during transfer and upon arrival to
464 the receiving organization; and
465 what is done when transfer to another source of care is not possible.
466 The hospital evaluates the quality and safety of the transfer process to ensure that patients were transferred with qualified staff
467 and the correct equipment for the patients condition.

468 Measurable Elements of ACC.5.1


469 1. The hospital develops a transfer process that addresses how responsibility for continuing care is moved to another
470 practitioner or setting.
471 2. The transfer process identifies who is responsible for monitoring the patient during transfer and the staff
472 qualifications required for the type of patient being transferred.
473 3. The transfer process identifies the supplies and equipment required during transport.
474 4. The transfer process addresses a follow-up mechanism that provides information about the patients condition upon
475 arrival to the receiving organization.
476 5. The transfer process addresses the situation in which transfer is not possible.
477 6. There is a process to evaluate the quality and safety of the transfer process.
478

479 Standard ACC.5.2 (formerly ACC.4.2)


480 The receiving organization is given a written summary of the patients clinical condition and the interventions provided by the
481 referring hospital.

482 Intent of ACC.5.2


483 To ensure continuity of care, patient information is transferred with the patient. A copy of the discharge summary or other
484 written clinical summary is provided to the receiving organization with the patient. The summary includes the patients clinical
485 condition or status, the procedures and other interventions provided, and the patients continuing needs.
486

487 Measurable Elements of ACC.5.2


488 1. A patient clinical summary document is transferred with the patient.
489 2. The clinical summary includes patient status.
490 3. The clinical summary includes procedures and other interventions provided.
491 4. The clinical summary includes the patients continuing care needs.

492

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493 Standard ACC.5.3 (formerly ACC.4.4)


494 The transfer process is documented in the patients record.

495 Intent of ACC.5.3


496 The record of each patient transferred to another health care organization contains documentation of the transfer. The
497 documentation includes the name of the organization and the name of the individual agreeing to receive the patient, the
498 reason(s) for the transfer, and any special conditions for transfer (such as when space at the receiving organization is available,
499 or the patients status). Also, it is noted if the patients condition or status changed during transfer (for example, the patient
500 dies or requires resuscitation). Any other documentation required by hospital policy (for example, a signature of the receiving
501 nurse or physician, the name of the individual who monitored the patient during transport) is included in the record.

502 Measurable Elements of ACC.5.3


503 1. The records of transferred patients note the name of the receiving health care organization and name of the
504 individual agreeing to receive the patient.
505 2. The records of transferred patients contain documentation or other notes as required by the policy of the transferring
506 hospital.
507 3. The records of transferred patients note the reason(s) for transfer.
508 4. The records of transferred patients note any special conditions related to transfer.

509 Transportation

510 Standard ACC.6 (formerly ACC.5)


511 The process for referring, transferring, or discharging patients, both inpatients and outpatients, includes planning to meet the
512 patients transportation needs.

513 Intent of ACC.6


514 The hospitals process for referring, transferring, or discharging patients includes an understanding of the transportation
515 needs of the patient. For example, patients from long term care facilities or rehabilitative centers needing outpatient services
516 or evaluation in the emergency department may arrive by ambulance or other medical vehicle. Upon completion of the
517 service, the patient may require assistance with transportation back to their home or another facility. In other situations, a
518 patient may drive themselves to the hospital for a procedure that impairs their ability to drive themselves home (such as eye
519 surgery, a procedure that requires sedation, and the like). Assessing the patient's transportation needs and assuring the patient
520 has safe transportation is the hospitals responsibility. Depending on hospital policy and the laws and regulations of the
521 region, the cost of the transportation may or may not be the responsibility of the hospital.
522 The type of transportation will vary and may be by ambulance or other vehicles owned by the hospital or by a source
523 designated by the family, or the family and/or friends may provide the transportation. The transportation selected will depend
524 on the patients condition and status.
525 When the transport vehicles are owned by the hospital, they need to be in compliance with all applicable laws and regulations
526 related to their operation, condition, and maintenance. The hospital identifies the transportation situations that have a risk of
527 infection and implements strategies to reduce infection risk. (Also see the PCI chapter for compliance with infection control

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528 standards appropriate for use.) The required drugs, medications, and other supplies needed within the vehicle are based on the
529 types of patients transported. For example, simply taking geriatric patients home from outpatient visits is very different than
530 transferring an infectious disease or burn patient to another hospital.
531 If the hospital contracts for transport services, the hospital must be assured that the contractor meets similar standards for
532 patient and vehicle safety. When transportation services are provided by the ministry of health, insurance organization, or
533 other entity not under the control or supervision of the hospital, reporting quality and safety issues to the responsible
534 organization provides valuable feedback that can help in making quality decisions related to patient transports.
535 In all cases, the hospital evaluates the quality and safety of the transportation services. This includes the receipt of, evaluation
536 of, and response to complaints regarding the transportation provided or arranged.

537 Measurable Elements of ACC.6


538 1. There is an assessment of transportation needs when any patient is referred to another source of care, transferred to
539 another care setting, or ready to go home following an inpatient admission or outpatient visit.
540 2. The transportation provided or arranged is appropriate to the needs and condition of the patient.
541 3. Transport vehicles owned by the hospital meet relevant laws and regulations related to their operation, condition, and
542 maintenance.
543 4. Contracted transportation services meet the hospitals requirements for quality and safe transport.
544 5. All vehicles used for transportation, contracted or hospital owned, have appropriate equipment, supplies, and
545 medications to meet the needs of the patient being transported.
546 6. There is a process in place to monitor the quality and safety of transportation provided or arranged by the hospital,
547 including a complaint process.
548

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1 Care of Patients (COP)


2 Standard COP.2.1
3 An individualized plan of care for each patient is developed and documented for each patient.

4 Intent of COP.2.1
5 The plan of care outlines care and treatment to be provided to an individual patient. The plan of care identifies a set of
6 actions that the health care team will implement to resolve or support the diagnosis identified by assessment, thus providing
7 for measurable outcomes. The overall goal of a plan of care is to achieve optimal clinical outcomes.
8 The planning process is collaborative and uses the data from the initial assessment and from periodic reassessments
9 performed by physicians, nurses, and other health care practitioners to identify and to prioritize the treatments, procedures,
10 nursing care, and other care to meet the patients needs. The patient and family are involved in the planning process with the
11 health care team. The plan is recorded in the patients record. The plan of care is developed within 24 hours of admission as
12 an inpatient. Based on the reassessment of the patient performed by the patients health care practitioners, the plan is updated
13 as appropriate to reflect the evolving condition of the patient. The plan of care is documented in the patients record.
14 The plan of care for a patient must be related to his or her identified needs. Those needs may change as the result of clinical
15 improvement or new information from a routine reassessment (for example, abnormal laboratory or radiography results), or
16 they may be evident from a sudden change in the patients condition (for example, loss of consciousness). As needs change,
17 the plan for the patients care also changes. The plan of care is revised based on these changes and is documented in the
18 record as notes to the initial plan or as revised or new measurable goals, or they may result in a new plan of care.
19 Measurable goals are selected by the responsible physician in collaboration with the nurse and other healthcare practitioners.
20 Measurable goals are observable, achievable targets related to patient care and expected clinical outcomes. They must be
21 realistic, specific to the patient, and time-based to provide a means for measuring progress and outcomes related to the plan
22 of car.
23 Note: A single, integrated plan of care that identifies measurable goals expected by each health care practitioner is preferable.
24 to the entry of a separate care plan by each practitioner. The plan of care for each patient should reflect individualized,
25 objective, and realistic measurable goals to facilitate reassessment and revision of the plan of care.

26 Measurable Elements of COP.2.1


27 1. The care for each patient is planned by the responsible physician, nurse, and other health care practitioners within 24
28 hours of admission as an inpatient.
29 2. The plan of care is individualized and based on the patients initial assessment data.
30 3. The plan of care is documented in the record in the form of measurable goals.
31 4. The measurable goals are updated or revised based on the reassessment of the patient by the healthcare
32 practitioners.

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33 5. The plan of care for each patient is reviewed when initially developed and when revised based on changes in patient
34 condition by the multidisciplinary team and documented in the patient record.
35 6. The planned care is provided. (Also see COP.2.3, intent statement)
36 7. The care provided for each patient is written in the patients record by the health professional providing the care.
37 (Also see ASC.5.2, ME 1; ASC.7.2, intent statement; and COP.2.3, ME 1)

38
39 Recognition of Changes to Patient Condition

40 Standard COP.A
41 Clinical staff are trained to recognize and respond to changes in a patients condition.

42 Intent of COP.A
43 Staff who do not work in critical care areas may not have adequate knowledge and training to assess and monitor patients
44 with critical conditions. However, a significant number of patients outside of critical care areas experience critical inpatient
45 events. Often, a patient will exhibit early warning signs (for example, a worsening of vital signs or a subtle change in
46 neurological status) shortly before experiencing significant clinical decline, resulting in a major event. The literature identifies
47 physiologic criteria that can assist staff in early detection of deteriorating patients. A majority of patients who experience
48 cardiopulmonary or respiratory arrest demonstrate clinical deterioration prior to arrest. When staff are able to identify these
49 patients early and request additional assistance from specially trained individuals, clinical outcomes improve.
50 All clinical staff require education and training to provide them with the knowledge and skills to recognize and intervene
51 when patient assessments identify physiological signs that are outside of the normal range, indicating a potential for patient
52 deterioration. Early response to changes in a patients condition is critical to potentially preventing further deterioration.
53 Hospitals that develop a systematic approach to early recognition and intervention of patients whose condition is
54 deteriorating may reduce cardiopulmonary arrests and patient mortality.

55 Measurable Elements of COP.A


56 1. The hospital develops a systematic approach for staff recognition and response to a patient whose condition appears
57 to be worsening.
58 2. The hospital develops and implements written documented criteria describing early warning signs of a change or
59 deterioration in a patients condition and when to seek further assistance.
60 3. Based on the hospitals early warning criteria, staff seek additional assistance when they have concerns about a
61 patients condition.
62 4. The hospital informs the patient and family how to seek assistance when they have concerns about a patients
63 condition.
64
65

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66 Resuscitation Services

67 Standard COP.B
68 Resuscitation services are available throughout the organization.

69 Intent of COP.B
70 Resuscitation services can be defined as clinical interventions for the emergent care of patients experiencing a critical, life-
71 threatening event, such as cardiac or respiratory arrest. When a cardiac or respiratory arrest occurs, the immediate initiation
72 of chest compressions or respiratory support may mean the difference between life and death or, at the very least, potentially
73 serious brain damage.
74 Successful resuscitation of patients in cardiopulmonary arrest is dependent on critical interventions, such as early defibrillation
75 and accurate implementation of advanced life support. These services must be available to all patients, 24 hours a day, every
76 day. Essential to providing these critical interventions is the quick availability of resuscitation equipment and properly trained
77 staff. Basic life support must be implemented immediately upon recognition of cardiac or respiratory arrest and a process
78 must be in place for providing advanced life support within a time frame consistent with evidence from literature.
79 Resuscitation services available within the hospital, including equipment and properly trained staff, must be based on clinical
80 evidence and the population served (for example, if the hospital has a pediatric population, pediatric resuscitation equipment
81 should be available).

82 Measurable Elements of COP.B


83 1. Resuscitation services are available and provided to all patients 24 hours a day, every day, throughout the
84 organization.
85 2. Resuscitation equipment for basic and advanced life support is available for use based on the needs of the population
86 served.
87 3. Resuscitation equipment is available throughout the organization in a time frame consistent with evidence from
88 literature.
89 4. Staff trained in advanced life support are available throughout the organization in a time frame consistent with
90 evidence from the literature.

91 Hospitals with Transplant Programs

92 Standard COP.C
93 The hospitals leaders provide resources to support the organ/tissue transplant program.

94 Intent of COP.C
95 The organ/tissue transplant program requires staff with specialized education and training and other resources in order to

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96 provide safe, quality care. Staff education and training must be specific to the responsibilities and requirements of
97 organ/tissue transplant. Other essential resources include supplies, patient rooms with ventilation required for the type of
98 transplant procedure (for example, positive pressure ventilation), required pharmaceuticals for the type of transplant
99 procedure, laboratory testing to assure tissue/organs are not contaminated, and other resources as identified by the program
100 director.
101 Additionally, resources related to information management systems are necessary to assist with the collection of data
102 associated with risks, outcomes, and other information that supports the quality of the transplant program.

103 Measurable Elements of COP.C


104 1. Trained staff are available to provide safe, quality care to the tissue/organ transplant program.
105 2. The hospitals leaders allocate resources for the tissue/organ transplant program.
106 3. Information management systems support quality improvement for the tissue/organ transplant program.
107

108 Standard COP.D


109 A qualified transplant program director is responsible for the transplant program.

110 Intent of COP.D


111 The responsibility of a hospital offering organ and tissue transplant services is to provide safe, high quality care to transplant
112 donors and recipients. At the core of this responsibility is an infrastructure capable of supporting all transplant program
113 activities. A key element of the infrastructure includes an individual(s) responsible for oversight of the organ/tissue
114 transplant program. One or more individuals, acting on a full-time or part-time basis, provide that oversight as part of their
115 assigned responsibilities or job descriptions. This individual is qualified in transplant management through education,
116 training, experience, license and/or certification. Their qualifications depend on the activities carried out.

117 Measurable Elements of COP.D


118 1. One or more individuals oversee the organ/tissue transplant program.
119 2. The individual is qualified for the hospitals program scope and complexity.
120 3. The individual fulfills the program oversight responsibilities as defined by the transplant program.
121

122 Standard COP.E


123 The transplant program includes a multidisciplinary team that consists of people with expertise in the relevant organ-specific
124 transplant programs.

125 Intent of COP.E

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126 The success of a transplant program and positive outcomes for transplant recipients and donors as well are dependent on a
127 team of healthcare providers that have clinical knowledge and expertise in organ-specific transplantation. The nursing,
128 psychological, pharmacological, and nutritional needs of an organ recipient and a living organ donor are unique. Thus, a
129 multidisciplinary team consists of individuals from:
130 medicine,
131 nursing,
132 nutrition,
133 pharmacology,
134 social services, and
135 psychological services.
136 This team should have the qualifications, training, and experience to provide care and services to transplant recipients and
137 living donors.

138 Measurable Elements of COP.E


139 1. The transplant program documents defines in writing the composition of the tissue/organ-specific transplant team.
140 2. The transplant program documents defines in writing the team members responsibilities.
141 3. Based on the services provided by the transplant team, the team includes individuals experienced in: medicine;
142 nursing; nutrition; pharmacology; social services, psychological services; and transplant coordination.
143 34. The transplant program evaluates team members for qualifications, training, and experience at the time each
144 individual is being considered for the transplant team.
145

146 Standard COP.F


147 There is a designated coordination mechanism for all transplant activities that involves physicians, nurses, and other health
148 care practitioners.

149 Intent of COP.F


150 Transplant services carry unique and critical risks to organ/tissue recipients and in the cases of live donors, to the donor as
151 well. An important component in assuring safe, quality care through all phases of the donor/recipient process is identifying
152 an individual(s) with overall responsibility for coordination and continuity of the live donors and recipients care. This
153 individual may be a physician, registered nurse, or other qualified healthcare professional.

154 Measurable Elements of COP.F


155 1. The individual responsible for the coordination of the live donor and transplant recipients care is identified and
156 available through all phases of transplant care.

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157 2. The clinical transplant coordinator facilitates continuity of care for transplant patients (candidates and recipients)
158 through the pre-transplant, transplant, and discharge phases of transplantation.
159 3. The clinical transplant coordinator facilitates continuity of care for living donors during evaluation, donation, and
160 discharge phases of donation.
161 4. The coordination of organ/transplant activities are communicated to all staff involved in the transplant program
162 activities.
163

164 Standard COP.G


165 The transplant program uses organ-specific transplant clinical eligibility and psychosocial suitability criteria for candidates.

166 Intent of COP.G


167 To come

168 Measurable Elements of COP.G


169 1. The transplant program documents defines in writing organ-specific candidate selection criteria.
170 2. The results of a medical evaluation are included in the determination of suitability for transplantation.
171 3. The transplant program documents organ compatibility confirmation in the transplant candidates medical record.
172

173 Standard COP.H


174 The transplant program obtains informed consent specific to organ transplantation from the transplant candidate.

175 Intent of COP.H


176 Factors that could affect the success of the graft or the candidates health as a recipient include, but are not limited to:
177 a) the donors history;
178 b) condition of the organs used;
179 c) age of the organs; and
180 d) potential risk of contracting infectious disease(s) if disease(s) cannot be detected in an infected donor.

181 Measurable Elements of COP.H


182 1. The transplant program follows the hospitals policy when obtaining informed consent from transplant candidates.
183 2. In addition to the information provided to any surgical patient as part of the informed consent process, the transplant

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184 program informs the prospective transplant candidate of potential psychosocial risks.
185 3. In addition to the information provided to any surgical patient as part of the informed consent process, the transplant
186 program informs the prospective transplant candidate of organ donor risk factors that could affect the success of the
187 graft or the candidates health as a recipient including, but not limited to a) thru d) of the intent statement.
188 4. In addition to the information provided to any surgical patient as part of the informed consent process, the transplant
189 program informs the prospective transplant candidate of the transplant centers observed and expected one-year survival
190 rate.
191 5. In addition to the information provided to any surgical patient as part of the informed consent process, the transplant
192 program informs the prospective transplant candidate about immunosuppressive drugs and potential associated costs.
193 6. In addition to the information provided to any surgical patient as part of the informed consent process, the transplant
194 program informs the prospective transplant candidate of alternative treatments.
195

196 Standard COP.I


197 The transplant program has written documented protocols for organ recovery and organ receipt to assure the compatibility,
198 safety, efficacy, and quality of human cells, tissues and organs for transplantation.

199 Intent of COP.I


200 To reduce the risk of organ rejection, the transplant surgeon must ensure the compatibility of donor organ(s) to the recipient.
201 The most frequently used tests for compatibility includes blood typing and cross matching and tissue typing. The transplant
202 surgeon ensures that testing for compatibility occurs before organ recovery and organ transplantation takes place.
203 Transmission of infectious diseases and malignancies is a potential risk for recipients of donor tissues and organs. Therefore,
204 the level of safety, efficacy and quality of human cells, tissues and organs for transplantation must be assured. Evaluation of
205 organ and tissue donors may identify those donors who have a higher risk for infection with a potentially harmful pathogen.
206 Donor screening of clinical history and donor testing for communicable diseases can significantly reduce the incidence of
207 donor transmission of disease. Donor screening should include evaluation of medical history, behavioral risk factors, and a
208 physical examination. Donor testing should include tests for H.I.V., hepatitis B, hepatitis C, and other recommended tests.
209 For any transplantation of human material, traceability should be ensured for the anticipated lifetime of the donor and the
210 recipient. Internationally agreed means of coding to identify tissues and cells used in transplantation are essential for full
211 traceability.

212 Measurable Elements of COP.I


213 1. The transplant team follow written organ recover protocols which include reviewing the donor data, recipient blood
214 type, and other vital data to ensure compatibility before organ recovery takes place.
215 2. The transplant surgeon is responsible for confirming the medical suitability of donor organs for transplantation into
216 the recipient.
217 3. When an organ arrives at the transplant center, the transplanting surgeon and at least one other licensed health care

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218 professional at the transplant center verify that the donors blood type and other vital data are compatible with the
219 recipient prior to transplantation.
220 4. The transplant surgeon is responsible for confirming that donor evaluation and donor testing for infectious diseases
221 and malignancy have been completed before organ recovery and organ transplant occur.
222 5. When an organ arrives at the transplant center, the transplanting surgeon and at least one other licensed health care
223 professional at the transplant center verify that evaluation and testing of the donor organ shows no evidence of disease.
224

225 Standard COP.J


226 Individualized patient care plans guide the care of transplant patients (both candidates and recipients).

227 Intent of COP.J


228 To come

229 Measurable Elements of COP.J


230 1. The transplant program has written documented organ-specific clinical guidelines for the pre-transplant, transplant,
231 and discharge phases of transplantation.
232 2. Each transplant patient (candidate and recipient) is under the care of a multidisciplinary patient care team coordinated
233 by the patients primary transplant physician throughout the pre-transplant, transplant, and discharge phases of
234 transplantation.
235 3. Transplant candidates are evaluated for the suitability of other medical and surgical therapies that may yield short and
236 long-term survival rates comparable to transplantation.
237 4. Transplant candidates receive a psychosocial evaluation.
238 5. The transplant program updates clinical information in the transplant patients (candidate and recipient) medical
239 record on an ongoing basis.
240

241 Transplant Programs Using Living Donor Organs

242 Standard COP.K


243 Transplant programs that perform living donor transplantation protect the rights of prospective or actual living donors.

244 Intent of COP.K


245 The growing demand and limited supply of deceased organs for donation have resulted in increased efforts to promote live
246 organ donation. Living donor standards for the selection of suitable candidates for donation, informed consent, and care

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247 following the donation do not universally exist. Living donors face difficult decisions and are at potential risk for life-long
248 complications and should not feel coerced or pressured into organ donation. To help with decisions and to assure that the
249 living donors rights are protected, an individual with knowledge of living organ donation, transplantation, medical ethics, and
250 informed consent must be identified.
251

252 Measurable Elements of COP.K


253 1. The living organ donor has the right to make a decision about donation in a setting free of coercion or pressure.
254 2. An individual with knowledge of living organ donation, transplantation, medical ethics, and informed consent is
255 identified as an advocate for the living donor.
256 3. The individual appointed as the living donor advocate is not involved in routine transplantation activities.
257 4. The individual appointed as the living donor advocate informs, supports, and respects the living donor in a culturally
258 appropriate manner during decision making.
259

260 Standard COP.L


261 Transplant programs performing living donor transplants obtain informed consent specific to organ donation from the living
262 donor.
263

264 Intent of COP.L


265 To come

266 Measurable Elements of COP.L


267 1. Informed consent for living donation is obtained by trained staff and is in a language the living donor can understand.
268 2. In addition to the information provided to any surgical patient as part of the informed consent process, the transplant
269 program informs the living donor of potential psychological risks of donation.
270 3. In addition to the information provided to any surgical patient as part of the informed consent process, the transplant
271 program informs the prospective living donor of potential complications and risks associated with living organ donation.
272 4. In addition to the information provided to any surgical patient as part of the informed consent process, the transplant
273 program informs the prospective living donor of potential future health problems.
274 5. The transplant program informs the prospective living door of alternative treatments for the transplant candidate.
275 6. The transplant program informs the prospective living donor of the donors right to opt out of donation at any time
276 during the donation process.
277

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278 Standard COP.M


279 Transplant programs that perform living donor transplants use clinical and psychosocial selection criteria to determine the
280 suitability of potential living donors.
281

282 Intent of COP.M


283 To come
284

285 Measurable Elements of COP.M


286 1. The transplant program documents defined in writing organ-specific living donor selection criteria.
287 2. The transplant programs living donor selection criteria are consistent with laws and regulations and the principles of
288 medical ethics.
289 3. The results of a medical evaluation related to the living donors own physical health are included in the determination
290 of suitability for donation.
291 4. The results of medical tests identifying infectious diseases or malignancies are included in the determination of
292 suitability for donation.
293 5. The results of a psychological evaluation are included in the determination of suitability for donation.
294 6. The transplant program documents organ compatibility confirmation in the living donors medical record.
295

296 Standard COP.N


297 Individualized patient care plans guide the care of living donors.

298 Intent of COP.N


299 To come

300 Measurable Elements of COP.N


301 1. Transplant programs performing living donor transplants are guided by written documented living donor guidelines
302 for care in the evaluation, donation, and discharge phases of donation.
303 2. Transplant programs performing living donor transplants provide multidisciplinary care by a team coordinated by a
304 physician to each donor throughout the donor evaluation, donation, and discharge phases of donation.
305 3. Living donor candidates receive a psychosocial evaluation.

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1 Anesthesia and Surgical Care


2 (ASC)
3 Surgical Care
4 Standard ASC.7.5 (new standard)
5 Surgical care that includes the implant of a medical device is planned with special consideration of how standard process and
6 procedures must be modified.
7 Intent of ASC.7.5
8 Many surgical procedures involve the implant of prosthesis, such as a hip, medical devices such as a pacemaker, insulin pump,
9 or remote monitoring devices. These types of surgical procedures require that routine surgical care must be modified to
10 consider special factors such as:
11 1. selection of devices based on available science and research;
12 2. any special privileges for the surgeon and special training for the surgical team;
13 3. modifications to the surgical check list to ensure implants are present in the operating theatre and special
14 considerations in marking the surgical site;
15 4. the qualifications and training of any outside technical staff required during the implant procedure.
16 5. an understanding of and reporting process for device related adverse events;
17 6. unique infection control considerations;
18 7. any special discharge instructions to the patient; and
19 8. the traceability of devices in the event of a recall.
20 These special considerations may be incorporated into guidelines, protocols, operating policies or other document to guide
21 the surgical team and result in consistent processes and outcomes.
22 Measurable Elements of ASC.7.5
23 1. The hospitals surgical services define the types of implantable devices that are included within its scope of services.
24 2. Policies and practices are modified to include 1) through 8) found in the intent statement.
25 3. Medical device implants are monitored as part of the departments priorities.

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1 Quality Improvement and Patient


2 Safety (QPS)
3 Standard QPS.1 (moved to GLD.4)
4 Those responsible for governing and managing the organization participate in planning and measuring a
5 quality improvement and patient safety program.
6 Intent of QPS.1
7 If an organization is to initiate and to maintain improvement and to reduce risks to patients and staff,
8 leadership and planning are essential. This leadership and planning come from the governing body of the
9 organization along with those who manage the clinical and managerial activities of the organization on a daily
10 basis. Collectively they represent the leadership of the organization. The leadership is responsible for
11 establishing the organizations commitment, approach to improvement and safety, and program management
12 and oversight. The leadership develops the quality and patient safety plan and, through its vision and support,
13 shapes the quality culture of the organization.
14 The governing body holds ultimate accountability for quality and patient safety in the organization, and, thus,
15 it approves the quality and patient safety plan (also see GLD.1.6); on a regular basis, it receives and acts on
16 reports related to the organizations program to improve quality and patient safety (also see GLD.1.6).
17 Measurable Elements of QPS.1
18 o 1. The organizations leadership participates in developing the plan for the quality improvement
19 and patient safety program.
20 o 2. The organizations leadership participates in measuring the quality improvement and patient
21 safety program.
22 o 3. The organizations leadership establishes the oversight process or mechanism for the
23 organizations quality improvement and patient safety program.
24 o 4. The organizations leadership reports on the quality and patient safety program to governance.
25

26 Standard QPS.1.1 (moved to GLD.4)


27 The organizations leaders collaborate to carry out the quality improvement and patient safety program.

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28 Intent of QPS.1.1
29 The organizations leaders have key roles in ensuring that the quality and patient safety plan shapes the
30 organizations culture and makes an impact on every aspect of operations. This plan takes collaboration and
31 commitment through a multidisciplinary approach. Leaders ensure the program addresses
32 the role of system design and redesign in the improvement process;
33 a multidisciplinary approach with all departments and services in the organization included in the
34 program;
35 coordination among the multiple organizational units concerned with quality and safety, such as the
36 clinical laboratory quality control program, a risk management program, a facility risk management program, a
37 patient safety office, or other types of offices or programs. An inclusive program is necessary to improving
38 patient outcomes, because patients receive care from many different departments and services and/or types of
39 clinical staff; and
40 a systematic approach in that it employs similar or uniform quality processes and knowledge to carry
41 out all improvement and patient safety activities.
42 Measurable Elements of QPS.1.1
43 o 1. The organizations leaders collaborate to carry out the quality improvement and patient safety
44 program. (Also see GLD.3.4, ME 2; SQE.11, ME 1; SQE.14, ME 1; and SQE.17, ME 1)
45 o 2. The quality improvement and patient safety program is organizationwide.
46 o 3. The program addresses the systems of the organization and the role of system design and
47 redesign in quality and safety improvement.
48 o 4. The program addresses coordination among all components of the organizations quality
49 measurement and control activities. (Also see GLD.3.4, ME 2, and PCI.10, ME 1)
50 o 5. The program employs a systematic approach to quality improvement and patient safety.
51

52 Standard QPS.1.2 (moved to GLD.5)


53 The leaders prioritize which processes should be measured and which improvement and patient safety
54 activities should be carried out.
55 Intent of QPS.1.2
56 A primary responsibility of leaders is to set priorities. Organizations typically find more opportunities for
57 quality measurement and improvement than they have human and other resources to accomplish. Therefore,
58 the leaders provide focus for the organizations quality measurement and improvement activities. The leaders

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59 prioritize those critical, high-risk, problem-prone, primary processes that most directly relate to quality of care
60 and safety of the environment. The leaders include the International Patient Safety Goals (also see pages 35
61 40). The leaders use available data and information to identify priority areas.
62 Measurable Elements of QPS.1.2
63 o 1. The leaders set organizational priorities for measurement activities.
64 o 2. The leaders set organizational priorities for improvement and patient safety activities.
65 o 3. The priorities include the implementation of the International Patient Safety Goals.
66

67 Standard QPS.1.3 (moved to GLD.4)


68 The leaders provide technological and other support to the quality improvement and patient safety program.
69 Intent of QPS.1.3
70 Measuring clinical and management functions in a health care organization results in the accumulation of data
71 and information. Understanding how well the organization is doing depends on the analysis of the data and
72 information over time and comparison with other organizations. For large or complex organizations, this
73 tracking and comparison may require technology and/or staff members with data management experience.
74 An organizations leaders understand the measurement and improvement priorities in terms of this necessary
75 support. They provide the support consistent with the organizations resources and quality improvement.
76 Measurable Elements of QPS.1.3
77 o 1. The leaders understand the technology and other support requirements for tracking and
78 comparing measurement results.
79 o 2. The leaders provide technology and support, consistent with the organizations resources, for
80 tracking and comparing measurement results.
81

82 Standard QPS.1.4 (moved to GLD.4.1)


83 Quality improvement and patient safety information is communicated to staff.
84 Intent of QPS.1.4
85 The regular communication of information about the quality improvement and patient safety program to staff
86 is essential. The communication is on a regular basis through effective channels, such as newsletters,
87 storyboards, staff meetings, and human resource processes. The information can be about new or recently

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88 completed improvement projects, progress in meeting the International Patient Safety Goals, the results of the
89 analysis of sentinel and other adverse events, or recent research or benchmark programs, among others.
90 Measurable Elements of QPS.1.4
91 o 1. Information on the quality improvement and patient safety program is communicated to staff.
92 o 2. The communications are on a regular basis through effective channels. (Also see GLD.1.6, ME
93 2)
94 o 3. The communications include progress on compliance with the International Patient Safety
95 Goals.
96

97 Standard QPS.1.5 (incorporated into new QPS.1)


98 Staff are trained to participate in the program.
99 Intent of QPS.1.5
100 Participating in data collection and analysis and planning and implementing quality improvements require
101 knowledge and skill that most staff do not have or do not use regularly. Thus, when asked to participate in the
102 program, staff members receive training consistent with their roles in the planned activity. Staff schedules may
103 need to be adjusted to accommodate sufficient time to fully participate in training and improvement activities
104 as part of regular work assignments. The organization identifies or provides a knowledgeable trainer for this
105 education.
106 Measurable Elements of QPS.1.5
107 o 1. There is a training program for staff that is consistent with their roles in the quality
108 improvement and patient safety program.
109 o 2. A knowledgeable individual provides the training.
110 o 3. Staff members participate in the training as part of their regular work assignments.
111
112 Design of Clinical and Managerial Processes

113 Standard QPS.2 (standard deleted)


114 The organization designs new and modified systems and processes according to quality improvement principles.
115 Intent of QPS.2
116 Organizations frequently have the opportunity to design new processes or need to modify existing processes. The

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117 new or modified process uses design elements from authoritative sources, including laws and regulations as
118 applicable. Such authoritative sources include clinical practice guidelines (also see standard QPS.2.1) when available
119 for clinical processes, national standards and norms, and other sources of information.
120 The design of new or modified processes may also be informed by the experiences of others considered to be
121 best/better/good practices. Such practices are evaluated by the organization, and relevant practices may be
122 used and tested.
123 When processes or services are designed well, they draw on a variety of information sources. Good process
124 design
125 is consistent with the organizations mission and plans;
126 meets the needs of patients, families, staff, and others;
127 uses current practice guidelines, clinical standards, scientific literature, and other relevant evidence-
128 based information on clinical practice design;
129 is consistent with sound business practices;
130 considers relevant risk management information;
131 builds on available knowledge and skills in the organization;
132 builds on the best/better/good practices of other organizations;
133 uses information from related improvement activities; and
134 integrates and connects processes and systems.
135 When an organization designs new processes, it selects suitable measures for the process. Once an
136 organization implements a new process, it collects data to see if the process is actually operating as expected.
137 Measurable Elements of QPS.2
138 o 1. Quality improvement principles and tools are applied to the design of new or modified
139 processes.
140 o 2. Design elements identified in the intent statement are included when relevant to the process
141 being designed or modified.
142 o 3. Measures are selected to evaluate how well the newly designed or redesigned process operates.
143 o 4. Measurement data are used to evaluate the ongoing operation of the process.
144

145 Standard QPS.2.1 (moved to GLD.11.1)

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146 Clinical practice guidelines, clinical pathways, and/or clinical protocols are used to guide clinical care.
147 Intent of QPS.2.1
148 The goals of health care organizations include
149 standardizing clinical care processes;
150 reducing risks within care processes, particularly those associated with critical decision steps;
151 providing clinical care in a timely, effective manner using available resources efficiently; and
152 consistently delivering high-quality care using evidence-based practice.
153 Organizations use a variety of tools to reach these and other goals. For example, health care practitioners seek
154 to develop clinical care processes and make clinical care decisions based on the best available scientific
155 evidence. Clinical practice guidelines are useful tools in this effort to understand and to apply the best science
156 to a particular diagnosis or condition.
157 In addition, health care practitioners seek to standardize care processes. Clinical care pathways and clinical
158 protocols are useful tools in this effort to ensure effective integration and coordination of care and efficient
159 use of available resources. Clinical practice guidelines, clinical care pathways, and clinical protocols relevant to
160 the organizations patient population and mission are
161 a) selected from among those applicable to the services and patients of the organization (mandatory
162 national guidelines are included in this process, if present);
163 b) evaluated for their relevance to identified patient populations;
164 c) adapted when needed to the technology, drugs, and other resources of the organization or to accepted
165 national professional norms;
166 d) assessed for their scientific evidence;
167 e) formally approved or adopted by the organization;
168 f) implemented and measured for consistent use and effectiveness;
169 g) supported by staff trained to apply the guidelines or pathways; and
170 h) periodically updated based on changes in the evidence and evaluation of processes and outcomes.
171 Organizations are expected to accomplish the following on an annual basis:
172 Clinical leaders select at least five priority areas on which to focus, such as patient diagnosis,
173 procedures, populations, or diseases, among others, for which guidelines, pathways, and protocols would
174 impact the quality and safety of patient care and reduce unwanted variation in outcomes.
175 Complete the process described in a) through h) for the identified priority focus areas.

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176 Measurable Elements of QPS.2.1


177 o 1. On an annual basis, clinical leaders determine at least five priority areas on which to focus the
178 use of guidelines, clinical pathways, and/or clinical protocols.
179 o 2. The organization follows the process described in a) through h) of the intent in implementing
180 clinical practice guidelines, clinical pathways, and/or clinical protocols.
181 o 3. The organization implements clinical guidelines and a clinical pathway or clinical protocol for
182 each identified priority area.
183 o 4. Clinical leaders can demonstrate how the use of clinical practice guidelines, clinical pathways,
184 and/or clinical protocols has reduced variation in processes and outcomes.
185 Note: In these standards and all Quality Improvement and Patient Safety (QPS) standards, leaders are individuals and leadership
186 is the collective group. Accountabilities are described at the individual or collective level. (Please also see the Governance,
187 Leadership, and Direction (GLD) chapter for other related requirements.

188 Management of Quality and Patient Safety Activities


189 Introduction
190 The overall plan for quality and patient safety in a hospital is approved by governance (see GLD.2) with the hospitals
191 leadership defining the structure and allocating resources required to implement the plan (see GLD.4). Leadership also
192 identifies the hospitals overall priorities for measurement and improvement (see GLD.5) with the department/service leaders
193 identifying the priorities for measurement and improvement within their department/service (see GLD.11 and GLD.11.1).
194 The standards in this Quality Improvement and Patient Safety (QPS) chapter identify the structure, leadership, and activities
195 to support the data collection, analysis and improvement for the identified priorities, hospital-wide and department- and
196 service-specific. This includes the collection, analysis, and response to hospital-wide sentinel events, adverse events, and near-
197 miss data. The standards also describe the central role of coordinating all the quality improvement and patient safety
198 initiatives in the hospital and providing the leadership for staff training and communication of quality and patient safety
199 information.

200 Standard QPS.1


201 A qualified leader(s) guides the implementation of the hospitals plan for quality improvement and patient safety and manages
202 the activities needed to carry out an effective program of continuous quality improvement and patient safety within the
203 hospital.

204 Intent of QPS.1


205 The continuous improvement in quality and patient safety in a hospital requires a well implemented plan. While governance
206 approves the plan and leadership provides resources to implement the plan, it takes daily capable leadership to carry out the
207 plan and make continuous improvement part of the fabric of how the hospital meets it mission and strategic priorities.
208 One or more qualified individuals see that the plan is carried out. This takes knowledge and experience in the many facets of

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209 data collection, data validation, data analysis, and in implementing sustainable improvements. The leader(s) also selects staff
210 with those capabilities needed for the program. At times, some of the key quality individuals may be located within a
211 department/service in the hospital. These individuals need to be supported with information and assistance. The leader(s)
212 also understands how to take the hospital wide priorities and the department/service level priorities and turn them into a
213 coordinated overall program.
214 Training and communication are also essential. The leader(s) and staff help to support data collection throughout the hospital
215 by assisting with data collection issues such as creating forms to collect data, identifying which data to collect, and how to
216 validate data. Staff throughout the hospital may need assistance in data validation, analysis, implementing improvements, and
217 evaluating if the improvements were sustained. The quality leaders and staff are thus constantly involved in training and
218 communicating quality and patient safety issues throughout the hospital.
219 Measurable Elements of QPS.1
220 1. A leader(s) who is experienced in the methods and processes of improvement is selected to guide the implementation
221 of the hospitals quality and patient safety plan and program.
222 2. The leader(s) selects and supports qualified staff for the program and supports those staff with quality and patient
223 safety responsibilities throughout the hospital.
224 3. The quality program provides support and coordination for the hospitals priorities for improvement.
225 4. The quality program implements a training program for all staff that is consistent with staffs roles in the quality
226 improvement and patient safety program.
227 5. The quality program is responsible for the regular communication of quality issues to all staff.
228
229 Measure Selection and Data Collection

230 Standard QPS.3 (measure selection moved to GLD.5 and GLD.11.1;


231 use of the International Library of Measures is now located in the
232 new chapter on Accreditation Participation Requirements [APR])
233 Note: The APR chapter is being developed by JCI Central Office Staff and is not part of the field review.
234 The organizations leaders identify key measures in the organizations structures, processes, and outcomes to
235 be used in the organization wide quality improvement and patient safety plan.
236 Standard QPS.3.1
237 The organizations leaders identify key measures for each of the organizations clinical structures, processes,
238 and outcomes.
239 Standard QPS.3.2
240 The organizations leaders identify key measures for each of the organizations managerial structures,

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241 processes, and outcomes.


242 Standard QPS.3.3
243 The organizations leaders identify key measures for each of the International Patient Safety Goals.
244 Intent of QPS.3 through QPS.3.3
245 Quality improvement and patient safety are data driven. Effective use of the data is best accomplished in the
246 broader context of evidence-based clinical practices and evidence-based management practices.
247 Because most organizations have limited resources, they cannot collect data to measure everything they want.
248 Thus, each organization must choose which clinical and managerial processes and outcomes are most
249 important to measure based on its mission, patient needs, and services. Measurement often focuses on those
250 processes that are high risk to patients, provided in high volume, or are problem prone. An organizations
251 leaders are responsible for making the final selection of key measures to be included in the organizations
252 quality activities.
253 The measures selected related to the important clinical areas include
254 1. patient assessments;
255 2. laboratory services;
256 3. radiology and diagnostic imaging services;
257 4. surgical procedures;
258 5. antibiotic and other medication use;
259 6. medication errors and near misses;
260 7. anesthesia and sedation use;
261 8. use of blood and blood products;
262 9. availability, content, and use of patient records;
263 10. infection prevention and control, surveillance, and reporting; and
264 11. clinical research.
265 At least five of the clinical measures must be selected from the Joint Commission International Library of
266 Measures. These 11 clinical measures were formerly the same measures identified in the third edition of the
267 hospital standards as QPS.3.1 through QPS.3.11.
268 The measures selected related to the important managerial areas include
269 a. the procurement of routinely required supplies and medication essential to meet patient needs;
270 b. reporting of activities as required by laws and regulations;

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271 c. risk management;


272 d. utilization management;
273 e. patient and family expectations and satisfaction;
274 f. staff expectations and satisfaction;
275 g. patient demographics and clinical diagnoses;
276 h. financial management; and
277 i. prevention and control of events that jeopardize the safety of patients, families, and staff.
278 These nine managerial measures were formerly the same measures identified in the third edition of the
279 hospital standards as QPS.3.12 through QPS.3.20. Managerial measures will be added to the Joint
280 Commission International Library of Measures at a future date.
281 An organizations leaders are responsible for making the final selection of targeted measurement activities. For
282 each of these areas, leaders decide
283 the process, procedure, or outcome to be measured;
284 the availability of science or evidence supporting the measure;
285 how measurement will be accomplished;
286 how the measures fit into the organizations overall plan for quality measurement and patient safety;
287 and
288 the frequency of measurement.
289 Identifying the process, procedure, or outcome to be measured is clearly the most important step. The measure
290 needs to focus on, for example, risk points in processes, procedures that frequently present problems or are
291 performed in high volume, and outcomes that can be clearly defined and are under the organizations control.
292 For example, an organization may choose to measure a particular surgical procedure (for example, repair of a
293 cleft lip) or a class of surgical procedures (for example, orthopedic procedures). In addition, the organization
294 may wish to measure the process used to select the surgical procedure for the cleft lip repair and may wish to
295 measure the process of prosthesis alignment in hip replacement surgery. Frequency of data collection is
296 associated with how often the particular process is used or procedure performed. Sufficient data from all cases
297 or a sample of cases are needed to support conclusions and recommendations. New measures are selected
298 when a current measure no longer provides data useful for analyzing the process, procedure, or outcome.
299 Thus, an organization must have a track record of continuous measurement in the area identified; however,
300 the actual measures may change.
301 To measure processes, the organization needs to determine how to organize the measurement activities, how
302 often to collect data, and how to incorporate data collection into daily work processes. The measures are also

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303 helpful in better understanding or more intensively assessing the areas under study. Likewise, the analysis of
304 the measurement data (also see QPS.4 through QPS.4.2) may result in strategies for improvement in the area
305 being measured. The measure then is helpful in understanding the effectiveness of the improvement strategy.
306 For the five clinical measures selected by the organization from the Joint Commission International Library of
307 Measures, data collection, analysis, and use will begin in 2011. Submission of data to JCI for these five
308 measures is voluntary in 2011. Mandatory submission may begin in 2012 or later.
309 Measurable Elements of QPS.3
310 o 1. The organizations leaders identify targeted areas for measurement and improvement.
311 o 2. The measurement is part of the quality improvement and patient safety program.
312 o 3. The results of measurement are communicated to the oversight mechanism and periodically to
313 the organizational leaders and the governance structure of the organization.
314 Measurable Elements of QPS.3.1
315 o 1. The clinical leaders identify key measures for each clinical area identified in 1) through 11) in
316 the intent statement.
317 o 2. At least 5 of the 11 required clinical measures are selected from the Joint Commission
318 International Library of Measures.
319 o 3. The leaders look at the science or evidence supporting each of the selected measures.
320 o 4. Measurement includes structure, processes, and outcomes.
321 o 5. The scope, method, and frequency are identified for each measure.
322 o 6. Clinical measurement data are collected and used to evaluate the effectiveness of
323 improvements.
324 Measurable Elements of QPS.3.2
325 o 1. The managerial leaders identify key measures for each managerial area identified in a) through
326 i) in the intent statement.
327 o 2. The leaders look at the science or evidence supporting each of the selected measures.
328 o 3. Measurement includes structure, processes, and outcomes.
329 o 4. The scope, method, and frequency are identified for each measure.
330 o 5. Managerial measurement data are collected and used to evaluate the effectiveness of
331 improvements.
332 Measurable Elements of QPS.3.3

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333 o 1. The clinical and managerial leaders identify key measures for each International Patient Safety
334 Goal.
335 o 2. International Patient Safety Goal measurement includes the areas identified in IPSG.1 through
336 IPSG.6.
337 o 3. Measurement data are used to evaluate the effectiveness of improvements.
338

339 Measure Selection and Data Collection

340 Standard QPS.2


341 Quality and patient safety program staff support the measure selection process throughout the hospital and provide
342 coordination and integration of measurement activities throughout the hospital.

343 Intent of QPS.2


344 Measure selection is a leadership responsibility. GLD.5 describes how the leadership of the hospital decides the priority areas
345 to measure for the entire hospital, and GLD.11 describes the measure selection process for each department/service. All
346 departments and servicesclinical and managerialselect measures related to their priorities. It can be anticipated that in
347 large hospitals, there is some opportunity for similar measures to be selected in more than one department. For example, the
348 pharmacy, infection control, and infectious disease departments/services may each set priorities related to reducing antibiotic
349 use in the hospital. The quality program described in these standards plays an important role in helping these
350 departments/services agree on a common measurement approach and facilitates the data collection of the measure(s)
351 selected. The quality program is also in the position to integrate all measurement activities in the hospital including
352 measurement of the safety culture and adverse event reporting systems. This integration of all the measurement systems will
353 provide the opportunity for integrated solutions and improvements.

354 Measurable Elements of QPS.2


355 1. The quality program supports the selection of measures throughout the hospital at the hospital-wide level and at the
356 department/service level.
357 2. The quality program provides coordination and integration of measurement activities throughout the hospital.
358 3. The quality program provides for the integrations of event reporting systems, safety culture measures and others to
359 facilitate integrated solutions and improvements.
360 4. The quality program tracks the progress on the planned collection of data for the priorities selected.
361

362 Data Aggregation and Information Resources

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363 Standard QPS.3 (formerly MCI.20 and MCI.20.1)


364 The quality program includes the aggregation of data to support patient care, hospital management, and the quality
365 management program.

366 Standard QPS.3.1 (formerly MCI.20.2)


367 The hospital has a process for using or participating in external databases.

368 Intent of QPS.3 and QPS.3.1


369 The quality program collects and analyzes aggregate data to support patient care and hospital management. Aggregate data
370 provides a profile of the hospital over time and allows the comparison of the hospitals performance with other organizations.
371 Thus, aggregate data are an important part of the hospitals performance improvement activities. In particular, aggregate data
372 from risk management, utility system management, infection prevention and control, and utilization review can help the
373 hospital understand its current performance and identify opportunities for improvement.
374 By participating in external performance databases, a hospital can compare its performance to that of other similar hospitals
375 locally, nationally, and internationally. Performance comparison is an effective tool for identifying opportunities for
376 improvement and documenting the hospitals performance level. Health care networks and those purchasing or paying for
377 health care often ask for such information. External databases vary widely from insurance databases to those maintained by
378 professional societies. Hospitals may be required by laws or regulations to contribute to some external databases. In all cases,
379 the security and confidentiality of data and information are maintained.

380 Measurable Elements of QPS.3


381 1. The quality program has a process to aggregate data.
382 2. Aggregate data and information support patient care, hospital management and the quality program.
383 3. Aggregate data and information are provided to agencies outside the hospital when required.
384

385 Measurable Elements of QPS.3.1


386 1. There is a process to participate in or to use information from external databases.
387 2. The process includes sending data or information to external databases in accordance with laws or regulations.
388 3. The process includes comparisons with external reference databases.
389 4. Security and confidentiality are maintained when contributing to or using external databases.
390

391 Standard QPS.3.2 (formerly MCI.21)

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392 Patient care, education, research, and management are supported with timely information from current sources.

393 Intent of QPS.3.2


394 Health care practitioners, researchers, educators, and managers often need information to assist with their responsibilities.
395 Such information may include scientific and management literature, clinical practice guidelines, research findings, and
396 educational methodologies. The Internet, print materials in a library, online search sources, and personal materials are all
397 valuable sources of current information.

398 Measurable Elements of QPS.3.2


399 1. Current scientific and other information supports patient care.
400 2. Current scientific and other information supports clinical education.
401 3. Current scientific and other information supports research.
402 4. Current professional and other information supports management.
403 5. Information is provided in a time frame that meets user expectations.
404

405 Validation and Analysis of Measurement Data

406 Standard QPS.4


407 Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the hospital.

408 Intent of QPS.4


409 To reach conclusions and to make decisions, data must be aggregated, analyzed, and transformed into useful information.
410 Data analysis involves individuals who understand information management, have skills in data aggregation methods, and know
411 how to use various statistical tools. Results of data analysis need to be reported to those individuals responsible for the process or
412 outcome being measured and who can take action on the results. These individuals may be clinical, managerial, or a
413 combination. Thus, data analysis provides continuous feedback of quality management information to help those individuals
414 make decisions and continuously improve clinical and managerial processes.
415 Understanding statistical techniques is helpful in data analysis, especially in interpreting variation and deciding where
416 improvement needs to occur. Run charts, control charts, histograms, and Pareto charts are examples of statistical tools useful
417 in understanding trends and variation in health care.
418 The quality program participates in the determination of how often data are aggregated and analyzed. The frequency of this
419 process depends on the activity or area being measured and the frequency of the measurement. For example, clinical
420 laboratory quality control data may be analyzed weekly to meet local regulations, and patient fall data may be analyzed
421 monthly if falls are infrequent. Thus, aggregation of data at points in time enables the hospital to judge a particular processs
422 stability or a particular outcomes predictability in relation to expectations.

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423

424 Measurable Elements of QPS.4


425 1. Data are aggregated, analyzed, and transformed into useful information.
426 2. Individuals with appropriate clinical or managerial experience, knowledge, and skills participate in the process.
427 3. Statistical tools and techniques are used in the analysis process when suitable.
428 4. The frequency of data analysis is appropriate to the process or outcome being studied.
429 5. Results of analysis are reported to those accountable for taking action.
430

431 Standard QPS.4.1 (incorporated into QPS.4 as ME#4)


432 The frequency of data analysis is appropriate to the process or outcome being studied and meets organization
433 requirements.
434
435 Intent of QPS.4.1
436 The quality program participates in the determination of how often data are aggregated and analyzed. The
437 frequency depends on the activity or area being measured, the frequency of measurement , and the
438 organizations priorities. For example, clinical laboratory quality control data may be analyzed weekly to meet
439 local regulations, and patient fall data may be analyzed monthly if falls are infrequent. Thus, aggregation of
440 data at points in time enables the organization to judge a particular processs stability or a particular outcomes
441 predictability in relation to expectations.
442 Measurable Elements of QPS.4.1
443 1. The frequency of data analysis is appropriate to the process or outcome under study.
444 2. The frequency of data analysis meets organization requirements.
445

446 Standard QPS.4.1


447 The analysis process includes comparisons internally, with other organizations when data are available, and with scientific
448 standards and desirable practices.

449 Intent of QPS.4.1


450 The goal of data analysis is to be able to compare a hospital in four ways:

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451 1. With itself over time, such as month to month, or one year to the next
452 2. With other similar organizations, such as through reference databases
453 3. With standards, such as those set by accrediting and professional bodies or those set by laws or regulations
454 4. With recognized desirable practices identified in the literature as best or better practices or practice guidelines
455 These comparisons help the hospital understand the source and nature of undesirable change and help focus improvement
456 efforts.

457 Measurable Elements of QPS.4.1


458 1. Comparisons are made over time within the hospital.
459 2. Comparisons are made with similar organizations when data are available.
460 3. Comparisons are made with standards when available.
461 4. Comparisons are made with known desirable practices.
462

463 Standard QPS.4.2 (new standard)


464 The analysis process includes a determination of the impact of priority improvements.

465 Intent of QPS.4.2


466 The quality program includes an analysis of the impact of priority improvements as supported by leadership (See GLD.5, ME
467 4). The quality program staff develop tools to evaluate the use of resources for the existing process and then re-evaluates the
468 use of resources for the improved process. The resources may be human, for example, time devoted to each step in a process,
469 the use of technology, or other resources. The analysis will provide useful information on which improvements impact
470 efficiency and therefore cost.

471 Measurable Elements of QPS.4.2


472 1. Data on the amount and type of resource use are collected on priority improvement projects before and following the
473 improvement.
474 2. The quality staff work with other units such as human resources, information technology, and finance in deciding
475 which data are to be collected.
476 3. The results of the analysis are used to refine the process and are reported through the quality coordination mechanism
477 to leadership.

478 Standard QPS.5


479 The hospital uses an internal process to validate data.

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480 Intent of QPS.5


481 A quality improvement program is only as valid as the data that are collected. Reliable measurements are thus at the core of all
482 improvements. To ensure that good, useful data have been collected, an internal data validation process needs to be in place.
483 Data validation is most important when;
484 1. a new measure is implemented (in particular, those clinical measures that are intended to help a hospital evaluate
485 and improve an important clinical process or outcome);
486 2. data will be made public on the hospitals website or in other ways;
487 3. a change has been made to an existing measure, such as the data collection tools have changed or the data
488 abstraction process or abstractor has changed;
489 4. the data resulting from an existing measure have changed in an unexplainable way;
490 5. the data source has changed, such as when part of the patient record has been turned into an electronic format
491 and thus the data source is now both electronic and paper; or
492 6. the subject of the data collection has changed, such as changes in average age of patients, comorbidities, research
493 protocol alterations, new practice guidelines implemented, or new technologies and treatment methodologies
494 introduced.
495 Data validation is an important tool for understanding the quality of the quality data and for establishing the level of
496 confidence decision makers can have in the data. Data validation becomes one of the steps in the process of setting priorities
497 for measurement, selecting what is to be measured, selecting and testing the measure, collecting the data, validating the data,
498 and using the data for improvement.
499 a) The essential elements of a credible data validation process include the following:
500 b) Re-collecting the data by a second person not involved in the original data collection.
501 c) Using a statistically valid sample of records, cases, and other data. A 100% sample would only be needed when the number of
502 records, cases, or other data is very small.
503 d) Comparing the original data with the re-collected data.
504 e) Calculating the accuracy by dividing the number of data elements found to be the same by the total number of data elements
505 and multiplying that total by 100. A 90% accuracy level is a good benchmark.
506 f) When data elements are found not to be the same, noting the reasons (for example, unclear data definitions) and
507 taking corrective actions.
508 g) Collecting a new sample after all corrective actions have been implemented to ensure the actions resulted in the
509 desired accuracy level.
510 When a hospital publishes data on clinical outcomes, patient safety, or other areas, or in other ways makes the data public,
511 such as on the hospitals website, the hospital has an ethical obligation to provide the public with the most accurate and
512 reliable information. The leaders of a hospital are accountable for ensuring that the data are accurate and reliable. This
513 reliability can be established through the hospitals internal process for data validity evaluation or, alternatively, can be judged
514 by an independent third party.

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515 Measurable Elements of QPS.5


516 1. Data validation is used by the quality program as a component of the improvement process selected by leadership.
517 2. The internal data validation process includes a) through f) in the intent statement.
518 3. Data are validated when any of the conditions noted in 1) through 6) are noted.
519 4. The leaders of the hospital assume accountability for the reliability of the quality and outcome data made public.
520

521 Standard QPS.5.1 (incorporated into QPS.5)


522 When the organization publishes data or posts data on a public Web site, the leaders of the organization
523 ensure the reliability of the data.
524 Intent of QPS.5.1
525 When an organization publishes data on clinical outcomes, patient safety, or other areas, or in other ways makes the data public,
526 such as on the organizations Web site, the organization has an ethical obligation to provide the public with the most accurate and
527 reliable information. The leaders of an organization are accountable for ensuring that the data are accurate and reliable. This
528 reliability can be established through the organizations internal process for data validity evaluation or, alternatively, can be judged by
529 an independent third party.
530 Measurable Elements of QPS.5.1
531 o 1. The leaders of the organization assume accountability for the reliability of the quality and
532 outcome data made public.
533 o 2. Data made public have been evaluated as to their reliability and validity.
534

535 Standard QPS.6


536 The hospital uses a defined process for identifying and managing sentinel events.

537 Intent of QPS.6


538 Each hospital establishes an operational definition of a sentinel event that includes at least
539 a) an unanticipated death, for example,
540 a death that is unrelated to the natural course of the patients illness or underlying condition (for
541 example, suicide); or
542 death of a full-term infant;

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543 b) major permanent loss of function unrelated to the patients natural course of illness or underlying condition;
544 c) wrong-site, wrong-procedure, wrong-patient surgery;
545 d) transmission of a chronic or fatal disease or illness as a result of infusing blood or blood products or
546 transplanting contaminated organs or tissues;
547 e) infant abduction or an infant sent home with the wrong parents; and
548 f) rape, incidences of workplace violence such as assault (leading to death or permanent loss of function); or
549 homicide of a patient, staff member, licensed independent practitioner, visitor, or vendor while on site at the
550 hospital. (Also see SQE.X)
551 The hospitals definition of a sentinel event includes a) through f) above and may include other events as may be required by
552 laws or regulations or viewed by the hospital as appropriate to add to its list of sentinel events. These events are called sentinel
553 because they identify a need for immediate investigation by the hospital. All events that meet the definition of sentinel events
554 must be assessed by performing a credible root cause analysis. Accurate details of the event are essential to a credible root
555 cause analysis, thus the root cause analysis needs to be performed soon after the event occurs or after becoming aware of the
556 event. The analysis and action plan should be completed within 45 days of the event or becoming aware of the event. When
557 the root cause analysis reveals that systems improvements or other actions can prevent or reduce the risk of such sentinel
558 events recurring, the hospital redesigns the processes and takes whatever other actions are appropriate to do so.
559 The goal of performing a root cause analysis is for the hospital to better understand the origins of the event. This allows the
560 hospital to identify systems and processes that may need to be changed modified in order to reduce the probability of a
561 similar event occurring in the future.
562 It is important to note that the terms sentinel event and medical error are not synonymous (also see JCI Sentinel Event Policy on
563 page XX. All errors do not always result in a sentinel event, nor does a sentinel event occur only as a result of an error.
564 Identifying an incident as a sentinel event is not an indicator of legal liability. (Also see SQE.11, ME 4)

565 Measurable Elements of QPS.6


566 1. The hospital leaders have established a definition of a sentinel event that at least includes a) through f) found in the
567 intent statement.
568 2. The hospital completes a root cause analysis of all sentinel events in a time period specified by the hospitals leaders
569 that does not exceed 45 days from the date of the event or when made aware of the event.
570 3. Hospital leaders take action on the results of the root cause analysis.
571

572 Standard QPS.7


573 Data are analyzed when undesirable trends and variation are evident from the data.

574 Intent of QPS.7


575 When the hospital detects or suspects undesirable change from what is expected, it initiates intense analysis to determine

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576 where best to focus improvement (also see MMU.7.1, intent statement). In particular, intense analysis is initiated when levels,
577 patterns, or trends vary significantly and undesirably from
578 what was expected;
579 that of other organizations; or
580 recognized standards.
581 An analysis is conducted for the following:
582 a) All confirmed transfusion reactions, if applicable to the hospital
583 b) All serious adverse drug events, if applicable and as defined by the hospital
584 c) All significant medication errors, if applicable and as defined by the hospital
585 d) All major discrepancies between preoperative and postoperative diagnoses
586 e) Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use
587 f) Other events, such as infectious disease outbreaks

588 Measurable Elements of QPS.7


589 1. Intense analysis of data takes place when adverse levels, patterns, or trends occur.
590 2. All confirmed transfusion reactions, if applicable to the hospital, are analyzed.
591 3. All serious adverse drug events, if applicable and as defined by the hospital, are analyzed.
592 4. All significant medication errors, if applicable and as defined by the hospital, are analyzed.
593 5. All major discrepancies between preoperative and postoperative diagnoses are analyzed.
594 6. Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use are analyzed.
595 7. Other events defined by the hospital are analyzed.
596

597 Gaining and Sustaining Improvement

598 Standard QPS.8


599 The organization uses a defined process for the identification and analysis of near-miss events.
600

601 Intent of QPS.8


602 In an attempt to proactively learn where systems may be vulnerable to actual adverse event occurrence, the organization

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603 collects data and information on those events identified as a near miss and evaluates those events in an effort to prevent
604 their actual occurrence. First, the organization establishes a definition of a near miss and what type of events are to be
605 reported. Second, a reporting mechanism is put into place, and finally there is a process to aggregate and to analyze the data to
606 learn where proactive process changes will reduce or eliminate the related event or near miss.

607 Measurable Elements of QPS.8


608 1. The organization establishes a definition of a near miss.
609 2. The organization defines the type of events to be reported. (Also see MMU.7.1 for medication near misses)
610 3. The organization establishes the process for the reporting of near misses. (Also see MMU.7.1 for medication near
611 misses)
612 4. The data are analyzed and actions taken to reduce near-miss events. (Also see MMU.7.1, ME 3)

613 Standard QPS.9


614 Improvement in quality and safety is achieved and sustained.

615 Intent of QPS.9


616 The information from data analysis is used to identify potential improvements or to reduce (or prevent) adverse events.
617 Routine measurement data, as well as data from intensive assessments, contribute to this understanding of where
618 improvement should be planned and what priority should be given to the improvement. In particular, improvements are
619 planned for the priority data collection areas identified by leaders.
620 Once planned, data are collected during a test period to demonstrate that the planned change was actually an improvement.
621 To ensure that the improvement is sustained, measurement data are then collected for ongoing analysis. Effective changes are
622 incorporated into standard operating procedure, and any necessary staff education is carried out. The hospital documents
623 those improvements achieved and sustained as part of its quality management and improvement program.

624 Measurable Elements of QPS.9


625 1. Improvements in quality and patient safety are planned, tested, and implemented.
626 2. Data are available to demonstrate that improvements are effective and sustained.
627 3. Policy changes necessary to plan, to carry out, and to sustain the improvement are made.
628 4. Successful improvements are documented.
629

630 Standard QPS.10 (incorporated into GLD standards and into QPS.8)
631 Improvement and safety activities are undertaken for the priority areas identified by the organizations leaders.
632 Intent of QPS.10

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633 The organization uses appropriate resources and involves those individuals, disciplines, and departments
634 closest to the processes or activities to be improved. Responsibility for planning and carrying an improvement
635 is assigned to individuals or a team, any needed training is provided, and information management or other
636 resources are made available.
637 Once planned, data are collected during a test period to demonstrate that the planned change was actually an
638 improvement. To ensure that the improvement is sustained, measurement data are then collected for ongoing
639 analysis. Effective changes are incorporated into standard operating procedure, and any necessary staff
640 education is carried out. The organization documents those improvements achieved and sustained as part of
641 its quality management and improvement program.
642 Measurable Elements of QPS.10
643 1. The priority areas identified by the organizations leaders are included in improvement activities.
644 2. Human and other resources needed to carry out an improvement are assigned or allocated.
645 3. Changes are planned and tested.
646 4. Changes that resulted in improvements are implemented.
647 5. Data are available to demonstrate that improvements are effective and sustained.
648 6. Policy changes necessary to plan, to carry out, and to sustain the improvement are made.
649 7. Successful improvements are documented.
650

651 Standard QPS.10


652 An ongoing program of risk management is used to identify and to reduce unanticipated adverse events and other safety risks
653 to patients and staff.

654 Intent of QPS.10


655 Hospitals need to adopt a proactive approach to risk management. One such way is a formalized risk management program
656 whose essential components include
657 a) risk identification;
658 b) risk prioritization;
659 c) risk reporting;
660 d) risk management;
661 e) investigation of adverse events; and
662 f) management of related claims.

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663 An important element of risk management is risk analysis, such as a process to evaluate near misses and other high-risk
664 processes for which a failure would result in a sentinel event. One tool that provides such a proactive analysis of the
665 consequences of an event that could occur in a critical, high-risk process is failure mode and effects analysis. The hospital can
666 also identify and use similar tools to identify and to reduce risks, such as a hazard vulnerability analysis.
667 To use this or similar tools effectively, the hospitals leaders need to adopt and to learn the approach, to agree on a list of
668 high-risk processes in terms of patient and staff safety, and then to use the tool on a priority risk process. Following analysis
669 of the results, the hospitals leaders take action to redesign the process or similar actions to reduce the risk in the process. This
670 risk-reduction process is carried out at least once per year and documented.

671 Measurable Elements of QPS.10


672 1. The hospitals risk management framework includes a) through f) in the intent.
673 2. At least annually, a proactive risk-reduction exercise is conducted on one of the priority risk processes.
674 3. High-risk processes are redesigned based on the analysis of the test results.

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1 Governance, Leadership, and


2 Direction (GLD)
3
4 Note: In all GLD standards, leaders are individuals and leadership is the collective group. Accountabilities are described at
5 the individual or collective level.
6

7 Governance of the Hospital

8 Standard GLD.1
9 Governance structure and authority are described in bylaws, policies and procedures, or similar documents.

10 Intent of GLD.1
11 There is an entity (for example, a ministry of health), an owner(s), or a group of identified individuals (for example, a board or
12 governing body) responsible for overseeing the hospitals operation and accountable for providing quality health care services
13 to its community or to the population that seeks care. This entitys structure, responsibilities, and accountabilities are
14 described in a document(s) that identifies how they are to be carried out. Also described is how the governing entity will be
15 evaluated against specific criteria. For example, the criteria can relate to the specific responsibilities and accountabilities that
16 are described in the documents required in measurable element 2 and how effectively they have been carried out, or/and to
17 the criteria for public governance or criteria developed and adopted by the governing entity.
18 The hospitals governance structure, along with the senior management structure, are represented or displayed in an
19 organizational chart or other document that shows lines of authority and accountability. The individuals represented on the
20 chart are identified by title or name.

21 Measurable Elements of GLD.1


22 1. The hospitals governance and senior management structure are described in a written document(s), and those
23 responsible for governance and management are identified by title and name.
24 2. Governance responsibilities and accountabilities are described in the documents.
25 3. The document(s) describes how the governing entity and senior management will be evaluated and the criteria approved for
26 the evaluation process.
27 4. There is an annual evaluation conducted of the governing entity and senior management and the results are
28 documented.
29 5. The document(s) describes when and how governance and senior management authority can be delegated.

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30

31 Standard GLD.1.1 (combines former GLD.1.1 through GLD.1.4)


32 The operational responsibilities and accountabilities of the governing entity are described in a written document(s).

33 Intent of GLD.1.1
34 The governing entitys responsibilities and accountabilities are described in a document(s) that identifies how they are to be
35 carried out. The governing entity has important responsibilities that must be carried out for the hospital to have clear
36 leadership, to operate efficiently, and to provide quality health care services. These responsibilities are primarily at the
37 approval level and include
38 approving and periodically reviewing the hospitals mission and ensuring the public is aware of the hospitals mission;
39 approving the hospitals various strategic and operational plans and the policies and procedures needed to operate
40 the hospital on a daily basis;
41 approving the hospitals participation in health care professional education and in research and the oversight of the
42 quality of such programs;
43 approving or providing a capital and operating budget(s) and other resources required to operate the hospital meet
44 the hospitals mission and strategic plan; and
45 appointing or approving the hospitals senior manager(s) or director, and providing for an annual evaluation of the
46 individual(s) performance.
47

48 Measurable Elements of GLD.1.1


49 1. Those responsible for governance approve, periodically review, and make public the hospitals mission statement.
50 2. Those responsible for governance approve the hospitals strategic plans, operational plans, policies, and procedures.
51 3. Those responsible for governance approve the hospitals capital and operating budget(s) and allocate other resources
52 required to meet the hospitals mission.
53 4. Those responsible for governance approve the hospitals participation in health care professional education and in
54 research and in the oversight of the quality of such programs;
55 5. Those responsible for governance appoint, and annually evaluate, the hospitals senior manager(s) or director(s).
56

57 Standard GLD.1.2 (formerly GLD.1.5)


58 Those responsible for governance approve the hospitals plan for quality and patient safety and regularly receive and act on
59 reports of the quality and patient safety program.

60 Intent of GLD.1.2
61 The governance structure approves or provides for all of the hospitals plans and policies and allocates resources to meet the

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62 hospitals mission. One important accountability is to carry out all responsibilities in a manner that supports the continual
63 improvement in quality and patient safety. This important investment in quality needs to be planned, provided adequate
64 resources, and monitored for progress. Thus, governance approves the quality plan on an annual basis and on a regular basis
65 receives quality reports. The reports can be global in nature or focus on a particular clinical service, patient group, or some
66 operational aspect. Thus, over a period of time, all aspects of the quality plan are presented to governance for their
67 information and discussion. When the discussion results in actions, such as allocation of additional resources, those actions
68 are recorded in minutes and are reexamined at a future meeting(s).
69

70 Measurable Elements of GLD.1.2


71 1. Those responsible for governance annually approve the hospitals plan for quality and patient safety.
72 2. Those responsible for governance regularly receive and act on reports of the quality and patient safety program.
73 3. Minutes reflect actions taken and any follow-up on those actions.
74

75 Senior Manager or Director Accountabilities

76 Standard GLD.2
77 A senior manager or director is responsible for operating the hospital and complying with applicable laws and regulations.

78 Intent of GLD.2
79 Effective leadership is essential for a hospital to be able to operate efficiently and to fulfill its mission. Leadership is what
80 individuals provide together and individually to the hospital and can be carried out by any number of individuals.
81 The senior manager or director is responsible for the hospitals overall, day-to-day operations. This includes the procurement
82 and inventory of essential supplies, maintenance of the physical facility, financial management, quality management, and other
83 responsibilities. The education and experience of the individual matches the requirements in the position description. The
84 senior manager or director cooperates with the hospitals managers to define the hospitals mission and to plan the policies,
85 procedures, and clinical services related to that mission. Once approved by the governing body, the senior manager or
86 director is responsible for implementing all policies and ensuring that all policies are complied with by the hospitals staff.
87 The senior manager or director is responsible for the hospitals
88 compliance with applicable laws and regulations;
89 response to any reports from inspecting and regulatory agencies; and
90 processes to manage and to control human, financial, and other resources.
91

92 Measurable Elements of GLD.2

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93 1. The education and experience of the senior manager match the requirements in the position description.
94 2. The senior manager or director manages the hospitals day-to-day operations, including those responsibilities
95 described in the position description.
96 3. The senior manager or director recommends policies, strategic plans, and budgets to the governing body.
97 4. The senior manager or director ensures compliance with approved policies.
98 5. The senior manager or director ensures compliance with applicable laws and regulations.
99 6. The senior manager or director responds to any reports from inspecting and regulatory agencies.
100

101 Leadership Accountabilities


102
103 Note: In these and all GLD standards, leaders are individuals and leadership is the collective group. Accountabilities are
104 described at the individual or collective level.
105

106 Standard GLD.3


107 The hospitals leaders are identified and are collectively responsible for defining the hospitals mission and creating the plans
108 and policies needed to fulfill the mission.

109 Intent of GLD.3


110 The leaders of a hospital arise from many sources. The governing body names the senior manager or director. The senior
111 manager or director may name other managers. Leaders may have formal titles, such as Medical Director or Director of Nursing,
112 Director of a clinical or non-clinical department or service, or may be informally recognized for their seniority, stature, or contribution to the
113 hospital. It is important that all leaders of a hospital are recognized and brought into the process of defining the hospitals
114 mission. Based on that mission, the leaders work collectively and collaboratively to develop the plans, policies and services
115 needed to fulfill the mission. When the mission and policy framework are set by owners or agencies outside the hospital, the
116 leaders work collaboratively to carry out the mission and policies.

117 Measurable Elements of GLD.3


118 1. The leaders of the hospital are identified.
119 2. Leadership is responsible for defining the hospitals mission.
120 3. Leadership is responsible for creating the policies and procedures necessary to carry out the mission.
121 4. Leadership ensures that policies and procedures are followed.
122

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123 Standard GLD.3.1 (integrates former GLD.3.1 and GLD.3.2)


124 Leadership identifies and plans for the type of clinical services required to meet the needs of the patients served by the
125 hospital.

126 Intent of GLD.3.1


127 Patient care services are planned and designed to respond to the needs of the patient population. Hospital plans describe the
128 care and services to be provided consistent with its mission. The leaders of the various clinical departments and services in the
129 hospital determine which diagnostic, therapeutic, rehabilitative, and other services are essential to the community. The leaders
130 also determine the scope and intensity of the various services to be provided by the hospital directly or indirectly. When
131 applicable to the mission of the hospital, leadership plans with community leaders and leaders of other hospitals to plan with
132 and participate with others in meeting community health care needs. The services planned reflect the strategic direction of the
133 hospital and the perspective of the patients cared for by the hospital.
134

135 Measurable Elements of GLD.3.1


136 1. Leadership determines that the type of care and services to be provided by the hospital are consistent with the
137 hospitals mission.
138 2. Leadership plans with community leaders and leaders of other organizations to meet the communitys health care needs.
139 3. Hospital plans describe the care and services to be provided.
140

141 Standard GLD.3.2 (formerly MCI.1)


142 The leadership of the hospital communicates with key stakeholders in its community to facilitate access to care and access to
143 information about its patient care services.

144 Intent of GLD.3.2


145 The leadership of hospitals defines its communities and patient populations and plans ongoing communication with those key
146 stakeholder groups. The communications may be directly to individuals or through public media and through agencies within
147 the community or third parties. The types of information communicated include
148 information on services, hours of operation, and the process to obtain care; and
149 information on the quality of services, which is provided to the public and to referral sources.

150 Measurable Elements of GLD.3.2


151 1. Leadership has identified its communities and populations of interest and key stakeholders.
152 2. Leadership implements a communication strategy with these stakeholders that includes information on its services,
153 hours of operation, and the process to obtain care.

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154 3. Leadership provides data and information on the quality of its services to stakeholders.
155

156 Standard GLD.3.3 (incorporates former MCI.5)


157 Leadership ensures effective communication throughout the hospital.

158 Intent of GLD.3.3


159 Effective communication within a hospital is a leadership issue. Thus, the hospitals leadership understands the dynamics of
160 communication among and between professional groups; structural units, such as departments; between professional and
161 nonprofessional groups; between health professionals and management; between health professionals and families; and with
162 outside organizations, for example. Leadership not only sets the parameters of effective communication but also serves as role
163 models with the effective communication of the hospitals mission, strategies, plans, and other relevant information.
164 Leadership pays attention to the accuracy and timeliness of information shared and communicated throughout the hospital.
165 To coordinate and to integrate patient care, leadership develops a culture that emphasizes cooperation and communication.
166 Formal (for example, standing committees, joint teams) and informal (for example, newsletters and posters) methods for
167 promoting communication among services and individual staff members are used. Coordination of clinical services comes
168 from an understanding of each departments mission and services and collaboration in developing common policies and
169 procedures.
170

171 Measurable Elements of GLD.3.3


172 1. Leadership ensures processes are in place for communicating relevant information throughout the hospital in a timely
173 manner.
174 2. Leadership ensures effective communication among clinical and nonclinical departments, services, and individual staff
175 members.
176 3. Leadership communicates the hospitals mission, policies, plans, and goals to staff.
177

178 Standard GLD.3.4 (formerly GLD.3.2)


179 Leadership ensures that there are uniform programs for the recruitment, retention, development, and continuing education of
180 all staff.

181 Intent of GLD.3.4


182 A hospitals ability to care for patients is directly related to its ability to attract and to retain qualified, competent staff.
183 Leadership recognizes that staff retention, rather than recruitment, provides greater long-term benefit. Retention is increased
184 when leadership supports staff advancement through continuing education. Thus, leadership plans and implements a uniform
185 program and processes related to recruitment, retention, development, and continuing education for each category of staff.

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186 The hospitals recruitment program considers published guidelines, such as those from the World Health Organization,
187 International Council of Nurses, and World Medical Association.

188 Measurable Elements of GLD.3.4


189 1. There is a planned process for staff recruitment.
190 2. There is a planned process for staff retention.
191 3. There is a planned process for staff personal development and continuing education.
192 4. The planning is collaborative and includes all departments and services in the hospital.
193

194 Leadership for Quality and Patient Safety

195 Standard GLD.4 (formerly QPS.1, QPS.1.1, and QPS.1.3)


196 Leadership plans and implements a quality improvement and patient safety program.

197 Standard GLD.4.1 (formerly QPS.1.4)


198 Leadership communicates quality improvement and patient safety information to governance and staff on a regular basis.
199

200 Intent of GLD.4 and GLD.4.1


201 If a hospital is to successfully initiate and to maintain improvement and reduce risks to patients and staff, leadership and
202 planning are essential. Leadership and planning begins with the governing body of the hospital, along with those who manage
203 and lead the clinical and managerial activities of the hospital on a daily basis. Collectively, these persons represent the
204 leadership of the hospital. Leadership is responsible for establishing and providing ongoing support for an organizational
205 commitment to quality. Leadership develops the quality and patient safety plan for governance approval, and through its
206 vision and support, shapes the quality culture of the hospital.
207 Leadership selects the approach to be used by the hospital to measure, assess, and improve quality and patient safety. Also,
208 leadership determines how the program will be directed and managed on a daily basis and ensures the program has adequate
209 resources to be effective.
210 Leadership also implements a structure and process for the overall monitoring and coordination of the program throughout
211 the hospital. These actions ensure coordination among all the department and services in measurement and improvement
212 efforts. Coordination can be achieved through a quality council, a committee, or some other structure. Coordination reduces
213 duplication of effort, for example, two departments independently measuring similar processes or outcomes.
214 Leadership also prepares regular reports for governance review and discussion and is responsible for carrying out the actions
215 of governance related to program reports. In addition to the regular quality reports, at least once every 12 months, the
216 leadership provides a report to governance that includes

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217 the number and type of sentinel events;


218 whether the patients and families were informed of the event; and
219 actions taken to improve safety in response to events.
220 Regular communication of information about the quality improvement and patient safety program to staff is essential. The
221 communication is on a regular basis through effective channels, such as newsletters, storyboards, staff meetings, and human
222 resource processes. The information can be about new or recently completed improvement projects, progress in meeting the
223 International Patient Safety Goals, the results of the analysis of sentinel and other adverse events, or recent research or
224 benchmark programs, among others.
225

226 Measurable Elements of GLD.4


227 1. Leadership participates in developing and implementing a hospital-wide plan for a quality improvement and patient
228 safety program.
229 2. Leadership selects a hospital-wide approach to measuring, assessing, and improving quality and patient safety.
230 3. Leadership determines how the program will be directed and managed on a daily basis and ensures the program has
231 adequate technology and other resources to be effective.
232 4. Leadership implements a structure and process for the overall monitoring and coordination of the quality
233 improvement and patient safety program.

234 Measurable Elements of GLD.4.1


235 1. Leadership reports on the quality and patient safety program regularly to governance.
236 2. Leadership provides, at least once every 12 months, a report to governance that includes the number and type of
237 sentinel events, whether the patients and families were informed of the sentinel event, and actions taken to improve
238 safety in response to sentinel events and follow-up.
239 3. Information on the quality improvement and patient safety program is regularly communicated to staff, including
240 progress on meeting the International Patient Safety Goals.
241

242 Standard GLD.5 (formerly QPS.1.2)


243 Leadership prioritizes which processes should be measured, which improvement and patient safety activities should be
244 implemented, and how success should be measured.

245 Intent of GLD.5


246 Due to staff and resource limitations, every process within a hospital cannot be measured and improved at the same time.
247 Thus, a primary responsibility of leadership is to set measurement and improvement priorities for the hospital. Leadership

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248 provides focus for the hospitals quality measurement and improvement activities, including measurement and activities
249 regarding the hospitals full compliance with the International Patient Safety Goals. Leadership priorities may focus on the
250 achievement of strategic objectives, for example, to become the leading regional referral center for cancer patients. Similarly,
251 leadership may give priority to projects that increase efficiency, eliminate patient flow problems in the emergency department,
252 or create a monitoring process for the quality of services provided by contractors. Leadership considers priorities at a system
253 level to spread the impact of improvements broadly throughout the hospital, for example, improving the hospitals
254 medication management system. The priority-setting process includes the consideration of available data on which systems
255 and process demonstrate the most variation in implementation and outcomes. Leadership ensures that when present, clinical
256 research and medical education programs are represented among the priorities.
257 Leadership also endorses and supports the measurement of the impact of improvements. For example, measuring
258 improvement in efficiency of a complex clinical process, and/or any reduction in cost and resource use following
259 improvement in a process. Measuring the impact of an improvement supports an understanding of the relative costs for
260 investing in quality and the human, financial, and other returns on that investment. Leadership supports the creation of simple
261 tools to quantify resource use of the old process and for assessing a new process. Combining an understanding of the impact
262 of an improvement on patient outcome, and the relative cost and resulting process efficiency, contributes to improved priority
263 setting in the future both at an organizational level and at a departmental/service level. When this information is combined
264 hospitalwide, leaders can better understand how to allocate available quality and patient safety resources.

265 Measurable Elements of GLD.5


266 1. Leadership uses available data to set collective priorities for measurement and improvement activities and consider
267 potential system improvements.
268 2. Leadership ensures that when present, clinical research and medical education programs are represented in the
269 priorities.
270 3. Leadership priorities include full compliance with the International Patient Safety Goals.
271 4. Leadership endorses and supports measuring the impact of hospitalwide and departmental/service improvements on
272 efficiency and resource use.
273

274 Leadership for Contracts and Resource Decisions


275

276 Contracts

277 Standard GLD.6 (incorporating parts of former GLD.3.3)


278 Leadership is accountable for the review, selection, and monitoring of clinical or management contracts for services.

279 Intent of GLD.6


280 Hospitals frequently have the option to either provide clinical and management services directly or to arrange for such
281 services through referral, consultation, contractual arrangements, or other agreements. Such services may range from

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282 radiology and diagnostic imaging services to financial accounting services and services provided for housekeeping, food, or
283 linens. The hospitals leadership describes, in writing, the nature and scope of services provided through contractual
284 agreements.
285 When contracts relate to health professional staffingfor example, a contract for critical care nursesthe contracts stipulate
286 that the professionals staff provided meet the hospitals requirement for similar staff. For example, the critical care nurses
287 meet the requirement of SQE.13 (see page XXX).
288 In all cases, there is leadership accountability for such contracts or other arrangements to ensure that the services meet patient
289 needs and are included as part of the hospitals quality management and improvement activities. Clinical leaders participate in
290 the review and selection of clinical contracts and are accountable for monitoring those contracts. Management leaders
291 participate in the review and selection of management contracts and are accountable for monitoring those contracts.

292 Measurable Elements of GLD.6


293 1. There is a process for leadership accountability of contracts to meet patient and management needs.
294 2. The hospital has a written description of the nature and scope of those services to be provided through contractual
295 agreements.
296 3. Health professional staff contracts require credential review comparable to the hospitals review process.
297 4. Clinical leaders are accountable for the review, selection and monitoring of clinical contracts and management leaders
298 are accountable for the review, selection and monitoring of management contracts.
299 5. When contracts are renegotiated or terminated, the hospital maintains the continuity of patient services.
300

301 Standard GLD.6.1 (incorporating parts of former GLD.3.3.1)


302 Leadership ensures that contracts and other arrangements are included as part of the hospitals quality improvement and
303 patient safety program.

304 Intent of GLD.6.1


305 The quality and safety of patient care require evaluation of all services provided by the hospital or provided through contracts. Thus,
306 the hospital needs to receive, to analyze, and to take action on quality information from outside sources. The contract with
307 the outside source of service includes quality and patient safety expectations and the data that are to be provided to the
308 hospital, their frequency, and their format. Department/service leaders receive and act on quality reports from contracting
309 agencies that relate to the scope of services provided within their department/service and ensure that the reports are
310 integrated into the hospitals quality measurement process.

311 Measurable Elements of GLD.6.1


312 1. All contracts stipulate the quality data that is to be reported to the hospital, the reporting frequency and mechanism,
313 and how the hospital will respond to quality issues.
314 2. Quality data reported under contracts is integrated into the hospitals quality monitoring program.

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315 3. The relevant clinical and managerial leaders participate with the quality improvement program in the analysis of
316 quality and safety information from outside contracts.
317 4. When contracted services do not meet quality and safety expectations, action is taken.
318

319 Standard GLD.6.2 (incorporating parts of former GLD.3.3.2)


320 Leadership ensures that independent practitioners not employed by the hospital have the right credentials for the services
321 provided to the hospitals patients.

322 Intent of GLD.6.2


323 Clinical leaders may recommend contracts with or arrange services from physicians, dentists, and other independent
324 practitioners outside the hospital or arrange for them to come into the hospital to provide services. In some cases, these
325 individuals may even be located outside the region or country of the hospital. The services provided may include telemedicine
326 or teleradiology. If the services provided determine the care choice or course of care for the patient, the practitioner must
327 proceed through the credentialing and privileging processes of the hospital.

328 Measurable Elements of GLD.6.2


329 1. Leadership determines those services that will be provided by independent practitioners outside the hospital.
330 2. All diagnostic, consultative, and treatment services provided by independent practitioners outside the hospital, such
331 as telemedicine, teleradiology, and interpretations of other diagnostics, such as electrocardiogram (ECG),
332 electroencephalogram (EEG), and electromyogram (EMG), and the like, are privileged by the hospital to provide such
333 services.
334 3. Independent practitioners who provide patient care services on the premises of the hospital but are not employees or
335 members of the clinical staff are credentialed and privileged as required in SQE.9 through SQE.12.
336 4. The quality of services by independent practitioners outside the hospital is monitored as a component of the
337 hospitals quality improvement program.
338
339 Resource Decisions

340 Standard GLD.7 (incorporates former GLD.3.2.1)


341 Leadership makes decisions related to the purchase or use of resourceshuman and technicalwith an understanding of the
342 quality and safety implications of those decisions.

343 Intent of GLD.7


344 Leadership improves decision making when they have data upon which to base those decisions. For example, when the
345 hospital needs to replace or add infusion pumps, information on maintenance requirements, staff training or re-training

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346 requirements, information on previous failure rates and patient safety incidents, preferences of staff, alarm issues, among
347 others, will result in decisions based more on quality and patient safety rather than cost alone. Similarly, when making
348 decisions regarding the reduction or reassignment of nursing staff, consideration of the implications for patient care quality
349 and patient safety need to be brought forward to inform the decision. Leadership develops a process to gather data and
350 information for key purchase or resource decisions to ensure they include a safety and quality due-diligence component.
351 One component of data gathering related to resource decisions is to understand the required or recommended equipment,
352 supplies, and medications necessary to provide a service. Recommendations on equipment, supplies, and medication can
353 come from a government agency, national or international anesthesia professional organizations, or other authoritative
354 sources.
355 When resource decisions are made by a third partyfor example, a ministry of healthleadership provides data and
356 information to the third party on their experiences and preferences to better inform future resource choices.
357 When a hospital uses what is identified as experimental technology and/or pharmaceutical agents in patient care procedures (that is,
358 technology or agents identified as experimental either nationally or internationally), there is a process to review and to approve such
359 use. It is essential that such approval occur prior to use in patient care. A determination is made if special patient consent is necessary.
360

361 Measurable Elements of GLD.7


362 1. Leadership seeks data to inform decisions related to the purchase and use of new technologies.
363 2. Leadership uses data and information on the quality and safety implications of biomedical equipment choices.
364 3. Leadership uses data and information on the quality and safety implications of staffing choices.
365 4. Leadership monitors the results of its decisions and use the data to evaluate and improve the quality of its resource
366 purchasing and allocation decisions.
367 5. The hospital uses the recommendations of professional organizations and other authoritative sources in making
368 resource decisions.
369

370 Standard GLD.7.1 (new standard)


371 Leadership seeks and uses data and information on the integrity of the supply chain for drugs, equipment, and supplies to
372 protect patients and staff from contaminated, fake, and diverted products.

373 Intent of GLD.7.1


374 Supply chain management is an important component of ensuring not only the timely availability of necessary supplies, but in
375 preventing drugs, biomedical equipment, and supplies that are contaminated, fake, or from diverted sources from reaching the
376 hospitals patients. This well-documented global problem begins with understanding the reputation, credibility, and ethical
377 operation of each component of the hospitals supply chain. Although this information may not be complete and may be
378 difficult to piece together, the hospital can, at minimum, decide where the most significant risks reside and make better
379 informed choices. Product tracking through bar coding and other means can help management and staff understand the

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380 supply chain and prevent diversion. Although there is no single global standard for supply chains, or even national standards
381 in many countries, it is the responsibility of hospital leadership to be informed on the issues and implement available
382 strategies to protect the integrity of their most important supply chains.

383 Measurable Elements of GLD.7.1


384 1. Leaders identify the supply chain of critical supplies and equipment.
385 2. Leaders evaluate the integrity of each supplier in that chain.
386 3. Leaders made resource decisions based on the level of risk in the supply chain.
387 4. Leaders track critical supplies to prevent diversion or substitution.
388

389 Clinical Staff Organization and Accountabilities

390 Standard GLD.8 (formerly GLD.4)


391 Medical, nursing, and other leaders of clinical services plan and implement an effective organizational structure to support
392 their responsibilities and authority.

393 Intent of GLD.8


394 Medical, nursing, and other leaders of clinical services have special responsibilities to patients and to the hospital. These
395 leaders
396 support good communication between professionals;
397 jointly plan and develop policies that guide the delivery of clinical services;
398 provide for the ethical practice of their professions; and
399 oversee the quality of patient care.
400 The leaders of the medical and nursing staff create a suitable, effective organizational structure to carry out these
401 responsibilities. The organizational structure(s) and the associated processes used to carry out these responsibilities can
402 provide a single professional staff composed of physicians, nurses, and others or separate medical and nursing staff structures.
403 The structure chosen can be highly organized with bylaws and rules and regulations or can be informally organized. In
404 general, the structure(s) chosen
405 includes all the relevant clinical staff;
406 is consistent with the hospitals ownership, mission and structure;
407 is appropriate for the hospitals complexity and size of the professional staff; and
408 is effective in carrying out the responsibilities listed above.

409 Measurable Elements of GLD.8

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410 1. There is an effective organizational structure(s) used by medical, nursing, and other clinical leaders to carry out their
411 responsibilities and authority.
412 2. The structure(s) is appropriate to the hospitals size and complexity.
413 3. The organizational structure(s) and processes support professional communication.
414 4. The organizational structure(s) and processes support clinical planning and policy development.
415 5. The organizational structure(s) and processes support oversight of professional ethical issues.
416 6. The organizational structure(s) and processes support oversight of the quality of clinical services.
417

418 Standard GLD.8.1 (formerly GLD.3.4)


419 The medical, nursing, and other leaders are educated in the concepts of quality improvement.

420 Intent of GLD.8.1


421 A hospitals primary purpose is to provide patient care and to work to improve patient care outcomes over time by applying
422 quality improvement principles. Thus, the medical, nursing, and other leaders of a hospital need to
423 be educated in or familiar with the concepts and methods of quality improvement;
424 personally participate in quality improvement and patient safety processes; and
425 ensure that clinical quality improvement includes opportunities for measuring professional performance.

426 Measurable Elements of GLD.8.1


427 1. Medical, nursing, and other leaders are educated in or are familiar with the concepts and methods of quality
428 improvement.
429 2. Medical, nursing, and other leaders participate in relevant quality improvement and patient safety processes.
430 3. Professional performance is measured as part of clinical performance improvement.
431

432 Direction of Departments and Services

433 Standard GLD.9 (incorporates old GLD.5.2, GLD.5.3, and GLD.5.4)


434 One or more qualified individuals provide direction for each department or service in the hospital.

435 Intent of GLD.9


436 The clinical care, patient outcomes, and overall management of a hospital are only as good as the clinical and managerial
437 activities of each individual department or service. Good departmental or service performance requires clear leadership from a

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438 qualified individual. In larger departments or services, leadership may be separated. In such a case, the responsibilities of each
439 role are defined in writing.
440 Each departments leaders communicate their human resources and other resource requirements to the hospitals senior
441 managers. This helps ensure that adequate staff, space, equipment, and other resources are available to meet patients needs at
442 all times. Although the directors make recommendations regarding human and other resource needs, those needs sometimes
443 change or are not fully met. Thus, directors have a process to respond to resource shortages to ensure safe and effective care
444 for all patients.
445 Directors consider the services provided and planned by the department or service and the education, skills, knowledge, and
446 experience needed by the departments professional staff to provide those services. Directors develop criteria reflecting this
447 consideration and then select staff. Directors may also work with human resources or other departments in the selection
448 process based on the directors recommendation.
449 Directors ensure that all staff in the department or service understand their responsibilities and establish the orientation and
450 training for new employees. The orientation includes the hospitals mission, the departments or services mission, the scope
451 of services provided, and the policies and procedures related to providing services. For example, all staff understands the
452 infection prevention and control procedures within the hospital and within the department or service. When new or revised
453 policies or procedures are implemented, staff are trained.
454 Note: Also see ACC.6.1, ME 1; ACS.2, ME 2; AOP.5.9 related to the direction of clinical laboratory services; AOP.6.7 related
455 to the direction of radiology and diagnostic imaging services; MMU.1.1 related to the direction of the pharmacy or
456 pharmaceutical services; and ACS.2 related to the direction of anesthesia services.

457 Measurable Elements of GLD.9


458 1. Each department or service in the hospital is directed by an individual with the training, education, and experience
459 comparable to the services provided.
460 2. Directors recommend space, equipment, staffing, and other resources needed by the department or service and have
461 a process in place to respond to shortages.
462 3. Directors recommend criteria for selecting the department or services professional staff and choose or recommend
463 individuals who meet those criteria.
464 4. Directors provide orientation and training for all staff of the duties and responsibilities for the department or service
465 to which they are assigned.
466

467 Standard GLD.10 (incorporates former GLD.5.1 and GLD.5.1.1)


468 The directors of each clinical department identify, in writing, the services to be provided by the department, and integrates or
469 coordinates those services with the services of other departments.

470 Intent of GLD.10


471 The directors of the hospitals clinical departments collaborate to determine the uniform format and content of the
472 department-specific planning documents. In general, the documents prepared by each clinical department define its goals, as

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473 well as identify current and planned services. Department policies and procedures reflect the departments goals and services
474 as well as the knowledge, skills, and availability of staff required to assess and to meet patient care needs.
475 Clinical services provided to patients are coordinated and integrated within each department or service. For example, there is
476 integration of medical and nursing services. Also, each department or service coordinates and integrates its services with other
477 departments and services. Unnecessary duplication of services is avoided or eliminated to conserve resources.

478 Measurable Elements of GLD.10


479 1. Department or service directors have selected and use a uniform format and content for planning documents.
480 2. The departmental or service documents describe the current and planned services provided by each department or
481 service.
482 3. Each departments or services policies and procedures guide the provision of identified services.
483 4. Each departments or services policies and procedures address the staff knowledge and skills needed to assess and to
484 meet patient needs.
485 5. There is coordination and/or integration of services with other departments and services.
486

487 Standard GLD.11


488 Directors evaluate the departments or services performance.

489 Intent of GLD.11


490 One of the important responsibilities of a department or service director is to implement the hospitals quality improvement
491 and patient safety program in the department. The selection of the department or service level measures reflects the following:
492 a) those measurement and improvement priorities set by the hospitals leadership that relate to the department or
493 service;
494 b) the measures that will be used in the ongoing professional practice review of the departments or services physicians
495 as described in SQE.X
496 c) the measures associated with department/service priorities to reduce variation, improve patient satisfaction, or
497 improve efficiency, for example.
498 The director is responsible for ensuring that the measurement activities provide the opportunity for the evaluation of staff as
499 well as the processes of care. Thus, measurement includes, over time, all the services provided. The resulting data and
500 information are important to the departments or services improvement efforts but are also important to the hospitals quality
501 improvement and patient safety program. Some departments, such as radiology and the clinical laboratory, have ongoing
502 quality control programs that are included in the measurement priorities.

503 Measurable Elements of GLD.11


504 1. Directors implement quality measures that address the services provided in their department or service, including

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505 criteria a) through c) in the intent statement, as appropriate to the department of service.
506 2. Directors implement quality control programs when indicated.
507 3. Department and service quality measurement and improvement activities are reported periodically to the quality
508 oversight mechanism of the hospital.
509

510 Standard GLD.11.1 (moved from QPS.2.1)


511 The directors of each clinical department/service select and implement clinical practice guidelines, clinical pathways, and/or
512 clinical protocols to guide clinical care.
513

514 Intent of GLD.11.1


515 The goals of health care hospitals include
516 standardizing clinical care processes;
517 reducing risks within care processes, particularly those associated with critical decision steps;
518 providing clinical care in a timely, effective manner using available resources efficiently; and
519 consistently delivering high-quality care using evidence-based practice.
520 Hospitals use a variety of tools to reach these and other goals. For example, health care practitioners seek to develop clinical
521 care processes and make clinical care decisions based on the best available scientific evidence. Clinical practice guidelines are
522 useful tools in this effort to understand and to apply the best science to a particular diagnosis or condition.
523 In addition, health care practitioners seek to standardize care processes. Clinical care pathways and clinical protocols are
524 useful tools in this effort to ensure effective integration and coordination of care and efficient use of available resources.
525 Clinical practice guidelines, clinical care pathways, and clinical protocols relevant to the hospitals patient population and
526 mission are
527 a) selected from among those applicable to the services and patients of the hospital (mandatory national guidelines are
528 included in this process, if present);
529 b) evaluated for their relevance to identified patient populations;
530 c) adapted when needed to the technology, drugs, and other resources of the hospital or to accepted national
531 professional norms;
532 d) assessed for their scientific evidence;
533 e) formally approved or adopted by the hospital;
534 f) implemented and measured for consistent use and effectiveness;
535 g) supported by staff trained to apply the guidelines or pathways; and

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536 h) periodically updated based on changes in the evidence and evaluation of processes and outcomes.
537 Clinical departments/services are expected to accomplish the following on an annual basis:
538 Department/service leadership selects at least five hospitalwide priority areas on which to focus, such as patient
539 diagnosis, procedures, populations, or diseases, among others, for which guidelines, pathways, and protocols would
540 impact the quality and safety of patient care and reduce unwanted variation in outcomes.
541 Complete the process described in a) through h) for the identified priority focus areas.

542 Measurable Elements of GLD.11.1


543 1. On an annual basis, department/service leadership determines at least five priority areas on which to focus the use of
544 guidelines, clinical pathways, and/or clinical protocols.
545 2. Department/service leadership follows the process described in a) through h) of the intent in implementing clinical
546 practice guidelines, clinical pathways, and/or clinical protocols.
547 3. Department/service leadership implements clinical guidelines and a clinical pathway or clinical protocol for each
548 identified priority area.
549 4. Department/service leadership can demonstrate how the use of clinical practice guidelines, clinical pathways, and/or
550 clinical protocols has reduced variation in processes and outcomes.
551

552 Organizational and Clinical Ethics

553 Standard GLD.12


554 The hospitals leaders establish a framework for ethical management that promotes a culture of ethical practices and decision
555 making to ensure that patient care is provided within business, financial, ethical, and legal norms and protects patients and
556 their rights.

557 Standard GLD.12.1


558 The hospitals framework for ethical management addresses operational and business issues, including marketing, admissions,
559 transfer, discharge, and disclosure of ownership and any business and professional conflicts that may not be in patients best
560 interests.

561 Standard GLD.12.2


562 The hospitals framework for ethical management addresses ethical issues and decision making in clinical care.

563 Intent of GLD.12 through GLD.12.2


564 Hospitals face many challenges in providing safe, quality health care. With advances in technology, financial constraints, and
565 increasing expectations, ethical dilemmas and controversies are much more common. The leaders of the hospital have a
566 professional and legal responsibility to create and promote an environment and culture that operate within an ethical

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567 framework. The ethical framework must apply to both the hospitals business and clinical activities alike. Leaders must
568 demonstrate ethical behaviors and develop guidelines for organizational performance and conduct. The leaders actions and
569 the hospitals guidelines for ethical behavior must be congruent with the hospitals vision, mission, and value statements,
570 personnel policies, annual reports, and other documents.
571 The framework supports the hospitals health care providers, other staff, and patients and family when confronted by ethical
572 dilemmas in patient care, such as disagreements between patients and their health care practitioners regarding care decisions
573 and interprofessional disagreements. Such support is readily available and includes ethics resources and training for health care
574 providers and other staff. In addition, national and international norms related to human rights and professional ethics must
575 be taken into consideration when creating an ethical framework and guiding documents.
576 The hospital operates within this framework to
577 disclose ownership and any conflicts of interest;
578 honestly portray its services to patients;
579 protect confidentiality of patient information;
580 provide clear admission, transfer, and discharge policies;
581 bill accurately for its services and assure financial incentives and payment arrangements do not compromise
582 patient care;
583 encourage transparency in reporting organizational and clinical performance measures;
584 establish a mechanism by which health care providers and other staff may report clinical errors and raise ethical
585 concerns with impunity, including disruptive staff behavior related to clinical and/or operational issues;
586 support an environment that allows free discussion of ethical concerns without fear of retribution;
587 provide an effective and timely resolution to ethical conflicts that arise;
588 assure nondiscrimination in employment practices and provision of patient care; and
589 reduce disparities in health care access and clinical outcomes.
590

591 Measurable Elements of GLD.12


592 1. The leaders establish a framework for the hospitals ethical management that promotes a culture of ethical practices
593 and decision making to ensure the protection of patients and their rights.
594 2. The ethical framework ensures that patient care is provided within business, financial, ethical, and legal norms.
595 3. The hospital assures non-discrimination in employment practices and provision of patient care.
596 4. The leaders examine national and international ethical norms for incorporation when developing the hospitals
597 framework for ethical conduct.

598 Measurable Elements of GLD.12.1

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599 1. The hospital discloses its ownership and any conflicts of interest.
600 2. The hospital honestly portrays its services to patients.
601 3. The hospital provides clear admission, transfer, and discharge policies.
602 4. The hospital accurately bills for services and assures financial incentives and payment arrangements do not
603 compromise patient care.
604 5. The hospital seeks to reduce disparities in healthcare access and clinical outcomes.

605 Measurable Elements of GLD.12.2


606 1. The hospitals framework for ethical management establishes a mechanism by which health care providers and other
607 staff may raise ethical concerns.
608 2. Support for identifying and addressing ethical concerns is readily available and includes ethics resources and training
609 for health care providers and other staff.
610 3. The hospital provides an effective and timely resolution to ethical conflicts that arise.
611 4. The hospitals framework provides for safe reporting of ethical and legal concerns without fear of retribution.
612

613 Standard GLD.13 (new standard)


614 Leaders create and support a culture of safety throughout the hospital.

615 Standard GLD.13.1 (new standard)


616 Leaders implement, monitor, and take action to improve the program for a culture of safety throughout the hospital.

617 Intent of GLD.13 and GLD.13.1


618 A culture of safety has been defined as: The safety culture of a hospital is the product of individual and group values,
619 attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and
620 proficiency of, a hospitals health and safety management. Hospitals with a positive safety culture are characterized by
621 communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the
622 efficacy of preventive measures.1
623 Safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position
624 in the hospital. Leaders demonstrate their commitment to a culture of safety and set expectations for those who work in the
625 hospital. Behaviors that are disruptive or intimidate others and affects morale or staff turnover can be harmful to patient care.
626 Key features of a program for a culture of safety include:
627 acknowledgment of the high-risk nature of a hospital's activities and the determination to achieve consistently safe
628 operations
629 an blame-free environment where individuals are able to report errors or near misses without fear of reprimand or
630 punishment

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631 encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
632 organizational commitment of resources to address safety concerns
633 Health care continues to have a culture of individual blame which impairs the advancement of a safety culture. There are
634 instances in which individuals should not be blamed for an error, for example, when there is poor communication between
635 patient and staff, when there is a need for rapid decision making, or when there are human factor design flaws in a treatment
636 process. However, certain errors are the result of reckless behavior and do require accountability. Examples of reckless
637 behavior may include failure to follow hand hygiene guidelines, not performing the time-out before surgery, or not marking
638 the surgical site. A culture of safety includes identifying and addressing issues related to systems that lead to unsafe behaviors.
639 At the same time though, hospitals must maintain accountability by establishing zero tolerance for reckless behavior.
640 Accountability distinguishes between human error (such as a mix-up), at-risk behavior (for example taking shortcuts), and
641 reckless behavior (such as ignoring required safety steps).
642 Leaders evaluate the culture on a regular basis using a variety of methods, such as formal surveys, focus groups, staff
643 interviews, and data analysis. Leaders encourage teamwork and create structures, processes, and programs that allow this
644 positive culture to flourish. Leaders must address undesirable behaviors of individuals working at all levels of the hospital,
645 including management, clinical and administrative staff, licensed independent practitioners, and governing body members.

646 Measurable Elements of GLD.13


647 1. Leaders establish and support an organizational culture that promotes accountability and transparency.
648 2. Leaders develop and document a code of conduct and identify behaviors that are unacceptable.
649 3. Leaders create and implement a process for managing unacceptable behaviors.
650 4. Leaders provide education and information (such as literature and advisories) relevant to the hospitals culture of safety
651 to all individuals who work in the hospital.
652 5. Leaders define how members of the population(s) served can help identify and manage issues related to a culture of
653 safety within the hospital.
654 6. Leaders provide resources to promote and support the culture of safety within the hospital.
655
656 Measurable Elements of GLD.13.1
657 1. Leaders provide a simple, accessible, and confidential system for reporting issues relevant to a culture of safety in
658 the hospital.
659 2. Leaders assure that all reports related to the hospitals culture of safety are investigated in a timely manner.
660 3. The hospital identifies systems issues that lead healthcare providers to engage in unsafe behaviors.
661 4. Leaders identify measures to evaluate and monitor the safety culture within the hospital.
662 5. Leaders prioritize and implement improvements identified from measurement and evaluation.
663 6. Leaders implement a process to prevent retribution against individuals who report issues related to the culture of
664 safety.

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665
666
667 Health Professional Education and Human Subject Research
668
669 Note: These standards apply to hospitals that conduct human subject research and/or provide health professional education
670 but do not meet the eligibility criteria for Academic Medical Center accreditation. See page XXX for Academic Medical Center
671 accreditation criteria.
672
673 Health Professional Education

674 Standard GLD.14 (formerly standard SQE.8.3)


675 Health professional education, when provided within the hospital, is guided by the educational parameters defined by the
676 sponsoring academic program and the hospitals leadership.

677 Intent of GLD.14


678 Frequently, hospitals are the clinical setting for medical, nursing, other health care practitioners, and other student training.
679 When the hospital participates in such training programs, the hospital
680 provides a mechanism(s) for oversight of the program(s);
681 obtains and accepts the parameters of the sponsoring academic program;
682 has a complete record of all trainees within the hospital;
683 has documentation of the enrollment status, licensure or certifications achieved, and academic classification of
684 the trainees;
685 understands and provides the required level of supervision for each type and level of trainee; and
686 integrates trainees into the hospitals orientation, quality, patient safety, infection prevention and control, and
687 other programs.

688 Measurable Elements of GLD.14


689 1. The hospital provides a mechanism(s) for oversight of the training program(s).
690 2. The hospital obtains and accepts the parameters of the sponsoring academic program.
691 3. The hospital has a complete record of all trainees within the hospital.
692 4. The hospital has documentation of the enrollment status, licensure or certifications achieved, and academic
693 classification of the trainees.
694 5. The hospital understands and provides the required level of supervision for each type and level of trainee.
695 6. The hospital integrates trainees into its orientation, quality, patient safety, infection prevention and control, and other

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696 programs.
697
698 Human Subject Research

699 Standard GLD.15 (modified from HRP standards from Academic Medical
700 Center requirements)
701 Human subject research, when provided within the hospital, is guided by laws, regulations and the hospitals leadership.

702 Intent of GLD.15


703 Human subject research on a large scale or small scale is a complex and significant endeavor for a hospital. The leadership of
704 the hospital recognizes the required level of commitment and personal involvement required to advance scientific inquiry in
705 the context of protecting the patients for whom they have made a commitment to diagnose and treat.
706 The leaders commitment to human subject research is not separate from their commitment to patient carecommitment is
707 integrated at all levels. Thus, ethical considerations, good communications, responsible leaders, regulatory compliance, and
708 financial and nonfinancial resources are components of this commitment. One such resource is adequate indemnity insurance
709 to compensate patients for adverse events due to the research protocol. The leaders recognize the obligation to protect
710 patients irrespective of the sponsor of the research.

711 Measurable Elements of GLD.15


712 1. Leadership identifies the official(s) responsible for maintaining the development of and compliance with all human
713 research policies and procedures.
714 2. Leadership assumes responsibility for patient protection irrespective of the sponsor of the research.
715 3. Leadership recognizes and establishes mechanisms for compliance with all regulatory and professional requirements
716 related to research.
717 4. Leadership provides adequate indemnity insurance to compensate patients participating in clinical research who
718 experience an adverse event.
719

720 Standard GLD.16 (modified from HRP standards from Academic Medical
721 Center requirements)
722 Patients and families are informed about how to gain access to clinical research, clinical investigation, or clinical trials
723 involving human subjects.

724 Intent of GLD.16


725 A hospital that conducts clinical research, clinical investigations, or clinical trials involving human subjects provides

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726 information to patients and families about how to gain access to those activities when relevant to the patients treatment
727 needs. When patients are asked to participate, they need information upon which to base their decisions. That information
728 includes
729 expected benefits;
730 potential discomforts and risks;
731 alternatives that might also help them; and
732 procedures that must be followed.
733 Patients are informed that they can refuse to participate or withdraw participation and that their refusal or withdrawal will not
734 compromise their access to the hospitals services.
735 The hospital has policies and procedures for providing patients and families with this information.

736 Measurable Elements of GLD.16


737 1. Appropriate patients and families are identified and informed about how to gain access to clinical research, clinical
738 investigations, or clinical trials relevant to their treatment needs.
739 2. Patients and families asked to participate are informed about expected benefits.
740 3. Patients and families asked to participate are informed about potential discomforts and risks.
741 4. Patients and families asked to participate are informed about alternatives that might also help them.
742 5. Patients and families asked to participate are informed about the procedures that must be followed.
743 6. Patients and families are assured that their refusal to participate or withdraw from participation will not compromise
744 their access to the hospitals services.
745 7. Policies and procedures guide the information and decision process.
746

747 Standard GLD.17 (formerly PFR.7.1)


748 Patients and families are informed about how patients who choose to participate in clinical research, clinical investigation, or
749 clinical trials are protected.

750 Intent of GLD.17


751 A hospital that conducts clinical research, clinical investigations, or clinical trials involving human subjects knows that its first
752 responsibility is to the patients health and well-being.
753 The hospital informs patients and families in advance about established processes to
754 review research protocols;
755 weigh the relative risks and benefits to the subjects;

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756 obtain subject consent; and


757 withdraw from participation.
758 This information is communicated to patients and families to assist with decisions regarding participation.

759 Measurable Elements of GLD.17


760 1. Patients and families are informed about the hospitals process for reviewing research protocols.
761 2. Patients and families are informed about the hospitals process for weighing the benefits and risks to the subjects.
762 3. Patients and families are informed about the hospitals process for obtaining consent.
763 4. Patients and families are informed about the hospitals process for withdrawing from participation.
764

765 Standard GLD.18 (formerly PFR.8)


766 Informed consent is obtained before a patient participates in clinical research, clinical investigation, and clinical trials.

767 Intent of GLD.18


768 When patients and families decide to participate in clinical research, clinical investigations, or clinical trials, informed consent
769 is granted. The information provided at the time the decision to participate was made serves as the basis for the informed
770 consent (also see PFR.6, intent statement). The individual(s) providing the information and obtaining the consent is noted in
771 the patients record.

772 Measurable Elements of GLD.18


773 1. Informed consent is obtained when a patient decides to participate in clinical research, clinical investigations, or
774 clinical trials.
775 2. Consent decisions are documented, dated, and based on the information identified in PFR.X.
776 3. The identity of the individual(s) providing the information and obtaining the consent is noted in the patients record.
777 4. Consent is documented in the patients record by signature or record of verbal consent.
778

779 Standard GLD.19 (formerly PFR.9)


780 The hospital has a committee or another way to oversee all research in the hospital involving human subjects.

781 Intent of GLD.19


782 When the hospital conducts clinical research, investigations, or trials that involve human subjects, a committee or other
783 mechanism to provide oversight for all such activities in the hospital is established. The hospital develops a statement of

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784 purpose for the oversight activities. Oversight activities include the review process for all research protocols, a process to
785 weigh the relative risks and benefits to the subjects, and processes related to the confidentiality and security of the research
786 information.

787 Measurable Elements of GLD.19


788 1. The hospital has a committee or other mechanism to oversee all research within the hospital.
789 2. The hospital develops a clear statement of purpose for the oversight activities.
790 3. Oversight activities include a review process.
791 4. Oversight activities include a process to weigh relative risks and benefits to subjects.
792 5. Oversight activities include processes to provide confidentiality and security of research information.
793
794 Reference
795 1. Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study
796 Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.

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1 Staff Qualifications and Education


2 (SQE)
3

4 Standard SQE.8.4
5 The hospital provides a staff health and safety program.
6 Intent of SQE.8.4
7 The health and safety of a hospitals staff are important to maintain staff health, satisfaction, and productivity. Because of their
8 contact with patients and patients infective material, many health care workers are at risk for exposure to and possible
9 transmission of vaccine-preventable diseases. Identifying epidemiologically important infections, determining staff at high risk
10 for these infections, and implementing screening and prevention programs (such as immunizations, vaccinations, and
11 prophylaxis) can significantly reduce the incidence of infectious disease transmission.
12 Violence in the workplace has become an increasingly common problem in health care organizations. Staff shortages,
13 increased patient acuity, and the misconception that violence does not occur in health care organizationsor if violence does
14 occur, it is part of the jobare just a few of the barriers to acknowledging that workplace violence exists and to developing
15 violence prevention programs.
16 Staff health and safety must be a part of the hospitals quality and patient safety program. How an hospital orients and trains
17 staff, provides a safe workplace, maintains biomedical and other equipment, prevents or controls health careassociated
18 infections, and many other factors determine the health and well-being of staff. (Also see PCI.5.1, ME 2)A staff health and
19 safety program can be located within the hospital or be integrated into external programs. Whatever the staffing and structure
20 of the program, staff understand how to report, to be treated for, and to receive counseling and follow-up for injuries such as
21 those that may result from needlesticks, exposure to infectious diseases, or workplace violence; the identification of risks and
22 hazardous conditions in the facility; and other health and safety matters. The program may also provide for initial employment
23 health screening, periodic preventive immunizations and examinations, and treatment for common work-related conditions,
24 such as back injuries, or more urgent injuries.
25 The design of the program includes staff input and draws upon the hospitals clinical resources as well as those in the
26 community.
27 Measurable Elements of SQE.8.4
28 1. The hospital provides a staff health and safety program that is responsive to urgent and non-urgent staff needs
29 through direct treatment and referral.
30 2. The hospital identifies epidemiologically significant infections, as well as staff that are at high risk for infections, and
31 implements a staff vaccination and immunization program.
32 3. The hospital provides evaluation, counseling, and follow-up of staff exposed to infectious diseases that is coordinated
33 with the infection prevention and control program. (Also see PCI.5, ME 2)
34 4. The hospital identifies areas for potential workplace violence and implements measures to reduce the risk.

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35 5. The hospital provides evaluation, counseling, and follow-up treatment of staff who are injured as a result of workplace
36 violence. (Also see QPS.6 for injuries that result in permanent harm or death)
37 6. Program data inform the hospitals quality and safety program.
38

39 Medical Staff
40 Determining Medical Staff Membership

41 Standard SQE.9
42 The hospital has a uniform process for gathering the credentials of those medical staff members permitted to provide patient
43 care without supervision.

44 Standard SQE.9.1
45 Medical staff members education, licensure/registration, and other credentials required by law or regulation and the hospital
46 are verified and kept current.

47 Standard SQE.9.2
48 There is a uniform, transparent decision process for the initial appointment of medical staff members.

49 Intent of SQE.9, SQE.9.1, and SQE.9.2


50 Explanations of terms and expectations found in these standards are as follows:
51 Credentials
52 Credentials are documents that are issued by a recognized entity to indicate completion of requirements or the meeting of
53 eligibility requirements, such as a diploma from a medical school, specialty training (residency) completion letter, completion of
54 the requirements of a medical professional organization, a license to practice, or recognition of registration with a medical or
55 dental council. These documents, some of which are required by law or regulation, but some by hospital policy, must be
56 verified from the source that issued the document.
57 Credentials can also be documents from individuals and entities that address some aspect of the applicants professional history
58 or competency, such as letters of recommendation, a history of all previous hospital medical staff appointments, records of
59 previous clinical care, health history, picture, or police background check, for example. These documents may be required by
60 hospital policy as part of the credential-gathering process, but are not verified from the source that issued the document unless
61 required by hospital policy. This requirement for verification of the credential will vary by the position the applicant is seeking.
62 For example, for an applicant for director of a clinical service, the hospital may want to verify information regarding the
63 individuals previous administrative positions and experience. Also, for clinical positions, the hospital may require a certain
64 number of years of experience and thus would verify this level of experience.
65

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66 Medical Staff
67 Medical staff are all physicians, dentists, and other professionals who are licensed to practice independently (without supervision)
68 and who provide preventive, curative, restorative, surgical, rehabilitative, or other medical or dental services to patients; or who
69 provide interpretative services for patients, such as pathology, radiology, or laboratory services. All classifications of
70 appointments, all types and levels of staff (employed, honorary, contract, visiting, and private community staff members), are
71 included. Visiting staff include those who are locum tenens, or invited experts, master class teachers, and others allowed to
72 provide services temporarily. A hospital must define those other practitioners, such as house officers,, hospitalists, and
73 junior doctors, that are no longer in training, but may or may not be permitted by the hospital to practice independently. The
74 term medical staff is thus inclusive of all doctors and other professionals permitted to treat patients with partial or full
75 independence, regardless of their relationship to the hospital (for example, employees or independent consultants).
76
77 Verification
78 Verification is the process of checking the validity and completeness of a credential from the source that issued the credential.
79 This process can be accomplished by an inquiry to a secure online database of, for example, those individuals licensed in the
80 hospitals city or country. The process can also be accomplished by documenting a telephone conversation with the issuing
81 source, or making an email or conventional postal letter inquiry with the source. Verification of credentials from outside the
82 country may be more complex and in some cases not possible. There should however be evidence of a credible effort to verify
83 the credential. A credible effort is characterized by multiple (at least two within 60 days) attempts by various methods (for
84 example, phone, email, and letter) with documentation of the attempts and result(s).
85 The three following situations are acceptable substitutes for a hospital performing primary source verification of credentials:
86 1. Applicable to hospitals overseen directly by governmental bodies, the governments verification process,
87 supported by the availability of transparent governmental regulations about primary source verification; plus
88 government licensure, or equivalent such as a registration; and the granting of specific status (for example,
89 consultant, specialist, and others) are acceptable.
90 2. Applicable to all hospitals, the existence of an affiliated hospital that has already conducted primary source
91 verification of the medical staff applicant, is acceptable as long as the affiliated hospital has current Joint
92 Commission International (JCI) accreditation with full compliance on its verification process found in SQE.9.1,
93 MEs 1 and 2 (SQE.9, ME 3 in JCIs 4th edition hospital standards). Full compliance means the hospitals
94 Official Accreditation Report indicates that all measurable elements are fully met, or any not met or partially met
95 measurable element required to be addressed by Strategic Improvement Plan (SIP) actions have been addressed
96 and are now in full compliance.
97 3. Applicable to all hospitals, the credentials have been verified by an independent third party, such as a designated,
98 official, governmental, or nongovernmental agency, as long as the following conditions apply: Any hospital that
99 bases its decisions in part on information from a designated, official, governmental, or nongovernmental agency
100 should have confidence in the completeness, accuracy, and timeliness of that information. To achieve this level of
101 confidence in the information, the hospital should evaluate the agency providing the information initially and then
102 periodically thereafter to ensure JCI standards continue to be met. See Appendix (to come) for the framework of
103 such an evaluation.
104 It is important to understand the process for issuing some credentials. For example, does the government agency issuing a

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105 license to practice base its decision on verification of education and/or an examination of competence? Also, if admission to a
106 specialty education program is based on verification of education and experience to date, the hospital does not need to verify
107 education again. The process used by the government agency is documented by the hospital. If the hospital does not have
108 direct knowledge of the process used by the agency to verify education, the hospital needs to perform its own verification.
109 Exception for SQE.9.1, ME 1, for Initial Surveys only. Primary source verification is required for new practitioners
110 who joined the medical staff within the four months prior to the initial JCI accreditation survey. All other practitioners must
111 have primary source verification completed by the time of the hospitals first triennial accreditation survey (which, in most
112 cases, is the hospitals second JCI accreditation survey). This process is accomplished over the three-year period between
113 surveys, according to a plan that places priority on the verification of the credentials of active practitioners providing high-risk
114 services.
115 Note: This exception refers only to the verification of credentials. All medical staff members have to have their credentials
116 gathered and reviewed, and their privileges granted. There is no phasing in of this process.
117 Appointment
118 Appointment is the process of reviewing an initial applicants credentials to decide if the individual is qualified to provide patient
119 care services that the hospitals patients need and the hospital can support with qualified staff and technical capabilities. For
120 initial applicants, the information reviewed is primarily from outside sources. Hospital policy identifies the individuals or
121 mechanism accountable for this review, any criteria used to make decisions, and how decisions will be documented.
122 Reappointment
123 Reappointment is the process of reviewing the medical staff members file to verify
124 continued licensure;
125 that the medical staff member is not compromised by disciplinary actions of licensing and certification agencies;
126 that the file contains sufficient documentation for seeking new or expanded privileges or duties in the hospital; and

127 that the medical staff member is physically and mentally able to provide patient care and treatment without
128 supervision.
129 The information for this review is from both internal and external sources. Hospital policy identifies the individuals or
130 mechanism accountable for this review, any criteria used to make decisions, and how decisions will be documented. The
131 credential file of a medical staff member should be a dynamic source of information and under constant review. For example,
132 when a medical staff member presents a certificate of achievement related to an advanced degree or advanced specialty
133 training, the new credential should be immediately verified from the issuing source. Similarly, when an outside agency
134 investigates a sentinel event related to a medical staff member and issues sanctions, this information should be used promptly
135 to reevaluate the clinical privileges of the medical staff member. To ensure that medical staff files are complete and accurate,
136 the files are reviewed at least every three years and a note in the file indicates any actions taken or that no action is necessary
137 and the appointment to the medical staff continues.

138 Measurable Elements of SQE.9


139 1. The hospital has an ongoing, uniform process to manage the credentials of medical staff members.
140 2. Medical staff members permitted by laws, regulations, and the hospital to provide patient care without supervision are
141 identified.

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142 3. Education, licensure/registration, and other credentials required by law or regulation are copied by the hospital and
143 maintained for each medical staff member in their personnel file or in a separate credential file.
144 4. All credentials required by hospital policy are copied by the hospital and maintained file for each medical staff
145 member in their personnel file or in a separate credential.

146 Measurable Elements of SQE.9.1


147 1. Education, licensure/registration, and other credentials required by law or regulation are verified from the source that
148 issued the credential.
149 2. Additional credentials required by hospital policy are verified from the source that issued the credential when required
150 by hospital policy.

151 Measurable Elements of SQE.9.2


152 1. All appointments are made according to hospital policy and are consistent with the hospitals patient population,
153 mission, and services provided to meet patient needs.
154 2. Appointments are not made until at least licensure/registration has been verified from the primary source, and the
155 medical staff member then provides patient care services under supervision until all credentials required by law and
156 regulation have been verified.
157 3. The method of supervision, frequency of supervision, and accountable supervisors are documented in the credential
158 file of the individual.
159

160 Medical Staff


161 The Assignment of Clinical Privileges

162 Standard SQE.10


163 The hospital has a standardized, objective, evidence-based procedure to authorize all medical staff members to admit and to
164 treat patients and/or to provide other clinical services consistent with their qualifications.

165 Intent of SQE.10


166 The determination of a medical staff members current clinical competence and making a decision about what clinical services
167 the medical staff member will be permitted to perform, often called privileging, is the most critical determination a hospital will
168 make to protect the safety of patients and to advance the quality of its clinical services.
169 Considerations for clinical privilege delineation at initial appointment include:
170 Decisions regarding a practitioners clinical competence, and thus what clinical privileges they are to be granted, are
171 based primarily on information and documentation received from outside the hospital. The source may include
172 specialty education programs, letters of recommendation from previous medical staff appointments and/or close
173 colleagues, and any quality data that may be released to the hospital. In general, these sources of information are not

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174 verified from the source unless required by hospital policy. Although these outside sources may not give clear,
175 objective evidence of current clinical competence, at least the areas of presumed competence are identified. Ongoing
176 professional practice review (SQE.11) will validate the areas of presumed competence.

177 There is no one best way to delineate those clinical activities the new medical staff member is privileged to perform.
178 Specialty training programs may identify and list the general competencies of that specialty in areas of diagnosis and
179 treatmentwith the hospital assigning privileges to diagnose and treat patients in those specialty competency areas.
180 Other organizations may choose to list out in detail each type of patient and treatment procedure.
181 Within each specialty area the process of privilege delineation is uniform, however this process may not be the same in
182 all specialty areas. Thus, the privileges will be different for general surgeons, pediatricians, dentists, or radiologists, for
183 example; however, within each of these groups the process for privilege delineation will be standardized.
184 The decision as to how clinical privileges are delineated in a specialty area is linked with other processes including
185 o selection by the department/service leaders of what processes are to be monitored through data collection
186 (see GLD.X);
187 o use of that data in the ongoing monitoring and evaluation process of the medical staff in the
188 department/service (see SQE.X); and
189 o use of the monitoring data in the process of reappointment and the renewal of privileges (see SQE.X.
190 In addition to the privileges granted in relation to the individuals education and training, the hospital identifies areas
191 of high risk, such as the administration of chemotherapeutic agents, other classes of drugs, or high-risk procedures for
192 which the medical staff member is explicitly granted such privileges or denied such privileges. The high-risk
193 procedures, drugs, or other services are identified by each specialty area and evident in the privilege delineation
194 process.
195 Also, privileges are not granted if the hospital does not have the special equipment or staff to support the exercise of a
196 privilege.
197 Finally, when an applicants licensure/registration has been verified from the issuing source, but other documents
198 such as education and traininghave yet to be verified, privileges are identified for the applicant. However, these
199 applicants may not practice independently until all credentials have been verified by the processes described above.
200 Such supervision is clearly defined in hospital policy as to level, conditions, and duration.
201 Note: When a medical staff member also has administrative responsibilities, such as chair or chief of a clinical department,
202 administrator of the hospital, or other such position, the responsibilities for this role are identified in a job description (see
203 SQE.1.1). Hospital policy identifies the primary source verification of the credentials presented in support of this
204 administrative role.
205 The privilege delineation process
206 1. is standardized, objective and evidence-based;
207 2. is documented in hospital policies;

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208 3. is active and ongoing as the credentials of medical staff members change;
209 4. is followed for all classes of medical staff membership; and
210 5. can be demonstrated as to how the procedure is used effectively.
211 The clinical privileges of all medical staff members are made available by printed copy, electronic copy, or other means to those
212 individuals or locations (for example, operating room, emergency department) in the hospital in which the medical staff
213 member will provide services. The medical staff member is provided a copy of his or her clinical privileges. Updated
214 information is communicated when the clinical privileges of a medical staff member change.

215 Measurable Elements of SQE.10


216 1. The privilege delineation process used by the hospital meets criteria 1) through 5) found in the intent statement.
217 2. The clinical privileges of all medical staff members are made available by printed copy, electronic copy, or other means
218 to those individuals or locations (for example, operating room, emergency department) in the hospital in which the
219 medical staff member will provide services.
220 3. Each medical staff member provides only those services that have been specifically granted by the hospital.
221

222 Medical Staff


223 Ongoing Monitoring and Evaluation of Medical Staff Members

224 Standard SQE.11


225 The hospital uses an ongoing standardized process to evaluate the quality and safety of the patient care provided by each
226 medical staff member.

227 Intent of SQE.11


228 Explanations of terms and expectations found in these standards are as follows:
229 Ongoing Monitoring and Evaluation
230 Ongoing monitoring and evaluation compose the process of continuously accumulating and analyzing data and information on
231 the behaviors, professional growth, and clinical results of medical staff members. The department/service chair or leader is
232 responsible for the integration of the data and information on medical staff and taking appropriate actions. Immediate actions
233 may be to counsel the staff member, place them under supervision, limit privileges, or other measures intended to limit risks to
234 patients and improve quality of care and patient safety. Longer term actions include synthesizing the data and information into
235 a recommendation for continued medical staff membership and clinical privileges. This process occurs at least every three
236 years. Other actions may be to note to other medical staff members the benchmark behaviors and clinical results evident in the
237 data and information of the medical staff member.
238 The ongoing monitoring and evaluation of medical staff members provides critical information to the process of maintaining
239 medical staff membership (SQE.X) and to the process of granting clinical privileges (SQE.X). Although three-year cycles are
240 required for renewing medical staff membership and clinical privileges, the process is intended to be ongoing and dynamic.

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241 Critical quality and patient safety incidents can arise if a medical staff members clinical performance issues are not
242 communicated and acted on when they arise.
243 The process of ongoing monitoring and evaluation is intended to
244 shape individual practices as they relate to quality, safe patient care;

245 provide the basis for reducing variation within a department/service through comparisons among colleagues and
246 the development of practice guidelines and clinical protocols; and
247 provide the basis for elevating the results of the entire department/service through comparisons with external
248 better practices and published research and clinical results.
249 The ongoing monitoring and evaluation of medical staff members encompasses three general areasbehaviors, professional
250 growth, and clinical results.
251 Behaviors
252 Medical staff members are leaders and mentors in creating a safe culture in a hospital. A safe culture is characterized by full
253 participation by all staff, without fear of reprisal or marginalization. Safe cultures also include high respect between professional
254 groups in which disruptive and other behaviors do not occur. Staff feedback through surveys and other mechanisms can shape
255 desired behaviors and can support medical staff role models.
256 An evaluation of behaviors can include
257 evaluation of whether a medical staff member understands and supports the hospitals code of behavior and the
258 identification of acceptable and unacceptable behaviors;
259 an absence of reported behaviors by the medical staff member that are identified as unacceptable; and

260 gathering, analysis, and use of information and data from staff surveys and other sources regarding the culture of
261 safety in the hospital.
262 The ongoing monitoring and evaluation process should indicate, as part of the review process, the relevant achievements and
263 challenges of the medical staff member in efforts to be a full participant in a safe and just culture.
264 Professional Growth
265 Medical staff members grow and mature as the organizations in which they practice evolve, introducing new patient groups,
266 technologies, and clinical science. Each medical staff member, to varying degrees, will reflect growth and improvement in the
267 following important dimensions of health care and professional practice:
268 a) Patient care, including provision of patient care that is compassionate, appropriate, and effective for health
269 promotion, disease prevention, treatment of disease, and care at the end of life. (Potential measures include frequency
270 of preventive services and reports from patients and families.)
271 b) Medical/clinical knowledge, including knowledge of established and evolving biomedical, clinical, epidemiologic,
272 and social-behavioral sciences, as well as the application of knowledge to patient care and the education of others.
273 (Potential measures include use of clinical guidelines including the development and revision of guidelines,
274 participation in professional conferences, and publications.)

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275 c) Practice-based learning and improvement, including use of scientific evidence and methods to investigate,
276 evaluate, and to continuously improve patient care based on self-evaluation and lifelong learning. (Potential measures
277 include self motivated clinical inquiry/research, acquiring new clinical privileges based on study and acquiring new
278 skills, and full participation in meeting requirements of professional specialty requirements or continuing education
279 requirements of licensure.)
280 d) Interpersonal and communication skills, including establishment and maintenance of effective exchange of
281 information and collaboration with patients, their families, and other members of health care teams. (Potential
282 measures include participation in teaching rounds, team consultations, team leadership, and patient and family
283 feedback.)
284 e) Professionalism, including commitment to continuous professional development, ethical practice, an understanding
285 and sensitivity to diversity, and a responsible attitude toward patients, their profession, and society. (Possible measures
286 include an opinion leader within the medical staff on clinical and professional issues, service on ethics panel or
287 discussions of ethical issues, keeping appointed schedules, and community participation.)
288 f) System-based practices, including awareness of and responsiveness to the larger contexts and systems of health
289 care, as well as the ability to call effectively on other resources in the system to provide optimal health care. (Possible
290 measures include understanding the meaning of frequently used, hospital-wide systems, such as the medication
291 system; and cognizance of the implications of the overuse, underuse, and misuse of systems.)
292 g) Stewardship of resources, including understanding of the need for stewardship of resources and practicing cost-
293 conscious care, including avoiding the overuse and misuse of diagnostic tests and therapies that do not benefit patient
294 care but add to health care costs. (Possible measures include participation in key purchasing decisions within their
295 practice area, participating in efforts to understand appropriate use of resources, and being aware of the cost to
296 patients and payors of the services they provide.)
297 The ongoing monitoring and evaluation process should recognize, as part of the review process, the relevant achievements and
298 challenges of the medical staff member in these professional growth areas.
299 Clinical Results
300 The ongoing monitoring and evaluation process for a medical staff member reviews information common to all medical staff
301 members as well as specific information related to the clinical privileges of the member and the services provided by their
302 specialty.
303 Hospitals collect a variety of data for use in management, for example, reporting to health authorities to support allocation of
304 resources or payment of services. To be useful in the ongoing evaluation of an individual medical staff member, the data
305 need to be collected in a manner that individual practitioners can readily be identified;

306 relate to the clinical practice of the individual medical staff member; and
307 can be benchmarked internally and/or externally to understand individual practitioner patterns.
308 Examples of such potential sources of data include; length-of-stay, frequency of diagnostic testing, blood usage, usage of
309 certain drugs, among others.
310 Data are also collected at the level of each department/service. The director/leader sets the priorities for measurement in the

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311 department for purposes of monitoring as well as improvement. The measures are specific to the services provided and the
312 clinical privileges of the individual medical staff members within the department. As with hospitalwide data, to be useful in the
313 ongoing evaluation of an individual department/service member, the data
314 need to be collected in a manner that individual practitioners can readily be identified;

315 relates to the clinical practice of the individual medical staff member; and

316 can be benchmarked within the department/service and/or externally to understand individual practitioner patterns.
317 Examples of such potential department/service data include frequency of clinical procedures performed, complications,
318 outcomes, use of resources such as consultants, among others.
319 Also, it is important to note that it is not anticipated that any department/service will have the capacity or need to monitor the
320 individual privileges of a practitioner. It is more feasible to collect data on key services or some aspect of key services for which
321 all or most department/service staff members have privileges.
322 Thus, there is no one set of data that will suffice to monitor and evaluate all medical staff members. The choice of data, the
323 frequency of monitoring and analysis, and the actual use of the data and documentation in the record of the medical staff
324 member is very specific to the department/service, the relevant profession, and to the privileges of the practitioner.
325 The monitoring and evaluation of medical staff members is supported by a variety of data sources, including electronic and
326 paper records, observations, and peer interactions.
327 In summary, the ongoing medical staff member monitoring and evaluation process
328 is standardized by type of medical staff member and/or department or clinical services unit;

329 uses objective and evidence based information as available;

330 is conducted by the individuals department or service head, senior medical manager, or by a medical staff review
331 body;
332 includes the monitoring and evaluation of senior medical staff and department heads by an appropriate professional;
333 and
334 the results of reviews, actions taken, and the impact of those reviews and actions on privileges (if any) are documented
335 in the medical staff members file.
336 Finally, while the process of monitoring and evaluation of medical staff members is intended to be ongoing, and data and
337 information may be accumulated on an ongoing basis, hospital policy requires a review at least once during a 12-month period.
338 The review is conducted by the individuals department or service head, a senior medical manager, or a medical staff review
339 body. Findings, conclusions, and any actions taken or recommended are recorded in the medical staff members file. When the
340 findings affect the appointment or privileges of the medical staff member, there is a process to take action on the findings.

341 Measurable Elements of SQE.11


342 1. All medical staff members are included in an ongoing professional practice monitoring and evaluation process.
343 2. The monitoring and evaluation process is defined by hospital policy and is standardized at the department/service
344 level.

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345 3. The monitoring and evaluation process notes achievements and challenges related to the data and information on the
346 behaviors, professional growth, and clinical results of the medical staff member.
347 4. The data and information from the monitoring are reviewed at least every 12 months by the individuals department
348 or service head, senior medical manager, or medical staff body, and the results, conclusions, and any actions taken are
349 documented in the medical staff members credentials file and other relevant files.

350 Medical Staff


351 Medical Staff Reappointment and Renewal of Clinical Privileges

352 Standard SQE.12


353 At least every three years, the hospital determines, from the ongoing monitoring and evaluation of each medical staff member,
354 if medical staff membership and clinical privileges are to continue with or without modification.

355 Intent of SQE.12


356 Explanations of terms and expectations found in these standards are as follows:
357 Reappointment
358 Reappointment is the process of reviewing, at least every three years, the medical staff members file to verify
359 continued licensure;
360 that the medical staff member is not compromised by disciplinary actions of licensing and certification agencies;

361 that the file contains sufficient documentation for seeking new or expanded privileges or duties in the hospital; and
362 that the medical staff member is physically and mentally able to provide patient care and treatment without
363 supervision.
364 The information for this review is gathered from the internal, ongoing monitoring and evaluation of the medical staff member,
365 as well as from external sources such as regulatory or professional organizations or agencies. Hospital policy identifies the
366 individual, such as the chief/director of a specialty service; or mechanism, such as a medical staff office when a
367 departments/service chief/director is not present or accountable for this review, any criteria used to make decisions, and how
368 decisions will be documented. The credential file of a medical staff member should be a dynamic source of information and
369 under constant review. For example, when a medical staff member presents a certificate of achievement related to an advanced
370 degree or advanced specialty training, the new credential should be immediately verified from the issuing source. Similarly,
371 when an outside agency investigates a sentinel event related to a medical staff member and issues sanctions, this information
372 should be used promptly to reevaluate the clinical privileges of the medical staff member. To ensure that medical staff files are
373 complete and accurate, the files are reviewed at least every three years and a note in the file indicates any actions taken or that
374 no action is necessary and the appointment to the medical staff continues.
375 Considerations for clinical privilege delineation at reappointment include the following:

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376 Medical staff members may be granted additional privileges based on advanced education and training. The education
377 and training are verified from the source providing the education or training or issuing the credential. The full exercise
378 of the added privilege may be delayed until the verification process is complete.
379 Medical staff members may have their privileges continued, limited, reduced, or terminated based on
380 o the results of the ongoing professional practice review process (SQE.11);
381 o limitations placed on the individuals privileges by an outside professional, governmental, or regulatory agency;
382 o the hospitals findings from an evaluation of a sentinel or other event;
383 o the health of the practitioner; or
384 o the request of the practitioner.

385 Measurable Elements of SQE.12


386 1. Based on the ongoing monitoring and evaluation of the medical staff member, the hospital determines, at least every
387 three years, if medical staff membership and clinical privileges are to continue with or without modification.
388 2. There is evidence in the file of each medical staff member that all credentials that require periodic renewal, payment of
389 a registration fee, or other action by the medical staff member are current.
390 3. Credentials obtained subsequent to initial appointment are evident in the file of the medical staff member and have
391 been verified from the primary source prior to use in modifying or adding to clinical privileges.
392 4. The renewal decision is documented in the medical staff members credential file and includes the identification of the
393 reviewer and any special conditions identified during the review.
394

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1 Management of Communications
2 and Information (MCI)
3 Management and Implementation of Documents

4 Standard MCI.18
5 Written documents, including policies, procedures, and plans are managed in a consistent and uniform manner.

6 Intent of MCI.18
7 Policies and procedures are intended to provide uniform knowledge on organizational clinical and nonclinical functions. A
8 written document guides how all policies, procedures, and plans in the hospital will be developed and controlled. This guidance
9 document includes the following key components:
10 a) Review and approval of all documents by an authorized person before issue
11 b) The process and frequency of review and continued approval of documents
12 c) The controls for ensuring that only current, relevant versions of documents are available
13 d) How changes in a document can be identified
14 e) The maintenance of document identity and legibility
15 f) A process for managing documents that originated outside the hospital
16 g) Retention of obsolete documents for at least the time required by laws and regulations, while ensuring that they will
17 not be mistakenly used
18 h) Identification and tracking of all documents in circulation
19 These processes for developing and maintaining policies, procedures, and plans are implemented.

20 Measurable Elements of MCI.18


21 1. There is a written guidance document that defines the requirements for developing and maintaining policies,
22 procedures, and plans including at least items a) through h) in the intent.
23 2. There are standardized formats for all similar documents, for example, all policies.
24 3. The requirements of the guidance document are implemented and evident in the policies, procedures, and plans found
25 throughout the hospital.

26

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27 Standard MCI.18.1 (new standard)


28 The policies, procedure, plans, and other documents that guide consistent and uniform clinical and nonclinical processes and
29 practices are fully implemented.

30 Intent of MCI.18.1
31 Throughout the accreditation standards found in this manual, policies, procedures, plans, and other written documents are
32 required (a full list can be found in the Survey Process Guide). These documents are required, as they reduce process variation
33 and reduce the risk inherent in processes. This is particularly important in clinical processes to improve quality and patient
34 safety.
35 A tracking system allows each document to be identified by title, date of issue, edition and/or current revision date, number of
36 pages, who authorized issue and/or reviewed the document, and database identification (if applicable). The tracking system
37 helps staff quickly locate a policy relevant to their assignment or a particular situation. For example, staff in the emergency
38 department can quickly locate the policy on informed consent when an unaccompanied minor requires a surgical procedure.
39 There is a process to ensure that staff members have read and are familiar with policies, procedures, and plans relevant to their
40 work. This process may be part of the orientation of the staff member to their department and their responsibilities, or may be
41 part of groupwide or hospitalwide special training sessions.
42 Most importantly, when a policy, procedure, or plan is relevant to the assignment of an individual, the intended actions
43 described in the document are evident in the actions of the individual.

44 Measurable Elements of MCI.18.1


45 1. Staff understand how to access documents relevant to their responsibilities.
46 2. Staff are trained and understands those documents relevant to their responsibilities.
47 3. The requirements of the policies, procedures and plans are fully implemented and evident in the actions of individual
48 staff members.
49 4. The implementation of policies, procedures, and plans is monitored and the information supports full
50 implementation.

MANAGEMENT OF COMMUNICATION AND INFORMATION (MCI) PAGE 2 of 2

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Shaded text indicates new standards, standards moved from another chapter, or standards moved within a chapter.

2013 Joint Commission International. This is a confidential draft meant for review only.
Do not distribute or otherwise reproduce this material.