SPG-Hospital 3rd Edition

Joint Commission International Accreditation

HHOOSSPPIITTAALL Survey Process Guide

Effective January 2008 3rd Edition Standards

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Contact Directory................................................................................................................. 1

Introduction .......................................................................................................................... 2

The Value of Joint Commission International Accreditation........................................ 2

Joint Commission International —Who Are We? .......................................................... 3

Who Is Eligible for a Hospital Survey? ............................................................................. 4

How to Request a Hospital Survey.................................................................................... 5

Survey Scheduling, Postponements and Cancellation .................................................... 6

The Standards Manual ......................................................................................................... 7

The Scoring Process........................................................................................................... 10

Accreditation Decision Rules - Effective January 2008................................................ 11

International Patient Safety Goals ................................................................................... 15

Accreditation Preparation ................................................................................................. 17

Preparation Timeline ........................................................................................................... 18

Accreditation Process Timeline ............................................................................................. 20

Survey Application ............................................................................................................. 21

The On-Site Survey ........................................................................................................... 40

Sample Survey Agendas..................................................................................................... 41

The Accreditation Decision .............................................................................................. 46

Survey Agenda - Detailed Description

Opening Conference ......................................................................................................... 48

Orientation to the Organization and Quality Improvement Plan............................... 50

Surveyor Planning Session ................................................................................................ 51

Document Review.............................................................................................................. 53

Documents Available in English.......................................................................................... 54

Daily Briefing ...................................................................................................................... 59

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Facility Tour ........................................................................................................................ 61

Facility Inspection Report – Sample Outline ..................................................................... 64

Individual Patient Tracer Activity .................................................................................... 65

System Tracer – Medication Management...................................................................... 68

System Tracer – Infection Control .................................................................................. 71

System Tracer – Data Use................................................................................................. 74

System Tracer – FMS with Emergency Management Tracer ..................................... 76

Staff Qualifications and Education.................................................................................. 80

Competency Assessment Process Review Forms ..................................................................... 82

Closed Medical Record Review........................................................................................ 85

Medical Review Tool ......................................................................................................... 87

GLD Interview Session ..................................................................................................... 90

Patient Safety Systems Evaluation ................................................................................... 92

Surveyor Team Meeting..................................................................................................... 94

Surveyor Report Preparation ............................................................................................ 95

Leadership Briefing Conference....................................................................................... 96

Organization Exit Conference.......................................................................................... 97

Survey Planning Reference Lists

Required Quality Monitors ............................................................................................... 99

Required Organization Plans .......................................................................................... 100

Required Policies, Procedures, Written Documents, or Bylaws................................ 102

Standards that Reference Law and Regulation............................................................. 111

Law and Regulation Worksheet ...................................................................................... .112

Revised: 08 2008

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Dear Colleague, Joint Commission International recognizes that hospital care is a constant, ongoing, important force in health care. With that in mind, Joint Commission International Accreditation offers an accreditation program for hospitals. Joint Commission International recognizes that health care organizations want a mechanism for comparing their performance with recognized, internationally accepted, standards. The standards that have been created to facilitate accreditation are patient-centered. These standards are written so as to apply to many different types of hospital organizations. For example, a single specialty oncology hospital or a multi-specialty acute care hospital could use the same set of standards to achieve international hospital accreditation. The hospital accreditation process provides organizations with a mechanism to demonstrate the quality and safety that are being provided in their hospitals. Also, recognizing that in many countries health care systems are judged by the type of hospital care that is provided, there are many incentives for accreditation. With this in mind, Joint Commission International Hospital Standards have been developed by an international task force whose members were drawn from many different types of hospitals. Using The Joint Commission Hospital Accreditation standards as a foundation and with input from the international hospital community, these standards and the survey process have been carefully and thoughtfully created. It is important for the reader to understand that the accreditation activity exists in a constantly changing environment. The demonstration of quality and safety is becoming more necessary in order to attract patients, insurers, and other stakeholders. Therefore, it is important to understand why the focus of accreditation is shifting in those countries where accreditation, at least for hospitals, has been present for some time. The focus of accreditation is shifting: � from viewing accreditation as a snapshot, to seeing it more like a movie or film � from viewing the survey as a contest to seeing it as a validation of a continuous process, and to welcoming

surveyor findings as opportunities for improvement � from preparing for the "exam" to continuously using the standards as a means to achieve and maintain

excellent operational systems, and deriving significant internal benefits � from a view that the survey process is too focused on policies and procedures, to one where the evaluation is

clearly understood as an intensive review of the actual delivery of care � from a process of potential consequences within the organization if there are recommendations made on

survey to a process of appreciation when opportunities that were not recognized by the organization are recognized on survey.

As part of this change in approach to accreditation, there are expectations for both you and Joint Commission International that this guide will help explain. If you have additional questions after reading this guide, please turn to page 1 for a directory of resources where you can get the answers. Yours truly,

David Jaimovich, MD Chief Medical Officer Joint Commission International

JCIA Hospital Survey Process Guide ~ 2008 1

Contact Directory JCI Accreditation Office 1515 West 22nd Street, Suite 1300W Oak Brook, Illinois 60523 USA Phone: +1.630.268.4800 Fax: +1.630.268.2932

E-mail: [email protected]

� Inquire about your completed Application for Survey, survey date or schedule, or assistance with specific problems related to your accreditation.

� Request information about interpreting and applying specific standards. � Register for, or receive information about education programs, and to purchase, or inquire

about publications. Joint Commission International (JCI) Web Site ........................ www.jointcommissioninternational.org

� General information about accreditation � JCI news � Information about accreditation status for specific organizations � Application for Survey � Frequently asked questions (FAQs) � JCI eZine newsletter � Revisions to standards � Standards

Joint Commission Resources Web Site ................................................................................ www.jcrinc.com

� Upcoming education programs � Catalog of publications � Access to official JCI publications and e-books � International Self-Assessment System (ISAS)

Joint Commission International Center for Patient Safety Web Site .............www.jcipatientsafety.org

A focal point for additional research and related efforts to develop and provide patient safety-related solutions. The Center will get input, feedback and guidance from an advisory group of patient safety experts, five global regional advisory councils, and strategic domestic and international partnerships with other patient safety-focused organizations. The Center will:

� Collaborate with other leading patient safety organizations around the globe to achieve its goals, including the identification, development and sharing of patient safety solutions.

� Be a credible source of valid and meaningful information and education about patient safety. � Engage patients and families in improving patient safety. � Engage practitioners and providers in improving patient safety. � Advocate for public policy that promotes patient safety. � Conduct research related to patient safety.


Introduction The Joint Commission International (JCI) Accreditation Hospital Survey Process Guide is designed to help you learn about The Joint Commission International Hospital standards and survey process. This overview will provide important information about Joint Commission International, the hospital standards manual, eligibility for accreditation, how to request accreditation, survey preparation, the on-site survey, and the accreditation decision. Please do not hesitate to contact the JCI Office by telephone or e-mail using the contact directory at the beginning of this guide for any other information your organization may need.

The Value of JCI Accreditation Accreditation may benefit your organization by: . . . giving you a competitive advantage

Accreditation provides evidence of quality patient care that helps level the playing field for organizations doing the same types of procedures.

. . . strengthening community confidence Achieving accreditation is a visible demonstration to patients and the community that your organization is committed to providing the highest quality services.

. . . assisting recognition from insurers, associations, employers, and other stakeholders Increasingly, accreditation is becoming a prerequisite for eligibility for reimbursement, for association membership, for community awareness, and for contracts or grants.

. . . validating quality care to patients Joint Commission International standards are focused on one goal: raising the safety and quality of care to the highest possible level. Achieving accreditation is a strong validation that you have taken the extra steps to meet a high level of safety and quality.

. . . helping you organize and strengthen your improvement efforts Accreditation encompasses state-of-the-art performance improvement concepts that help you continuously improve quality.

. . . enhancing staff education The survey process is designed to be educational, not punitive. JCI surveyors are trained to help you improve your internal procedures and day-to-day operations.

. . . improving risk management By enhancing risk management efforts, accreditation may improve access to, or reduce the cost of liability coverage. It can also assist in lowering adverse events or outcomes for the organization, and, more importantly, for the patient

. . . facilitating staff recruitment As staff recruitment becomes more difficult, achieving accreditation as a demonstration of your organization’s commitment to quality and patient safety will enhance recruitment efforts.

. . . promoting team building skills for staff


The process of obtaining and maintaining accreditation demands a team approach to good patient care. Establishing processes and systems that support this demonstration is achieved through good team activities.

Joint Commission International—Who Are We?

Joint Commission International (JCI) is a division of Joint Commission Resources (JCR), the subsidiary of The Joint Commission. For more than 80 years, The Joint Commission and its predecessor organization have been dedicated to improving the quality and safety of health care services. Today the largest accreditor of health care organizations in the United States, The Joint Commission surveys nearly 20,000 health care programs through a voluntary accreditation process. The Joint Commission and its subsidiary are both not-for-profit corporations. The mission of The Joint Commission is to improve the quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission was founded in 1951 under the auspices of the American Hospital Association, the American Medical Association, the American College of Physicians, and the American College of Surgeons, with the later addition of the American Dental Association, to act as an independent accrediting body for hospitals nationwide. As such, The Joint Commission currently accredits nearly 80% of U.S. hospitals. Because of the changing nature of health care in America, The Joint Commission has, over the years, broadened its scope to include accreditation of many non-hospital settings, beginning in 1975. JCI extends The Joint Commission’s mission worldwide. Through international consultation, accreditation, publications and education, Joint Commission International helps to improve the quality of patient care in many nations. Joint Commission International has extensive international experience working with public and private health care organizations and local governments in more than 60 countries. JCI established the Hospital Accreditation Program to encourage quality patient care in all types of hospital facilities. Today’s health care environment is changing rapidly, and hospital providers are experiencing new competitive pressures in the health care marketplace. Providing safe, high quality care to patients and continually improving performance are benchmarks of success. Joint Commission International accreditation of a hospital is a widely recognized standard for high quality services. Why Choose JCI Over Other Options JCI is the leader in accreditation, with more than 10 years of experience across the full spectrum of health care organizations. JCI accreditation represents the “Gold Seal of Approval TM” in health care and provides the most comprehensive evaluation process.


The JCI Patient-Centered Accreditation Process Significant changes were made to The Joint Commission International accreditation process in 2006 to make the process more focused on the patient’s experience of care. To understand the changes in the process, a new term, Tracer Methodology, was introduced. The patient-centered process also shifts accreditation away from survey preparation to continuous standards compliance. The survey becomes just the on-site evaluation piece of a continuous quality improvement process. Our Standards Represent an International Consensus In July 2007, a revised set of Standards was being published for implementation January 1, 2008. This 3rd Edition of the International Standards for Hospitals was accomplished through the following processes: JCI Standards Committee, Accreditation Committee, and Board of Directors Our standards undergo extensive field review prior to their publication. We have established an International Standards Committee, composed of experts in the healthcare quality and patient safety field. This Committee provides advice and assistance in the development of new and revised standards, and recommends improvements to the accreditation process for Accreditation Committee review and approval by the Board of Directors. This committee has overseen the revision of the standards and their introduction to the health care community. Regional International Advisory Groups On a regular basis, Regional International Advisory Groups representing ministries of health, professional healthcare associations, and national accrediting organizations, meet to discuss ongoing issues and potential future improvements to the JCI accreditation process. Field Review Process When periodic revisions or changes are made to the standards, health care organizations, whether accredited or not, are given an opportunity to comment on those changes. Field review announcements were posted on the JCI web site and sent to the JCI list serve to elicit individual/organization’s comments to develop the 3rd edition of the hospital standards. To join the JCI list serve, please contact the JCI Accreditation Office or sign up on the JCI web site. Standards Interpretation JCI will answer specific questions about any JCI standards and how they are interpreted. This is a no-cost service that you can access by telephone, e-mail, or through the JCI web site. Please direct standards-related inquiries to Paul vanOstenberg by phone at +1.630.268.7481 or by e-mail to [email protected].

Who Is Eligible for an International Hospital Survey?

Any hospital may apply for JCI hospital accreditation if it meets the following requirements:

� The organization is currently in operation as a health care provider in the country, and licensed (if required)


� The organization assumes, or is willing to assume, responsibility for improving the quality of its care and services

� The organization provide services addressed by JCI standards

How to Request an International Hospital Accreditation Survey Organizations that wish to be accredited by JCI may obtain an Application for Survey by contacting the JCI Accreditation Office (see contact directory on page 1), from the JCI web site at www.jointcommissioninternational.org, or from this Survey Process Guide. The Application for Survey should be submitted to JCI at least six months prior to your organization’s preferred on-site accreditation survey dates. Applications can be submitted in electronic format by e-mail attachment to [email protected] or by fax to +1 630 268 2921 (see application on page 21). The Application for Survey is valid for six months from the date submitted, which means your organization can submit your application, and still have time to complete your preparations before the on-site survey takes place. It is best to submit your application when you are confident you will be able to demonstrate a four-month track record of compliance with the standards at the time of the on-site survey (see the Preparation Timeline on page 18). On your Application for Survey, you may indicate three months when you would like the survey to take place, and also, please specify any time periods during the year for which you would not like the survey to take place. JCI will make every effort to accommodate your time request, if possible. The earlier you submit your request, the more likely it is that your specific request can be accommodated. Once the Application for Survey is received, you will be contacted by the Manager for JCI Accreditation Services, who will:

� Answer your questions about survey preparation, and help you through each step of the accreditation process

� Analyze your Application for Survey, and contact you if there are any questions or items requiring clarification

� Update changes to your demographic information, including address, contact name(s), etc. � Assist you with locating other resources or JCI contacts to answer your questions � Coordinate scheduling the on-site survey � Forward the proposed contract agreement to the organization for review and authorization.

JCI schedules on-site surveys based on information provided in your Application for Survey. Based on the information provided, JCI determines the number of days required for a survey, the composition of the survey team and the services to be reviewed. Four to six months before the survey, the proposed accreditation survey contract agreement will be sent to the organization. Until the signed contract agreement and the down payment of the first 50% of the survey fees are received, the scheduled survey can not be confirmed. You will also receive


notification of the surveyors’ names before your survey. The survey team leader will contact the person responsible for the survey at your organization approximately four to eight weeks before the survey to finalize the agenda, coordinate the availability of certain staff for key survey activities, as well as provide information regarding the surveyor’s travel arrangements and logistics. Handling Changes During the Application Process Once your organization has submitted the application, your organization must notify JCI within 30 days if it undergoes a change that modifies the information reported in the Application for Survey. Information that must be reported includes:

� A change in organization name and/or ownership � A significant increase or decrease in the volume of services � The addition of a new type of health service � The deletion of an existing health service � A significantly altered building/physical plant � New construction or acquisition of a new structure in which patient care or services will be

provided It may be necessary for JCI to schedule an additional survey for a later date if its survey team arrives at the organization and discovers that a change was not reported. JCI may also review any unreported services addressed by its standards. In either event, there may be additional fees assessed. JCI will make the final accreditation decision for the organization only after reviewing all services provided by the organization for which The Joint Commission International has standards.

Survey Scheduling, Postponements and Cancellation Initial Schedules for Surveys Joint Commission International (JCI) schedules surveys systematically and efficiently to keep accreditation fees to a minimum. Therefore, organizations are encouraged to accept scheduled survey dates. Initial surveys, that is, an organization’s first full accreditation survey, should be scheduled within six months from the time the JCI receives the organization’s Application for Survey. JCI tries to honor specifically requested weeks during which an organization prefers not to be surveyed. The organization should include these specific dates with the completed Application for Survey, whenever possible. There may, however, be circumstances that prevent JCI from accommodating these dates. Definition of Postponement JCI also provides for the postponement of initial surveys or resurveys. A postponement is an organization’s request to alter an already-scheduled survey date or request to push back the survey date before it is actually scheduled. An organization should direct a request for a postponement to the Manager for JCI Accreditation Services as soon as possible.


Accepted Reasons for Postponement An organization may postpone scheduled surveys when one or more of the following events happen:

� A natural disaster or another major unforeseen event occurs that totally or substantially disrupts operations

� The organization is involved in a major strike, has ceased accepting patients, and is transferring patients to other facilities

� Patients, the organization, or both are being moved to another building during the scheduled survey

JCI reserves the right to conduct an on-site survey if the organization continues to provide patient care services under such circumstances. Cancellation The survey may be canceled by either party without penalty or damages in the event acts of GOD, war, terrorism, government regulation, disaster, strikes, civil disorders or other emergencies of a similar nature that make it impossible, illegal or unreasonable to go forward provided notice of the event requiring cancellation is communicated in writing as soon as practically possible. Further, JCI may follow the advice of relevant ministries concerned with evaluating political and military circumstances with regard to scheduling surveys. If the organization cancels the survey fewer than thirty (30) prior to the first date of the survey for any reason or reasons other than those previously stated, JCI accreditation may require payment of one-half of the survey fees to recover costs JCI accreditation has incurred.

The Standards Manual The Joint Commission International Accreditation Standards for Hospitals, 3rd Edition is the place to begin when preparing for accreditation. Even if you do not immediately pursue accreditation, the manual is an excellent tool to help your organization evaluate current practices and structures. The manual contains functional standards that are organized around the way care is provided in a hospital setting. The standards address patient-focused performance and are organized around functions and processes, including both clinical and organizational functions, common to all health care organizations. The manual is designed for use in self-assessment activities and is the basis for an accreditation survey. The standards manual is divided into two sections: patient-focused functions and organization functions.


PATIENT-FOCUSED FUNCTIONS

Access to Care and Continuity of Care These standards address which patient needs can be met by the health care organization; the efficient flow of services to the patient; and the appropriate transfer or discharge of the patent to his or her home or to another care setting. Patient and Family Rights These standards address issues such as promoting consideration of patient’s values; recognizing the organization’s responsibilities under law; informing patients of their responsibilities in the care process. Standards regarding patient rights with respect to informed consent, resolution of complaints and confidentiality are included. Assessment of Patients This chapter addresses the assessment of patients at all points of care within the organization. This includes collecting information and data on the patient’s physical and psychosocial history; analyzing the data and information to identify the patient’s health care needs; and developing a plan of care to meet those identified needs. Care of Patients This chapter discusses the activities basic to patient care. It includes processes of planning for and coordinating care, monitoring results, modifying care, and planning for follow-up. The chapter also includes nutrition care, pain management and end of life care. Anesthesia and Surgical Care This chapter addresses sedation and anesthesia use as well as surgical care. It includes processes of preparing, monitoring and planning for after-care for patients receiving sedation or anesthesia and/or having surgery. Medication Management and Use This chapter addresses the systems and processes for selecting, procuring, storing, ordering/prescribing, transcribing, distributing, preparing, dispensing, administering, documenting, and monitoring of medication therapies. Patient and Family Education This chapter contains standards that address the effectiveness of education being provided and what modalities are being used to succeed with education. This chapter also looks at patients’ readiness to learn by considering language needs and how they learn best. ORGANIZATION FUNCTIONS

This manual also includes chapters related to how well the management system works for the benefit of the patient. Pertinent to that management system is the importance of core processes that


support good management. For example, leadership requirements, infection control, and ongoing emphasis on infection control. Quality Improvement and Patient Safety These standards focus on how well a hospital designs processes; measures its performance; assesses its performance; and, ultimately, improves its performance. Examples of improvement efforts include: designing a new service; flowcharting a clinical process; measuring outcomes; comparing performance with other like organizations; and selecting areas for priority attention. Prevention and Control of Infections These standards address how the hospital identifies and reduces the risk of acquiring and transmitting infections. Areas covered include how infections are reported and what ongoing surveillance activities are in place. Governance, Leadership, and Direction Effective leadership depends on the performance of the following processes: � Planning and designing services, including defining a clear mission with a vision of the future

and the values which underlie day to day activities � Directing services, including responsibility for developing and maintaining policies, providing

adequate number of staff and determining qualifications and competence � Integrating and coordinating services � Improving performance, including the leaders’ critical roles in initiating performance and

maintaining an organization’s performance improvement activities Facility Management and Safety These standards measure how well a safe, functional and effective environment for patients, staff members, and other individuals in the organization is being maintained. The following areas are addressed: emergency preparedness, security, life safety, medical equipment, utility systems, hazardous materials and waste management. Staff Qualification and Education This chapter includes sections on human resources planning; orientation, training and education of staff; competence assessment; handling staff requests; and credentialing and privileging of licensed independent practitioners and nursing. Management of Communication and Information These standards address how well the hospital obtains, manages and uses information to provide, coordinate and integrate services. The principles of good information management apply to all methods, whether paper-based or electronic, and Joint Commission International standards are equally compatible with either method.


The Scoring Process The Intent Statement expands on the standard and what it is intended to achieve through the measurable elements. Measurable Elements (MEs) are the components of the standard that are scored by the surveyor on site. MEs clearly present the requirements that are assessed during the on-site review, and are identical to the scoring elements the surveyors use in their laptop systems. MEs will be scored on a three-point scale of “0” =Non-Compliance or Not Met; “5” = Partial Compliance or “Partially Met”, and “10” = Satisfactory Compliance .or “Fully Met” The following guidelines are intended to provide a basis for scoring compliance with the standards. They do not supersede the judgment of the surveyors. 1. Each measurable element of a standard is scored “Fully Met”, “Partially Met”, “Not Met”, or

“Not Applicable”; 2. Score “Fully Met” if the answer is “Yes” or “Always” to the specific requirements of the

measurable element and:

A. 12 month look-back period of compliance for triennial surveys; or

B. 4 month look-back period of compliance for initial surveys 3. Score “Partially Met” if the answer is “Usually ” or “Sometimes” to the specific requirements of

the measurable element and : A. 5-11 month look-back period of compliance for triennial surveys

or B. 1-3 month look-back period of compliance for initial surveys

4. Score “Not Met” if the answer is “Rarely ” or “Never” to the specific requirements of the

measurable element and: A. 0-4 month look-back period of compliance for triennial surveys

or B. Less than 1 month look-back period of compliance for initial surveys

5. Score “Not Applicable” if the requirements of the measurable element do not apply.


Joint Commission International Hospital Accreditation Program

Accreditation Decision Rules Effective Date 1 January 2008

I ACCREDITATION DECISIONS

INTRODUCTION The Accreditation Committee considers all information from the full survey and any required follow-up report and/or focused survey in making its decision regarding accreditation. The outcome is that the organization meets the criteria for accreditation or does not meet the criteria and is denied accreditation. The criteria for these two potential outcomes are as follows:

A. ACCREDITED This decision results when an organization meets all the following conditions.

1. The organization demonstrates acceptable compliance with each standard. Acceptable compliance is:

• A score of at least “5” on each standard. 2. The organization demonstrates acceptable compliance with the standards in each

chapter. Acceptable compliance is:

• An aggregate score of at least “7” for each chapter of standards. 3. The organization demonstrates overall acceptable compliance. Acceptable compliance is:

• An aggregate score of at least “8.5” on all standards.

4. The organization demonstrates acceptable compliance with all International Patient Safety Goal requirements. Acceptable compliance is:

• A score of at least “5” on each International Patient Safety Goal.

B. ACCREDITATION DENIED This decision results when an organization meets one or more of the following conditions at the end of any 30 day follow-up period to a full accreditation survey.

1. One or more standard is scored less than a “5”. 2. The aggregate score of one or more chapter of standards is less than a “7”. 3. The aggregate score for all standards is less than “8.5”. 4. One or more International Patient Safety Goal is scored less than a “5”. 5. A required follow-up focused survey has not resulted in acceptable compliance with

the applicable standards and/or International Patient Safety Goal requirements.


This decision results when JCI withdraws the accreditation of an organization or when the organization voluntarily withdraws from the accreditation process.

II ASSIGNMENT OF FOLLOW-UP REQUIREMENTS AS A RESULT OF A FULL

SURVEY.

INTRODUCTION Full surveys are conducted at the time of initial accreditation and at the time of re-accreditation, every three years. When a full survey results in one or more of the conditions for accreditation considered not met or partially met, the organization is provided a period of time to come into acceptable compliance, the follow-up period. Acceptable compliance can then be demonstrated by submitting a written report, or by a visit from one or more surveyors to the organization. A visit is named a Focused Survey, as only the standards and/or International Patient Safety Goal in non-compliance are the focus of the survey. The follow-up period is not to exceed 1 month.

A. PROCESS

Based on the documented findings of the accreditation survey team, the JCIA Central Office determines those standards and International Patient Safety Goal requirements for which a focused survey will be required and those standards and International Patient Safety Goals for which the written report has sufficiently demonstrated compliance.

B. FOCUSED SURVEY

• A focused survey is required within 2 months for standards and International Patient Safety Goals that require surveyor observation, staff or patient interviews, or the inspection of the physical facility to determine compliance.

• Focused survey requirements must be completed prior to a decision by the Accreditation Committee.

C. WRITTEN REPORT

• A written report is required for standards and International Patient Safety Goals that require a plan, policy or procedure, or other documentation that can be sent to the JCI Accreditation Central office.

• During 2008, a written report is required within 30 days when any new 3rd Edition standard or measurable element, as identified in Appendix A to these Rules, is scored less than a “5”.

• Written report requirements can be satisfied at the time of a focused survey when both are required.


APPENDIX A HOSPITAL ACCREDITATION DECISION RULES EFFECTIVE 1 JANUARY – 31 DECEMBER 2008

TABLE OF APPLICABLE STANDARDS

MEASURABLE ELEMENT (ME)

STANDARD ME Name

Number of MEs

CONTENT of MEASURABLE ELEMENTS

PFR.11 ME#1-5 5 Harvesting & transplanting organs

COP.2.4 ME#2 1 Patient/family informed of unanticipated outcome of care & treatment

ASC.1 ME#4 1

Outside sources of anesthesia services based on director recommendation, acceptable record performance & compliance with law & regulation

ASC.2 ME#1-7 7

Qualified individual(s) responsible for management of anesthesia services (P/P, oversight, QC program, recommending outside sources, monitoring/reviewing anesthesia services)

ASC.3 ME#1, 3, 4 3 Policies/procedures guide care of moderate & deep sedation

MMU.1 ME#1, 4 2

Plan/policy or document how medication use is organized & managed; documented review of medication management system in past 12 months

MMU.2.1 ME#5-6 2 Process to monitor patient response to medications added to the list; annual review medication list

MMU.5.1 ME#2, 6, 2 Each prescription order reviewed for appropriateness; review facilitated by record (profile) for all patients

QPS.2.1 ME#4 1 Process used to adapt, adopt or update at least one guideline and one pathway per 12 months

QPS.3.6 ME#1 Near misses only

1 Clinical monitoring of near misses


QPS.7 ME#1-3 3 Defined process for identification & analysis of near misses

QPS.10 ME#1-4 4

Program for identifying & reducing unanticipated adverse events & safety risks, including use of a proactive risk-deduction tool annually on one or more priority risk processes

PCI.4 ME#1, 2 2 Adequate staffing & resources allocated to the PCI program

PCI.7.1 ME#3 1 Policy for reuse of single-use devices & materials, based on elements in intent statement

GLD.1 ME# 4 1 One documented performance evaluation of governance & senior management

GLD.1.6 ME# 2 1 Governance regularly receives & acts on the reports of the quality & safety program

GLD.3.2 ME# 4 1 Leaders process for reviewing & approving, before used in care, experimental procedures, technologies, & pharmaceutical agents

GLD.3.3 ME#5 1

Diagnostic, consultative, & treatments services provided by independent contractors outside the organizations are privileged by the organization

FMS.8.2 ME#1-3 3 Product/equipment recall system in place, including the use of any equipment under recall

SQE.8.4 ME#1-5 5 Organization provides a staff health & safety program

SQE.10 ME#2, 3 2

Policies demonstrate how privileging decisions are reached; considers sources of information in intent statements as relevant & also findings of annual performance review

SQE.11 ME#1 1 Ongoing professional practice evaluation of each member of the medical staff, based on findings of quality improvement activities

SQE.15 ME#3 1 Verification of credentials from original source for other health profession staff

51 Total MEs Capped


International Patient Safety Goals The purpose of The Joint Commission International Patient Safety Goals is to promote specific improvements in patient safety. The Goals highlight problematic areas in health care and describe evidence and expert-based solutions to these problems. Recognizing that sound system design is fundamental to the delivery of safe, high quality health care, these Goals focus on system-wide solutions, wherever possible. Joint Commission International (JCI) introduced the International Patient Safety Goals in 2006. JCI surveyors evaluated compliance with these goals during accreditation surveys in 2006, but these findings did not affect the accreditation decision. Effective 1 January 2007, hospitals were required to demonstrate compliance with the International Patient Safety Goals in order to achieve and maintain accreditation. Effective 1 January 2008, the International Patient Safety Goals are published with intent statements and measurable elements similar to other JCI standards. Organizations that design alternative approaches to meeting a Goal are required to request JCI consideration and approval of such alternatives.


International Patient Safety Goals

Goal #1 Identify Patients Correctly

Requirement The organization develops an approach to improve accuracy of patient identifications. (See Intent and Measurable Elements on page 32 of 3rd Edition Standards)

Goal #2 Improve Effective Communication

Requirement The organization develops an approach to improve the effectiveness of communication among caregivers. (See Intent and Measurable Elements on page 32 of 3rd Edition Standards)

Goal #3 Improve the Safety of High-Alert Medications

Requirement The organization develops an approach to improve the safety of high-alert medications. (See Intent and Measurable Elements on page 33 of 3rd Edition Standards)

Goal #4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

Requirement The organization develops an approach to ensuring correct-size, correct-procedure, and correct-patient surgery. (See Intent and Measurable Elements on page 34 of 3rd Edition Standards)

Goal #5 Reduce the Risk of Health Care–acquired Infections

Requirement The organization develops an approach to reduce the risk of health care-associated infections. (See Intent and Measurable Elements on page 35 of 3rd Edition Standards)

Goal #6 Reduce the Risk of Patient Harm Resulting from Falls

Requirement The organization develops an approach to reduce the risk of patient harm resulting from falls. (See Intent and Measurable Elements on page 35 of 3rd Edition Standards)


Accreditation Preparation After Joint Commission International (JCI) accepts the organization’s Application for Survey, both parties make preparations for the on-site survey. To help organizations prepare for accreditation, Joint Commission International offers seminars, custom education, numerous publications, International Self-Assessment System (ISAS), and this Hospital Survey Process Guide. These resources provide specific information on JCI standards and teach concepts related to hospital care. Go to The Joint Commission Resources web site www.jcrinc.com for up-to-date information on available educational resources. JCI organizes a team of surveyors to match the organization’s needs and unique characteristics. JCI will make every effort to provide surveyors fluent in the language(s) used at the organization. If JCI surveyors with the appropriate language capabilities are not available, it is the organization’s responsibility to provide interpreter services throughout the survey. The interpreter(s) must be fluent

in English and the language(s) used at the organization, experienced in concurrent verbal

translation, knowledgeable of medical terminology, follow recognized Medical Interpreting Standards of Practice and abide by the confidentiality policies and regulations set up by the hospital. The interpreter(s) should not be a member of the organization staff. The survey follows actual patient care through the facility, and includes interviews with key personnel, observation of the organization’s administrative and clinical activity, assessment of the physical facilities and patient care equipment, and review of documentation. A sample survey agenda appears on page 39-43. The actual agenda will be customized by the survey team to fit the needs and services of your organization. The JCI survey team leader will contact your organization approximately four to eight weeks prior to the survey to discuss and coordinate a workable and mutually agreeable agenda. The survey team leader identifies those services/areas which need to be included in the review and suggests the staff who should be involved in each survey activity.

Suggested “Ready to Go” List

It would facilitate the survey process if the following items could be readily available to the surveyors at the time of the survey: • High-level organization chart • Accurate list of the patients currently receiving care in the hospital • Required Quality Monitors; • Required Organization Plans; and • Required Policies and Procedures, Written Documents, or Bylaws • Operative procedures schedule for the day (for main Operating Theater and Day Surgery) • Current map of the hospital campus • Sample of all medical record forms The list of required policies and procedures, as well as plans, appears on pages 96-102


PREPARATION TIMELINE Organizations Requesting an Initial Survey

JCI Activity Your Activity

6 months before preferred month of survey

Submit your Application for Survey to the

JCI Accreditation Office (electronically or

by mail). Upon receipt of your Application for Survey

� JCI Manager for Accreditation Services reviews the application.

� You will be e-mailed a complimentary copy of this Hospital Survey Process Guide.

Staff member(s) with knowledge of your organization’s services, sites, and patient volume will need to complete and submit the Application for Survey (electronically or by mail). The application should be received by JCI no later than 4-6 months before the preferred survey dates.

Organizations Requesting Re-accreditation JCI Activity Your Activity

6-9 months before the due date of your next triennial survey

An Application for Survey is e-mailed to prepare for the next on-site survey.

Within two months of receiving the Application for Survey from JCI

Staff member(s) with knowledge of your organization’s services, sites, and patient volume will need to complete and submit the Application for Survey (electronically or by mail). The application should be received by JCI no later than 4-6 months before the preferred survey dates.

All Organizations Requesting Accreditation


4–6 months before survey

A proposed contract agreement is e-mailed to the organization. An invoice for down payment of the first 50% of the survey fees is e-mailed by the Finance Department when the signed contract is received.

The signed contract should be e-mailed or faxed to JCI no later than 60 days prior to the survey date. Notify your accounts payable staff to expect an invoice and remit payment with the wire transfer form (found in the application) no later than 45 days prior to survey date.

8 weeks before survey Verification of survey date(s) and names of surveyor(s) are e-mailed to the organization.

4 - 8 weeks before survey The survey team leader contacts your organization’s survey coordinator to finalize your survey agenda and to request pre-survey information.

Appropriate staff member(s) will need to discuss the proposed survey agenda and determine whether times are feasible for your organization, given



patient needs and availability of staff.

Survey Surveyor(s) arrives for on-site survey. At the conclusion of the survey, you receive a copy of the exit report, which details partial or non-compliant areas identified during survey. This report is not final until the JCI central office staff has reviewed the report and discussed each of the findings with the survey team and JCIA leadership.

During the survey, staff should be available as outlined on the survey agenda.

Within 60 days after survey

JCI reviews and approves official report of survey findings. A follow-up written report or focused survey may be required prior to an accreditation decision determination. If the accreditation is granted, the award letter, report, and accreditation certificate are mailed when all the survey fees and expenses have been paid. The gold seal guidelines and publicity kit will also be posted to the Accredited Organization Resource Center at the JCI website (www.jointcommissioninternational.org/accredited. The CEO of the surveyed organization will be sent a Satisfaction Survey to assist JCIA in performance improvement activities.

For any standards scored as non-compliant, submit the follow-up written report as requested to JCI. The CEO of the surveyed organization should encourage members of the leadership team to provide input into completion of the JCIA Satisfaction Survey.

Within 2 weeks after the certificate is mailed

Your organization’s name, location, and date of accreditation is added or updated for public viewing on the JCI web site at: www.jointcommissioninternational.org

Ongoing Each accredited organization will have access via the JCI website Accredited Organization Resource Center to the JCI newsletter, e-zine, as well as many other resources, publications and services that will assist in achieving continuous compliance with the standards.

Staff should review all changes featured in the newsletter to keep abreast of changes and developments in the standards and survey process. Compliance with new standards and survey processes for accredited organizations is required.

Staff should review the new accreditation manual or supplement to act on any new and modified standards, scoring guidelines, policies, and procedures.

Within 30 days of any significant organizational changes

The organization must notify JCI (via letter, fax, or e-mail) of any significant change in the organization (as defined in the “Joint Commission International Accreditation Policies and Procedures” chapter of the hospital standards manual).

6-9 months before the due date of your next triennial survey

An Application for Survey is mailed to the organization to prepare for the next on-site survey.


Accreditation Process Timeline

12-24 Months

Prior to

Survey

6-9 Months

Prior to

Survey

4-6 Months

Prior to

Survey

2 Months

Prior to

Survey

Survey

Dates

Within 2

Months After

Survey

6-9 Months Prior

to Triennial Due

Date

Obtain JCI Standards

manual and begin

preparing for JCI

Accreditation

Submit application

for survey to JCI,

and schedule

survey dates with

JCI

JCI Survey Team

Leader contacts your

organization to

determine survey

agenda and logistics

Receive Accreditation

Decision and Survey

Findings Report from JCI

Receive and complete JCI

Survey Contract and

invoices for survey fees JCI

Accreditation

survey occurs

Submit revised

application and

schedule triennial JCI

Accreditation

resurvey

Continuous

quality

improvement

journey

Survey Application for Hospitals 21

Joint Commission International Accreditation

Survey Application for

HOSPITALS

September 2008


JJOOIINNTT CCOOMMMMIISSSSIIOONN IINNTTEERRNNAATTIIOONNAALL AACCCCRREEDDIITTAATTIIOONN AApppplliiccaattiioonn ffoorr SSuurrvveeyy ooff aa HHoossppiittaall

� INIITAL ACCREDITATION � TRIENNIAL ACCREDITATION (Please check one)

I. APPLICANT INFORMATION

1. Organization Name:

(The entry text below, as entered, will be used for your certificates. A maximum length of 60-characters is allowed.)

2. Address:

[street number]

[city/province and/or state]

[postal code]

[country]

Website:

3. Main Telephone Number:

[country code] [city code] [number]

4. Ownership:

[Owner Name/Parent Company]

[Ownership Type]

(e.g. private-non governmental, governmental-military)


Ownership Address: (if different from above)

[street number]

[city/province and/or state]

[postal code]

[country]

5. Ownership Primary Contact:

Name: [Mr./Mrs./Miss/Ms./Dr.]

Title:

E-mail:

Tel: [country code] [city code] [number]

Mobile: [country code] [city code] [number]

Fax: [country code] [city code] [number]

6. Staff Information:

Chief Executive Officer: (or equivalent) Please note that this person will receive the Customer Satisfaction Survey Name:

[Mr./Mrs./Miss/Ms./Dr.]

Title:

E-mail:

Tel:




Fax:


Chief Medical Director: (or equivalent) Name:

[Mr./Mrs./Miss/Ms./Dr.]

Chief Nursing Director: (or equivalent)


Representative of Governing Board: (or equivalent group)


Survey Coordinator or equivalent: (provide contact information)


Title:

E-mail:




7. Name and Title of Individual Responsible for Application:

Name: [ Mr./Mrs./Miss/Ms./Dr.] Title: E-mail:



Mobile:




II. ORGANIZATIONAL DESCRIPTION

8. Number of Inpatient Beds (currently in operation):

9. Average Daily Inpatient Census:

10. Ambulatory/Outpatient Annual Visits: (Includes clinics, outpatient surgery, radiology, etc.)

11. Emergency Room Visits:

12. List the Clinical Medical Services currently provided by the Organization:

(e.g., obstetrical, surgical, radiology, laboratory, pediatrics, psychiatry)

13. List the Clinical Medical Services licensed that the Organization is currently licensed to provide:

14. List any additional Clinical Medical Services or structure changes that will occur within the next 12 months.


15. List the Top Five Patient Discharge Diagnoses and the Top Five Surgical Procedures Performed: (This can be used to prepare the patient record list in advance without taking time from the document review session.)

Top Five Diagnoses Top Five Surgical Procedures

16. List Hospital Departments or Services: (non-clinical services that support hospital services) (e.g., human resources, housekeeping, dietary, information systems, finance)

17. List any Contracted Services:


18. Do you own and operate a medical transport service?

� Yes If you answered “yes”, continue to #19 and #20 below.

� No If you answered “no”, please skip to question #21.

19. Number of medical transports per year?

20. Does your medical transport services use advanced life support/paramedics?

21. In what language is the medical record documentation written?

22. In what language is the patient care conducted?

23. In what language are the policies, procedures and committee minutes?


24. Site Demographics. List the buildings /locations in which care is provided to patients. List sites separately wherever there is a distinct street address. Buildings with the same address or connected site should be considered as one site. (Use separate sheet if needed)

Building Name /

Number Location Main or Additional Site How many

kilometers from main site?


25. Inpatient Care Units/Wards. List Inpatient Care Units/Wards, the Number of Beds, and The Type of Care Given on each Unit/Ward. (See examples below. Use separate sheet if needed.) NOTE: Do not include/combine more than one patient unit/ward. It is critical that the team knows each area that houses patients in order to randomly select those areas that will be visited when utilizing tracer methodology. The team must be knowledgeable of all patient care areas on-site as well as the areas separate from the hospital. Please list “Yes” in the anesthesia / sedation column if any level of sedation is administered on the unit/ward.

Name of

Unit/Ward Number of Beds

Type of Care Given

Floor Facility/Site

Anesthesia / Sedation

Administered

Ward A 32 Intensive Care 3 Main site Yes

Ward B7 10 Mental Health 2 Building C No


26. List the number of surgical/operating room theaters located in the organization. (Include all buildings where care is provided. E.g., main operating theater, obstetrics operating theater, cardiac operating theater, pediatric surgery operating theater.)

Operating Room Theater

Building Name


27. Ambulatory/Outpatient Units/Clinic. List Ambulatory/Outpatient Units, the Number of Visits and the Type of Service Provided (See examples below. Use separate sheet if needed.) NOTE: It is essential that all outpatient settings on-site and off-campus are listed so that the total out-patient areas are known. Include specific information for each of the areas. For example, if the area would require visits on specific days or if the clinic hours would not fall within the survey hours of 8:00 a.m. and 5:00 p.m. Please list “Yes” in the anesthesia / sedation column if any level of sedation is administered in the ambulatory/outpatient unit.

Name of

Ambulatory/ Outpatient Unit

or Clinic

Number of Annual Visits

Type of Care Given

Floor Facility/Site

Anesthesia / Sedation

Administered

Surgery Center 225 Podiatry 1 Building G Yes

Behavioral Health Outpatient Clinic

175 Mental Health 1 Main Site No

Total Number of Annual Visits


28. Please provide your usual hours of operation, such as for Outpatient/Ambulatory Clinics, and provide information on any daily religious observances, staff functions, etc. that will need to be part of or affect the survey agenda and activities of the survey team.

III. HOME CARE SERVICES

29. Does your organization provide services in the patient’s home:

� Yes If you answered “yes”, please complete #30 and #31 below.

� No If you answered “no”, please skip to question #32 in the next section.

30. Average number of patients visited in the home per day by all staff:

31. Please indicate the type of care provided in the patient’s home:

� Home Health (nursing service) � Personal Care and support � Home Medical Equipment � Home Pharmacy � Hospice Service/Palliative Care in the home � Other (please describe)


IV. SCHEDULING AND TRAVEL (Section must be completed in full)

32. Please indicate three months in which the organization could have the survey scheduled:

Month Year

33. Please specify any time periods during the year for which you would not like

the survey to take place., if the preferred months cannot be accommodated.

From DD/MM/YY

To DD/MM/YY

34. Travel Instructions:*

Air Transportation:

Please indicate the airport(s) nearest to your organization that the surveyors should fly into:


Ground Transportation: Please provide the following instructions to assist the surveyors in making their ground transportation arrangements.

Travel directions from airport to hotel:

Travel directions from hotel to organization:

Recommended method of transport (taxi, car service):

Assembly point at organization when surveyors arrive:

Recommended Hotel Accommodations: (internet access is required)

Please recommend two to three business oriented hotels near your organization that have

internet access. Internet access is required for the surveyors to complete the survey report

each evening. If possible, please include the Marriott, Hilton or Intercontinental hotel nearest

to your organization, as these hotels provide preferred rates for the surveyors. If your

organization has a preferred rate with business hotels near your organizations, please include

the specific information and directions for obtaining the preferred rates for surveyors.


Hotel Name Address Telephone/Fax (please include country and city code)

E-mail / Web Site

*For insurance/security purposes the survey team is required to make travel reservations through JCI's travel agent.

35. Please enter any comments or other information you feel may be pertinent to your survey.


V. FINANCE

36. Name and title of individual responsible for processing invoices and payments: Name: [Mr./Mrs./Miss/Ms./Dr.]

Title:

E-mail:



37. Does your organization have any special billing requirements?

For example, (if you will be billed for the surveyors’ travel and maintenance expenses)

38. Does your organization require an itemized statement of charges in addition to the standard invoice?

� Yes � No

39. Does your organization require receipts for the expenses?

� Yes � No

40. All invoices are sent to the billing contact by email. Does your organization also require an original copy sent by mail/courier?

� Yes � No

**All invoices are due upon receipt. Payments should be made by wire transfer. Included with your contract will be a wire transfer form with the detailed information to transfer funds to our bank. VERY IMPORTANT - Please complete and submit the wire transfer form to the fax number or email address listed on the form so we can properly credit your account once the payment is received.


(THIS PAGE/SECTION WILL NEED TO BE PRINTED AND FAXED TO JCI.)

WIRE TRANSFER FORM

Please complete the following information and fax or email this form to JCI

prior to the wire transfer so we can properly credit your account once the

payment is received.

JCI’s fax number is +1-630-792-2992

e-mail: [email protected]

Organization:

Name:

Telephone Number:

Country Code City Code Number

Fax Number:

Country Code City Code Number

Amount of Transfer: USD$

Date transfer will occur:

Service dates from:

(to)

Transfer description

(invoice number):

The wire transfer, in U.S. dollars, should be sent to JCI’s account at:

The Northern Trust Bank

One Oakbrook Terrace

Oakbrook Terrace, Illinois 60181, U.S.A.

JCI's account number is: 1054386

JCI’s Swift Code: CNORUS44

JCI’s ABA number is: 071000152

Any fees incurred for the wire transfer will be the responsibility of the payor.

If you have any questions concerning the wire transfer please contact Bonnie Quinn

at JCI phone +1-630-268-7492 and fax +1-630-268-2992


VI. AUTHORIZATION The undersigned makes request to Joint Commission International for an accreditation

survey of the Applicant Organization named below. By signing this document we hereby provide accurate and truthful information within this application. I am authorized to make this agreement on behalf of:

Name of Applicant Organization:

Name: Title: Signature: Date:

Return Completed Application by FAX or EMAIL To: Joint Commission International Accreditation

Fax: +1 630 268 2921 E-mail: [email protected]


The On-Site Survey

The purpose of a Joint Commission International (JCI) accreditation survey is to assess the extent of an organization’s compliance with applicable JCI standards. Organizations undergoing their first survey need to demonstrate a track record of four months of compliance with the standards. Organizations being resurveyed need to demonstrate twelve months of compliance with the standards. Understanding the organization and assessing compliance is accomplished through a number of methods including the following: � receipt of verbal information concerning implementation of standards, or examples of their

implementation, enabling analysis of compliance; � on-site observation by JCI surveyors; and � review of documents that demonstrate compliance and assistance in orienting surveyors to the

organization’s operations. The on-site survey uses the “tracer methodology” to follow a sample of active patients through their experiences of care in the organization and to evaluate individual components of care and systems of care. An important characteristic of the JCI survey process is on-site evaluation education conducted by the surveyors. This support occurs throughout the survey as surveyors’ offer suggestions for approaches and strategies that may help the organization better meet the intent of the standards and, more importantly, improve performance. The on-site evaluation consists of the following steps:

� Opening conference and orientation to the organization � Survey planning meeting � Leadership interview � Patient care and service area visits guided by patient and system tracer activities � Competence assessment � Facilities management reviews and building tour(s) � Exit conference

Front-Line Staff Ownership of the Process Involving staff in the accreditation process and continuing to involve them through ongoing assessments and review of processes and systems enhance ownership, which results in continued safe and quality care for patients and their families.


Sample Survey Agenda

Joint Commission International Name of Hospital Date of Survey

(5 Day-3 Surveyors)

DAY ONE

Physician

Nurse

Administrator

08:00 - 08:30

Opening Conference

08:30 – 10:30

Document Review

10:30 – 11:00

Surveyor Planning Session

11:00 - 12:00

Hospital’s Overview of Organization Services and Quality Improvement Plan

[Orientation of Surveyors to the Organization (Organization Chart) and the Quality Improvement Process. A brief (10 minutes) Quality Improvement example may be included

demonstrating the Organization’s methodology as well as sustained improvement.]

12:00 - 13:00

Lunch and Tracer Planning

(Surveyors will eat alone as this time is used for planning)

13:00 - 16:00

Individual Tracer Activity

Individual Tracer Activity

Facility Tour

16:00 - 16:30

Survey Integration/Document Review/Tracer Planning



DAY TWO

Physician

Nurse

Administrator

08:00 - 08:30

Daily Briefing

(Time for surveyors to share with the organization observations from previous day)

08:30 - 10:30

Infection Control System

Tracer

Facility Tour

10:30 -12:00

Individual Patient Tracer


Review of Selected FMS Documents

12:30 - 13:00



13:00 - 16:00




16:00 – 16:30




DAY THREE

Physician

Nurse

Administrator

08:00 - 08:30

Daily Briefing


08:30 - 11:00

Medication System Tracer


11:00 - 12:00



FMS System Tracer

12:00 - 13:00



13:00 - 14:00




14:00 – 16:00

Staff Qualifications & Education Interview for

Medical Staff

Staff Qualifications & Education Interview for

Nursing Personnel

Staff Qualifications &

Education Interview for other hospital Personnel

16:00 – 16:30




DAY FOUR

Physician

Nurse

Administrator

08:00 – 08:30

Daily Briefing


08:30 – 10:00




10:00 – 11:00

Patient Safety Systems

Evaluation


Evaluation


Evaluation

11:00 – 12:00

Review of Selected Closed

Patient Records

Review of Selected Closed

Patient Records


12:00 – 13:00



13:00 – 16:00




16:00 – 16:30




DAY FIVE

Physician

Nurse

Administrator

08:00 - 09:00 GLD Interview Session

09:00 - 10:30




10:30 - 12:00

Data System Tracer

12:00 - 13:00

Lunch

(Surveyors will eat alone as this time is used for Integration)

13:00 - 15:00

Surveyors Complete Integration of Findings

(Surveyors Only)

15:00 - 16:00

Leadership Briefing Conference

16:00 – 16:30

Organization Exit Conference

(Leaders can decide who participates in this session; the size of the group is not limited.)


The Accreditation Decision The final accreditation decision is based on your organization’s compliance with Joint Commission International (JCI) standards. Organizations do not receive a numeric score as part of the final accreditation decision. When an organization successfully meets the JCI requirements, it will be awarded an accreditation decision of:

• Accredited This decision indicates that an organization is in compliance with all applicable standards at the time of the on-site survey or has successfully addressed all survey requirements for improvement in its written report within 60 days after survey for re-surveys, or within six months for initial surveys.

Promoting Your Accreditation After you have received official notification of the accreditation decision, publicize your achievement of international accreditation by notifying patients, the public, the local media, third-party payers, and resident referral sources. JCI provides a free publicity kit to accredited organizations that includes:

• Suggestions for celebrating your accreditation

• Guidelines for publicizing your JCI accreditation

• Frequently asked questions

• Sample news release

• Fact sheet Information about your accreditation status will be posted on JCI web site, www.jointcommissioninternaitonal.org. The web site allows anyone to locate JCI accredited organizations within a country. The Continuing Accreditation Cycle The accreditation process does not end when the on-site survey is completed. In the three years between on-site surveys, Joint Commission International will continue to monitor for compliance with all of the JCI hospital standards on an ongoing basis throughout the three year accreditation cycle. For this reason, it is very important that the organization maintain compliance with the standards between on-site surveys. Continuous survey compliance means less focus on the “ramp up” for survey every three years. Instead, organizations can and should continually improve their systems and operations, eliminating the need for intense survey preparation. Continuous compliance with the JCI standards directly contributes to the maintenance of safe, quality care and improved organizational performance.


SURVEY AGENDA

Detailed Descriptions


Opening Conference PURPOSE: During the opening conference, the surveyor(s) describes the structure and content of the survey to the organization LOCATION: At the discretion of the hospital HOSPITAL PARTICIPANTS: � Chief Executive Officer � Individual responsible for coordinating the hospital’s survey agenda � Others at the discretion of the organization SURVEYORS: All surveyors STANDARDS / ISSUES TO BE ADDRESSED: Introduction and coordination of the survey DOCUMENTS/MATERIALS NEEDED: Final survey agenda WHAT WILL OCCUR:

• Introduction of surveyors

• Introduction of hospital leadership

• Review and modify agenda

• Surveyors will answer questions about the survey agenda; explain the scoring of compliance to the standards, and pertinent decision rules pertaining to the submission of the preliminary report to the Accreditation Committee. The team leader will explain that scoring of compliance to the standards will be limited to those processes that have been implemented prior to the beginning of the survey. The survey team will not be able to score compliance to a standard if new or revised policies, procedures, or practices are made during the survey, since the team would not have sufficient time to determine the effectiveness of these activities.

• Surveyors will explain the use of the Tracer Methodology during the survey process activities.

• Surveyors will advise leaders the only presentation allowed during the survey is scheduled on the survey agenda for the session entitled, Hospital Overview of Organization Services and Quality Improvement Plan. The surveyor will follow the planned survey agenda when conducting the tracer activities. Staff should be prepared to answer questions. The surveyor will also obtain pertinent information through various other methods.

• Surveyors will explain the concept of “drilling down” as an interviewing technique/ approach that has the aim of gathering specific information about a process or outcome. Staff members involved in “drilling down” inquiries should not perceive this approach as


personal or necessarily an indication of non-compliance. It is an indication that the surveyor(s) are evaluating the establishment of systems to support a process.

• Surveyors will explain the staff involvement in the patient record review process.

• Surveyors will explain the staff involvement in the staff qualifications and education interview.

• Surveyors will explain the purpose and the leaders’ involvement in the daily briefing sessions.

• The hospital staff will be encouraged to ask questions and seek clarification from surveyors throughout the survey process.

• Hospital staff will notify the surveyors where lunch will be served or where they can purchase lunch.

• Hospital staff will identify country-specific information that would ensure that the survey team observes significant customs and values of the organization during the survey process, especially if observance of customs impacts the survey agenda. For example, how would the organization prefer that surveyors conduct survey sessions during times that staff members’ participate in prayer activities? Hospital staff should indicate how staff members would prefer to be addressed and discuss the use of interpreters, when needed.

• Hospital staff will show the surveyors where they can meet with each other. This should be the same room where documents are gathered for surveyor review.

• Hospital staff will introduce the surveyors to the staff member who will provide assistance throughout the day. This staff person will help the surveyor move quickly between hospital locations and maintain the planned schedule. This staff person is usually a leader of the organization or the survey coordinator.

HOW TO PREPARE:

• Identify a meeting or conference room large enough for the surveyors to meet with the key hospital leaders and survey coordinator(s).

• Confirm that computers with high-speed internet connectivity and a document printer are in the room and available for the surveyors to use.

• Notify hospital receptionists so they can direct the surveyors to the appropriate room when they arrive.

• Have copies of the survey agenda available for all participants in the opening conference.

• Prior to the survey, decide which hospital leader or staff member will accompany each surveyor throughout the survey day.

• Arrange for surveyors to be served or purchase lunch.

• Notify hospital staff of the survey agenda.

• Each surveyor will wear a name badge that will identify him or her as a JCIA surveyor. If the organization requires additional organization identification, prepare and make it available to surveyors in the opening conference.


Orientation to the Organization’s Services and the Quality Improvement Plan PURPOSE: The organization orients the surveyor(s) to the services the organization provides and its Quality Improvement process. This provides the surveyor(s) with baseline information about the organization and the quality and safety program that can help focus subsequent survey activities. LOCATION: At the discretion of the hospital HOSPITAL PARTICIPANTS: � Chief Executive Officer � Individual responsible for coordinating the hospital’s survey agenda � Medical Staff Leadership � Nursing Leadership � Staff responsible for Quality Management and Patient Safety Program, if applicable � Others at the discretion of the organization SURVEYORS: All surveyors STANDARDS / ISSUES TO BE ADDRESSED: Overview of the organization’s services Overview over the Quality and Safety Program and Process DOCUMENTS/MATERIALS NEEDED: Organization chart Quality improvement example WHAT WILL OCCUR:

1. The organization will give a presentation about the structure and methods of the quality Improvement and patient safety program.

2. The presentation should show how quality and safety information flows through the organization/committee structure

3. The presentation should describe a. how quality and safety measures have been chosen b. how the measures were prioritized for data collection c. how data are collected, aggregated and analyzed d. how findings from data analysis are communicated and used for planning

improvements. 4. The organization may choose to present a quality improvement example to demonstrate the

organization’s methodology as well as sustained improvement.


Surveyor Planning Session PURPOSE: During this session, the surveyor(s) reviews data and information about the organization and plans the survey agenda. The surveyor(s) also selects initial tracer patients/residents/clients. LOCATION: The organization is asked to have space available for this activity, usually the room designated as the “surveyor headquarters.” This space should have the following:

• conference table

• power outlets

• telephone

• Computers with high speed internet connection/access

• printer HOSPITAL PARTICIPANTS: Organization Survey Coordinator (as needed by team) SURVEYORS: All surveyors on site WHAT OCCURS: This time is set aside for the surveyor(s) to review and discuss pertinent data and plan the survey agenda. The surveyor(s) review the following (as applicable to the setting): Note: These materials should remain available to the surveyors for the entire duration of the survey.

• Performance improvement data

• Infection control surveillance data

• Facility Management and Safety Plan annual reviews. Surveyors should review in preparation for the Facility Tour session

• Facility Management and Safety multidisciplinary team meeting minutes for the 12 months prior to survey. Surveyors should review in preparation for the Facility Tour session.

• List of departments/units/areas/programs/services within the organization (if applicable)

• An organization chart and map of the organization

• List of scheduled home visits for the duration of the survey including type of service, disciplines, date of admission, and location. Includes branch locations (if applicable).

• Key contact person (e.g., supervisor, scheduler) who can assist surveyors in planning tracer selection Selection of Individual Tracers

• Surveyors review the information from the survey application and the list of patients currently receiving care in the hospital to guide their selection of patients to trace.


• Surveyors identify a clinical/service group and some general information about the patient population receiving care and services.

• Surveyors describe to the organization the type of patient that they are seeking to trace and request staff’s assistance in identifying an individual.

• In surveys exceeding one day, the surveyor(s) informs the organization during the morning daily briefing about the types of tracers he or she wants to perform that day to facilitate activity planning. This does not mean that the surveyor(s) will identify a specific patient from the list supplied by the organization. For example, the surveyor(s) may choose to trace:

o A hospital orthopedic surgery patient who is receiving physical therapy

o A home care patient who is receiving surgical wound care

o An ambulatory patient who visited the internal medicine clinic and had laboratory services

o A patient with limited mobility, who smokes, who uses oxygen, or has cognitive impairment

o An intensive care patient who is receiving blood gas testing

o A patient with developmental disabilities

• In team surveys, tracer selection should be coordinated to avoid overlap of visits to various units to the extent possible.

• In organizations with multiple sites, individual tracers will include patients who move between locations and services addressed by the represented accreditation programs.

• The Individual Tracer Activity Guide provides more detailed information on tracer selection.


Document Review PURPOSE: The purpose of the document review is to survey standards that require some written evidence of compliance, such as an emergency preparedness plan or a patient rights document. Additionally, the purpose of the document review is to orient the survey team to the organizational structure and management structure of the hospital. LOCATION: A meeting room or office that will be used throughout the duration of the survey as a meeting place and work area for the survey team. HOSPITAL PARTICIPANTS: Participants should include hospital staff members that are familiar with the documents, can translate them, and respond to questions that the surveyors may have during the session. At the discretion of the team, surveyors may designate a limited number of staff members to attend and participate in the document review session. The session may be conducted as an interview of staff about the documents. This approach has been very effective when language barriers exist and the survey activities necessitate the use of professional interpreters. SURVEYORS: All members of the survey team STANDARDS/ISSUES TO BE ADDRESSED: Almost all standards chapters make reference to plans, policies, procedures, etc. that are to be written. The next section and the back of this guide will assist in understanding the particular documents that are a part of the accreditation survey. DOCUMENTS/MATERIALS NEEDED: The documents that should be available to the survey team for their review or reference during the survey process are listed at the back of this guide. The lists are:

1. Required Quality Monitors

2. Required Organization Plans

3. Required Policies and Procedures, Written Documents, or Bylaws

4. Accurate list of the patients currently receiving care in the hospital

5. Operative procedures schedule for the day (for main Operating Theater and Day Surgery)

6. Current map of the hospital campus

7. Sample of all medical record forms


In addition, the organization should complete and have available for the survey teams the worksheet related to relevant national or local health care related laws and regulations. The Law and Regulation Worksheet is located at the back of this guide. The documents that must be available to the surveyors in ENGLISH are listed below:

1. The policies and/or procedures require the use of two patient identifiers, not including the use of the patient’s room number or location. (IPSG 1)

2. A collaborative process is used to develop policies and/or procedures that will establish

uniform processes to ensure the correct site, correct procedure, and correct patient, including procedures done in settings other than the operating theatre. (IPSG 4)

3. The organization has established entry and/or transfer criteria for its intensive and

specialized services or units, including research and other programs to meet special patient needs (ACC.1.4)

4. There is policy guiding the appropriate transfer of patients (ACC.4)

5. The organization has listed those procedures and treatments that require separate consent.

(PFR.6.4.1)

6. Policies and procedures guide the procurement and donation process. (PFR.11)

7. Organization policy and procedure define the assessment information to be obtained for inpatients. (AOP.1)

8. Organization policy and procedure define the assessment information to be obtained for

outpatients. (AOP.1)

9. Organization policy identifies the information to be documented for the assessments. (AOP.1)

10. The scope and content of assessments by each clinical discipline are defined in policies.

(AOP.1.1)

11. The scope and content of assessments performed in inpatient and outpatient settings are defined in policies. (AOP.1.1)

12. The handling, use, and administration of blood and blood products is guided by

appropriate policies and procedures. (COP.3.3)

13. The care of comatose patients is guided by appropriate policies and procedures. (COP.3.4)

14. The care of patients who are on life support is guided by policies and procedures. (COP.3.4)


15. The care of patients on dialysis is guided by appropriate policies and procedures. (COP.3.6)

16. The care of patients receiving chemotherapy or other high-risk medications is guided by

appropriate policies and procedures. (COP.3.9)

17. Policies and procedures guide the safe prescribing, ordering and transcribing of medications in the organization. (MMU.4)

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

(MMU.4)

19. Acceptable medication orders or prescriptions are defined in policy(s) and at least elements a) through i) are addressed in the policy(s). (MMU.4.1)

20. A medication error and near miss are defined. (MMU.7.1)

21. The hospital leaders have established a definition of a sentinel event that at least includes a)

through c) found in the intent statement. (QPS.5)

22. Other events defined by the organization are analyzed (QPS.6)

23. The organization establishes a definition of a near miss and the type of events to be reported. (QPS.7)

24. There is a comprehensive program and plan to reduce the risk of health care– associated

infections in patients. (PCI.5)

25. There is a comprehensive program and plan to reduce the risk of health care– associated infections in health care workers. (PCI.5)

26. Risk-reduction goals and measurable objectives are established and regularly reviewed.

(PCI.5)

27. When single-use devices and materials are reused, there is a policy that includes items a) through e) in the intent statement, and the policy is implemented. (PCI.7.1)

28. The organization’s governance structure is described in written documents. (GLD.1)

29. Governance responsibilities and accountabilities are described in the documents. (GLD.1)

30. The documents describe how the performance of the governing entity and managers will be

evaluated and any related criteria. (GLD.1)

31. There is an organization chart or document. (GLD.1)


32. There is a written policy or protocol that defines the requirements for developing and

maintaining policies and procedures including at least items a) through h) in the intent, and it is implemented. (MCI.18)

33. There is a written protocol that outlines how policies and procedures that originated outside

the organization will be controlled, and it is implemented. (MCI.18)

34. There is a written policy or protocol that defines retention of obsolete policies and procedures for at least the time required by law and regulation, while ensuring that they will not be mistakenly used, and it is implemented. (MCI.18)

35. There is a written policy or protocol that outlines how all policies and procedures in

circulation will be identified and tracked, and it is implemented. (MCI.18) WHAT WILL OCCUR: 1. The documents should be made available to the survey team in the meeting room that has

been designated for their use throughout the duration of the survey. 2. At the beginning of the session, one staff person should briefly orient the survey team to the

organization of the documents. 3. During the remainder of the session, there should be a staff member readily available, in

person or by telephone that can respond to any questions the surveyors may have during this session.

4. The materials should remain available to the survey team throughout the survey for

reference purposes. However, if documents are required for use by organization staff, they can, of course, be removed. Surveyors may schedule a second document review session during the course of the survey. The review generally is scheduled for hospitals that have a survey of longer than three (3) days, and may be scheduled on surveys of a shorter duration, based on need. The survey team may also request additional documents throughout the survey to clarify or to become knowledgeable of the organization’s policies and procedures or performance. Hospital staff should be as proactive as possible in complying with requests for documents.

5. Some of them will have been translated into English. For other required documents, an

interpreter should be available. HOW TO PREPARE: It is very likely that many of the required documents will be part of other larger documents. It is not necessary to remove or photocopy pertinent sections of these documents. Guidelines for cross-referencing this information are provided below. The organization can identify the required sections by using bookmarks or tabs.


Other documents, such as minutes, reports, etc. may be freestanding or individual documents. It is the hospital’s decision whether to provide the original document or to provide a photocopy. It is always good to have several examples of these documents, such as the minutes of a committee from the last few meetings. If the hospital has a large quantity of examples or a large volume of materials on a given topic, select the most representative or the most pertinent. There will not be time for surveyors to review large amounts of material on any given topic. ORGANIZATION OF THE MATERIALS: Because the issues identified in the document review list may be addressed in different documents from one organization to another, the following guidelines for the organization of the material for use by the surveyors are provided: Group the freestanding or individual documents according to the three lists provided in this guide:

• Required Quality Monitors

• Required Organizational Plans

• Required Policies and Procedures, Written Documents, or Bylaws When possible, please indicate the standards that the document addresses. The documents may be grouped in binders, folders, or other means of separating major topical areas. Gather in one place such existing documents. Identify where in the document the specific information required by the standard may be found. There are several ways the information may be identified:

• A guide or index

• Bookmarks or tabs Note: When computer-based information is provided through use of monitors rather than

through paper versions:

• Each member of the survey team should be provided with a monitor;

• A printer should be available in case a member of the survey team wishes to print a paper copy of a given document;

• Printed copies should be available of bylaws and longer documents that may require extensive reading or scanning by surveyors.

EVALUATION OF THE POLICIES AND PROCEDURES BY THE SURVEY TEAM: The documents reviewed by the survey team provide an overview of what they expect to see in actual practice during the survey process. Thus, they would expect to find that when, for example, a new procedure on the disposal of infectious waste is developed:


• Appropriate staff have been educated about the new procedure;

• Any special skills or other needed training has taken place;

• It can be observed that waste is actually being disposed of according to the new procedure; and

• If any documentation is required by the procedure, it is available for review. The presence of a policy or procedure alone does not usually determine the score of the standard. Rather, it is also the daily practice (implementation) of what is in the policy or procedure. The survey team will be seeking evidence that the practice related to the policy or procedure is well implemented and thus sustainable. In the event that the implementation appears incomplete to the survey team or that implementation occurred in a manner that is not sustainable, the survey team will make a recommendation that more time is allowed for better evidence of sustainable implementation, and to incorporate that recommendation into the survey follow-up requirements. In general, the length of time a policy has been implemented is often referred to as a “track record”. The survey team will look for a four-month “track record” for policy-related standards during an initial survey and for a twelve-month “track record” during a triennial survey. For a policy related standard to be scored “fully met” the “track record” requirement must be met. When the “track record” period has not been met, but the survey team finds that the policy has been implemented in a sustainable manner, the team has the prerogative to score the standard as “fully met”.


Daily Briefing PURPOSE: To facilitate understanding of the survey process and the findings that contributes to the accreditation decision. LOCATION: At the discretion of the hospital. HOSPITAL PARTICIPANTS: Organization Survey Coordinator (as needed by team)

SURVEYORS: All surveyors on site

WHAT OCCURS: The daily briefing occurs every morning of a multi-day survey, with the exception of the first day. The session is intended to be brief; 60 minutes is suggested. When multiple surveyors are on site, the briefing is conducted jointly with the JCIA Team Leader as facilitator. During the daily briefing with the organization the surveyor(s) will:

• Offer a concise summary of the survey process activities completed on the previous day.

• Make general comments regarding significant issues resulting from the previous day’s activities.

• Note any specific positive findings.

• Emphasize patterns or trends of significant concern that could lead to non-compliance determinations.

• Inform the organization that final findings for any given standard will be possible only when all activities are complete and results are aggregated.

• Allow the organization to provide information that may have been missed during the previous survey day.

• Address organization requests for consultation on findings and indicate when such consultation can take place.

• Schedule time for more extensive discussion or review of additional evidence of compliance on issues that arise.

• Review the agenda for the survey day ahead (including the identification of individual patient tracers) and make any necessary adjustments based on organization needs or the need for more intensive assessment of an issue.

• Conclude the briefing and transition to the next activity(s) according to the agenda. Do not expect the surveyor(s) to:

• Repeat observations made at a previous daily briefing unless it is in the context of identifying a systemic issue.


• Discuss in detail each survey activity, specific records, and discussions held with individuals during tracers.

• Delay scheduled activities for the current day to have an in-depth discussion of issues from the previous day.

Special Situations There may be instances when a surveyor(s) will be scheduled for activity that is not taking place at the same location where a daily briefing would normally occur, especially when surveying with a team. There may also be situations where a surveyor(s) is brought in for a day or two and departs earlier than the rest of the team. If one or more surveyors cannot be physically present for the daily briefing, the surveyor(s) will:

• Try to make arrangements to join via conference call when at a different location.

• Share details of previous day’s activities and findings with another surveyor for the daily briefing presentation, even if a conference call is anticipated.


Facility Tour

PURPOSE: The purpose of the facility tour is to address issues related to:

• The physical facility

• Medical and other equipment

• Patient and visitor safety

• Infection control. LOCATION: Selected patient care settings, inpatient and ambulatory units, treatment areas and other areas including admitting, kitchen, pharmacy, central storage, laundry and power plant (if applicable). It is recommended that the tour begins on the roof, working downward in the building. The surveyor will be looking to see that the corridors and exit paths of travel are free for safe exit of the facility in an emergency. HOSPITAL PARTICIPANTS: � Chief Engineer � Safety Officer and/or Facility Manager � Directors of Admitting, Pharmacy and Dietary (when the surveyor is present in their areas) SURVEYORS: Administrator surveyor (physician and/or nurse surveyor when team does not include an administrator) STANDARDS/ISSUES TO BE ADDRESSED: � Facility Management and Safety (FMS) � Prevention and Control of Infections (PCI) � Staff Qualifications and Education (SQE) DOCUMENTS/MATERIALS NEEDED: 1. Documents (such as plans, policy and procedures, test and maintenance reports (FMS.2 a

through f)) that describes the plans for (a)safety and security (FMS.4), (b)hazardous materials (FMS.5), (c)emergencies (FMS.6), (d)fire safety (FMS.7), (e)medical equipment (FMS.8) and (f)utility systems (FMS.9)

2. Facility inspection report (FMS.4.1)


WHAT WILL OCCUR: Prior to the facility tour, the surveyors will have reviewed the above mentioned facility management and safety plans (FMS.2). The surveyors will also review selected portions of the facility inspection report prepared by the organization and visit patient care areas as well as non-patient care areas of the facility. In all areas the surveyors will observe the facility and interview staff to learn how the organization manages the facility to:

• Reduce and control hazards and risks

• Prevent accident and injuries

• Maintain safe conditions NOTE: In some survey agendas, two surveyors will visit separate sections of the facility at the

same time. The organization should be prepared to have staff available to guide and assist each surveyor on the tour of the facility.

The non-patient areas visited by the surveyors include:

• The boiler room

• The emergency power generator

• The loading/receiving dock

• Central storage areas or warehouse

• The laundry, if applicable

• Food service/kitchen

• Oxygen storage rooms

• Areas designated as hazardous, such as locker rooms, clean and soiled linen rooms, and oxygen storage rooms

• The bottoms of laundry and garbage chutes

• Heating and air conditioning equipment rooms to evaluate storage practices and utility systems maintenance

HOW TO PREPARE:

• Prior to survey, the organization leaders and facility manager(s) should carefully read the relevant standards.

• The facility manager(s) should tour the facility, conduct an inspection according to the standards, and attempt to address any deficiencies prior to survey.

• FMS.4.1 requires that the organization conduct its own inspection of the facility. This information should be available to the surveyors. All buildings in which patients are housed or treated are included in the inspection and the report.

• The organization should be aware of relevant laws, regulations and facility inspections and be able to share this information with the surveyors (FMS.1).

• Representatives of the organization should be prepared to show the surveyors how their facility management plans are be implemented. For example, how hazardous materials are stored and disposed.


• Prior to survey, the organization should check that all medical equipment has current inspections, testing and maintenance and that this is documented (FMS.8 and 8.1).

• Representatives of the organization should be prepared to explain or demonstrate how potable water and electrical power are consistently available 24 hours a day (FMS.9).

• The organization should have the following items available for the surveyor(s) to use when conducting the facility tour:

-Flashlight -Master key -Ladder (to look above ceiling tiles)


Sample Outline of a Facility Inspection Report I. The building(s) included in the report: A. The patient care activities that take place in each building B. Any local codes, laws, or classifications for the buildings based on the activities C. The approximate age of each building II. The building by building results of the inspection: A. Any general conditions of the building that relate to local codes, laws, regulations, etc. B. Specific findings related to law, regulation, codes, and accreditation standards. For

example, Building 1, second floor west, fire exit door does not close properly; Building 1, room 210, broken chair next to bed; Building 3, 2nd floor laboratory, hazardous materials stored on the floor near an exit.

III. The plan to correct the findings: A. Timetable B. Estimated budget (short range and longer range, if appropriate) IV. The plan for monitoring the facility improvement process and for the continuing monitoring

and improvement of the facility to ensure that facility safety concerns are prevented or eliminated through an ongoing planning and inspection process.

NOTE: The facility inspection report can be in any format that makes it an effective management

tool for the hospital. The inspection can be conducted by knowledgeable hospital staff or by outside consultants. The report should be as comprehensive as possible to demonstrate that the hospital is aware of all conditions in its buildings, and has plans to improve the safety of its buildings


Individual Patient Tracer Activity PURPOSE: A tracer follows the experiences of an individual patient in order to evaluate the organization’s performance against international standards. One approach to conducting a tracer is to sequentially follow the course of care and services received by the patient from pre-admission through post-discharge. During an individual tracer, the surveyor will:

• Follow the course of care, treatment, or service provided to the patient by and within the organization using current records whenever possible.

• Assess the interrelationships between and among disciplines and departments, programs, services, or units, and the important functions in the care and services being provided

• Evaluate the performance of relevant processes, with particular focus on the integration and coordination of distinct but related processes

• Identify potential concerns in the relevant processes HOSPITAL PARTICIPANTS: During a tracer, surveyors will converse with a wide variety of staff involved in the patient’s care, treatment or services. This could include nurses, physicians, therapists, case managers, aides, pharmacy and lab personnel, and support staff. SURVEYORS: Nurse, physician or administrator surveyor STANDARDS TO BE ADDRESSED: All standards chapters may be addressed during this visit DOCUMENTS /MATERIALS NEEDED: The clinical records of patients currently receiving care in the unit/setting WHAT WILL OCCUR: Using the information from the application, the surveyor(s) will select patients from an active patient list to “trace” their experience throughout the organization. Patients typically selected are those who have received multiple or complex services and therefore, more contact with various parts of the organization. This will provide the opportunity to assess continuity of care issues. To the extent possible, the surveyor(s) will make every effort to avoid selecting tracers that occur at the same time and may overlap in terms of sites within the organization. The surveyor will follow the patient's experience, looking at services provided by various individuals and departments within the organization, as well as “hand-offs” between them. This type of review is designed to uncover systems issues, looking at both the individual components of an organization, and how the components interact to provide safe and quality patient care. The number of patients followed under the Tracer Methodology will depend on the size and complexity of the organization, and the length of the on-site survey.


The tracer starts in the patient care setting or unit in which the patient and the clinical record are currently located. This is where the surveyor begins to trace the entire care or service process from preadmission through post-discharge. The surveyor has approximately two hours to conduct a tracer, although it may be shorter or longer depending upon complexity and other circumstances. Multiple patient records may be reviewed during a single designated tracer activity. As appropriate to the provision of care being reviewed, the tracer will include the following elements:

• Review of the record with the staff person responsible for the patient’s care, treatment, or service provided to the patient. If the responsible staff person is not available, the surveyor may speak with other staff members. Supervisor participation in this part of the tracer should be limited. Additional staff involved in the patient’s care will meet with the surveyor as the tracer proceeds. For example, the surveyor will speak to a dietician if the patient being traced has nutritional issues.

• Observation of direct patient care.

• Observation of medication process.

• Observation of infection control issues.

• Observation of care planning process.

• Discussion of data use in individual units – quality improvement measures being used, what has been learned, improvements made using data, data dissemination.

• Observation of the impact of environment on safety and staff roles in minimizing environmental risk.

• Interview with the patient and/or family (if it is appropriate and permission is granted by the patient and/or family). The discussion will focus on the course of care, and, as appropriate, attempt to verify issues identified during the tracer.

• When visiting the emergency department, the surveyor will also address emergency management and explore patient flow issues. Patient flow issues may also be explored in ancillary care areas and other patient care units as relevant to the patient being traced. For example, if the patient received a blood transfusion, the surveyor may visit the blood bank.

• The surveyor(s) may pull and review two to three additional records to verify issues that may have been identified. The surveyor(s) may ask staff in the unit, program, or service to assist with the review of the additional records. The following criteria can be used to guide the selection of additional records depending on the situation:

o Similar or same diagnosis or tests o Patient close to discharge o Same diagnosis but different physician/practitioner o Same test but different location o Same age or sex o Length of stay

• Interview with staff.

• Review of minutes and procedures as needed. A surveyor(s) may arrive in a patient care setting or unit and need to wait for staff to become available. In these cases, the surveyor(s) will use this time productively (e.g., to tour the unit,


program, or service and to address environment of care issues, or observe care/treatment/service processes). Surveyors will avoid visiting an area at the same time, and will minimize multiple visits to the same location. TRACER SELECTION CRITERIA Patient tracer selection may be based on, but not limited to the following criteria:

• A patient on dialysis.

• A psychiatric patient.

• A pediatric patient.

• A patient receiving imaging services.

• A patient receiving rehabilitation services.

• Patients related to system tracers such as infection control and medication management.

• Patients who cross programs (e.g. patients scheduled for a follow-up in ambulatory care, home care

• Patients received from the hospital, long term care patients transferred from the hospital, mental health care clients receiving ambulatory services, and patients receiving home care services).

• Patients due for discharge that day or the next day

• Patients who cross programs such as hospital to care continuum. Linkages to Other Survey Activities Issues identified from the tracer activities may lead to further exploration in the systems tracers or other survey activities such as the Facilities Tour and GLD Interview. Findings from tracer visits provide focus for other tracers and may influence the selection of other tracers. They may also identify issues related to the coordination and communication of information relevant to the safety and quality of care services.


System Tracer – Medication Management PURPOSE: This session explores the organization’s medication management as well as potential risk points in the system. HOSPITAL PARTICIPANTS: Individuals selected by the organization to participate in the group session should, as a group, be able to speak to the full spectrum of medication management processes from medication procurement through monitoring the effects of administered medications. As applicable, appropriate participants might include a direct care or service representative from the following areas:

• Clinical staff that have a role in medication management processes as part of the direct care, treatment, or services they render, such as a nurse, physician, therapist, dieticians, or others.

• Clinician from the pharmacy or consultant pharmacist who is knowledgeable about the selection of medications available for use and medication monitoring

• Staff member responsible for medication education of both staff and patients.

• A clinical staff member who may add a unique perspective about any identifiable or specific patient.

• A person who can speak to performance improvement if any performance improvement initiatives associated with medication management have been conducted or are being conducted. Note: A separate representative from quality improvement is not necessary if other participants can speak to medication management improvements e.g., therapist on a medication QI team.

• Clinician from the lab

• Environmental safety personnel involved in the maintenance of pumps In order to facilitate a beneficial exchange between the surveyor(s) and the organization, the organization should identify a relatively small group of active participants for discussions and interviews. Other staff may attend as observers During the focused-tracer activity the surveyor(s) will visit areas relevant to medication management processes and talk to staff that is available in these areas about their role in medication management. SURVEYORS: Nurse or physician surveyor. WHAT WLL OCCUR: Various methodologies are used to evaluate an organization’s medication management system including a group discussion session; a medication management, focused-tracer; and information from individual patient tracers. The medication processes that are evaluated include: Selection and Procurement, Storage, Ordering and Transcribing, Administration, and Monitoring.


Group Discussion The discussion session explores medication management processes in the organization and hand-off points between processes. During the group discussion, the surveyor(s) and organization staff: 1. Explore each applicable medication management process. Participants in the group share the

organization’s approach to medication management based on their experience. 2. For each medication management process discuss:

• Areas of concern, “symptoms”

• Immediate or proximal causes for an area of concern

• Potential solutions 3. Explore the continuity of medication management processes and their relationship to other

supporting processes and systems. 4. Identify potential areas of concern in the organization’s medication management system and

actions that might be taken. 5. Identify any specific medication management issues requiring further exploration as part of

subsequent tracers and other survey activities. 6. Review the International Patient Safety Goals (IPSGs) related to medication management

Specific aspects of medication management that may be addressed during the discussion and focused-tracer include:

• Medication selection, procurement and storage including IPSG #3

• Ordering, order entry, and transcription and IPSG #2

• Preparation and dispensing

• Administration and IPSG #1

• Monitoring and IPSGs #5 and #6

• Reporting of errors/system breakdowns/near misses

• Data collection, analysis, evaluation of systems and actions taken including any performance improvement initiatives related to medication management

• Medication education – patients and staff

• Information management related to medication management

• Patient involvement as part of a medication management team The influence of other organization systems for planning, data use, performance improvement, communication and staff competence/effectiveness may be explored with respect to medication management system and processes. Focused-Tracer Activity The focused-tracer activity may take place prior to or after the group discussion. The surveyor explores the path of a selected medication in the organization using a current medical record. The


surveyor then focuses on medication management processes informed by prior survey activities such as the medication management group discussion or observations made during previous patient tracers. Notes: In organizations with more than one program accredited by The Joint Commission International and in organizations with multiple sites, only one Medication Management Session is scheduled. If it is not feasible for staff to participate from all programs/sites, the organization may need to teleconference individuals from distant locations into the group discussion. In shorter surveys, when a separate Medication Management system tracer is not scheduled, the surveyors will address medication management in patient tracers and during the Data Use system tracer.


System Tracer – Infection Control PURPOSE: During the discussion of the infection control program, the surveyor(s) and organization will be able to:

• Identify strengths and potential areas of concern in the infection control program.

• Begin to determine actions necessary to address any identified risks in infection control processes.

• Begin the assessment or determine the degree of compliance with relevant standards.

• Identify infection control issues requiring further exploration. Note: When a separate Infection Control System Tracer is not noted on the agenda (for example, on shorter surveys), the surveyor(s) will address infection control throughout individual patient tracers and during the Data Use System Tracer. HOSPITAL PARTICIPANTS: Individuals from the organization selected for participation should be able to address issues related to the infection control program in all major departments or areas within the organization. This group should include, but not be limited to, representation from, as applicable to the organization:

• Clinical staff, including physicians, nurses, pharmacists, laboratory personnel

• Clinicians who are knowledgeable about the selections of medications available for use and pharmacokinetic monitoring

• Clinicians from the laboratory (when applicable) who are knowledgeable about microbiology

• Clinical staff including those individuals involved in infection control and a sample of individuals involved in the direct provision of care, treatment and services.

• Staff responsible for the physical plant.

• Organization leadership. NOTE: In order to facilitate a beneficial exchange between the surveyor(s) and the organization, the organization should identify a relatively small group of active participants for discussions and interviews. Other staff may attend as observers. SURVEYORS: Nurse or physician surveyor. WHAT WILL OCCUR: The session will open with introductions and a review of the goals for the infection control systems tracer, which includes:

• Exploration, critical thinking, and potential problem solving about the infection control program.


• Identification of potential areas of concern in the infection control program, areas for improvement, and actions that could be taken.

Process

• Activity will begin in a patient care area identified by the surveyor(s).

• The surveyor(s) may move to other settings as appropriate and applicable to tracing infection control processes across the organization.

• The surveyor(s) will observe staff and engage them in discussion focused on infection control practices in any setting that is visited during this system tracer activity.

• Activity will end in a short group meeting with individuals responsible for the organization’s infection control program. During this time the surveyor(s) will identify potential areas of concern and gain a better understanding of the IC system for further discussion and exploration with staff knowledgeable about the organization’s infection control program.

Discussion The surveyor(s) will draw from tracer activity experience, organization infection control surveillance data, and other infection control related data, to inspire scenarios for discussion with the organization. Participants will be asked to discuss the following aspects of the organization’s infection control program as it relates to the scenarios:

• How patients with infections are identified by the organization

• How patients with infections are considered within the context of the infection control program

• Current and past surveillance activity—taking place in the last 12 months or more for re-surveys and four months or more for initial surveys

• Type of analysis being conducted on infection control data, including comparisons

• Reporting of infection control data—frequency and audience

• Prevention and control activities (e.g., staff training, education of patient/resident/client population, housekeeping procedures)

• Physical facility changes, either completed or in progress, that have an impact on infection control

• Actions taken as a result of surveillance and the outcomes of those actions Organizations may use infection control data during this part of the activity if it is relevant to the discussion. Discussion can revolve around patients already included in IC surveillance and reporting activities, or those not yet confirmed as meeting a definition or criteria for entry into and monitoring through the infection control surveillance system. In addition to surveyor-identified scenarios, the organization is encouraged to present examples of cases that will highlight various aspects of the infection control program. Some of the scenarios the surveyors will want to discuss, as applicable to the organization, may include but are not limited to:

• Patients seen with fever of unknown origin

• Patients with a post operative infection

• Patients admitted to the organization post-operatively


• Patients placed on an antibiotic new to the list of available medications (preferably one with corresponding culture and sensitivities, blood levels, and/or other labs used for dosing)

• Patients placed on some form of isolation or precaution because of diagnosis of infectious disease. If not easily identifiable, consider patients with any of the following diagnoses (this is not an exhaustive list): varicella, pulmonary tuberculosis, invasive haemophilus influenzae, meningococcal disease, drug-resistant pneumococcal disease, pertussis, mycoplasma, mumps, rubella, MRSA, VRE, Clostridium difficile, RSV, enteroviruses, skin infections (impetigo, lice, scabies)

• Infection control practices related to emergency management.

• Patients placed on some form of isolation or precaution because of being immunocompromised

• Recent changes in physical facilities that have an impact on infection control.

• Patients with known case of active tuberculosis Conclusion The surveyor(s) and organization will summarize identified strengths and potential areas of concern in the infection control program. The surveyor(s) will provide education as applicable. Note: Usually, a single infection control system tracer session will be scheduled. This session is intended to review infection control for all services provided by the organization. Participants in this system tracer should include individuals that are able to address infection control in all services offered by the organization.


System Tracer – Data Use PURPOSE: This session is focused on the organization’s use of data in improving safety and quality of care. HOSPITAL PARTICIPANTS: Individuals from the organization selected for participation should be able to address issues related to the use of data in all major departments or areas within the organization. This group should include but is not limited to representation from the following services:

• Clinical staff, including individuals involved in performance improvement and a sample of individuals involved in the direct provision of care, treatment, and services

• Representation from physicians, nurses, and pharmacists

• Individuals who are knowledgeable about the information systems available for data collection, analysis, and reporting

• A representative from the organization’s leadership In order to facilitate a beneficial exchange between the surveyor(s) and the organization, the organization should identify a relatively small group of active participants for discussions and interviews. Other staff may attend as observers. SURVEYORS: Nurse, physician or administrator surveyor. WHAT WILL OCCUR: During the session, the surveyor(s) and organization will discuss: 1. The measures that are being used for improvement.

• Improvements that have been made as the result of data collection and analysis.

• How performance improvement methods are used throughout the organization.

• The basics of data gathering and preparation, including:

o Selection of measures

o Data collection and aggregation

o Data analysis and interpretation

o Dissemination/transmission of findings

o Taking action

o Monitoring performance/improvement These issues will be explored in the context of each of the specific data discussion topics described below. The surveyor(s) may incorporate examples obtained from previous individual patient tracer findings of the survey team.


When system tracer time has not been scheduled for Medication Management and Infection Control, the use of data in these areas can be covered during this session. Medication Management Data Issues Medication management data collection issues are addressed here in shorter surveys where only one System Tracer (Data Use) is scheduled. Discussion explores: 1. Data collected on the performance of the organization’s medication management system and

processes, including trends or issues that have been identified, and changes made as a result of that review

2. Medication data the organization is collecting. Medication management data collection should be relevant to the services provided by the organization and patients served. The organization should be collecting data related to the “risk points” it has identified in its medication management system evaluation. Examples of such data based on an assessed risk point might include but are not limited to:

� Number of pharmacy interventions � Turn-around times from order to administration � Adverse drug events (ADEs) � Use of high risk medications � All suggested measures in QPS.3.5 and 3.6 (use of antibiotics)

Infection Control Data Issues Applicable in smaller surveys where only one System Tracer (Data Use) is scheduled. Discussion explores: 1. Surveillance methods for health care-associated and non-health care-associated infections. 2. Types of data collected

• Whether infection-related data are collected

• Whether the organization has developed and implemented a system for measuring improvements

3. Use of standardized definitions. 4. Control methods (includes data dissemination to physicians, staff, leaders, external entities). 5. Prevention based on data findings. 6. The organization’s plans to collect data relevant to the JCI prevention and control of infection

standards. Conclusion As a result of this session, the surveyor and the organization will: 1. Identify strengths and weaknesses in the organization’s use of data, areas for improvement, and

actions that could be taken. 2. Identify specific data use issues requiring further exploration as part of subsequent survey activities. 3. Provide appropriate education, as applicable.

Note: In hospitals with multiple sites, only one Data Use Session is usually scheduled. If it is not feasible for staff to participate from all programs/sites, the organization may need to teleconference individuals from distant locations into the group discussion.


Facility Management and Safety System Tracer PURPOSE: The purpose of this session is to provide guidance for evaluating the organization’s system and performance for managing risk within the facility management and safety program (FMS). The surveyor and the organization will:

� Identify areas of concern and strengths in the organization’s processes. � Identify or determine the action(s) necessary to address any identified areas of concern. � Assess or determine the organization’s actual degree of compliance with relevant standards.

HOSPITAL PARTICIPANTS: Individuals from the organization selected for participation should be able to address issues related to FMS in all major departments or areas within the organization. This group should include representation from the following services (in some organizations, individuals may be responsible for multiple roles):

� Person(s) designated by leadership who coordinates safety management activities. � Person(s) designated by leadership who coordinates security management activities. � Person who manages the organization’s facility (ies). � Person responsible for the organization’s emergency management activities. � Person who manages the organization’s building utility systems. � Person responsible for maintaining the organization’s medical/laboratory equipment. � Leader of the environment of care team or safety committee. � Organizational leadership.

In complex organizations that have decentralized FMS management activities at remote sites, those persons responsible for managing the activities listed above at those sites should be available (i.e., in person, by conference call, etc.). SURVEYORS: Administrative Surveyor WHAT WILL OCCUR: The duration of the session lasts about 60-90 minutes. The group discussion (Part I) section activity represents approximately 30% of the session and occurs after the surveyor has had the opportunity to review the following documents:

� The annual evaluations of the FMS management plans that deal with risks in the environment

� The FMS multidisciplinary team meeting minutes (previous twelve months). It is also important that observations related to FMS made by other members of the survey team (if applicable) and any FMS-related issues and information identified from previous surveys be discussed during this session.


Introduction The surveyor reviews the objectives of the FMS session with the organization’s participants. Discussion Guidelines During this time the surveyor should draw discussion from the organization that will give insight into the following aspects of its environment of care management processes, as shown in the FMS Risk Management Cycle below. Plan

� What specific risks related to its environment of care have been identified by the organization?

Teach

� How have roles/responsibilities for staff/volunteers been communicated by the organization (Human Resources).

Implement

� What procedures and controls (both human and physical components) does the organization implement to minimize the impact of risk to patients, visitors, and staff?

Respond

� What procedures does the organization implement to respond to an FMS incident/ failure? � How, when, and to whom are FMS problems, incidents, and/or failures reported within the

organization. Monitor

� How is FMS performance (both human activities and physical components) monitored by the organization

� What monitoring activities have taken place within the last 12 months?

FMS Risk

Management Cycle

PLAN

TEACH

IMPLEMENT

RESPOND

MONITOR

IMPROVE


Improve � What facility management and safety issues are currently being analyzed. � What actions have been taken as a result of FMS monitoring activities?

The organization should discuss how the six FMS risk categories (*1) and construction activities have been addressed in each of the management processes listed above. The following matrix is provided to assist in determining patterns of management process or risk category areas of concern and strengths. The following matrix is a screening tool for use in selecting a particular management process or risk category to explore in the second part of this session. Selection of a particular management process or risk category should be based upon information gathered from the following: the discussion phase of this session, FMS-related information from previous surveys, and any unusual observations made during survey prior to this session. Note: The six FMS risk categories include: general safety and security, hazardous materials and waste, emergency management, fire safety, medical/laboratory equipment, and utilities.

SAFETY SECURITY HAZARDOUS MATERIAL

FIRE MED/LAB EQUIPMENT

UTILITIES EMERGENCY MANAGEMENT

PLAN TEACH IMPLEMENT RESPOND MONITOR IMPROVE

*During this session, the organization’s performance in addressing the emergency management requirements of standards FMS.6 and FMS.6.1 will be reviewed including its performance in:

� Identifying and analyzing potential environmental risks in the organization; � Identifying its role in relation to the community’s, county’s, or region’s emergency

management program; � Identifying processes for the timely sharing of information with other healthcare

organizations that provide services within the contiguous geographic area; � Identifying an structure used during emergencies that links with the community’s incident

response structure; and � Making any necessary improvements to its emergency management based on critiques of

emergency management drills. Discussion should focus around the management processes and not the FMS risk categories. Surveyors should not be the primary speakers during this time, but rather listeners to the discussion. This is not intended to be an interview. Observation Guidelines (Part Two) The surveyor then observes and evaluates the organization’s performance in managing FMS risk. This activity represents approximately 70% of the session and occurs after the group discussion portion of the session.


The particular management process or risk selected for observation and further evaluation is based upon the following:

� FMS documents previously reviewed. � Observations by other survey team members. � Knowledge gained during the group discussion portion of this session.

The surveyors will observe the implementation of those particular management processes determined to be potentially vulnerable or, will trace a particular risk(s) in one or more of the FMS risk categories the organization manages by:

� Beginning where the risk is encountered or first occurs. (i.e., a starting point might be where a particular safety or security incident occurs, a particular piece of medical equipment is used, or a particular hazardous material enters the organization).

� Having staff describe or demonstrate their roles and responsibilities for minimizing the risk, what they are to do if a problem or incident occurs, and how to report the problem or incident.

� Assessing any physical controls for minimizing the risk (i.e., equipment, alarms, building features).

� Assessing the emergency management plan for mitigation, preparedness, response, and recovery strategies, actions and responsibilities for each priority emergency.

� Assess the emergency plan for responding to utility system disruptions or failures (e.g., alternative source of utilities, notifying staff, how and when to perform emergency clinical interventions when utility systems fail, and obtaining repair services)

� If equipment, alarms, or building features are present for controlling the particular risk, reviewing implementation of relevant inspection, testing, or maintenance procedures.

� If others in the organization have a role in responding to the particular problem or incident, having them describe or demonstrate that role, and reviewing the condition of any equipment they use in responding.

If the risk moves around in the organization’s facility (i.e., a hazardous material or waste), the surveyor will follow the risk from “cradle to grave.”

Conclusion (Part Three) The surveyor summarizes any potential areas of concern in the management process or risk category observed. Staff responsible for managing that particular process or risk reviewed provides information regarding their role in addressing any areas of concern observed. The organization should provide information regarding processes that have been developed to address any potential areas of concern observed. The organization should provide information regarding existing activities that have been implemented to address any potential areas of concern observed.

NOTE: In order to facilitate a beneficial exchange between the surveyor and the organization, the organization should identify a relatively small group of active participants for discussions and interviews. Other staff may attend as observers.


Staff Qualifications and Education Session PURPOSE: The purpose of this interview is to address the hospital’s process to recruit, orient, educate and evaluate all hospital staff. In addition, the interview addresses the hospital’s process for evaluating the credentials of the medical staff, nursing staff, and other health professional staff and their ability to provide clinical services consistent with their qualifications. LOCATION: Small meeting rooms at the discretion of the hospital’s leaders HOSPITAL PARTICIPANTS FOR EACH INTERVIEW WHEN HELD SEPARATELY: Generally, two separate interviews will be conducted. Each should be conducted separately and in different locations. The physician surveyor will conduct the medical staff interview and the nurse and administrator surveyors will jointly conduct the interview for nursing staff and all other staff. The survey team may elect to conduct up to four separate interviews, depending on the size of the organization and the types of hospital and health care professional staff present in the organization. Medical Staff:

• Elected or appointed senior leader of the medical staff and/or Medical Director (if applicable)

• Representatives of the medical staff involved in credential collection and review Nursing Staff:

• Manager of the Human Resources/Personnel department

• Chief nurse

• Other representatives of the nursing staff involved in the orientation, education and training of nursing staff

Other Health Professional Staff:

• Manager of the Human Resource/Personnel department

• Representatives of group(s) involved in the orientation, education and training of health professional staff

Other Hospital Staff:

• Manager of the Human Resource/Personnel department

• Representatives of group(s) involved in the orientation, education and training of hospital staff SURVEYORS: Medical Staff – Physician surveyor Nursing Staff and Other Health Professional Staff: – Nurse surveyor Other Hospital Staff – Administrator and/or nurse surveyor STANDARDS ISSUES TO BE ADDRESSED: Staff Qualifications and Education (SQE) standards


DOCUMENTS/MATERIALS NEEDED: � Policy and procedures related to Human Resources/Personnel management, and staff

credentials. � A sample of hospital personnel files and of health professional staff credential files. Surveyors will provide instructions on the first day of the survey, generally during the document review session, regarding this interview and the preparation of the files for review. The survey team will provide the Director of Human Resources with a list that identifies the type and number of personnel and medical staff files selected for review later in the survey during the staff qualifications and education interview. Sample request and review forms are shown on the next few pages. The survey team will provide copies of the current survey tool on the first day of the survey. It is important to know that the surveyors’ tools that are used throughout the survey may change at any time to continually improve the survey team’s abilities to fairly and accurately score the organization’s compliance with standards. The tool merely reflects current JCIA standards. HOW TO PREPARE: The organization should include a list of all current personnel and medical staff in the document review session on the first day. The list should identify the specific discipline, hire date, and department or service assigned (for example: Registered Nurse; Hired July 20, 2001; Intensive Care Unit). These documents should be in ENGLISH, when possible. Closely review all personnel and credential files using the Competence Assessment Process Review Form. Be sure all required elements are in the files.


MEDICAL STAFF Competence Assessment Process Review

Request and Review Form

1 2 3 4 5 Name or Category of Staff

Licensure, education, training, and experience documented. Verified

from original source, when possible. SQE.9 #2

Copies of any required license certification, or registration (current). SQE.9 #4

Reevaluated at least every three years or more frequently, when required by organization policy.

SQE.9 #5

Authorized to admit and treat patients and provide clinical

services.

SQE.10

Staff providing patient care /other designated staff trained and

competent in resuscitative techniques. SQE.8.1


NURSING STAFF Competence Assessment Process Review


1 2 3 4 5 6 Name or Category of Staff

Licensure, education, training and experience are documented;

Information verified from original source, when possible.

SQE.12

Record contains copies of any required license, certification, or registration.

SQE.12

Responsibilities are defined in a current job description.

SQE.1.1

Ability to carry out

responsibilities in job description evaluated at appointment.

SQE.3 #2

At least one documented evaluation each year or more frequently, if required by organization. SQE.3 #5

Staff providing patient care or others, as

designated, trained and competent in resuscitative techniques. SQE.8.1


OTHER HEALTH PROFESSIONAL STAFF Competence Assessment Process Review


1 2 3 4 5 6 Name or Category of Staff

Licensure, education, training, and experience are documented and

verified.

SQE.15 #2 #3

Record contains copies of any required license, certification, or registration.

SQE.15 #5

Responsibilities are defined in a current job description.

SQE.1.1

Ability to carry out responsibilities in job description evaluated at appointment.

SQE.4 #2

At least one documented evaluation each year or more frequently, if

required by policy. SQE.4 #5

Staff providing patient care, or designated others, trained and competent in resuscitative techniques. SQE.8.1


CLOSED MEDICAL RECORD REVIEW (OPTIONAL*) *Session is held at the request of the surveyors in order to validate the organization’s compliance with the documentation track record (4-months for initial surveys and 12-months for triennial surveys) Closed Patient Record Review Form: Instructions for Use Purpose of the form: The purpose for using the form is to gather and document compliance with the standards that require documentation in the patient’s record based on additional closed record review beyond the open records that are evaluated during the tracer activities. Organization of the form: The form is organized by topic headings (e.g., consents, assessments) and includes the specific standard number and the standard requirement (e.g., blood consent, medical assessment). This form will be provided by the survey team and used for the review. The form may be revised periodically to reflect approved changes in the standards. Review process: 1. The surveyor enters the number of the record being reviewed and the type of record (requested

recorded by diagnosis) on the top of the form. (Example: Record # 5554 Congestive Heart Failure)

2. The record is reviewed briefly to decide what type of patient or care was received (e.g. surgery, medical, emergency, rehabilitation).

Use of the form during the accreditation survey: 1. The team leader may request five to ten (5-10) closed records for review. The records will be

requested if the surveyors want to validate the organization’s documentation track record (4-month or 12-month) and/or ensure compliance with documentation or patient care process requirements due to situations or information identified during the tracer activities.

2. The survey team will also indicate the time period for selecting the records, typically the past four months or past year. Hospital staff should acquaint the survey team with the organization’s practice and expectation regarding the completion of a patient record following discharge of a patient.

3. To conduct the closed patient record review, the hospital leaders should provide one staff member with a translator, if needed for each surveyor involved in the closed record review. The selected staff person(s) should be knowledgeable about both the medical record and the clinical care processes in order to assist the surveyor(s).


4. The surveyor will review the selected records with the assistance of the hospital representative, as needed, to complete the form; one column of the form is completed for each record reviewed. If more that five records are reviewed, the surveyor will use another form.

5. For each documentation requirement, the surveyor will check the form to indicate if the required element is present, “yes”; if the element is not present, the surveyor will either check not present, “no” or not applicable to this patient’s record, “NA”.

6. The survey team aggregates the completed review forms to score the standards. The findings from the active or open review of patient records are integrated into aggregation and scoring.

7. The team leader retains the forms to support the survey findings.


MEDICAL RECORD REVIEW TOOL

Medical Record 1

Medical Record 2

Medical Record 3

Medical Record 4

Medical Record 5

#______________ DX:

#______________ DX:

#______________ DX:

#______________ DX:

#______________ DX:

TOTAL

STD

Documentation Requirement

Y N NA Y N NA Y N NA Y N NA Y N NA Y/N

CONSENTS PFR.6.3

General consent

PFR.6.4 Surgical or Invasive Procedures Consent Anesthesia and Moderate and Deep Sedation Consent Blood and blood Products Consent High-risk Procedures and Treatments Consent

ASC.5.1

Risks, benefits and alternatives of anesthesia

ASC.7.1 Risks, benefits, potential complications and alternatives of surgery

PFR.8

Clinical research, investigation, and trials consent

ASSESSMENTS AOP.1.4.1; Medical assessment in 24 hours; Updated if less than

30 days old Nursing assessment in 24 hours

AOP 1.5 Assessment findings are documented within 24 hours of admission (Medical & Nursing)

AOP.1.5.1

Medical assessment documented prior to surgery

AOP.1.6

Nutritional and functional screening

AOP.1.8.1

Early screening for discharge planning

AOP.1.8.2

Screening for pain on admission

AOP.2

Physician reassessment daily for acute patients

PFE.2

Education needs assessment


Medical Record 1

Medical Record 2

Medical Record 3

Medical Record 4

Medical Record 5

#______________ DX:

#______________ DX:

#______________ DX:

#______________ DX:

#______________ DX:

TOTAL

STD



ASC.3

Pre-sedation assessment

ASC.4

Pre-anesthesia assessment

OTHER ASC.5

Anesthesia Plan

ASC.7.2

Written Surgical Report -Description of the surgical procedure, findings, and any surgical specimens -A postoperative diagnosis -The names of the surgeon and surgical assistants -Available before the patient leaves the post-anesthesia recovery area.

ASC.6

Arrival and discharge times for post anesthesia care.

MMU.4

List of current medications taken prior to admission

MMU.4.3

Medications prescribed or ordered and administered are recorded

PFE.2.1

Assessment includes: -The patient’s and family’s beliefs and values; -Their literacy, educational level, and language; -Emotional barriers and motivations; -Physical and cognitive limitations; and -The patient’s willingness to receive information.

MCI.19.3

The author, date and time (When required) of every entry

ACC.3.2 Discharge Summary Contains:

-Reason for admission

-Significant physical and other findings

-Significant diagnoses and co-morbidities

-Diagnostic and therapeutic procedures performed

-Significant medications and other treatments


Medical Record 1

Medical Record 2

Medical Record 3

Medical Record 4

Medical Record 5

#______________ DX:

#______________ DX:

#______________ DX:

#______________ DX:

#______________ DX:

TOTAL

STD



-The patient’s condition at the time of discharge

-Discharge medications, all of the medications to be

taken at home -Follow-up instructions

ACC.4.4 Transferred Patients:

-Name of the health care organization and the

individual agreeing to receive the patient

-The reason(s) for transfer

-Any special conditions related to transfer -Any change of patient condition or status during transfer


GLD Interview Session PURPOSE: The purpose of the leadership interview is to assess communication among senior leaders of the organization and how they address organizational performance issues. LOCATION: At the discretion of the hospital’s leaders HOSPITAL PARTICIPANTS:

� Chief Executive Officer � Chief Operating Officer, when applicable � Chairman, Governing body or similar representative � Elected or appointed leader of the medical staff � Medical Director, when applicable � Nurse Executive � Quality Improvement Coordinator � Other senior leaders, at the discretion of the hospital

To foster an interactive process, a large group is not recommended for this interview. SURVEYORS: All surveyors on site STANDARDS/ISSUES TO BE ADDRESSED: Collaborative involvement of the senior leaders of the organization in governing, managing and directing the organization will be evaluated. The standards to be addressed are:

� Governance, Leadership and Direction (GLD) � Staff Qualifications and Education (SQE) � Patient and Family Rights (PFR) � Care of Patients (COP) � Anesthesia and Surgical Care (ASC) � Medication Management and Use (MMU) � Management of Communication and Information (MOI)

DOCUMENTS/MATERIALS NEEDED: No documents are required to be available during the leadership interview. However, during the document review session, the surveyors may have reviewed the following documents in preparation for the leadership interview:

• Organizational chart

• Mission statement

• Budget and resource allocation


• Strategic planning documents

• Information management plan

• Quality Management plan

• Worksheet of applicable laws and regulations WHAT WILL OCCUR: The surveyors will ask questions related to leadership activities and the decisions that have been made. Everyone present should participate in answering the questions. The surveyors will assess compliance with certain standards from the Governance, Leadership and Direction (GLD) chapter as well as other standards. Surveyors will also identify issues during the leadership interview that they will pursue in later survey activities. HOW TO PREPARE: Identify the participants in the leadership interview. While leaders should be familiar with all of the standards, have the organization's leaders closely read the GLD chapter prior to survey. In preparation for this interview, it would be useful to turn the standards into questions. Mock interviews could then be conducted with participants so they can feel more comfortable with possible questions. Some sample questions are: GLD.1.2 – Please explain the process you, as leaders, use to approve the policies and plans used to operate your organization. Measurable element #3 - What are your strategies and programs for health care professional education and research? GLD.1.6 – What is a recent example of how the governance of this organization has supported and promoted quality management and improvement efforts? GLD.3.3 – How do you monitor the services offered by an outside organization with which you have a contract to provide services? GLD.5.1 – What is your process for identifying in writing the services provided by each department? How do you know the documents are current?


Patient Safety Systems Evaluation PURPOSE: The purpose of the Patient Safety Systems Evaluation session is to assess the organizations process for identifying and implementing organization wide systems to improve quality and patient safety. LOCATION: At the discretion of the hospital’s leaders HOSPITAL PARTICIPANTS: Key members of the organization who have responsibilities for the various aspects of patient safety, include RCA, Proactive risk assessments (FMEA), International Patient Safety Goal, risk management, etc. To foster an interactive process, a large group is not recommended for this session. SURVEYORS: Physician, nurse and administrator surveyors STANDARDS/ISSUES TO BE ADDRESSED: Collaborative involvement of key members of the organization who have responsibilities for the various aspects of patient safety. The standards to be addressed are:

� Governance, Leadership and Direction (GLD) � Quality Improvement and Patient Safety (QPS) � Prevention and Control of Infection (PCI) � Medication Management and Use (MMU) � Facilities Management and Safety (MCI)

DOCUMENTS/MATERIALS NEEDED:

• Failure Mode Effects Analysis (FMEA) and/or other proactive risk assessment

• Root Cause Analyses (RCA)

• Infection Control Risk Assessment and plan

• Medication Management System evaluation

• Facilities Management Risk Assessment plan WHAT WILL OCCUR: o Discussion about specific elements of the various activities which interface to develop a

organization-wide systems approach to patient safety o Review examples that highlight this process and demonstrate how improvements have been

achieved


o Assign surveyors to accompany selected hospital staff to clinical area(s) to demonstrate how the process is working currently to increase patient safety.

The surveyors will ask questions related to risk assessment activities and the decisions that have been made. Everyone present should participate in answering the questions. HOW TO PREPARE: Identify key members of the organization who have responsibilities for the various aspects of patient safety, include RCA, Proactive risk assessments (FMEA), International Patient Safety Goal, risk management, etc. The participants in the Patient Safety Systems Evaluation session should be familiar with all of the standards and the organizations internal processes regarding risk assessment, identifying and responding to sentinel events. Have the organization's leaders closely review the related chapter requirements and the relevant internal process documents.


Surveyor Planning Meeting PURPOSE: On surveys being conducted by more than one surveyor, scheduled team meetings provide an opportunity for surveyors to share information and observations, plan for upcoming survey activities, and plan for communication and coordination with the organization. HOSPITAL PATICIPANTS None SURVEYORS: All surveyors on site LOCATION: Surveyor headquarters WHAT WILL OCCUR: For surveys lasting more than one day, a 45-minute session is scheduled at the end of each day to allow surveyors an opportunity to debrief and plan for subsequent survey days and activities. Surveys lasting longer than two days will include an additional 30-minute session before or after lunch to allow for mid-day activity planning and observation sharing. During these sessions surveyors will:

� Identify areas that have been visited during tracer activity � Coordinate locations, services, etc. that will be visited during continuing tracer activity � Share observations on organization performance � Identify key findings that have surfaced � Ask other surveyors to follow up on potential issues � Identify issues/areas that all surveyors should be exploring during individual patient and

system tracers When surveyors are in different locations at the times scheduled for Team Meetings, they may request assistance from the organization in facilitating communication among the members of the team (e.g., availability of a speaker phone or phone with conference call functionality, etc.). Note: When only one surveyor is present, this time is an opportunity to plan upcoming survey

activities, including the selection of additional tracers.


Survey Report Preparation PURPOSE: Surveyor(s) will use this time to compile, analyze and organize the data he or she has collected throughout the survey into a report reflecting the organization’s compliance with standards. HOSPITAL PARTICIPANTS: None SURVEYORS: All surveyors LOCATION: Designated surveyor conference room and a predetermined off-site location. WHAT WILL OCCUR: This time is reserved on the agenda for the surveyor(s) to review their observations and determine if there are any findings that reflect issues of standards compliance. When offsite, the surveyor(s) will be using their laptop computers to prepare the report and plan for the Leadership Briefing Conference. The surveyor(s) may ask organization representatives for additional information during this session to confirm or disprove a finding.


Leadership Briefing Conference

Leadership Briefing Conference PURPOSE: The purpose of this conference is to report

• Distribute the final report to the leaders and review the findings and scores

• Discuss the outcome of the Decision Rules

• Review the process for recording and submitting evidence of standards compliance into the Corrective Action Plan submitted to JCIA within 30 days

• Facilitate leaders in a discussion to identify appropriate o strategies for ensuring compliance with the findings identified in the survey report

LOCATION: At the discretion of the hospital’s leaders HOSPITAL PARTICIPANTS:

� Chief Executive Officer � Chief Operating Officer � Chairman, Governing body, or similar representative � Medical staff leadership � Nursing leadership � Others at the discretion of the hospital’s leaders

SURVEYORS: Physician, nurse and administrator surveyors STANDARDS/ISSUES TO BE ADDRESSED: Survey findings DOCUMENTS/MATERIALS NEEDED: None WHAT WILL OCCUR: The surveyors will open the conference and cover the following:

• Purpose of the conference

• Summary of compliance findings related to standards

• Discussion of any compliance findings for which there are questions or differences of perspective

• The content of the survey findings report

• The expected follow-up to the survey findings

• Education, as time permits, on areas indicated for follow-up within the 30 days.

The surveyors will explain the survey follow-up process regarding communication of the accreditation decision by the JCI Central Office.


Organization Exit Summary PURPOSE: At the discretion of hospital leadership the purpose of this conference is to communicate the survey findings to the hospital staff. LOCATION: At the discretion of the hospital’s leaders HOSPITAL PARTICIPANTS:

� Chief Executive Officer � Chief Operating Officer � Chairman, Governing body, or similar representative � Medical staff leadership � Nursing leadership � Others at the discretion of the hospital’s leaders

SURVEYORS: Physician, nurse and administrator surveyors STANDARDS/ISSUES TO BE ADDRESSED: Survey findings DOCUMENTS/MATERIALS NEEDED: None WHAT WILL OCCUR: The surveyors will open the conference and cover the following:

• Describe the organization’s journey to accreditation as a milestone toward the ultimate goal of continuous improvement in quality and patient safety

• Summarize the key positive organizational characteristics discovered during the survey activities which recognize success in their effort toward quality and patient safety

• Summarize the high-level findings from the survey report activities

• Assist the participants to understand where the organization fits into the timeline and next

steps in the journey to achieving accreditation and beyond


SURVEY PLANNING

Reference Lists


JOINT COMMISSION INTERNATIONAL ACCREDITATION Required Quality Monitors The organization chooses which clinical and managerial processes and outcomes are most important to monitor based on its mission patient needs and services provided. The organization’s leaders identify key measures (indicators) to monitor the organization’s clinical and managerial structures, processes and outcomes. Required Clinical monitoring includes structure, process or outcomes data selected by the leaders on aspects of:

QPS.3.1 patient assessment QPS.3.2 laboratory safety QPS.3.3 radiology and diagnostic imaging safety QPS.3.4 surgical procedures QPS.3.5 antibiotics and other medication use QPS.3.6 monitoring of medication errors and near misses QPS.3.7 anesthesia and sedation use QPS.3.8 use of blood and blood products QPS 3.9 availability, content and use of patient records QPS.3.10 infection control, surveillance and reporting QPS.3.11 clinical research

Required Managerial monitoring includes structure, process or outcomes data selected by the leaders on aspects of:

QPS.3.12 procurement of routinely required supplies and medications essential to meet patient needs

QPS.3.13 reporting of activities as required by law and regulation QPS.3.14 risk management QPS.3.15 utilization management QPS.3.16 patient and family expectations and satisfaction QPS.3.17 staff expectations and satisfaction QPS.3.18 patient demographics and clinical diagnoses QPS.3.19 financial management QPS.3.20 surveillance, control and prevention of events that jeopardize the safety of

patients, families and staff including the International Patient Safety Goals

Required General measures to be monitored: Clinical and managerial monitoring data are used to study targeted areas for improvement (QPS.3.1 through QPS.3.20 ME 2) and to monitor and evaluate the effectiveness of the improvements (QPS.3.1 through QPS.3.20 ME 3).


JOINT COMMISSION INTERNATIONAL ACCREDITATION Required Organization Plans The following standards identify requirements that relate to a written plan. A plan is usually more comprehensive in content than a policy or procedure. A plan can also be more long range, or strategic in content. Frequently a plan also sets priorities for the entire organization. For example, the quality management and improvement plan may address the organizations commitment to quality, how quality improvement efforts will be organized. It will also identify priorities for the short and long-range, and how those priorities will be achieved. QUALITY IMPROVEMENT AND PATIENT SAFETY: There is a written plan for an organization-wide quality improvement and patient safety program. [QPS.1] GOVERNANCE, LEADERSHIP, AND DIRECTION: Organization plans (strategic or other documents) describe the care and services to be provided consistent with the mission. [GLD 3.2] Directors of each clinical department or service identify in writing the current and planned services to be provided by the department or service. [GLD 5.1] FACILITY MANAGEMENT AND SAFETY: The organization has a master plan to reduce evident risks in the environment [FMS.2] or individual plans that include, as appropriate to the facility and activities of the organization, the following areas: [FMS.4 through FMS.10]:

1. Safety and Security (FMS.4.2) • Safety – buildings, grounds, and equipment do not pose a risk to patients, staff and

visitors • Security – protect the facility and occupants from loss, destruction, tampering, and

unauthorized access or use 2. Hazardous materials – handling, storage and use of radioactive and other materials

(FMS.5) 3. Emergencies – response to epidemics, disasters and emergencies (FMS.6) 4. Fire safety –property and occupants are protected from fire and smoke (FMS.7) 5. Medical equipment – equipment selected, maintained and used in a manner to reduce

risks (FMS.8) 6. Utility systems – electric, water and other utility systems maintained to minimize risk of

failure (FMS.9.1)


STAFF QUALIFICATION AND EDUCATION: There is a plan for staffing the organization, developed collaboratively by the clinical and managerial leaders, that identifies the number, types and desired qualifications of staff. [SQE 6] MEDICATION MANAGEMENT AND USE There is a plan (policy or other document) that identifies how medication use is organized and managed throughout the organization (MMU.1). PREVENTION AND CONTROL OF INFECTIONS There is a comprehensive program and plan to reduce the risk of health care-associated infections in patients, health care workers and visitors (PCI.5).


JOINT COMMISSION INTERNATIONAL ACCREDITATION Required Policies and Procedures, Written Documents, or Bylaws

Each of the following standards identify a requirement for a written document. In some cases document is in the form of a policy and procedure. In other cases, the document is less formal, but addresses the issue identified in the standard. In many cases a number of standard requirements can be combined into one policy and procedure. For example, many of the patient assessment requirements are interconnected and can be contained in one policy. The surveyors may not need to review all these documents in detail. It is however best to gather all these documents into one book or alternatively, identify the document by standard number in the traditional location of the document for easy location. NOTE: Please refer to the guidelines for document review for detailed suggestions on the presentation of documents for the surveyors. A select few of these documents need to be in English. The documents that need to be in English are identified below in caps. Other documents do not need to be translated. For documents that are not in English, the survey team will have one member able to read the documents or alternatively, the survey team may request that one or more individuals are available to describe the contents of the document and answer questions concerning the document.

International Patient Safety Goals Goal Measurable Element(s) Page

Number Goal 1 1. A collaborative process is used to develop policies and/or procedures that address

the accuracy of patient identification. 2. The policies and/or procedures require the use of two patient identifiers, not including the use of the patient’s room number or location. (ENGLISH)

32

Goal 2 1. A collaborative process is used to develop policies and/or procedures that address the accuracy of verbal and telephone communications.

33

Goal 3 1. A collaborative process is used to develop policies and/or procedures that address the location, labeling, and storage of concentrated electrolytes.

33

Goal 4 1. A collaborative process is used to develop policies and/or procedures that will establish uniform processes to ensure the correct site, correct procedure, and correct patient, including procedures done in settings other than the operating theatre. (ENGLISH)

34

Goal 5 1. A collaborative process is used to develop policies and/or procedures that address reducing the risk of health care–associated infections.

35

Goal 6 1. A collaborative process is used to develop policies and/or procedures that address reducing the risk of patient harm resulting from falls in the organization.

35


Access to Care and Continuity of Care (ACC) Standard Measurable Element(s) Page

Number ACC.1 5. Policies identify which screening and diagnostic tests are standard before

admission. 7. Policies define how patients are informed when there will be a wait or delay in care and treatment and the reasons for the delay or wait, and how the information will be documented.

41

ACC.1.1 1. Policies and procedures are used to standardize the outpatient registration process. 2. Policies and procedures are used to standardize the inpatient admitting process. 4. The policies and procedures address admitting emergency patients to inpatient units. 5. The policies and procedures address holding patients for observation. 6. The policies and procedures address managing patients when bed space is not available on the desired service or unit or elsewhere in the facility.

42

ACC.1.4 1. The organization has established entry and/or transfer criteria for its intensive and specialized services or units, including research and other programs to meet special patient needs. (ENGLISH)

44

ACC.2 2. Established criteria or policies determine the appropriateness of transfers within the organization.

45

ACC.3 1. There is a policy guiding the appropriate referral and/or discharge of patients. 6. Organization policy guides the process of patients “on pass” for a defined period of time.

46

ACC.4 1. There is policy guiding the appropriate transfer of patients. (ENGLISH) 48


Patient and Family Rights (PFR) Standard Measurable Element(s) Page

Number PFR.1 5. Policies and procedures guide and support patient and family rights in the

organization. 56

PFR.2 1. Policies and procedures are developed to support and promote patient and family participation in care processes.

59

PFR.2.3 3. Policies and procedures are implemented to guide the process for patients to make their decisions known to the organization and for modifying decisions during the course of care.

61

PFR.3 4. Policies and procedures identify participants in the process. 5. Policies and procedures identify how the patient and family participate.

63

PFR.6 1. The organization has a clearly defined informed consent process described in policies and procedures.

64

PFR.6.4.1 1. The organization has listed those procedures and treatments that require separate consent. (ENGLISH)

66

PFR.7 7. Policies and procedures guide the information and decision process. 67 PFR.9 2. The organization develops a clear statement of purpose for the oversight

activities. 68

PFR.11 1. Policies and procedures guide the procurement and donation process. (ENGLISH) 2. Policies and procedures guide the transplantation process.

69


Assessment of Patients (AOP) Standard Measurable Element(s) Page

Number AOP.1 1. Organization policy and procedure define the assessment information to be

obtained for inpatients. (ENGLISH) 2. Organization policy and procedure define the assessment information to be obtained for outpatients. (ENGLISH) 3. Organization policy identifies the information to be documented for the assessments. (ENGLISH)

74

AOP.1.1 1. The scope and content of assessments by each clinical discipline are defined in policies. (ENGLISH) 2. The scope and content of assessments performed in inpatient and outpatient settings are defined in policies. (ENGLISH)

74

AOP.1.4.1 1. The initial medical assessment is conducted within the first 24 hours of admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy. 2. The initial nursing assessment is conducted within the first 24 hours of admission as an inpatient or earlier as indicated by the patient’s condition or hospital policy.

77

AOP.1.6 1. Qualified individuals develop criteria to identify patients who require further nutritional assessment. 4. Qualified individuals develop criteria to identify patients who require further functional assessment.

78

AOP.3 5. Those qualified to conduct patient assessments and reassessments have their responsibilities defined in writing.

81

AOP.5.1 3. Written policies and procedures address the handling and disposal of infectious and hazardous materials.

83

AOP.5.3 1. The organization has established the expected report time for results. 84 AOP.5.6 1. Procedures guide the ordering of tests.

2. Procedures guide the collection and identification of specimens. 3. Procedures guide the transport, storage, and preservation of specimens. 4. Procedures guide the receipt and tracking of specimens.

85

AOP.5.11 1. A roster of experts for specialized diagnostic areas is maintained. 88 AOP.6.2 3. Written policies and procedures address compliance with applicable standards,

laws, and regulations. 4. Written policies and procedures address handling and disposal of infectious and hazardous materials.

89

AOP.6.10 1. The organization maintains a roster of experts for specialized diagnostic areas. 93


Care of Patients (COP) Standard Measurable Element(s) Page

Number COP.1 2. Policies and procedures guide uniform care and reflect relevant laws and

regulations. 97

COP.3 1. The organization’s leaders have identified the high-risk patients and services. 2. The leaders use a collaborative process to develop applicable policies and procedures.

100

COP.3.1 1. The care of emergency patients is guided by appropriate policies and procedures. 101 COP.3.2 1. The uniform use of resuscitation services throughout the organization is guided

by appropriate policies and procedures. 101

COP.3.3 1. The handling, use, and administration of blood and blood products is guided by appropriate policies and procedures. (ENGLISH)

102

COP.3.4 1. The care of comatose patients is guided by appropriate policies and procedures. (ENGLISH) 2. The care of patients who are on life support is guided by policies and procedures. (ENGLISH)

102

COP.3.5 1. The care of patients with a communicable disease is guided by appropriate policies and procedures. 2. The care of immune-suppressed patients is guided by appropriate policies and procedures.

102

COP.3.6 1. The care of patients on dialysis is guided by appropriate policies and procedures. (ENGLISH)

102

COP.3.7 1. The use of restraint is guided by appropriate policies and procedures. 102 COP.3.8 1. The care of frail, dependent elderly patients is guided by appropriate policies and

procedures. 3. The care of young, dependent children is guided by appropriate policies and procedures. 5. Patient populations at risk for abuse are identified and their care is guided by appropriate policies and procedures.

102

COP.3.9 1. The care of patients receiving chemotherapy or other high-risk medications is guided by appropriate policies and procedures. (ENGLISH)

102

COP.6 2. Patients in pain receive care according to pain management guidelines. 104


Anesthesia and Surgical Care (ASC) Standard Measurable Element(s) Page

Number ASC.3 1. Appropriate policies and procedures, addressing at least elements a) through f)

found in the intent statement, guide the care of patients undergoing moderate and deep sedation. (ENGLISH)

111

Medication Management and Use (MMU) Standard Measurable Element(s) Page

Number MMU.1 1. There is a plan or policy or other document that identifies how medication use is

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

119

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

120

MMU.31 1. Organization policy defines how appropriate nutrition products are stored. 2. Organization policy defines how radioactive, investigational and similar medications are stored. 3. Organization policy defines how sample medications are stored and controlled. 4. Organization policy defines how emergency medications are stored and maintained.

122

MMU.3.3 2. Policies and procedures address any use of medications known to be expired or outdated. 3. Policies and procedures address the destruction of medications known to be expired or outdated.

123

MMU.4 1. Policies and procedures guide the safe prescribing, ordering and transcribing of medications in the organization. (ENGLISH) 2. Policies and procedures address actions related to illegible prescriptions and orders. (ENGLISH)

123

MMU.4.1 1. Acceptable medication orders or prescriptions are defined in policy(s) and at least elements a) through i) are addressed in the policy(s). (ENGLISH)

124

MMU.7.1 1. A medication error and near miss are defined. (ENGLISH) 129


Quality Improvement and Patient Safety (QPS) Standard Measurable Element(s) Page

Number QPS.1 1. The organization’s leadership participates in developing the plan for the quality

improvement and patient safety program. 143

QPS.3 1. The leaders identify key measures to monitor clinical areas. 2. The leaders identify key measures to monitor managerial areas.

149

QPS.5 1. The hospital leaders have established a definition of a sentinel event that at least includes a) through c) found in the intent statement. (ENGLISH)

151

QPS.6 7. Other events defined by the organization are analyzed. (ENGLISH) 152 QPS.7 1. The organization establishes a definition of a near miss and the type of events to

be reported. (ENGLISH) 152

Prevention and Control of Infections (PCI) Standard Measurable Element(s) Page

Number PCI.5 1. There is a comprehensive program and plan to reduce the risk of health care–

associated infections in patients. (ENGLISH) 2. There is a comprehensive program and plan to reduce the risk of health care– associated infections in health care workers. (ENGLISH) 6. Risk-reduction goals and measurable objectives are established and regularly reviewed. (ENGLISH)

159

PCI.7.1 3. When single-use devices and materials are reused, there is a policy that includes items a) through e) in the intent statement, and the policy is implemented. (ENGLISH)

161

PCI.8 1. Patients with known or suspected contagious diseases are isolated in accordance with organization policy and recommended guidelines. 2. Policies and procedures address the separation of patients with communicable diseases from patients and staff who are at greater risk due to immunosuppression or other reasons.

163


Governance, Leadership, and Direction (GLD) Standard Measurable Element(s) Page

Number GLD.1 1. The organization’s governance structure is described in written documents.

(ENGLISH) 2. Governance responsibilities and accountabilities are described in the documents. (ENGLISH) 3. The documents describe how the performance of the governing entity and managers will be evaluated and any related criteria. (ENGLISH) 5. There is an organization chart or document. (ENGLISH)

170

GLD.1.1 1. Those responsible for governance approve the organization’s mission. 171 GLD.3.2 1. Organization plans describe the care and services to be provided. 174 GLD.5.1 2. The departmental or service documents describe the current and planned services

provided by each department or service. 177

GLD.5.3 1. The director develops criteria related to the needed education, skills, knowledge, and experience of the department’s professional staff.

178

GLD.6.1 3. The organization provides clear admission, transfer, and discharge policies. 180

Facility Management and Safety (FMS) Standard Measurable Element(s) Page

Number FMS.2 1. There are written plan(s) that address the risk areas a) through f) in the intent

statement. 185

FMS.4.1 1. The organization has a documented, current, accurate inspection of its physical facilities.

186

FMS.5 1. The organization identifies hazardous materials and waste and has a current list of all such materials within the organization.

187

FMS.8 2. There is an inventory of all medical equipment. 190


Staff Qualifications and Education (SQE) Standard Measurable Element(s) Page

Number SQE.6 1. There is a written plan for staffing the organization. 210 SQE.8.4 4. There is a policy on the provision of staff vaccinations and immunizations.

5. There is a policy on the evaluation, counseling, and follow-up of staff exposed to infectious diseases that is coordinated with the infection prevention and control program.

204

Management of Communication and Information (MCI) Standard Measurable Element(s) Page

Number MCI.7 1. Policy establishes those care providers who have access to the patient’s record(s). 219 MCI.10 1. There is a written policy for addressing the privacy and confidentiality of

information that is based on and consistent with law and regulation. 220

MCI.11 1. The organization has a written policy for addressing information security, including data integrity, that is based on or consistent with law or regulation.

221

MCI.12 1. The organization has a policy on retaining patient clinical records and other data and information.

221

MCI.18 1. There is a written policy or protocol that defines the requirements for developing and maintaining policies and procedures including at least items a) through h) in the intent, and it is implemented. (ENGLISH) 2. There is a written protocol that outlines how policies and procedures that originated outside the organization will be controlled, and it is implemented. (ENGLISH) 3. There is a written policy or protocol that defines retention of obsolete policies and procedures for at least the time required by law and regulation, while ensuring that they will not be mistakenly used, and it is implemented. (ENGLISH) 4. There is a written policy or protocol that outlines how all policies and procedures in circulation will be identified and tracked, and it is implemented. (ENGLISH)

224

MCI.19.2 1. Those authorized to make entries in the patient clinical record are identified in organization policy.

226


JOINT COMMISSION INTERNATIONAL ACCREDITATION Standards that Reference Laws and Regulations

The International Standards for Hospitals were designed to be surveyed in the context of relevant, country-specific local and national laws and regulations. The survey process takes into account the laws and regulations under which a hospital operates and provides patient care in one of two ways:

1. If a relevant law and/or regulation set a less stringent expectation than the accreditation standard, then the expectation of the accreditation standard is surveyed and scored.

2. If, on the other hand, the law and/or regulation set a more stringent expectation than the accreditation standard, then the survey team will expect to find that the hospital is in compliance with the relevant law and/or regulation.

A senior manager or director is responsible for operating the organization and for complying with applicable laws and regulations (GLD.2). The survey team will expect that this individual:

• Is knowledgeable concerning the applicable laws and/or regulations;

• Is aware of how the organizations complies with such laws and/or regulations; and

• Has satisfactorily responded to any citations or reports from agencies responsible for the enforcement of the laws and/or regulations.

The Law and Regulation Worksheet that follows is designed to familiarize the organization with those particular standards that reference country-specific laws and/or regulations, and to provide a summary of relevant applicable laws and/or regulations to the survey team for appropriate evaluation of the accreditation standards. Note: Use the worksheet to indicate when there are laws and/or regulations that are in conflict with each other, and when there are laws and/or regulations that are in conflict with the standard. Please complete this worksheet and provide it to the survey team at the document review session. The worksheet contains additional space to include other laws and regulations that may be applicable to the accreditation survey process, but may not be referenced in the standards.


Law and Regulation Worksheet

STANDARD NUMBER

APPLICABLE LAW/REGULATION?

(YES/ NO)

NAME OF LAW/REGULATION

IF YES

IS LAW/REGULATION MORE STRINGENT THAN STANDARD?

note conflicts (YES / NO)

ACCESS (ACC)

ACC.6

RIGHTS (PFR)

PFR.1 PFR.1.6 PFR.2.3 PFR.6 PFR.6.2 PFR.11

ASSESSMENT (AOP)

AOP.1.1 AOP.1.7 AOP.3 AOP.5 AOP.5.8 AOP.6 AOP.6.1 AOP.6.2 AOP.6.7

CARE (COP)

COP.1

ANESTHESIA/ SURGERY (ASC)

ASC.1 ASC.2

MEDICATIONS (MMU)

MMU.1 MMU.3 MMU.4.2 MMU.5 MMU.6


STANDARD NUMBER


(YES/ NO)


IF YES



EDUCATION (PFE)

NONE

QUALITY (QPSI)

QPS.2

QPS.3.13

INFECTIONS (PCI)

PCI.3

PCI.10.6

GOVERNANCE (GLD)

GLD.2

GLD.6

FACILITY (FMS)

FMS.1

FMS.4.2

FMS.5

STAFF (SQE)

SQE.1

SQE.9

SQE.13

SQE.15

SQE.16

COMMUNICATION &

INFORMATION (MCI)


STANDARD NUMBER


(YES/ NO)


IF YES



MCI.10

MCI.12

MCI.18

MCI.19.4

SPG-Hospital 3rd Edition

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Transcript of SPG-Hospital 3rd Edition