New Changes In

JCI 5th

Edition Hospital Standards

Dr.Mahboob Ali Khan MHA,CPHQ,Phd Harvard

Renowned Healthcare Quality Consultant,

1

5th Edition Update Overview

• Global healthcare has changed in many ways

over the last 3 years of the 4th Edition and

will continue to change • Standards ensure hospital care not only

reflects up to date practice but also help

hospitals prepare for a different future • Change means that improving quality and

patient safety will always be a work in progress

with continuous advances but no end point • Some of these changes in global healthcare

stimulated revisions to the JCI standards

2

What Is New In This 5th

Edition

• Many changes • Continuous readiness & compliance

of JCI accredited hospitals is

emphasized by conducting

unannounced as well as announced

surveys by JCI. • All of the significant changes are listed

in a table at the beginning of each of

patient-centered and organization

management- centered chapters

• Nearly, all of the 4th

edition text has

been edited for clarity in the 5th

edition • The total number of standards has

been reduced by more than 10%

& MEs by more than 5%

What Is New In This

• New standards and established standards

deemed by the field as more difficult to

meet are supported with evidence-based

references • References of various types are cited in the

text of the standard's intent and are listed at

the end of the applicable standard chapter • A new Section, “ Accreditation Participation

Requirements” (APR) has been added.

16

What Is New In This 5th

Edition

• Standards requiring a written policy or

procedure are indicated by a icon after the

standard text . In previous editions, each

required policy or procedure was specified in

its own ME. In this edition, all policies and

procedures will be scored together at MOI.9

and MOI.9.1.

• Examples that better illustrate compliance

are provided in most standards' intents • JCI’s policies and procedures are

summarized and moved from the front of the

manual to their current location on page 253.

Starting in late 2013, JCI policies will be

published on JCI’s public website.

What Is New In This 5th

Edition

• The Medical Professional Education

(MPE) and Human Subjects Research

Programs (HRP) standards for

Academic Medical Center Hospitals

are now included in this manual. • The “Management of Information”

(MOI) chapter has been changed from

“Management of Communication and

Information” (MCI) in the 4th

edition. • Widespread wording changes for clarity,

including frequently substituting the term

program for plan or process

18

Accreditation Participation

Requirements (APR)

19

APR Chapter

New Chapter

It is about how compliance will be evaluated

APRs are not scored like standards during the on-site

survey; hospitals are considered either compliant or not

compliant with the APR

Most of APR requirements have been moved from many

4th

edition documents

The consequence of non-compliance 20

APR Chapter Standards

• APR.1 – timely submission of data and information • APR.2 – accurate and complete information • APR.3 – reporting changes in hospital profile • APR.4- Hospital permits on site review of compliance or

verification of concerns or regulatory sanctions (at ANY TIME) • APR.5- Hospital allows JCI to request/review results and reports

of external evaluations from publicly recognized bodies • APR.6- Hospital allows observations by JCI Board members and

JCI staff

21

APR Chapter Standards

• APR.7- The selection and use of the Library of Measures

is integrated into the hospital’s measurement priorities • APR.8 – The hospital accurately represents

its accreditation status and program • APR.9 – Any hospital staff member can report concerns

about safety or quality of care without retaliatory action • APR.10 – translation and interpretation services

are provided by licensed translation and

interpretation professionals 22

APR Chapter

• APR.11 – The hospital notifies the public it serves about

how to contact its hospital management and JCI to report

concerns about patient safety and quality of care • APR.12 - The hospital is required to provide patient care

in an environment that poses no risk of an immediate

threat to patient safety, public health or staff safety

23

Joint Commission Patient Centered

International 5th

Standards

Edition Hospital

IPSG, ACC,

Standards

PFR & AOP

Major Changes in the IPSG,

ACC, PFR, and AOP Chapters

24

Major Changes in the IPSG, ACC,

PFR, and AOP Chapters

• Focus on highlights, not all changes • Clearer and more comprehensive intent

statements, with more examples • New decision rule #5 for IPSG’s

25

IPSG

International Patient Safety

Goals

26

IPSG Major Changes

Emphasizes the need for more

focused compliance on 3

distinct communication-related

areas

Highlights reporting of critical

results of diagnostic tests as an

important communication issue

Introduces a new requirement

for effective handovers of

patient care within the hospital-

NEW STANDARD IPSG.2.2

27

IPSG Major Changes

Clarify expectations for

high-alert medications &

concentrated electrolytes

Clarifies the purpose and

content of the preoperative

verification process & the

approach for the time-out

procedure

28

IPSG Major Changes

Clarifies the need to address

fall risk assessment and

reassessment in both inpatients

& outpatients

Raises requirements for

addressing falls to include

locations and situations at high

risk for falls

29

ACC

Access to Care and

Continuity of Care

30

ACC Major Changes

Adds a new requirement for hospitals to

manage the flow of patients throughout

the hospital NEW STANDARD

ACC.2.2.1

Separates the AMA requirements

according to two conditions:

• Leaving Against Medical Advice with

notification: full D/C summary is required • Leaving Against Medical Advice without

notification

31

New standard to require mechanism to manage patient

flow throughout the organization including:

32

PFR

Patient and Family Rights

33

PFR Major Changes

added a new requirement for informing patients and

families of the tests & treatments that require a

separate informed consent

Informed Consent must be in a manner/language that

patient understands (NEW) & must have uniform

recording requirement (NEW)

Informed Consent to be obtained before high risk

procedures or treatments & before admission for

inpatient care

34

PFR Major Changes

Further emphasized the need

to ensure patient & family

rights regarding organ & tissue

donation

Clarify requirements regarding

organ & tissue procurement 35

AOP

Assessment of Patients

36

AOP Major Changes

- Patient assessment and documentation

must be more patient centric - Patient and family participation in

decisions more critical - Patient record and out‐patient summaries are essential communication tools

- Patient and family education at

many points in care process

37

AOP Major Changes

Establishes a NEW STANDARD to

emphasize the need to reduce special

risks for laboratory staff related to

infection control & biohazards

Adds a NEW STANDARD to detail

requirements for reference (contract)

laboratories used by the hospital

Introduces a NEW STANDARD specific

to blood bank and transfusion services

Joint Commission

Patient Centered

Standards

International 5th

Edition Hospital

COP, ASC, MMU

Standards

& PFE

Major Changes in the COP,

ASC, MMU, and PFE Chapters

39 Edits by PVO, Sept 23 2013

COP

Care of Patients

40

COP Major Changes

Emphasizing the need for uniform

process for prescribing patient

orders

Adds new requirement: the person

requesting, and the reason for

requesting, the procedure or

treatment are documented in the

patient’s record

Clearly identify expectations for the

care of high-risk patients in the

hospital

41

COP Major Changes

Introduces new requirement for staff

training to recognize & respond to

changes in a patient’s condition

NEW STANDARD

Adds new requirement to emphasize

the need for resuscitation services to

be available & consistent throughout

the hospital NEW STANDARD

COP.3.2

Adds ME to emphasize the need for

timely distribution of food and

honoring special requests 42

COP Major Changes

Adds a requirement on communication

with patients regarding potential pain from

planned treatments, procedures, or

examinations

Introduces several standards to

emphasize the need for safety & quality of

organ and tissue transplant services

NEW STANDARDS COP.8- COP.9.3

43

ASC

Anesthesia and Surgical Care

44

ASC Major Changes

Adds a description of sedation &

anesthesia

Emphasizes the importance of

standardization, qualification of

practitioners, and professional

practice guidelines as they relate to

procedural sedation

Adds a new requirement for discussing

the risks, benefits, and alternatives of

procedural sedation with the patient,

family, and other decision makers

NEW STANDARD ASC.3.3

45

ASC Major Changes

Adds text to include documentation of the

anesthesia agent, dose, and anesthetic

technique in the patient’s anesthesia

record

Emphasizes the need for postoperative

analgesia education

Adds clarification that monitoring

needs to be consistent with

professional practice guidelines

Clarifies that the patient’s assessment

should also be used to guide the

identification of significant findings during

monitoring

46

ASC Major Changes

Better detail requirements of

surgery documentation in the

patient’s record

Adds text to expand on what is

included in postsurgical plan of

care

Adds a new requirement regarding

the special considerations needed

in planning surgical care that

involves the implanting of medical

devices

NEW STANDARD ASC.7.4

47

MMU

Medication Management and Use

48

MMU Major Changes

• Emphasizes the need for proper storage

of medications inside and outside of the

pharmacy • Introduces concept that hospitals should

define standards of practice for a safe

and clean dispensing environment • Required elements for prescriptions

are separated from the processes for

problematic or special types of

prescriptions • New requirements for auditing by

hospital to determine the accuracy

and completeness of prescriptions 49

MMU Major Changes

Recognizes two reviews of

the prescriptions • Review 1 - Review

of appropriateness • Review 2 - Review of

medication against order

Identifies that properly trained staff

other than pharmacists may

perform the medication review for

appropriateness & specifies that the

requirement applies when the

pharmacy is open or closed

50

PFE

Patient and Family Education

51

PFE Major Changes

• Chapter now contains standards relating

to general education principle • Specific education has been moved to

chapters where education applies

Compliance with PFE Chapter

Uniform documentation and staffknowledge

Patient and Staff interview and Medical

records review

• Compliance issues: Staff and patient lack of knowledge

No evidence of documentation

or training

• 52

Joint Commission

Organization

Management

International 5th

Standards

Edition Hospital

Standards QPS, PCI, &

GLD

Major Changes in the QPS, PCI,

and GLD Chapters

53

QPS

Quality Improvement and

Patient Safety

54

QPS Major Changes

QPS.1 - Qualified leader of quality

program NEW STANDARD

• Selection of the right individual to

lead program • Selection of the right staff for

program functions • Coordination of quality across

the organization • Implementation of a staff training program • Regular communication to hospital

staff about quality issues

55

QPS Major Changes

QPS.2 – Support and coordination

of quality within the hospital

NEW STANDARD

• Quality program supports

the selection of measures • The program has a supportive

function for department/service and

hospital wide measure priorities • Program integrates event reporting

systems, safety culture measures

and others to facilitate an

integrated approach • Tracks progress

56

QPS Major Changes

QPS.5 – Impact Analysis

NEW STANDARD

• At least one impact analysis

of cost efficiency per year of

an improvement project • Evaluate and re-evaluate the

use of resources for the

current and improved process • Coordination with other

departments: HR, IT, Finance • Report to leadership

57

QPS Major Changes

QPS.7 – Managing Sentinel Events

• Sentinel event definition has

been expanded to include:

• Death of a full term infant • Transmission of a chronic or

fatal disease – blood, blood

products, or transplant • Rape, assault, homicide

– while on site at hospital • Reporting requirement change-

completion time of Root Cause

Analysis within 45 days from

date of the event 58

PCI

Prevention and Control

of Infections

59

PCI Major Changes

Emphasize the need for hospitals to

track infection risks and trends in an

effort to reduce risks within the hospital

• Use a risk-based approach to

identify epidemiologically important

infection prevention strategies and

focus on infection prevention. • Consider clinical practice guidelines,

and antibiotic stewardship • Annual assessment of the program

60

PCI Major Changes

Clarifies further requirements

for safe handling and disposal

of sharps and needles

Increases the emphasis on

reducing the risk of infections

associated with the operations

of food services

Addresses reporting to and

taking action on reports from

public health agencies

61

PCI Major Changes

Clarifies further that the infection

prevention and control program is

staffed according to hospital size,

level of risk, and the program’s

complexity & scope

Emphasizes that program

strategies should cross all levels

of the hospital

Emphasizes the importance of

mechanical and engineering

controls in minimizing infection risk

62

PCI Major Changes

concentrate on programs

integration of infection prevention

and control program with the

hospital quality program

A new emphasis on the measure

selection and measurement based

on the hospital wide and

department/service specific priorities

Requires reporting the data and

recommendations to the

leadership on a quarterly basis

63

PCI Major Changes

A new requirement on

theenvironmental cleaning of

contaminated isolation rooms NEW

Focuses in the management of

sudden influx of patients with

contagious diseases and

airborne infection when negative

rooms are not available NEW

64

GLD

Governance, Leadership and

Direction

65

Governance, Leadership and Direction (GLD) Overview

66

GLD Major Changes

Leadership role in communication

• Clear and consistent

communication is a responsibility

of leadership • Process, effectiveness and content • Measure of “effectiveness”

of communication

67

GLD Major Changes

Leadership reports to staff and governance

• Develop and implement a quality program

and select leadership for the program

• Quarterly report to governance • Six month review of sentinel events • Progress communicated to staff • Review minutes: governance, senior

leadership, and quality departments • “Sustainability of Improvements”

68

GLD Major Changes

Leadership sets hospital wide improvements

• Focus on measurement for system

improvement • Focus on research and education when

present • Focus on full compliance with IPSGs • Evaluate the impact of Improvement

69

GLD Major Changes

NEW STANDARD to emphasize the

need to protect patients and staff from

contaminated, fake, and diverted drugs,

medical technology, and supplies

NEW STANDARD for hospital leadership

to create, implement, support, monitor, and

take action to improve a culture of safety

70

GLD Major Changes

NEW STANDARDS applicable to hospitals that

conduct human subjects research but do not

meet the eligibility criteria for Academic

Medical Center Hospital accreditation

- NEW STANDARD to emphasize the need for

department/ service quality improvement

activities to be used in the ongoing

professional practice reviews of physicians and

the annual performance evaluations of nursing

and other health professionals staff

71

Joint Commission

Organization

Management

International 5th

Standards

Edition Hospital

Standards FMS, SQE, &

MOI

Major Changes in the FMS,

SQE, and MOI Chapters

72 Edits by PVO, Sept 23 2013

FMS

Facility Management and Safety

73

FMS Major Changes

Emphasize the distinctions

formanagingall aspects of the

hazardous materials and waste program;

References the WHO list of

hazardous materials and waste categories

Program for control and disposal

Explanation of content of MSDS

(Material Safety Data Sheets)

Immediate availability of the MSDS to

manage spills

74

FMS Major Changes

Medical technology’s term

introduced (formerly

medical equipment)

Includes all fixed and portable

medical equipment used for

diagnosis, treatment, monitoring

and direct care of individuals

New requirement for testing of

alternative water and electricity

sources quarterly (NEW)

New requirement for determination

of on-site fuel storage needs related

to emergency power (NEW)

75

FMS.9 – Utility Systems

NEW STANDARD

• Expanded to all utilities • A program for effective and efficient

operation • Inventory of utilities

system defined • Written inspection, maintenance

activities, inspecting and testing

intervals defined • Criteria from manufacturers

maintenance and testing

requirements • Labeling of utility system controls

introduced 76

SQE

Staff Qualifications and Education

77

SQE Major Changes

• Total rewrite of some standards to add

clarity with terminology explained • New Measurable Elements and wording

changes, consolidation of other Measurable

Elements • Flow of standards now is more like natural

process

• Identifies the need for more rigorous

vaccinations program for staff (NEW) • Acknowledges that violence in the workplace has

become an increasingly common problem in

health care organizations (NEW) 78

SQE Major Changes

New, more complete

explanations for key terms:

credentials medical staff verification appointment reappointment

Revise the requirement for primary source verification for initial surveys (new time frame)

Clarifies requirements

for determining medical

staff membership

79

SQE Major Changes

Clarify requirements regarding the

privilege delineation process for medical

staff members

Provides definition of key terms &

expectations to clarify requirements

for monitoring and evaluation of

medical staff

Emphasize the need to document and

take action on findings that affect the

appointment or privileges of medical

staff members (new)

Separates out and clarifies

requirements for reappointment and

renewal of clinical privileges of medical

staff members based on ongoing

monitoring and evaluation 80

MOI

Management of Information

81

MOI Major Changes

• New language in the standards, intent

and MEs

• Need to assess, test, evaluate health

information technology (HIT) systems

before and after implementation

• Evaluate HIT systems for usability,

effectiveness and patient safety

• Stakeholders participate in selection,

implementation and evaluation of

HIT system 82

MOI Major Changes

• Written guidelines on documents,

policies, procedures, and plans

managed to a consistent manner

• Standardized formats of similar

documents • Evidence found when

documents reviewed

83

MOI Major Changes

MOI.9.1 – Consistency across the organization in

policy management

NEW STANDARD

• Ensuring proper implementation of policies,

procedures, plans that guide clinical and

nonclinical practices

• P

When this symbol is found a document is expected

• All are scored together at this standard – one

score for the hospital - not at each location • Tracking, training, knowledge and

implementation are expected

84

5th

Edition JCI Hospital Standards Manual

Challenging

Achievable

Focused on the safety and quality of patient care

BEST WISHES From Dr.Mahboob Khan Phd

85