JCI 2nd Edition

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Joint Commission International Accreditation Hospital Survey Process Guide 4th Edition Effective 1 January 2011 Version 2

Transcript of JCI 2nd Edition

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Joint Commission International Accreditation

Hospital

S u r v e y P r o c e s s G u i d e4 t h E d i t i o n

Effective1 January 2011

Version 2

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Senior Editor: Maria R. Aviles, M.A.Project Manager: Andrew BernotasManager, Publications: Paul ReisAssociate Director, Production: Johanna HarrisExecutive Director: Catherine Chopp Hinckley, Ph.D.Joint Commission International Reviewers: Ann Jacobson, Claudia Jorgenson, Paul van Ostenberg, Brenda White

Joint Commission InternationalA division of Joint Commission Resources, Inc.

The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the international community through the provision ofeducation, publications, consultation, and evaluation services.

Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of Joint CommissionInternational. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no specialconsideration or treatment in, or confidential information about, the accreditation process.

© 2010 Joint Commission International

All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher.

Printed in the U.S.A. 5 4 3 2 1

Requests for permission to make copies of any part of this work should be mailed toPermissions EditorDepartment of PublicationsJoint Commission ResourcesOne Renaissance BoulevardOakbrook Terrace, Illinois 60181 [email protected]

ISBN: 978-1-59940-404-2Library of Congress Control Number: 2010930481

For more information about Joint Commission Resources, please visit http://www.jcrinc.com.

For more information about Joint Commission International, please visit http://www.jointcommissioninternational.org.

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

Introduction ..................................................................................................................................................................................1

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

Joint Commission International—Who Are We?..........................................................................................................................2

Who Is Eligible for an International Hospital Accreditation Survey?............................................................................................4

How to Request an International Hospital Accreditation Survey ................................................................................................4

Survey Scheduling, Postponements, and Cancellations ............................................................................................................5

The Standards Manual ................................................................................................................................................................6

Scoring Guidelines for Survey Consistency ................................................................................................................................8

Accreditation Decision Rules (Effective 1 January 2011) ..........................................................................................................14

Accreditation Preparation ..........................................................................................................................................................16

Preparation Timeline ............................................................................................................................................................17

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

The On-Site Survey ..................................................................................................................................................................21

Sample Survey Agenda ............................................................................................................................................................22

Tracer Methodology ..................................................................................................................................................................27

The Accreditation Decision ........................................................................................................................................................30

Survey Agenda: Detailed Descriptions ......................................................................................................31

Opening Conference..................................................................................................................................................................32

Orientation to the Hospital’s Services and the Quality Improvement Plan................................................................................34

Surveyor Planning Session........................................................................................................................................................35

Document Review......................................................................................................................................................................37

Documents Available in English ..........................................................................................................................................37

Daily Briefing..............................................................................................................................................................................41

Facility Tour................................................................................................................................................................................43

Sample Outline of a Facility Inspection Report ....................................................................................................................45

Individual Patient Tracer Activity................................................................................................................................................46

System Tracer: Medication Management ..................................................................................................................................49

System Tracer: Infection Control ..............................................................................................................................................52

System Tracer: Improvement in Quality and Patient Safety......................................................................................................54

Quality Improvement and Patient Safety (QPS) Monitoring Plan: Measures Documentation Tool......................................57

System Tracer: Facility Management and Safety System ........................................................................................................59

Undetermined Survey Activities ................................................................................................................................................63

Education Session: Hospital Decision Rules, Scoring Guidelines, and Strategic Improvement Plan ......................................64

Staff Qualifications and Education Session ..............................................................................................................................65

Medical Staff Qualifications Worksheet ................................................................................................................................67

Competency Assessment Process Review Forms ..............................................................................................................68

Closed Medical Record Review ................................................................................................................................................70

Medical Record Review Tool ................................................................................................................................................71

Leadership Conference ............................................................................................................................................................76

Surveyor Team Meeting ............................................................................................................................................................78

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Table of Contents

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Surveyor Report Preparation ....................................................................................................................................................79

Leadership Exit Conference ......................................................................................................................................................80

Survey Planning: Reference Lists ..............................................................................................................81

Required Quality Monitors ........................................................................................................................................................82

Required Hospital Plans ............................................................................................................................................................83

Required Policies and Procedures, Written Documents, or Bylaws..........................................................................................85

Standards That Reference Laws and Regulations ..................................................................................................................100

Law and Regulation Worksheet .........................................................................................................................................101

External Auditing Body Recommendation Worksheet .......................................................................................................106

Index ............................................................................................................................................................107

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Contact DirectoryJoint Commission International Accreditation Central Office1515 West 22nd Street, Suite 1300WOak Brook, IL 60523 U.S.A.Phone: +1.630.268.4800Fax: +1.630.268.2996E-mail: [email protected]

Contact Joint Commission International for any of the following:• To inquire about a completed application for survey, survey date, or schedule or for assistance with specific problems or

information related to accreditation• To register for or receive information about education programs and to purchase or to inquire about publications

Joint Commission International Web Site: http://www.jointcommissioninternational.orgVisit the Web site to obtain any of the following:

• General information about accreditation• Joint Commission International news• Information about accreditation status for specific hospitals• Application for survey• Frequently asked questions (FAQs)• JCInsight, JCI’s newsletter• Revisions to standards• Standards• To submit a complaint about an accredited organization

Joint Commission Resources Web Site: http://www.jcrinc.comVisit the Web site to obtain any of the following:

• Information about upcoming education programs• Catalog of publications• Access to official JCI publications and e-books• Video streaming presentations

IntroductionThe Joint Commission International Accreditation Hospital Survey Process Guide is designed to help hospitals learn about JointCommission International (JCI) standards and the survey process. This guide will provide hospitals with important informationabout JCI, the hospital standards manual, eligibility for accreditation, how to request accreditation, survey preparation, the on-site survey, and the accreditation decision.

Hospitals should not hesitate to contact any of the JCI Accreditation Offices by telephone or e-mail using the contact directoryabove for any other information they may need.

Joint Commission International European OfficeDr. Carlo Ramponi, Managing Director13, Chemin du Levant Immeuble JB Say F-01210 Ferney-Voltaire France Phone: +33.4.50.42.60.82 Fax: +33.4.50.42.48.82E-mail: [email protected]

Joint Commission International Middle East OfficeDr. Ashraf Ismail, Managing DirectorP.O. Box 505018Dubai Healthcare CityDubai, United Arab Emirates Phone: +971.4369.4930 Fax: +971.4362.4951E-mail: [email protected]

Joint Commission International Asia Pacific OfficeDr. Paul Chang, Managing Director37th FloorSingapore Land Tower50 Raffles PlaceSingapore 048623 Phone: +65.6829.7208 Fax: +65.6829.7070E-mail: [email protected]

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The Value of Joint Commission International AccreditationAccreditation may benefit hospitals by accomplishing the following:

• Giving hospitals a competitive advantageAccreditation provides evidence of high-quality patient care that helps level the playing field for hospitals performing thesame types of procedures.

• Strengthening community confidenceAchieving accreditation is a visible demonstration to patients and the community that a hospital is committed to providingthe highest-quality services.

• Obtaining recognition from insurers, associations, employers, and other stakeholdersIncreasingly, accreditation is becoming an eligibility prerequisite for reimbursement, association membership, communityawareness, and contracts or grants.

• Validating high-quality care to patientsJCI standards are focused on achieving one goal: raising the safety and quality of care to the highest possible level. Achievingaccreditation is a strong validation that a hospital has taken the extra steps to meet a high level of safety and quality.

• Helping hospitals organize and strengthen their improvement effortsAccreditation encompasses state-of-the-art performance improvement concepts that help hospitals continuously improvequality.

• Enhancing staff educationThe survey process is designed to be educational, not punitive. JCI surveyors are trained to help hospitals improve theirinternal procedures and day-to-day operations.

• Improving risk managementBy enhancing risk management efforts, accreditation may improve access to or reduce the cost of liability coverage. It canalso assist in lowering adverse events or outcomes for the hospital and, more importantly, for the patient.

• Facilitating staff recruitmentAs staff recruitment becomes more difficult, achieving accreditation as a demonstration of a hospital’s commitment toquality and patient safety will enhance recruitment efforts and retention of staff.

• Promoting team-building skills for staffThe process of obtaining and maintaining accreditation demands a team approach to good patient care. Establishingprocesses and systems that support good patient care is achieved through strong team activities.

Joint Commission International—Who Are We?JCI is a division of Joint Commission Resources (JCR), the subsidiary of The Joint Commission. For more than 75 years, TheJoint Commission (U.S.A.) and its predecessor organization have been dedicated to improving the quality and safety of healthcare services. Today, The Joint Commission is the largest accreditor of health care organizations in the United States—it surveysnearly 18,000 health care programs through a voluntary accreditation process. The Joint Commission and JCI are bothnongovernmental, not-for-profit U.S. corporations.

The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with otherstakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of thehighest quality and value.

The Joint Commission was founded in 1951 under the auspices of the American Hospital Association, the American MedicalAssociation, the American College of Physicians, and the American College of Surgeons, with the later addition of the AmericanDental Association, to act as an independent accrediting body for organizations nationwide. As such, The Joint Commissioncurrently accredits nearly 80% of U.S. health care organizations. Because of the changing nature of health care in America,beginning in 1975, The Joint Commission broadened its scope to include accreditation of many non-hospital settings.

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JCI extends The Joint Commission’s mission worldwide. Through international consultation, accreditation, publications, andeducation, JCI helps to improve the quality of patient care in many nations. JCI has extensive international experience workingwith public and private health care organizations and local governments in more than 90 countries.

JCI established the Hospital Accreditation Program to encourage high-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 thehealth care marketplace. Providing safe, high-quality care to patients and continually improving performance are benchmarks ofsuccess. JCI hospital accreditation is a widely recognized standard for high-quality services.

Why Choose Joint Commission International 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 ApprovalTM” in health care and provides the most comprehensive evaluationprocess.

The Joint Commission International Patient-Centered Accreditation ProcessSignificant changes were made to the JCI accreditation process in 2006 to make the process more focused on the patient’s careexperience. To help clarify the changes to this process, tracer methodology was introduced as a new term. The new patient-centered process also shifts accreditation away from survey preparation to continuous standards compliance. The survey becomesmerely the on-site evaluation piece of a continuous quality improvement process. See pages 27–29 for more information ontracer methodology.

Joint Commission International Standards Represent an International ConsensusIn July 2010, a revised set of standards was published for implementation on 1 January 2011. The standards in the fourthedition of the Joint Commission International Accreditation Standards for Hospitals were created through the following processes:

JCI Standards Committee, Accreditation Committee, and Board of DirectorsThe standards undergo extensive field review prior to being published. An International Standards Committee, composed ofexperts in the health care quality and patient safety fields, was established. This committee provides advice and assistance indeveloping new and revised standards and recommends improvements to the accreditation process. These changes are reviewedby the Accreditation Committee and are approved by the Board of Directors. This committee also oversees the revision of thestandards and their introduction to the health care community.

Regional International Advisory GroupsRegional International Advisory Groups, representing ministries of health, professional health care associations, and nationalaccrediting organizations, meet on a regular basis to discuss ongoing issues and potential future improvements to the JCIaccreditation process.

Field Review ProcessWhen periodic revisions or changes to the standards are made, health care organizations, whether accredited or not, are given anopportunity to comment on those changes. Field review announcements are posted on the JCI Web site and are sent to the JCIlist serve to elicit individual/organization comments. To join the JCI list serve, please contact the JCI Accreditation CentralOffice or sign up on the JCI Web site (see the Contact Directory on page 1).

Standards InterpretationJCI will answer specific questions about JCI standards and how they are interpreted. This is a no-cost service that can beaccessed by telephone, by e-mail, or through the JCI Web site. Please direct standards-related inquiries to StandardsInterpretation at http://www.jointcommissioninternational.org/interpretation-question/.

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Who Is Eligible for an International Hospital AccreditationSurvey?Any hospital may apply for JCI hospital accreditation if it meets the following requirements:

• The hospital is currently in operation as a health care provider in the country and is licensed (if required).• The hospital assumes, or is willing to assume, responsibility for improving the quality of its care and services.• The hospital provides services addressed by JCI standards.

How to Request an International Hospital AccreditationSurveyHospitals that wish to be accredited by JCI can obtain an application for survey by downloading the application from the JCIWeb site at http://www.jointcommissioninternational.org/Programs-Hospitals/.

The application for survey should be submitted to JCI at least six months prior to the hospital’s preferred on-site accreditation surveydates. Applications should be submitted, in electronic format, by e-mail attachment to [email protected] or by fax to+1.630.268.2996.

The application for survey is valid for six months from the date it is submitted; this means a hospital can submit its applicationand still have time to finish preparations before the on-site survey takes place. It is best to submit the application when thehospital is confident it will be able to demonstrate a four-month track record of compliance with the standards at the time ofthe on-site survey (see “Preparation Timeline” on pages 17–19).

On the application for survey, hospitals must indicate three months when they would like the survey to take place and fiveadditional weeks during the year when they would not like the survey to take place. JCI will make every effort to accommodatethese time requests. The earlier the request is submitted, the more likely the specific requests can be accommodated.

After the application for survey is received, the manager for JCI Accreditation Services will contact the hospital. The managerwill do the following:

• Answer the hospital’s questions about survey preparation and help guide individuals through each step of the accreditationprocess

• Analyze the application for survey and contact the hospital if there are any questions or items requiring clarification• Update changes to the hospital’s demographic information, including the address, contact name(s), and so forth• Assist in locating other resources or JCI contacts to answer questions• Schedule the on-site survey and assign the survey team and survey team leader• Forward the contract agreement for the on-site survey for a signature

JCI schedules on-site surveys based on information provided in the application for survey. Based on this information, JCIdetermines 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 accreditation survey contract agreement will be sent to the hospital. Until the signedcontract agreement and the down payment of at least 50% of the survey fees are received, the scheduled survey cannot beconfirmed. The hospital will also receive notification of the surveyor’s(s’) name before its survey. The survey team leader willcontact the person responsible for the hospital’s survey approximately four to eight weeks before the survey to finalize the agendaand to coordinate the availability of certain staff for key survey activities, as well as to provide information regarding thesurveyor’s(s’) travel arrangements and logistics.

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Handling Changes During the Application ProcessIf a hospital undergoes a change that modifies the information reported in the application for survey after it submits itsapplication, the hospital must notify JCI immediately of the change. Changes that must be reported to JCI include thefollowing:

• A change in hospital name, ownership, and/or leadership• 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• A required closure of a department or service by a regulatory or other legal authority

It may be necessary for JCI to schedule an additional survey for a later date if its survey team arrives at the hospital and discoversthat a change was not reported. JCI may also review any unreported services addressed by its standards. In either case, additionalfees may be assessed. JCI will make the final accreditation decision for the hospital only after reviewing all services provided bythe hospital for which JCI has standards.

Survey Scheduling, Postponements, and CancellationsInitial Schedules for SurveysJCI schedules surveys systematically and efficiently to keep accreditation fees to a minimum. Therefore, hospitals are encouragedto accept scheduled survey dates. Initial surveys (a hospital’s first full accreditation survey) should be scheduled within sixmonths from the time JCI receives the hospital’s application for survey.

JCI tries to honor specific requests for times during which a hospital prefers not to be surveyed. The hospital should includethese specific dates in the completed application for survey, when possible. There may, however, be circumstances that preventJCI from accommodating these dates.

Definition of PostponementJCI also allows the postponement of initial surveys or re-surveys. A postponement is a hospital’s request to alter an alreadyscheduled survey date or to push back the survey date before it is actually scheduled. A hospital should direct a request for apostponement to the manager for JCI Accreditation Services. A new survey application may be required when a new date isestablished if the original application is older than six months.

Acceptable Reasons for PostponementA hospital may postpone scheduled surveys when one or more of the following events occur:

• A natural disaster or another major unforeseen event that totally or substantially disrupts operations• A major strike that causes a hospital to cease accepting patients and to transfer patients to other facilities• Patients and/or the hospital are being moved to another building during the scheduled survey

JCI reserves the right to conduct an on-site survey if the hospital continues to provide patient care services under suchcircumstances. Prior to postponing a scheduled survey, it is recommended that hospitals contact the manager for JCIAccreditation Services.

JCI understands that hospital operations may need to be modified to accommodate construction and temporary disruptions inservice. These situations are expected as part of managing hospitals and do not require postponement of a scheduled survey.

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CancellationThe survey may be canceled by JCI or the hospital without penalty or damages in the event that acts of God, wars, terrorism,government regulations, disasters, strikes, civil disorders, or other emergencies of a similar nature make it impossible, illegal, orunreasonable to go forward, provided notice of the event requiring cancellation is communicated in writing as soon as practicallypossible. Further, JCI may follow the advice of relevant ministries concerned with evaluating political and military circumstanceswith regard to scheduling surveys.

If the hospital cancels the survey 60 days or less prior to the first day of the survey for any reason(s) other than those previously stated,JCI Accreditation Services may require payment of one half of the survey fees to recover costs JCI Accreditation Services has incurred.

The Standards ManualThe Joint Commission International Accreditation Standards for Hospitals, Fourth Edition, is the place to begin preparing foraccreditation. The introduction to the manual contains the applicable JCI accreditation policies and procedures (see pages 1–7).Hospitals considering accreditation can review these policies and procedures to better understand the expectations beforebeginning the accreditation journey. Even if hospitals do not pursue accreditation immediately, the manual is an excellent tool tohelp them evaluate current practices and structures. The manual contains functional standards that are organized around the waycare is provided in a hospital setting. The standards address patient-focused performance and are organized around functions andprocesses, including clinical and organizational, that are common to all health care organizations. The manual is designed to beused in self-assessment activities and forms the basis for an accreditation survey.

The JCI publication Joint Commission International Accreditation: Getting Started, Second Edition, provides detailed informationto assist hospitals plan the approach, structure, and process for beginning the accreditation journey.

The standards manual is divided into two sections: patient-centered functions and organization functions.

Patient-Centered FunctionsThe first section of the manual contains standards related to the patient and includes the standards in the following paragraphs.

International Patient Safety Goals (IPSG)The purpose of the International Patient Safety Goals is to promote specific improvements in patient safety. The goals highlightproblematic areas in health care and describe evidence- and expert-based consensus solutions to problems related to patientsafety. Recognizing that sound system design is intrinsic to the delivery of safe, high-quality health care, the goals generally focuson systemwide solutions, whenever possible.

Access to Care and Continuity of Care (ACC)These standards address which patient needs can be met by the health care organization, the efficient flow of services to patients,and the appropriate transfer or discharge of patients to their home or to another care setting.

Patient and Family Rights (PFR)These standards address issues such as promoting consideration of patients’ values, recognizing the hospital’s responsibilitiesunder law, and informing patients of their responsibilities in the care process. Standards regarding patient rights with respect toinformed consent, resolution of complaints, and confidentiality are also included.

Assessment of Patients (AOP)This chapter addresses patient assessment at all points of care within the hospital. Assessment includes collecting informationand data on the patient’s physical and psychosocial history, analyzing the data and information to identify the patient’s healthcare needs, and developing a plan of care to meet those identified needs. This chapter also includes standards that addresslaboratory services and diagnostic imaging and radiology services.

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Care of Patients (COP)This chapter discusses activities basic to patient care, including processes for planning and coordinating care, monitoring results,modifying care, and conducting follow-ups. The chapter also includes high-risk care services, nutrition care, pain management,and end-of-life care.

Anesthesia and Surgical Care (ASC)This chapter addresses sedation and anesthesia use and surgical care. Topics include procedures for preparing, monitoring, andplanning for after care for patients who received sedation or anesthesia and/or who had surgery.

Medication Management and Use (MMU)This chapter addresses systems and processes for selecting, procuring, storing, ordering/prescribing, transcribing, distributing,preparing, dispensing, administering, documenting, and monitoring medication therapies.

Patient and Family Education (PFE)This chapter contains standards that address the effectiveness of education that is provided to patients and families and themodalities employed to successfully educate these individuals. This chapter also examines patients’ readiness to learn byconsidering their language needs and learning preferences.

Organization FunctionsThe chapters in the second section of the manual examine the benefits of the hospital’s management system for patients,focusing on core processes that support good management. Examples of core processes include leadership requirements, infectionprevention and control, and the qualifications and education of staff.

Quality Improvement and Patient Safety (QPS)These standards focus on the success of a hospital’s design processes as well as processes the hospital uses to measure, assess, andultimately improve its performance. Examples of improvement efforts include designing a new service, documenting a clinicalprocess on a medical record, measuring outcomes, comparing performance with other similar organizations, and selectingpriority areas for attention.

Prevention and Control of Infections (PCI)These standards address the methods a hospital uses to design and implement a program to identify and reduce the risk ofpatients and staff acquiring and transmitting infections. Areas covered in this chapter include the process for reporting infectionsand the types of ongoing surveillance activities that are in place.

Governance, Leadership, and Direction (GLD)Effective leadership depends on successfully performing the following processes:

• Planning and designing services—defining a clear mission, including a vision of the future and the values that underlie day-to-day activities

• Directing services—developing and maintaining policies, providing an adequate number of staff, and determining theirqualifications and competence

• Integrating and coordinating services—identifying and planning the clinical services required and integrating andcoordinating those services within and between departments

• Improving performance—leaders’ critical roles in initiating performance and maintaining a hospital’s performanceimprovement activities

Facility Management and Safety (FMS)These standards measure the hospital’s maintenance of a safe, functional, and effective environment for patients, staff members,and other individuals. Areas addressed include emergency preparedness, security, safety, life safety, medical equipment, utilitysystems, hazardous materials, and waste management.

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Staff Qualifications and Education (SQE)This chapter includes sections on human resources planning; staff orientation, training, and education; staff competenceassessments; handling staff requests; and credentialing and privileging of licensed independent practitioners, nurses, and otherpractitioners.

Management of Communication and Information (MCI)These standards address how well the hospital obtains, manages, and uses information to provide, coordinate, and integrateservices. The principles of good information management apply to all methods, whether paper-based or electronic, and JCIstandards are equally compatible with either method.

Scoring Guidelines for Survey ConsistencyPurpose of This DocumentEach measurable element (ME) of a standard is scored as either “fully met,” “partially met,” “not met,” or “not applicable.” Thepurpose of this document is to bring consistency to the assignment of these scores, recognizing that many types of evidence willbe examined prior to the survey team arriving at a final score for each ME.

Determining the Appropriate Score1. “Fully Met” Score

A. An ME is scored “fully met” if the answer is “yes” or “always” to the specific requirements of the ME. Also considered arethe following:i. A single negative observation may not prevent a score of “fully met.” (Also see “Consideration of Impact and

Criticality” on pages 9–10.)ii. If 90% or more of observations or records (for example, 9 out of 10) are met

B. The track record related to a score of “fully met” is as follows:i. A 12-month look-back period of compliance for triennial surveysii. A 4-month look-back period of compliance for initial surveys

2. “Partially Met” ScoreA. An ME is scored “partially met” if the answer is “usually” or “sometimes” to the specific requirements of the ME. Also

considered are the following:i. If 50% to 89% (for example, 5 through 8 out of 10) records or observations demonstrate complianceii. Evidence of compliance cannot be found in all areas/departments in which the requirement is applicable (such as

inpatients but not outpatients, surgery but not day surgery, sedating areas except dental).iii. When there are multiple requirements in one ME, at least half (50%) are present.iv. A policy/process is developed, implemented, and sustainable but does not have the track record required for “fully met.”v. A policy/process is developed and implemented but does not seem to be sustainable.

B. The track record related to a score of “partially met” is as follows:The requirements of the ME are “fully met”; however, there is onlyi. a 5- to 11-month look-back period of compliance for triennial surveys; orii. a 1- to 3-month look-back period of compliance for initial surveys.

3. “Not Met” ScoreA. An ME is scored “not met” if the answer is “rarely” or “never” to the specific requirements of the ME. Also considered are

the following:i. If 49% or fewer (for example, 4 or less out of 10) records or observations demonstrate complianceii. There was a finding of “not met” for the ME during the last full survey and now the finding is 67% or fewer

observations of compliance.iii. When there are multiple requirements in one ME, 49% or fewer are present.iv. A policy/process is developed but is not implemented.

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B. The track record related to a score of “not met” is as follows:The requirements of the ME are “fully met”; however, there is onlyi. a less than 5-month look-back period of compliance for triennial surveys; orii. a less than 1-month look-back period of compliance for initial surveys.

C. If an ME of a standard was scored “not met” and some or all of the other MEs are dependent on the one scored “not met,”then the remaining MEs that are tied to the prior ME are scored as “not met.” See the figure below for AOP.1.4 as an example:

4. “Not Applicable” ScoreAn ME is scored “not applicable” if the requirements of the ME do not apply based on the organization’s services, patientpopulation, and so forth (for example, the organization does not conduct research).

Other Considerations1. The Look-Back Period for New Standards

The effective date of new standards is published with the standards. Hospitals are expected to be in compliance with thestandards on the published effective date. The look-back period for new standards can go back only to the effective date ofthe standard. Thus, for a new standard effective 1 January, the look-back period on a 1 April triennial survey is 3 monthsback to the 1 January effective date, not the 12 months for existing standards. Similarly, for a 1 April initial survey, thelook-back is 3 months rather than 4 months.

If a hospital does not meet the shorter look-back period for a new standard, the score on the ME will be influenced in thesame manner in which a full 12-month (triennial) or 4-month (initial) look-back period would be influenced. Forexample, if on a triennial survey, the possible look-back period for a new standard is 6 months, and the hospital is in fullcompliance (“fully met”) with the ME, but the organization can demonstrate compliance going back only 4 months, theME will be scored “partially met,” as 67% of the required look-back was met. The ME would be scored “not met” ifcompliance could be demonstrated for only 2 months, or 33% of the possible look-back period.

2. The Look-Back Period on Follow-Up Focused SurveysIf, following a full survey—initial or triennial—a follow-up focused survey is required within 90 days per the accreditationdecision rules, the look-back period at the time of the follow-up focused survey is from the date of the follow-up focusedsurvey, not from the date of the full survey. This will permit hospitals with good compliance for an ME on full survey, butinadequate look-back periods, to obtain 3 months of additional look-back and thus possibly obtain full credit forcompliance with the ME.

3. Consideration of Impact and CriticalityScores may be influenced by other factors, such as the impact or criticality of noncompliance for a standard or an ME.Impact refers to the effect or outcome of the finding. Criticality refers to the level or measure of importance of the finding.It is important to note that impact and criticality determinations are not rule based, nor are they individual based; rather,they are determinations made by the entire survey team, usually at the time each surveyor’s findings are integrated todetermine the final score of an ME.

AOP.1.4 Assessments are completed in the time frame prescribed by the organization.

❒ 1.Appropriate time frames for performing assessments are established for all settings and

services.

Not Met

❒ 2.Assessments are completed within the time frames established by the organization. Not Met

❒ 3.The findings of all assessments performed outside the organization are reviewed and/or

verified at the time of admission to inpatient status. Not Met

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Impact and criticality influence scoring in the following two ways:1. The impact of a particular compliance percentage or the actual number of noncompliant observations is an

important consideration. For example, 12 incomplete medication orders found in the record of 1 patient and madeby 1 physician are limited in impact and may actually be scored as 1 finding. Twelve incomplete medication ordersby 12 different physicians in 12 different patient records indicates far greater potential for patient harm and wouldbe scored as multiple findings. Thus, the sample of records and/or medication orders for review should be selectedin a manner that has the potential to reveal the greatest impact.

2. The criticality of the finding, rather than the actual number of noncompliant observations, is also important. Forexample, 1 blocked emergency exit out of 12 exits observed is a critical finding if the exit is from a crowded patientcare area. The finding is less critical if the blocked exit is from a little-used storage area.

4. Measurable Elements That Contain Multiple ExpectationsNote: The following standards are taken from the fourth edition of the Joint Commission International AccreditationStandards for Hospitals.

Each standard contains an ME that includes multiple compliance expectations (for example, elements [a] through [h]found in the intent statement). An explanation is provided with each standard to describe how these multiple complianceexpectations are to be evaluated and combined into a single score for the ME.

Standard PFR.6.1The unit of analysis is the information provided to individual patients. However, ME 1 states that information is provided“relevant to their condition and planned treatment.” Therefore, surveyors would likely use mixed sources of information,such as interviews with staff, patients, and families, and a review of the medical records to ascertain if the relevantinformation was provided to the patient.

Standard AOP.1.9The unit of analysis includes addressing elements (a) through (i) for each dying patient “as indicated by the patient’scondition.” Surveyors would likely use mixed sources of information, such as interviews with staff, patients, and families,and a review of the medical records to ascertain if the relevant information was provided to the patient.

Standard AOP.5.9The unit of analysis is the quality control program. Each of the elements (a) through (e) to be included in the programare scored in separate MEs (ME 2 through ME 5), with the exception of element (d), which is scored in AOP.5.5, ME 4.

Implementation of the program is scored in ME 6. All elements identified must be implemented for ME 6 to be scored as“fully met.” If only two or three of the elements are implemented, ME 6 would be “partially met,” and if only one of theelements is implemented, then ME 6 would be “not met.”

Standard COP.1The unit of analysis is the provision of uniform care throughout the organization. Surveyors would likely use mixed sources ofinformation, such as interviews with staff, patients, and families; a review of the medical records; information from patienttracers; and visits to patient care units to ascertain if the care provided is uniform throughout the organization.

Standards COP.3.1 Through COP.3.9The unit of analysis is the policy or procedure for each standard. In some instances, the organization may choose to developone policy/procedure that includes all of the standards. If there is a policy/procedure for each standard, then eachpolicy/procedure is scored separately and must include elements (a) through (f). If there is one policy/procedure that addressesall nine standards (this is not recommended), then all elements must be addressed individually for each standard.

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Standard COP.7The unit of analysis includes addressing elements (a) through (e) for each dying patient. Surveyors would likely use mixedsources of information, such as interviews with staff, patients, and families, and a review of the medical records toascertain if the organization routinely incorporates these elements for dying patients. Evidence of such things as sensitivityand respect would more likely be obtained through speaking with staff, patients, and families rather than through a reviewof the medical records.

Standard ASC.3The unit of analysis for elements (a) through (f ) is the sedation policy and procedure. The score is based on having morethan 50% of elements (a) through (f ) addressed in the policy.

The unit of analysis for elements (g) through (k) is the competency records of staff permitted to perform proceduralsedation in which elements (g) through (k) must be present.

Surveyors would obtain a sample of files from staff identified as competent to perform sedation and determine if all 5elements are present in the staff files, add the total number of elements present, and divide this total by the total numberof possible elements. For example, if 10 competency files were examined, there is a possible total of 50 elements. Afterreviewing the records, 22 elements were found to be present in the 10 competency records, so 22/50 = 0.44 (or 44%).ME 4 would be scored as “not met.”

Standard ASC.6The unit of analysis is the appropriate discharge of each postanesthesia patient. Elements (a) through (c) of the intentdescribe the three alternative methods by which a postanesthesia patient may be appropriately discharged. Therefore,scoring of ME 3 is based on whether the records of postanesthesia patients document that the patient was discharged byone of the three described methods.

Standard ASC.7.2The unit of analysis is the brief operative note in which elements (a) through (f ) must be present. Surveyors would gathera sample of clinical records, identify which of six elements are present in the operative note, add the total number ofelements present, and divide this total by the total number of possible elements. For example, if 10 brief operative noteswere examined in the clinical records, there is a possible total of 60 elements. After reviewing the operative notes, 42elements were found to be present in the 10 summaries, so 42/60 = 0.70 (or 70%). ME 1 would be scored as “partiallymet.”

Standard MMU.3Each of the elements (a) through (f ) is addressed in a separate ME; therefore, the elements are scored individually.

Standard MMU.4.1For ME 1, the unit of analysis is the policy. Each of the elements (a) through (i) must be addressed in the policy. Scoringof ME 1 would be based on the percentage of the elements addressed in the policy.

For ME 2, the unit of analysis is the written medication order. Surveyors would review multiple medication orders (ideallyfrom numerous physicians) and identify the elements of a complete medication order named in the policy that are presentin each order.

Standard MMU.5.1The unit of analysis is the prescription or order that includes elements (a) through (g). However, surveyors would likelyuse mixed sources of information, such as reviewing the process with multiple staff (such as physicians, pharmacists, and

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nurses) to ascertain whether the organization routinely incorporates these elements in its medication order review. Scoringmay be based on the consistency of the description of the process by staff.

Standard PFE.2.1The unit of analysis is the assessment tool (or something similar) in the clinical record that addresses elements (a) through(e) regarding the patient’s and family’s variables for learning.

Surveyors would look at the assessment tool of 10 clinical records for which there is a possible total of 50 elements. Forexample, after reviewing 10 assessments, surveyors find a total of 38 elements to be present, so 38/50 = 0.76 (or 76%).ME 1 would be scored as “partially met.”

Standard QPS.2ME 2 states that design elements are included when relevant to the process being designed or modified. Surveyors wouldlikely use mixed sources of information, such as interviewing multiple leaders, to determine how new processes aredesigned or modified. Scoring may be based on the consistency of the description of the process during the interviews.

Standard QPS.2.1The unit of analysis is the guidelines that have been implemented. The process for selecting and implementing guidelinesincludes elements (a) through (h); however, surveyors would likely use multiple sources of information to learn about theprocess. This investigation may include asking how the most recent guidelines were selected, asking what the process wasfor implementing the guidelines, and perhaps observing the use of the guidelines with the identified population on theclinical units.

Standard QPS.5The unit of analysis for ME 2 is the internal data validation process. The score would be based on the process using thecriteria identified in elements (a) through (f ) to validate data and take corrective actions when needed.

The unit of analysis for ME 3 is the clinical measures identified in QPS.3.1. The score would be based on theorganization using the data validation process for any of the 11 clinical measures identified by the organization leadersthat are new, going to be made public, or changed in any way (such as unexplained change in results, change in datasource, change in subject, and the like).

Standard QPS.6The unit of analysis is the sentinel event policy/description. The score is based on addressing more than 50% of elements(a) through (d) in the policy.

Standard QPS.11The unit of analysis is the risk management framework. The score would be based on the framework containing thecomponents identified in elements (a) through (f ).

Standard PCI.6The unit of analysis for ME 1 is the infection prevention and control program. The program would be expected toinclude elements (a) through (f ) of the intent statement.

The unit of analysis for ME 2 would be the evaluation of the data collected for elements (a) through (f ) of the intentstatement.

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Standard PCI.7.1.1The unit of analysis is the policy for reuse of single-use devices. The score is based on addressing more than 50% ofelements (a) through (e) in the policy and the policy being implemented. (See ME 3 of the standard.)

Standard GLD.5.5The unit of analysis is the process used by leaders to select department- or service-level monitors. The process uses thecriteria identified in elements (a) through (d), as appropriate to the department or service. Surveyors would use multiplesources of information to learn about the process, such as interviewing leaders, reviewing the safety program or policy, andthe like.

Standard FMS.2The unit of analysis is a plan or multiple plans that address elements (a) through (f ).

Standards FMS.3 and FMS.3.1The unit of analysis would include evaluating whether elements (a) through (g) were performed by the individual who hasoversight for the program. Surveyors would use multiple sources of information to determine if all of the elements havebeen addressed, for example, by asking how the plan was implemented, interviewing staff to determine how they wereeducated, reviewing the annual reports to the governing body, and the like.

Standards FMS.6 and FMS.6.1The unit of analysis is the emergency plan and program that includes the process for elements (a) through (g). Scoring isbased on the number of elements included in the plan and program.

Standard SQE.1.1The unit of analysis is a job description for each of the identified individuals in elements (a) through (d). Scoring wouldbe based on the presence of a job description for each of the individual job categories present in the organization.

Standard SQE.10The unit of analysis is the decision to grant reappointment for each clinical practitioner. ME 2 states that the decision isguided by items (a) through (f ) in the intent statement. Therefore, surveyors would ask organization leaders to identifythe information they used to guide them in their decision to reappoint each clinical practitioner.

Standard MCI.18The unit of analysis is the policy defining the requirements for developing and maintaining policies and procedures in theorganization. The score is based on addressing more than 50% of elements (a) through (h) in the policy.

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Accreditation Decision Rules (Effective 1 January 2011)I. ACCREDITATION DECISIONS

INTRODUCTIONThe Accreditation Committee considers all information from the initial or triennial full survey and any required follow-upfocused survey in making its decision regarding accreditation. The outcome is that the organization meets the criteria foraccreditation or does not meet the criteria and is denied accreditation. The criteria for these two potential outcomes are asfollows:

A. ACCREDITEDThis decision results when an organization meets all of the following conditions:

• The organization demonstrates acceptable compliance with each standard. Acceptable compliance is:– A score of at least “5” on each standard.

• The organization demonstrates acceptable compliance with the standards in each chapter. The International PatientSafety Goals are considered a chapter. Acceptable compliance is:– An aggregate score of at least “8” for each chapter of standards.

• The organization demonstrates overall acceptable compliance. Acceptable compliance is:– An aggregate score of at least “9” on all standards.

• The total number of measurable elements found to be “not met” or “partially met” is not above the mean (three ormore standard deviations) for organizations surveyed under the organization accreditation standards within theprevious 24 months.

B. ACCREDITATION DENIEDThis decision results when an organization meets one or more of the following conditions at the end of any requiredfollow-up focused survey subsequent to an initial or triennial full survey or during the period of accreditation as a result ofa focused survey for the evaluation of one or more policy-related conditions that may place the organization At Risk forDenial of Accreditation.*

• One or more standards is scored less than “5.”• The aggregate score of one or more chapter of standards is less than “8.”• The aggregate score for all standards is less than “9.”• The total number of measurable elements found to be “not met” or “partially met” is above the mean (three or

more standard deviations) for organizations surveyed under the organization accreditation standards within theprevious 24 months.

• A required follow-up focused survey subsequent to an initial or triennial full survey has not resulted in acceptablecompliance with applicable standards.

• One or more of the conditions that place the organization At Risk for Denial of Accreditation* have not beenresolved at the time of the focused survey to evaluate the condition.

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Joint Commission International Accreditation Hospital Survey Process Guide

* Conditions that place an organization At Risk for Denial of Accreditation are as follows:• An immediate threat to patient/public health or staff safety exists within the organization.• An individual who does not possess a license, registration, or certification is providing or has provided health care services in the organization that would, under

applicable law or regulation, require such a license, registration, or certification and that placed the organization’s patients at risk for a serious adverse outcome.• Joint Commission International is reasonably persuaded that the organization submitted falsified documents or misrepresented information in seeking to achieve or

retain accreditation, as required by the Information Accuracy and Truthfulness Policy.• A number of noncompliant standards (“not met” or “partially met”) at the time of survey are above the mean (three or more standard deviations) for organizations

in the same program surveyed during the previous 24 months.• The organization does not possess a license, certificate, and/or permit, as, or when, required by applicable law and regulation, to provide the health care services for

which the organization is seeking accreditation.• The organization has not met the accreditation policy for “Reporting Requirements Between Surveys.”• The organization fails to submit an acceptable Strategic Improvement Plan (SIP) within 120 days of the organization’s survey.

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• The organization voluntarily withdraws from the accreditation process.• The organization does not permit the performance of any survey by Joint Commission International.

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

INTRODUCTIONFull surveys are conducted at the time of initial accreditation and at the time of reaccreditation, every three years. At theconclusion of the survey, the findings are evaluated against the required conditions for accreditation. When the survey resultsmeet all the conditions for accreditation, the organization receives an Accredited status. The organization will then berequested to develop a Strategic Improvement Plan (SIP) that defines the improvement strategy(ies) and/or approach to bringany noncompliant standards and/or International Patient Safety Goals into acceptable compliance. However, when the resultsof a full survey do not meet one or more of the conditions for accreditation, the organization will have a period of time tocome into acceptable compliance. Acceptable compliance can then be demonstrated by a visit from one or more surveyors tothe organization. The visit is named a follow-up focused survey, as only the standards and/or International Patient SafetyGoals in noncompliance are the “focus” of the survey.

A. PROCESSAn Official Survey Findings Report is sent to the organization by the Accreditation Office within 10 to 15 days followingthe survey. An SIP will be requested for any “not met” standard(s)/measurable element(s) and/or International PatientSafety Goal(s) cited in the survey report when the organization meets the conditions for accreditation. The SIP explainsthe organization’s process in defining the improvement strategy(ies) and/or approach, including specific actions to bringthe cited findings into acceptable compliance. The plan also identifies the methodology to prevent reoccurrence andsustain improvements over time. The SIP is due to the Accreditation Office for review and acceptance within 45 daysafter receiving the final report.

B. A Preliminary Survey Findings Report is sent to the organization by the Accreditation Office when the documentedfindings of the accreditation survey team do not meet one or more of the conditions for accreditation. The preliminaryreport is sent to the organization within 10 to 15 days after the survey; the report includes all standard(s)/measurableelement(s) and/or International Patient Safety Goals that were found to be not compliant at the time of the survey. Eachof the noncompliant (“partially met” and/or “not met”) findings will be reviewed for compliance by the surveyors duringthe follow-up focused survey.

C. FOLLOW-UP FOCUSED SURVEYA follow-up focused survey is required within 90 days from the date when the organization received the PreliminarySurvey Findings Report. During the on-site visit, the surveyor(s) will determine the organization’s compliance with thestandards and International Patient Safety Goals through various survey activities and methods, such as direct observation,staff or patient interviews, review of documents, review of medical records and/or personnel files, or the inspection of thephysical facility.

When the results of the follow-up focused survey meet all the conditions for accreditation, the organization receives anAccredited status. The organization will then be requested to develop an SIP.

When the results of the follow-up focused survey do not meet one or more of the conditions for accreditation, theorganization will receive a Denied Accreditation status by the Accreditation Committee.

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Accreditation PreparationAfter JCI accepts the hospital’s application for survey, both parties make preparations for the on-site survey. To help hospitals preparefor accreditation, JCI offers seminars, custom education, numerous publications (such as Joint Commission International Accreditation:Getting Started, Second Edition), online education and training (such as webinars or live video streaming), a new electronic self-assessment tool, and this Hospital Survey Process Guide. These resources provide specific information on JCI standards and teachconcepts related to hospital care. Go to the JCI Web site at http://www.jointcommissioninternational.org/Products-and-Services/ forup-to-date information on available educational resources.

JCI organizes a team of surveyors to match the hospital’s needs and unique characteristics. JCI will make every effort to providea surveyor(s) who is fluent in the language(s) used at the hospital. If a JCI surveyor(s) with the appropriate language capabilitiesare not available, it is the hospital’s responsibility to provide interpreter services throughout the survey. The interpreter(s) mustbe fluent in English and the language(s) used at the hospital, be experienced in verbal and written translation, be able to followrecognized Medical Interpreting Standards of Practice, and abide by the confidentiality policies and regulations set up by thehospital.

On-site hospital accreditation surveys are typically conducted by three or more surveyors, depending on the size and complexityof the hospital. The survey follows actual patient care through the facility and includes interviews with key personnel,observation of the hospital’s administrative and clinical activities, assessment of the physical facilities and patient care equipment,and review of documentation. A sample survey agenda appears on pages 22–26. The actual agenda will be customized by thesurvey team to fit the needs and services of the hospital.

The survey team leader will contact the hospital approximately four to eight weeks prior to the survey to discuss and coordinatea workable and mutually agreeable agenda. The survey team leader identifies those services/areas that need to be included in thereview and suggests staff who should be involved in each survey activity.

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Joint Commission International Accreditation Hospital Survey Process Guide

Suggested “Ready to Go” List

The survey process can be facilitated if the following items are readily available to the surveyor(s) at the time of the survey:

• High-level organization chart

• Accurate list of the patients currently receiving care in the hospital, including their diagnosis, age, unit/service, physician, and

date of admission

• Required quality, monitors, and data

• Clinical pathways and clinical practice guidelines

• Proactive risk assessments, such as a failure mode and effects analysis (FMEA), hazard vulnerability analysis (HVA), and

infection control risk assessment (ICRA)

• Required organization plans (for example, facility management and safety plan)

• Required policies and procedures, written documents, or bylaws

• A list of the operative and other invasive procedures scheduled for the day, including surgeries in the operating theatre, day

surgeries, cardiac catheterizations, endoscopies/colonoscopies, and in vitro fertilizations

• Current map of the hospital campus

• Sample of all medical record forms

The list of required policies and procedures and plans appears on pages 85–99.

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Preparation Timeline

Hospitals Requesting an Initial Survey

Hospitals Requesting Reaccreditation

JCI Activity Hospital’s Activity

6 months before preferred month of

survey

Review the first section of the standards

manual to better understand the

expectations related to JCI accreditation

policies and procedures.

Submit the application for survey to the

JCI Central Accreditation Office

(electronically or by fax).

Upon receipt of the application for

survey

JCI Manager for Accreditation Services

will review the application.

The hospital will be e-mailed a

complimentary copy of this HospitalSurvey Process Guide.

JCI Activity Hospital’s Activity

6 to 9 months before the due date of

the next triennial survey

An application for survey is e-mailed to

prepare for the next on-site survey.

Complete application at least 4 to 6

months before the accreditation

expires

Staff member(s) with knowledge of the

hospital’s services, sites, and patient

volume will need to complete and submit

the application for survey (electronically

or by fax). The application should be

received by JCI no later than 4 to 6

months before the preferred survey

dates.

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All Hospitals Requesting Accreditation

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Joint Commission International Accreditation Hospital Survey Process Guide

JCI Activity Hospital’s Activity

4 to 5 months before survey A contract agreement is e-mailed to the

hospital.

An invoice for down payment of at least 50% of

the survey fees is e-mailed by the Finance

Department when the signed contract is

received. Hospitals can elect to pay 100%

based on the preference of the hospital.

E-mail or fax the signed contract to JCI no

later than 90 days prior to the survey date.

Notify accounts payable staff to expect an

invoice and to remit payment with a wire-

transfer form (found in the application) no

later than 60 days prior to survey date.

8 weeks before survey Verification of survey date(s) and name of

surveyor(s) are e-mailed to the hospital.

4 to 8 weeks before survey The survey team leader contacts the hospital’s

contact person to finalize the survey agenda

and to request presurvey information.

Appropriate staff member(s) will need to

discuss the proposed survey agenda and

determine whether times are feasible for

the hospital, given patient needs and

availability of staff.

Hospitals must follow the guidelines in

requesting observers during a survey

(refer to the survey agreement and

policies in the manual).

Survey Surveyor(s) arrives for the on-site survey. At

the conclusion of the survey, the hospital

receives a copy of the Exit Report, which

details partial or noncompliant areas that need

to be addressed. This report is not final until

the JCI Accreditation Central Office has

reviewed the report.

As outlined on the survey agenda, staff

should be available during the survey. An

approved observer may not answer

questions or contribute to discussions

unless requested by the surveyor(s).

Within 15 days after survey JCI reviews, approves, and sends the Official

Survey Findings Report. A follow-up 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

after all the survey fees have been paid.

The Gold Seal guidelines and publicity kit will

also be posted to the Accredited Hospital

Resource Center on the JCI Web site at

http://www.jointcommissioninternational.org/

accredited.

The chief executive officer (CEO) of the

surveyed organization will be sent a JCI

Accreditation Satisfaction Survey to assist JCI

in performance improvement activities.

After the JCI Accreditation Central Office

sends the Official Survey Findings Report,

the hospital should begin either of the two

follow-up processes as requested:

• Develop the SIP if accredited.

• Prepare for the follow-up focused survey

if the conditions for accreditation were

not met.

The CEO of the surveyed organization

should encourage members of the

leadership team to provide input for the

JCI Accreditation Satisfaction Survey.

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Joint Commission International Accreditation Hospital Survey Process Guide

19

All Hospitals Requesting Accreditation, continued

JCI Activity Hospital’s Activity

Within 3 days after the

certificate is mailed

The organization’s name, location, and date

of accreditation are added or updated for

public viewing on the JCI Web site at

http://www.jointcommissioninternational.org.

The hospital may request JCI Accreditation

Services to place a link on the JCI Web

site to the accredited hospital’s Web site.

Ongoing Each accredited hospital will have access to

the Accredited Hospital Resource Center via

the JCI Web site, which contains the JCI

newsletter (JCInsight), 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 official

changes and developments in the

standards and survey process.

Compliance is required with new

standards and survey processes for

accredited hospitals.

Periodic submission of evidence of

compliance is required as part of the

accreditation process. Examples include

International Patient Safety Goal

monitoring data, SIP compliance data, and

self-assessments of standards

compliance.

6 months after publication of a

new JCI hospital standards

edition

JCI publishes a new edition of the hospital

standards approximately every three years.

The manual becomes effective for all

accredited hospitals and all surveys 6 months

after publication.

Staff should review the new accreditation

manual or supplement to implement and

act on any new and modified standards,

scoring guidelines, policies, and

procedures. If JCI needs to visit the

hospital, the current, effective standards

will be used.

Within 30 days of any

significant organizational

changes

The hospital must notify JCI (via letter, fax,

or e-mail) of any significant change in the

hospital (as defined in the “Joint

Commission International Policies and

Procedures” chapter of the standards

manual).

6 to 9 months before the due

date of the next triennial

survey

An application for survey is mailed to the

hospital to prepare for the next on-site survey.

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Accreditation Process Timeline

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Joint Commission International Accreditation Hospital Survey Process Guide

12 to 24 MonthsPrior to Survey

6 to 9 MonthsPrior to Survey

4 to 6 MonthsPrior to Survey

4 to 8 WeeksPrior to Survey

SurveyDates

Within 15 DaysAfter Survey

6 to 9 MonthsPrior to

Triennial DueDate

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Joint Commission International Accreditation Hospital Survey Process Guide

21

The On-Site SurveyThe purpose of a JCI accreditation survey is to assess the extent of a hospital’s compliance with applicable JCI standards.Hospitals undergoing their first survey need to demonstrate a track record of 4 months of compliance with the standards.Hospitals being re-surveyed need to demonstrate 12 months of compliance with the standards. Understanding the hospital andassessing compliance is accomplished through a number of methods, including the following:

• Receipt of verbal information concerning implementation of standards or examples of their implementation• On-site observation by a JCI surveyor(s)• Review of documents that demonstrate compliance and assistance in orienting the surveyor(s) to the hospital’s operations

The on-site survey uses tracer methodology to follow a sample of active patients through their experiences of care in the hospitaland to evaluate individual components and systems of care.

An important characteristic of the JCI survey process is on-site education conducted by the surveyor(s). This support occursthroughout the survey as the surveyor(s) offers suggestions and strategies that may help the hospital better meet the intent of thestandards and, more importantly, improve performance.

The on-site review consists of the following steps:1. Opening conference and orientation to the organization2. Survey planning meeting3. Document review4. Closed patient medical record review5. Patient care and service area visits guided by patient and system tracer activities6. Competence assessment and credentials evaluation7. Environment of care reviews and building tour8. Leadership interview9. Leadership exit conference

Frontline Staff Ownership of the ProcessInvolving staff in the initial accreditation process and continuing to involve them in ongoing assessments and process and systemreviews enhance ownership, which results in continued safe and high-quality care for patients and their families. During thetracer activities, the surveyor(s) will focus his or her discussions on the clinical and support staff and will request manager andleadership staff only to provide clarification, if needed.

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Sample Survey AgendaJoint Commission International

Name of HospitalDate of Survey

(5 Days, 3 Surveyors)

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Joint Commission International Accreditation Hospital Survey Process Guide

FMS: Facility Management and Safety

Day 1

Time Surveyor 1 Surveyor 2 Surveyor 3

0730 – 0815Team Meeting with Survey Coordinator and Translators

(Discussion of logistical support issues and requirements)

0815 – 0900 Opening Conference and Agenda Review

0900 – 1000 Hospital Overview and Review of Services

1000 – 1200Document Review

(One room with separate working area for each team member)

1200 – 1300Surveyor Working Lunch

Team debriefing and survey planning

1300 – 1600 Tracer Activity Tracer Activity FMS Document Review

1600 – 1630Meeting with Survey Coordinator

(Identify needs for the following day)

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Sample Survey Agenda, continued

* See page 63 for more information on “Undetermined Survey Activities.”

Day 2

Time Surveyor 1 Surveyor 2 Surveyor 3

0800 – 0900 Daily Briefing

0900 – 1100 Tracer Activity Undetermined Survey Activity*

FMS Tracer

1100 – 1200 Tracer Activity Tracer Activity

1200 – 1300Surveyor Working Lunch

(Team debriefing and survey planning)

1300 – 1600

Medication Management

System Tracer (includes

review of medication error

data)

1300 – 1500

Infection

Control

System

TracerFacility Tour

1500 – 1600

Tracer/

Undetermined

Survey

Activity*

1600 – 1630Meeting with Survey Coordinator

(Identify needs for the following day)

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Sample Survey Agenda, continued

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Joint Commission International Accreditation Hospital Survey Process Guide

FMEA: Failure mode and effects analysis

SQE: Staff qualifications and education

* See page 63 for more information on “Undetermined Survey Activities.”

Day 3

Time Surveyor 1 Surveyor 2 Surveyor 3

0800 – 0900 Daily Briefing

0900 – 1200

Required Monitor Review

(Combined activity with two surveyors)

Improvement in Quality and Patient Safety System Tracer

FMEA and Pathway/Guideline Discussion

(Combined activity with two surveyors)

Tracer/Undetermined Survey

Activity*

1200 – 1300Surveyor Working Lunch

(Team debriefing and survey planning)

1300 – 1430 SQE Medical StaffTracer/Undetermined Survey

Activity*Tracer Activity

1430 – 1600 Tracer Activity SQE NursingUndetermined Survey

Activity*

1600 – 1630Meeting with Survey Coordinator

(Identify needs for the following day)

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25

Sample Survey Agenda, continued

SQE: Staff qualifications and education

* See page 63 for more information on “Undetermined Survey Activities.”

Day 4

Time Surveyor 1 Surveyor 2 Surveyor 3

0800 – 0900 Daily Briefing

0900 – 1100

Closed Patient Record Review

(Combined activity with two surveyors, one room with

separate work spaces)

SQE Other Health

Professionals

1100 – 1200Tracer/Undetermined Survey

Activity*

Tracer/Undetermined Survey

Activity*Tracer Activity

1200 – 1300Surveyor Working Lunch

Team debriefing and survey planning

1300 – 1400 Leadership Interview

1400 – 1600 Tracer Activity

Education Session: Scoring

Guidelines, Decision Rules,

and SIP

Tracer/Undetermined Survey*

Activity

1600 – 1630Meet with Survey Coordinator

(Identify needs for the following day)

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Sample Survey Agenda, continued

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Joint Commission International Accreditation Hospital Survey Process Guide

* See page 63 for more information on “Undetermined Survey Activities.”

Day 5

Time Surveyor 1 Surveyor 2 Surveyor 3

0800 – 0900 Daily Briefing

0900 – 1030Undetermined Survey

Activity*

Undetermined Survey

Activity*

Undetermined Survey

Activity*

1030 – 1130 Survey Integration

1130 – 1500

Surveyor Working Lunch

Exit Report Preparation

(Will require individual Internet access and shared printer access)

1500 – 1600 Leadership Exit Report

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Joint Commission International Accreditation Hospital Survey Process Guide

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Tracer MethodologyTracer methodology is the foundation of the JCI on-site survey and accomplishes the following:

• Incorporates the use of information provided in the accreditation survey application and previous survey and monitoringreports

• Follows the experience of care for a number of patients through the hospital’s entire health care process• Allows the surveyor(s) to identify issues in one or more steps of the patient care process or the interfaces between processes

Individual Patient Tracer ActivityThe individual patient tracer activity is an evaluation method that is conducted during the on-site survey and is designed to“trace” the care experiences that a patient had during his or her stay in the hospital. Tracer methodology is used to analyze ahospital’s system of providing care, treatment, and services using actual patients as the framework for assessing internationalstandards compliance. During an individual tracer, the surveyor(s) will perform the following:

• Follow the course of care, treatment, and services provided to the patient by and within the hospital using current recordswhenever possible

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

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

• Identify potential concerns in the relevant processes

Using the information from the application, the surveyor(s) will select patients from an active patient list to “trace” theirexperiences throughout the hospital. Patients typically selected are those who have received multiple or complex services andtherefore have experienced more contact with various parts of the hospital. This interaction will provide the opportunity to assesscontinuity of care issues (also see Glossary in the Joint Commission International Accreditation Standards for Hospitals, FourthEdition). To the extent possible, the surveyor(s) will make every effort to avoid selecting tracers that occur at the same time andthat may overlap in terms of sites within the hospital.

Individual Patient Tracer Selection CriteriaPatient tracer selection may be based on, but not limited to, the following criteria:

• Patients in the top five diagnoses groups for that hospital• Patients related to system tracers, such as infection prevention and control and medication management• Patients who cross programs. Examples include:

– Patients scheduled for a follow-up in outpatient care or patients transitioning from hospital to home care– Patients entering or leaving the hospital from or to the care continuum, such as long term care and hospice

The surveyor(s) will follow the patient’s experiences, looking at services provided by various individuals and departments withinthe hospital as well as “handoffs” between them.

This type of review is designed to uncover systems issues, to look at the individual components of a hospital, and to examinehow the components interact to provide safe, high-quality patient care.

The surveyor(s) may start a tracer where the patient is currently located. He or she can then move to where the patient firstentered the hospital’s systems; to an area of care provided to the patient that may be a priority for the hospital; or to any areas inwhich the patient received care, treatment, and services. The order will vary.

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The number of patients followed under tracer methodology will depend on the size and complexity of the hospital and the length ofthe on-site survey. As appropriate to the provision of care being reviewed, the tracer will include the following elements:

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

• Observation of direct patient care• Observation of medication processes• Observation of infection prevention and control issues• Observation of care planning processes• Discussion of data use in the hospital. This includes quality improvement measures being used, information that has been

learned, improvements made using data, and data dissemination (also see the Glossary in the Joint Commission InternationalAccreditation Standards for Hospitals, Fourth Edition).

• Observation of the impact of the environment on safety and staff roles in minimizing environmental risk• Observation of maintenance of medical equipment (also see the Glossary in the Joint Commission International Accreditation

Standards for Hospitals, Fourth Edition) and review of qualified personnel responsible for the maintenance of the medicalequipment

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

• Address emergency management and explore patient flow issues in the emergency department. Patient flow issues may alsobe explored in ancillary care areas and other patient care areas as relevant to the patient being traced. For example, if thepatient received a blood transfusion, the surveyor(s) may visit the blood bank.

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

• Similar or same diagnosis or tests• Patient close to discharge• Same diagnosis but different physician/practitioner• Same test but different location• Same age or sex• Length of stay• Interview with staff• Review of minutes and procedures as needed

Linkages to Other Survey ActivitiesIssues identified from the individual patient tracer activities may lead to further exploration in the system tracers or other surveyactivities, such as the facilities tour and the governance and leadership interview.

Findings from tracer visits provide focus for other tracers and may influence the selection of other tracers. They may also identifyissues related to the coordination and communication of information relevant to the safety and quality of care services.

Individual-Based System Tracer ActivityIndividual-based system tracers look at a specific system or process across the hospital. When possible, this activity will focus onthe experiences of specific patients or on activities relevant to specific patients. This differs from the individual tracers in thatduring individual tracers, the surveyor(s) follows a patient through his or her course of care, evaluating all aspects of care ratherthan a system of care. During an individual-based system tracer, the surveyor(s) will perform the following:

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

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• Evaluate communication among disciplines and departments• Identify potential concerns in relevant processes

An individual-based system tracer includes unit/department visits to evaluate the implementation of the system process and toreview the impact on patient care services and treatments. The tracer also includes an interactive session that involves asurveyor(s) and relevant staff members and that will utilize information from unit/department visits and individual tracers.Points of discussion in the interactive session include the following:

• The flow of a process across the hospital, including identification and management of risk points, integration of keyactivities, and communication among staff/units involved in the process

• Strengths in the process, weaknesses in the process, and possible actions to take in areas needing improvement• Issues requiring further exploration in other survey activities• A baseline assessment of international standards and IPSG compliance• Education by the surveyor(s), as appropriate

Medication Management System TracerThe medication management individual-based system tracer explores a hospital’s medication management process while focusingon subprocesses and potential risk points (such as handoff points). This tracer activity helps the surveyor(s) evaluate thecontinuity of medication management from the procurement of a medication through the monitoring of its effect on patients.(See pages 49–51.)

Infection Control System TracerThe infection prevention and control individual-based system tracer explores a hospital’s infection prevention and controlprocesses. The goals of this session are to assess a hospital’s compliance with the relevant Prevention and Control of Infections(PCI) and Facility Management and Safety (FMS) standards, to identify infection prevention and control issues that requirefurther exploration, and to determine actions that may be necessary to address any identified risks and to improve patient safety.(See pages 52–53.)

Improvement in Quality and Patient Safety System TracerThe focus of this system tracer is the processes a hospital uses to collect, analyze, interpret, and use data to improve patient safetyand care. The surveyor(s) will also evaluate the effectiveness of the hospital’s implementation of quality and safety action plans,processes, and programs. (See pages 54–56.)

Facility Management and Safety SystemThe focus of this system tracer is the process the hospital uses to evaluate the hospital’s facility management and safety (FMS)system and performance in managing risk. The surveyor(s) will evaluate the strengths in the hospital’s FMS processes, review theaction(s) taken to address any identified areas of concern, and determine the hospital’s actual degree of compliance with relevantstandards. (See pages 59–62.)

The Role of Staff in Tracer MethodologyStaff will be asked to provide the surveyor(s) with a list of patients presently in the hospital, including the patients’ names,current locations in the hospital, and diagnoses, as appropriate. The surveyor(s) may request assistance from hospital staff forselection of appropriate tracer patients. As the surveyor(s) moves around the hospital, he or she will converse with a wide varietyof staff involved in the traced patient’s care, treatment, and services. This staff could include nurses, physicians, therapists, casemanagers, aides, pharmacy staff, lab personnel (as appropriate), and support staff. If those staff members are not available, thesurveyor(s) will ask to speak to another staff member who would perform the same function(s) as the member who has cared foror is caring for the tracer patient. Although it is preferable to speak with the direct caregiver, it is not mandatory because thequestions that will be asked are questions that any caregiver should be able to answer in providing care to the patient beingtraced.

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The Accreditation DecisionThe final accreditation decision is based on the hospital’s compliance with JCI standards. Hospitals do not receive a numericscore as part of the final accreditation decision. When a hospital successfully meets JCI accreditation requirements, it will receivean award of Accredited. This decision indicates that a hospital is in compliance with all applicable standards at the time of theon-site survey. The JCI Accreditation Central Office may request an SIP, which must be accepted by the JCI AccreditationCentral Office, or the status of Accredited could be removed.

Promoting AccreditationAfter a hospital receives official notification of the accreditation decision, it can publicize its international accreditationachievement by notifying patients, the public, the local media, third-party payers, and resident referral sources. JCI provides afree publicity kit to accredited hospitals that includes the following:

• Suggestions for celebrating accreditation• Guidelines for publicizing JCI accreditation• Frequently asked questions• Sample news release• Fact sheet

Information about a hospital’s accreditation status will be posted on the JCI Web site at http://www.jointcommissioninternational.org.The Web site allows anyone to locate JCI–accredited hospitals within a country and region of the world.

The Continuing Accreditation CycleThe accreditation process does not end when the on-site survey is completed. In the three years between on-site surveys, JCIrequests ongoing evidence of compliance and corrective actions, such as a self-assessment, periodic submission of compliancedata, root cause analyses, and/or response to complaints. For this reason, it is very important for the hospital to maintaincompliance with standards between on-site surveys as well as new standards published in new editions of the manual.

Continuous survey compliance means that hospitals can focus less on “ramping up” for survey every three years and, instead, can(and should) focus on continually improving their systems and operations, thereby eliminating the need for intense surveypreparation. Continuous compliance with JCI standards directly contributes to the maintenance of safe, high-quality care andimproved organizational performance.

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Detailed DescriptionsSurvey Agenda:

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Opening ConferencePURPOSEDuring the opening conference, the surveyor(s) describes the structure and content of the survey to the hospital.

LOCATIONAt the discretion of the hospital

HOSPITAL PARTICIPANTS• Chief executive officer• Individual responsible for coordinating the hospital’s survey agenda, such as a survey coordinator• Others, at the discretion of the hospital

SURVEYOR(S)All surveyors

STANDARDS/ISSUES TO BE ADDRESSEDIntroduction and coordination of the survey

DOCUMENTS/MATERIALS NEEDEDFinal survey agenda

WHAT WILL OCCUR• Surveyor(s) will be introduced.• Hospital leadership will be introduced.• Agenda will be reviewed and modified.• Surveyor(s) will answer questions about the survey agenda.• Surveyor(s) will explain the use of tracer methodology during the survey process activities.• Surveyor(s) will advise leaders that the only presentation allowed during the survey is scheduled on the survey agenda for the

session entitled “Orientation to the Hospital’s Services and the Quality Improvement Plan.” The surveyor(s) will follow theplanned survey agenda when conducting the tracer activities. Staff should be prepared to answer questions. The surveyor(s)will also obtain pertinent information through various other methods.

• Surveyor(s) will explain the concept of “drilling down” as an interviewing technique/approach that aims to gather specificinformation about a process or outcome. Staff members involved in drilling down inquiries should not perceive thisapproach as personal or necessarily an indication of noncompliance. It is an indication that the surveyor(s) is evaluating theestablishment of systems to support a process.

• Surveyor(s) will explain the staff involvement in the patient record review process.• Surveyor(s) will explain the staff involvement in the staff qualifications and education interview.• Surveyor(s) will explain the purpose of and the leaders’ involvement in the daily briefing sessions.• Hospital staff will be encouraged to ask questions and seek clarification from the surveyor(s) throughout the survey process.• Hospital staff will notify the surveyor(s) where lunch will be served or where he or she can purchase lunch.• Hospital staff will identify country-specific information to ensure that the survey team observes significant customs and

values of the hospital during the survey process, particularly if observance of customs impacts the survey agenda. Forexample, how would the hospital prefer that the surveyor(s) conduct survey sessions during times that staff membersparticipate in prayer activities? In addition, hospital staff should indicate how staff members would prefer to be addressedand should discuss the use of interpreters, when needed.

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• Hospital staff will show the surveyors where the surveyors can meet as a group. This location should be the same roomwhere documents are gathered for surveyor review.

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

HOW TO PREPARE• Set up a meeting or conference room large enough for the surveyor(s) to meet with key hospital leaders and survey

coordinators.• Notify hospital receptionists, so they can direct the surveyor(s) to the room when he or she arrives.• 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 surveyor(s) to be served or to purchase lunch.• Notify hospital staff of the survey agenda.• The surveyor(s) will wear a name badge that will identify him or her as a JCI surveyor(s). If the hospital requires additional

hospital identification, prepare and make it available to the surveyor(s) in the opening conference.

Note: The survey team leader will conduct a brief meeting prior to the opening conference with the CEO, survey coordinator,and translators to discuss the logistics and expectations for the on-site survey and use of translators. If there will be any approvedobservers, hospitals must provide a list of their names, titles, and organization affiliations to the survey team leader.

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Orientation to the Hospital’s Services and the QualityImprovement PlanPURPOSEThe hospital orients the surveyor(s) to the services, programs, and strategic activities the hospital provides and its qualityimprovement process. This information provides the surveyor(s) with baseline information about the hospital and its quality andpatient safety program that can help focus subsequent survey activities.

LOCATIONAt the discretion of the hospital

HOSPITAL PARTICIPANTS• Chief executive officer• Individual responsible for coordinating the hospital’s survey agenda, such as a survey coordinator• Medical staff leadership• Nursing leadership• Staff responsible for the quality improvement and patient safety program, if applicable• Others, at the discretion of the hospital

SURVEYOR(S)All surveyors

STANDARDS/ISSUES TO BE ADDRESSED• Overview of the hospital’s services• Overview of the quality improvement and patient safety program and process

DOCUMENTS/MATERIALS NEEDED• Organization chart• Quality improvement example

WHAT WILL OCCUR• The hospital will give an overview of its structure, services, and strategic activities.• The hospital will include a brief presentation about the structure and methods of the quality improvement and patient

safety program.• The presentation should show how quality and safety information flows through the hospital/committee structure.• The presentation should describe the following:

– How quality and safety measures were chosen– How the measures were prioritized for data collection– How data are collected, aggregated, and analyzed– How findings from data analysis are communicated and used for planning improvements

• The hospital may choose to present a quality improvement example to demonstrate the hospital’s methodology andsustained improvement.

• The surveyor(s) will ask questions, as needed, to clarify information or to request additional information for use at a latertime.

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Surveyor Planning SessionPURPOSEDuring this session, the surveyor(s) reviews data and information about the hospital and plans the survey agenda. Thesurveyor(s) also selects initial tracer patients/residents/clients.

LOCATIONThe hospital should provide space for this activity, usually the room designated as the “surveyor headquarters.” This space shouldhave the following items:

• Conference table• Power outlets• Telephone• High-speed Internet connection/access for each surveyor• Printer

HOSPITAL PARTICIPANTS• Hospital survey coordinator (as needed by team)• Translators (as needed by team)

SURVEYOR(S)All surveyors

WHAT WILL OCCURThis time is set aside for the surveyor(s) to review and discuss pertinent data and plan the survey agenda. The surveyor(s) reviewsthe following items (as applicable to the setting), and these materials should remain available to the surveyor(s) for the entireduration of the survey:

• Performance improvement data, including committee meeting minutes, for 12 months prior to the survey• Infection prevention and control surveillance data, including committee meeting minutes, for 12 months prior to the survey• Facility management and safety plan annual reviews. The surveyor(s) will review these documents to prepare for the facility

tour session.• Facility management and safety multidisciplinary team meeting minutes for the 12 months prior to the survey. The

surveyor(s) will review these documents to prepare for the facility tour session.• A list of departments/units/areas/programs/services within the hospital (if applicable)• An organization chart and map• A current list of inpatients, including their names, diagnoses, ages, admission dates, physicians, and units/services• A list of the operative and other invasive procedures scheduled for the day, including surgeries in the operating theatre(s),

day surgeries, cardiac catheterizations, endoscopies/colonoscopies, and in vitro fertilizations• A list of the scheduled home visits for the duration of the survey, including type of service, disciplines, dates of admission,

and locations. The list should include branch locations (if applicable).• Name of key contact person (such as a supervisor or scheduler) who can assist the surveyor(s) in planning tracer selection• A list of contact telephone numbers in case the surveyor(s) needs to reach key staff

SELECTION OF INDIVIDUAL TRACERS• Surveyor(s) reviews the information from the survey application and the list of patients currently receiving care in the

hospital to guide his or her selection of patients to trace.• Surveyor(s) identifies a clinical/service group and some general information about the patient population receiving care and

services.

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• Surveyor(s) describes to the hospital the type of patient that he or she is seeking to trace and requests staff ’s assistance inidentifying an individual.

• In surveys longer than one day, the surveyor(s) informs the hospital during the morning daily briefing about the types oftracers he or she wants to perform that day to facilitate activity planning. This does not mean that the surveyor(s) willidentify a specific patient from the list supplied by the hospital. For example, the surveyor(s) may choose to trace thefollowing types of patients:– A hospital orthopedic surgery patient who is receiving physical therapy– A home care patient who is receiving surgical wound care– An ambulatory patient who visited the internal medicine clinic and had laboratory services– A patient with limited mobility, who smokes, who uses oxygen, or who has cognitive impairment– An intensive care patient who is receiving blood gas testing– A patient with developmental disabilities– A patient who is receiving sedation and/or anesthesia

• Surveyor(s) will trace patients in all intensive care units and sedation/anesthesia areas of the hospital.• In team surveys, tracer selection should be coordinated when possible to avoid overlap of visits to various units.• In hospitals with multiple sites, individual tracers will include patients who move between locations and services addressed

by the represented accreditation programs.

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Document ReviewPURPOSEThe objective of the document review session is to survey standards that require some written evidence of compliance, such as anemergency preparedness plan or a patient’s rights document. In addition, this session orients the survey team to the structure of thehospital and management.

LOCATIONA meeting room or office that will be used throughout the duration of the survey as a meeting place and work area for the surveyteam

HOSPITAL PARTICIPANTSParticipants should include hospital staff members who are familiar with the documents that will be reviewed, can translate these, andare able respond to questions the surveyor(s) may have during the session. At the discretion of the team, the surveyor(s) may designatea limited number of staff members to attend and participate in the document review session. The session may be conducted as aninterview of staff about the documents. This approach has been very effective when language barriers exist and the survey activitiesnecessitate the use of professional interpreters.

SURVEYOR(S)All surveyors

STANDARDS/ISSUES TO BE ADDRESSEDAlmost all standards chapters make reference to plans, policies, and procedures that are to be written. The following section and the“Survey Planning: Reference Lists” section on pages 81–106 will assist staff members in understanding the particular documents thatare a part of the accreditation survey.

DOCUMENTS/MATERIALS NEEDEDThe documents that should be available to the survey team for their review or reference during the survey process are listed in the“Survey Planning: Reference Lists” section on pages 81–106. The list of documents includes the following:

• Required quality monitors with data from the past 4 months (initial surveys) and/or 12 months for triennial surveys• Required organization plans• Required policies and procedures, written documents, or bylaws• Minutes of the key committees for the past year, such as Performance Improvement, Infection Prevention and Control, Safety,

Leadership/Management Team Meetings, and Medication Systems• An accurate list of the patients currently receiving care in the hospital• A list of the operative and other invasive procedures scheduled for the day, including surgeries in the operating theatre(s), day

surgeries, cardiac catheterizations, endoscopies/colonoscopies, and in vitro fertilizations• A sample action plan for a root cause analysis for a sentinel event or a near miss• A sample FMEA action plan • An example of a measure from the JCI Library of Measures on which a validation was performed (see page 82)• A current map of the hospital campus• A sample of all medical record forms• A list of the five clinical practice guidelines, clinical pathways, and/or clinical protocols the hospital selected to guide clinical care

In addition, the hospital should complete and have available for the survey teams the worksheet related to relevant national or localhealth care–related laws and regulations. (See the Law and Regulation Worksheet on pages 101–105.)

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DOCUMENTS AVAILABLE IN ENGLISHDocuments showing evidence of compliance with the followingstandards must be provided to the surveyors in English:

Required Hospital Plans• There is a plan for an organizationwide quality improve-

ment and patient safety program. (QPS.1)• Organization plans describe the care and services to be pro-

vided consistent with the mission. (GLD.3.2, intent)

Required Hospital Programs• All equipment used for laboratory testing is regularly

inspected, maintained, and calibrated, and appropriaterecords are maintained for these activities. (AOP.5.4)

• Quality control procedures are in place, followed, and docu-mented. (AOP.5.9)

• A radiation safety program is in place that addresses poten-tial safety risks and hazards encountered within or outside ofthe department. (AOP.6.2, ME 1)

• All equipment used to conduct radiology and diagnosticimaging studies are regularly inspected, maintained, and cali-brated, and appropriate records are maintained for theseactivities. (AOP.6.5)

• Quality control procedures are in place, followed, and docu-mented. (AOP.6.8)

Required Policies and Procedures, Written Documents, orBylaws

• Policies and procedures support consistent practice in all sit-uations and locations. (IPSG.1, ME 5)

• Policies and procedures support consistent practice in verify-ing the accuracy of verbal and telephone communications.(IPSG.2, ME 4)

• Policies and/or procedures are developed to address the iden-tification, location, labeling, and storage of high-alert med-ications. (IPSG.3, ME 1)

• Policies and procedures are developed that will support uni-form processes to ensure the correct site, correct procedure,and correct patient, including medical and dental proceduresdone in settings other than the operating theatre. (IPSG.4,ME 4)

• Policies and/or procedures are developed that support con-tinued reduction of health care–associated infections.(IPSG.5, ME 3)

• Policies and/or procedures support continued reduction ofrisk of patient harm resulting from falls in the organization.(IPSG.6, ME 4)

• The organization has established entry and/or transfer crite-ria for its intensive and specialized services or units, includ-ing research and other programs to meet special patientneeds. (ACC.1.4, ME 1)

• The organization has a clearly defined informed consentprocess described in policies and procedures. (PFR.6, ME 1)

• The organization has listed those procedures and treatmentsthat require separate consent. (PFR.6.4.1, ME 1)

• Organization policy and procedure define the assessmentinformation to be obtained for inpatients. (AOP.1, ME 1)

• Organization policy and procedure define the assessmentinformation to be obtained for outpatients. (AOP.1, ME 2)

• Organization policy identifies the information to be docu-mented for the assessments. (AOP.1, ME 3)

• The minimum content of assessments performed in inpa-tient settings is defined in policies. (AOP.1.1, ME 3)

• The minimum content of assessments performed in outpa-tient settings is defined in policies. (AOP.1.1, ME 4)

• Written policies and procedures address the handling anddisposal of infectious and hazardous materials. (AOP.5.1,ME 3)

• The uniform use of resuscitation services throughout the organ-ization is guided by appropriate policies and procedures.(COP.3.2, ME 1)

• The handling, use, and administration of blood and bloodproducts are guided by appropriate policies and procedures.(COP.3.3, ME 1)

• Appropriate policies and procedures, addressing at least ele-ments (a) through (f) found in the intent statement, guidethe care of patients undergoing moderate and deep sedation.(ASC.3, ME 1)

• There is a presedation assessment performed that is consis-tent with organization policy to evaluate risk and appropri-ateness of the sedation for the patient. (ASC.3, ME 3)

• Established criteria are developed and documented for therecovery and discharge from sedation. (ASC.3, ME 6)

• There is a plan or policy or other document that identifieshow medication use is organized and managed throughoutthe organization. (MMU.1, ME 1)

• Policies and procedures guide the safe prescribing, ordering,and transcribing of medications in the organization.(MMU.4, ME 1)

• Policies and procedures address actions related to illegibleprescriptions and orders. (MMU.4, ME 2)

• A medication error and near miss are defined through a col-laborative process. (MMU.7.1, ME 1)

• The organization’s leadership participates in developing the planfor the quality improvement and patient safety program.(QPS.1, ME 1)

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• The hospital leaders have established a definition of a sen-tinel event that at least includes (a) through (d) found in theintent statement. (QPS.6, ME 1)

• The organization establishes a definition of a near miss.(QPS.8, ME 1)

• The program is guided by appropriate policies and proce-dures [to reduce risks of health care–associated infections].(PCI.5, ME 5)

• When single-use devices and materials are reused, the policyincludes items (a) through (e) in the intent statement.(PCI.7.1.1, ME 2)

• The organization develops an infection prevention and con-trol program that includes all staff and other professionalsand patients and families. (PCI.11, ME 1)

• The organization’s governance structure is described in writ-ten documents, and those responsible for governance andmanaging are identified by title or name. (GLD.1, ME 1)

• The organization has a written description of the nature andscope of services provided through contractual agreements.(GLD.3.3, ME 2)

• There are written plans that address the risk areas (a) though(f) in the intent statement. (FMS.2, ME 1)

• There is a process described in policy for the review of eachmedical staff member’s credential file at uniform intervals atleast once every three years. (SQE.9.1, ME 1)

• The organization uses a standardized process that is docu-mented in official organization policy for granting privilegesto each medical staff member to provide services on initialappointment and on reappointment. (SQE.10, ME 1)

• The ongoing professional practice evaluation and annualreview of each medical staff member are accomplished by auniform process that is defined by organization policy.(SQE.11, ME 2)

• There is a written policy or protocol that defines the require-ments for developing and maintaining policies and proce-dures including at least items (a) through (h) in the intent,and it is implemented. (MCI.18, ME 1)

• There is a written protocol that outlines how policies andprocedures that originated outside the organization will becontrolled, and it is implemented. (MCI.18, ME 2)

• There is a written policy or protocol that defines retention ofobsolete policies and procedures for at least the timerequired by laws and regulations, while ensuring that theywill not be mistakenly used, and it is implemented.(MCI.18, ME 3)

• There is a written policy or protocol that outlines how allpolicies and procedures in circulation will be identified andtracked, and it is implemented. (MCI.18, ME 4)

WHAT WILL OCCUR• The documents should be made available to the survey team

in the meeting room that has been designated for their usethroughout the duration of the survey.

• At the beginning of the session, one staff person shouldbriefly orient the survey team to the organization of the documents.

• During the remainder of the session, a staff member whocan respond to any questions the surveyor(s) may haveshould be readily available (in person or by telephone).

• The materials should remain available to the survey teamthroughout the survey for reference purposes. However, ifdocuments are required for use by hospital staff, they can beremoved. The surveyor(s) may schedule a second documentreview session during the course of the survey. The review isgenerally scheduled for hospitals that have a survey of longerthan three days but may be scheduled on surveys of a short-er duration based on need. The survey team may alsorequest additional documents throughout the survey to clarify or become knowledgeable about the hospital’s policies and procedures or performance. Hospital staffshould be as proactive as possible in complying with requests for documents.

• Some of the documents may need to be translated intoEnglish, whereas other documents may require an inter-preter to be made available.

HOW TO PREPAREIt is highly probable that many of the required documents will bepart of larger documents. Hospitals do not need to remove orphotocopy pertinent sections of these documents. Instead,hospitals can identify these sections using bookmarks or tabs.Guidelines for cross-referencing this information are provided inthe next section.

Other documents, such as minutes and reports, may befreestanding or individual documents. Hospitals should decidewhether to provide the original document or a photocopy. It isalways beneficial to have several examples of these documents,such as committee minutes from the last few meetings.

If the hospital has a large quantity of examples or a large volumeof materials on a given topic, it should select the mostrepresentative or the most pertinent examples. There will not betime for the surveyor(s) to review large amounts of material onany given topic.

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ORGANIZATION OF THE MATERIALSBecause the issues identified in the document review list may be addressed in different documents depending on the hospital, thefollowing guidelines for organizing the documents to be used by the surveyor(s) are provided.

Group the freestanding or individual documents according to the following three lists provided in this guide:1. Required quality monitors (See page 82.)2. Required hospital plans (See page 83.)3. Required policies and procedures, written documents, or bylaws (See pages 85–99)

Note: When possible, please indicate the standards that the document addresses. The documents may be grouped in binders or folders,or other means may be used to separate major topical areas.

Gather the documents in one place. Identify the location in the document where the specific information that is required by thestandard may be found. The hospital may use methods such as the following to identify the information:

• A guide• An index• Bookmarks• Tabs

Note: When information is provided using computer monitors rather than paper, the following conditions should be met:• 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.• Staff may be needed to assist the surveyor(s) in locating the documents in the computer.

Printed copies of bylaws and longer documents that may require extensive reading or scanning by the surveyor(s) should be available.

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

• That appropriate staff have been educated about the new procedure• That any special skills or other needed training has taken place• That waste is actually being disposed of according to the new procedure• That any documentation required by the procedure is available for review

The presence of a policy or procedure alone usually does not determine the score of the standard. Rather, the score is determined by thedaily practice (implementation) of the policy or procedure. The survey team will look for evidence that the practice related to the policyor procedure is well implemented, as appropriate, throughout the hospital and thus is sustainable. In the event the implementationappears incomplete to the survey team, or the implementation occurred in a manner that is not sustainable, the survey team will makea recommendation that more time be allowed for better evidence of sustainable implementation and for incorporating therecommendation into the survey follow-up requirements.

In general, the length of time a policy has been implemented is referred to as a “track record.” The survey team will look for a 4-monthtrack record for policy-related standards during an initial survey and for a 12-month track record during a triennial survey. For policy-related standards 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 thestandard as “fully met.”

The track record for new standards will be from the “effective date” to the date of survey. For example, if a new standard/ME iseffective on 1 January, and the survey takes place on 1 June of the same year, the required track record for the new standard/ME is 5months for “fully met.”

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Daily BriefingPURPOSETo facilitate understanding of the survey process and the findings that contribute to the accreditation decision

LOCATIONAt the discretion of the hospital

HOSPITAL PARTICIPANTS• Hospital survey coordinator (as needed by team)• Chief executive officer• Designated leaders (as determined by the hospital)

SURVEYOR(S)All surveyors

WHAT WILL OCCURThe daily briefing occurs every morning of a multiday survey with the exception of the first day. The session is intended to bebrief; 30 to 60 minutes is suggested depending on the number of surveyors on the team.

When multiple surveyors are on site, the briefing is conducted jointly, with the survey team leader serving as the facilitator.

During the daily briefing with the hospital, the surveyor(s) will perform the following actions:• 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 noncompliance determinations. The surveyor(s) does

not report minor, one-time, or single observations that do not impact scoring.• Inform the hospital that final findings for any given standard will be possible only when all activities are complete and

results are aggregated• Allow the hospital to provide information that may have been missed during the previous survey day• Address hospital requests for discussion on findings and indicate when such discussions 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 hospital needs or the need for more intensive assessment of an issue during the“undetermined survey activity” time

• Conclude the briefing and transition to the next activity(s) according to the agenda

Do not expect the surveyor(s) to perform the following actions:• 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 conversations held with individuals during tracers• Delay scheduled activities for the current day to have an in-depth discussion of issues from the previous day

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SPECIAL SITUATIONSThere may be instances when a surveyor(s) will be scheduled to survey an activity that is not taking place at the same locationwhere a daily briefing would normally occur; this may take place particularly when surveying with a team. There may also besituations in which a surveyor(s) is brought in for a day or two and departs earlier than the rest of the team. If a surveyor(s)cannot be physically present for the daily briefing, the surveyor(s) will do the following:

• Try to make arrangements to join via conference call• Share details of the previous day’s activities and findings with another surveyor for the daily briefing presentation, even if a

conference call is anticipated

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Facility TourPURPOSEThe purpose of the facility tour is to address issues related to the following:

• The physical facility• Medical and other equipment• Patient, visitor, and staff safety and security• Infection prevention and control• Emergency preparedness• Hazardous materials and waste• Staff education

LOCATIONSelected patient care settings, inpatient and ambulatory units, treatment areas, and other areas, including, but not limited to,admitting, kitchen, pharmacy, central storage, laundry, morgue, and power plant (if applicable). The surveyor(s) will be lookingto see if the corridors and exit paths of travel are free for the safe exit of the facility in an emergency. The tour is designed tocover high-risk areas for safety and security.

HOSPITAL PARTICIPANTS• Chief engineer• Safety officer and/or facility manager• Directors of admitting, pharmacy, and dietary (when the surveyor[s] is present in their areas)• Infection control practitioner

SURVEYOR(S)Administrator surveyor(s) (physician and/or nurse surveyor[s] 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)• Assessment of Patients (AOP)• Management of Communication and Information (MCI)

DOCUMENTS/MATERIALS NEEDED• Documents, such as plans, policy and procedures, test and maintenance reports (as identified in [a] through [f ] of the intent

statement for FMS.2), that describe the plans for the following:(a) Safety and security (FMS.4)(b) Hazardous materials (FMS.5)(c) Disaster preparedness (FMS.6)(d) Fire safety (FMS.7)(e) Medical equipment (FMS.8)(f ) Utility systems (FMS.9)

• Facility Improvement Plan (described in the intent statement for FMS.4 through FMS.4.2)

WHAT WILL OCCURPrior to the facility tour, the surveyor(s) will have reviewed the Facility Improvement Plan and the safety plan(s) described inFMS.2. They will then visit different areas of the facility to check the implementation of these plans. The surveyor(s) will alsoreview selected portions of the facility inspection report prepared by the hospital.

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The surveyor(s) will visit patient care areas as well as non–patient care areas of the facility. In all areas, the surveyor(s) willobserve the facility and interview staff to learn how the hospital manages the facility to accomplish the following:

• Reduce and control hazards and risks• Prevent accidents and injuries• Maintain safe conditions• Maintain secure conditions• Implement emergency response plans

Note: In some survey agendas, two surveyors will visit separate sections of the facility at the same time. The hospital should beprepared to have staff available to guide and assist each surveyor on the tour of the facility.

The non–patient care areas visited by the surveyor(s) include the following:• The boiler room• The emergency power generator• The loading/receiving dock• Central storage areas or warehouse• Central sterile supply department• Laboratory• The laundry, if applicable• Food service/kitchen• Oxygen storage rooms• Hazardous materials storerooms• Areas designated as hazardous, such as locker rooms, clean and soiled linen rooms, and oxygen storage rooms• The bottoms of laundry and garbage chutes• The morgue• Heating and air-conditioning equipment rooms to evaluate storage practices and utility systems maintenance• The roof

HOW TO PREPARE• Prior to survey, the hospital 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 surveyor(s). 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 should be able to share this

information with the surveyor(s) (FMS.1). (Complete the relevant sections of the Law and Regulation Worksheet on pages 101–105.)

• Representatives of the hospital should be prepared to show the surveyor(s) how their facility management plans areimplemented. For example, they should demonstrate how hazardous materials are stored and disposed of.

• Prior to survey, the organization should ensure that all medical equipment has been inspected, tested, and maintained andthat these activities are documented (FMS.8 and FMS.8.1).

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

• The hospital 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)

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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 buildingB. Any local codes, laws, or classifications for the buildings based on the activitiesC. 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, and regulationsB. Specific findings related to law, regulation, codes, and accreditation standards. Examples include “Building 1, second

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

III. The plan to correct the findings

A. TimetableB. 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 thefacility to ensure that facility safety concerns are prevented or eliminated through an ongoing planning and inspectionprocess

Note: The facility inspection report can be in any format that makes it an effective management tool for the hospital. Theinspection can be conducted by knowledgeable hospital staff or by outside consultants. The report should be as complete aspossible to demonstrate that the hospital is aware of all conditions in its buildings and has plans to improve the safety of itsbuildings.

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Individual Patient Tracer ActivityPURPOSEA tracer follows the experiences of an individual patient to evaluate the hospital’s performance against international standards.One approach to conducting a tracer is to sequentially follow the course of care, treatment, and services received by the patientfrom preadmission through postdischarge. During an individual tracer, the surveyor(s) will do the following:

• Follow the course of care, treatment, and services provided to the patient by and within the hospital using current recordswhen possible

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

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

• Identify potential concerns in the relevant processes

HOSPITAL PARTICIPANTSDuring a tracer, the surveyor(s) will converse with a wide variety of staff involved in the patient’s care, treatment, and services.Staff could include nurses, physicians, therapists, case managers, aides, pharmacy and lab personnel, and support staff.

SURVEYOR(S)Nurse, physician, or administrator surveyor(s)

STANDARDS/ISSUES TO BE ADDRESSEDAll standards chapters may be addressed during this visit.

DOCUMENTS/MATERIALS NEEDEDThe clinical records of patients currently receiving care in the unit/setting

WHAT WILL OCCURUsing the information from the application, the surveyor(s) will select patients from an active patient list to trace theirexperience throughout the hospital. Patients typically selected are those who have received multiple or complex services andtherefore have had more contact with various parts of the hospital. This contact will provide the opportunity to assess continuityof care issues. To the extent possible, the surveyor(s) will make every effort to avoid selecting tracers that occur at the same timeand that may overlap in terms of sites within the hospital.

The surveyor(s) will follow the patient’s experience, looking at services provided by various individuals and departments withinthe hospital, as well as at “handoffs” between them. This type of review is designed to uncover systems issues, looking at boththe individual components of a hospital and how the components interact to provide safe, high-quality patient care.

The number of patients followed under tracer methodology will depend on the size and complexity of the organization, thenumber of surveyors, and the length of the on-site survey. The tracer starts in the patient care setting or unit where the patientand the clinical record are currently located. This is where the surveyor(s) begins to trace the entire care, treatment, or serviceprocess from preadmission through postdischarge. The surveyor(s) has approximately two hours to conduct a tracer, although itmay be shorter or longer depending on its complexity and other circumstances. Multiple patient records may be reviewed duringa single designated tracer activity.

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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, and services. If the responsible staff

person is not available, the surveyor(s) may speak with other staff members. Supervisor participation in this part of thetracer should be limited. Additional staff involved in the patient’s care will meet with the surveyor(s) as the tracer proceeds.For example, the surveyor(s) will speak to a dietitian if the patient being traced has nutritional issues.

• Observation of direct patient care• Observation of medication processes• Observation of infection prevention and control issues• Observation of care planning processes• Discussion of data use in individual units. This discussion may include quality improvement measures being used,

information that has been learned, improvements made using data, and data dissemination.• Observation of the impact of the environment on safety• Staff roles in minimizing environmental risk• Review of emergency equipment, supplies, and processes• 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, will attempt to verify issues identified during the tracer.• When visiting the emergency department, the surveyor(s) 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 patientbeing traced. For example, if the patient received a blood transfusion, the surveyor(s) 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. Thesurveyor(s) may ask staff in the unit, program, or service to assist with the review of the additional records. The followingcriteria can be used to guide the selection of additional records depending on the situation:– Similar or same diagnosis or tests– Patient close to discharge– Same diagnosis but different physician/practitioner– Same test but different location– Same age or sex– 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 may need to wait for staff to become available. In these cases, thesurveyor(s) will use this time productively (for example, to tour the unit, program, or service; to address environment of careissues; or to 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 CRITERIAPatient tracer selection may be based on, but not limited to, the following criteria:

• A patient on dialysis• A psychiatric patient• A pediatric and/or neonatal patient• A maternity patient• A patient receiving imaging services• A patient receiving rehabilitation services• Patients related to system tracers, such as infection prevention and control and medication management

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• Patients received from the hospital, long term care patients transferred from another organization, mental health care clientsreceiving ambulatory services, and patients receiving home care services

• Patients due for discharge that day or the next day• Patients who cross programs. Examples include:

– Patients scheduled for a follow-up in ambulatory care or home care– Patients entering or leaving the hospital from or to the care continuum, such as long term care and hospice

LINKAGES TO OTHER SURVEY ACTIVITIESIssues identified from the tracer activities may lead to further exploration in the system tracers or other survey activities, such asthe facilities tour and governance and leadership interview. The surveyor(s) will use time scheduled as “undetermined surveyactivity” on the agenda to conduct additional activities to clarify issues, to gather additional information, and to evaluatestandards compliance that is not directly related to a patient tracer.

Findings from tracer visits provide focus for other tracers and may influence the selection of other tracers. They may also identifyissues related to the coordination and communication of information relevant to the safety and quality of care services.

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System Tracer: Medication ManagementPURPOSEThis session explores the hospital’s medication management process as well as potential risk points in the system.

Note: When a separate Medication Management System Tracer is not noted on the agenda (for example, on shorter surveys), thesurveyor(s) will address medication management throughout individual patient tracers and during the Improvement in Qualityand Patient Safety System Tracer.

HOSPITAL PARTICIPANTS• Individuals selected by the hospital 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 ofadministered medications.

• Clinical staff of pharmacy and other clinical support departments that are part of the medication management system willparticipate in the focused-tracer activity.

As applicable, appropriate participants might include a direct care or service representative from the following areas:• Clinical staff, such as a nurse, physician, therapist, or dietitian, who have a role in medication management processes as part

of the direct care, treatment, and services they render• Clinician from the pharmacy or a consultant pharmacist who is knowledgeable about the selection of medications available

for use and medication monitoring• Staff member responsible for medication education of 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 conductedNote: A separate representative from quality improvement is not necessary if other participants can speak to medicationmanagement improvements (for example, a therapist on a medication quality improvement team).

• Clinician from the laboratory• Environmental safety personnel involved in the maintenance of pumps

Note: To facilitate a beneficial exchange between the surveyor(s) and the hospital, the hospital should identify a relatively smallgroup 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, talk withavailable staff in these areas about their roles in medication management, review documentation, and possibly interview apatient.

SURVEYOR(S)All surveyors available to participate

WHAT WLL OCCURThe Medication Management System Tracer is composed of three parts.

Part 1This part consists of a practical medication tracer that extends from the point of order entry to patient administration andmonitoring. It is similar to a patient tracer, but traces a medication rather than a patient. The medication chosen for the tracer isgenerally a high-risk/high-alert medication.

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Part 2For the next part, a conference with a small group of leaders involved with the medication system is held. Discussion items mayinclude the following:

• Policy review. A select group of policies chosen from processes just seen on the practical tracer in Part 1 could be validatedduring the policy review. A policy review could occur if an issue requires clarification or if there were inconsistencies foundin processes during a tracer. Examples might include pediatric medication processes, destruction of recalled medications, andcomplete order policy.

• Review of the annual medication system evaluation and actions taken to improve the system based on the evaluation• Review of data related to new services or changes in the medication system

The conference agenda is flexible and unique to the system that is being evaluated.

Various methodologies are used to evaluate a hospital’s medication management system, including a group discussion session; amedication management focused tracer; a review of data for medication errors, near misses, and other medication monitors; andindividual patient tracers. The medication processes that are evaluated include selecting, procuring, storing, ordering/transcribing, administering, and monitoring. As determined by the surveyor(s), the session may start with the focused tracer orwith the group discussion.

Part 3The last part consists of a review of data related to medication errors, near misses, and adverse drug reactions. These data arereviewed during this part rather than during the Improvement in Quality and Patient Safety System Tracer and may be includedas part of the group discussion rather than as a separate activity.

Focused-Tracer ActivityThe focused-tracer activity may take place prior to or after the group discussion. The surveyor(s) explores the path of a selectedhigh-risk, high-alert, or other medication in the hospital using a current medical record and/or a drug selected from thehospital’s high-alert medication list. The surveyor(s) will trace the drug for a patient through all medication processes fromadding the drug to the formulary through monitoring the drug’s effect on the patient. The surveyor(s) then focuses onmedication management processes informed by prior survey activities, such as the medication management group discussion orobservations made during previous patient tracers.

Group DiscussionThe discussion session explores medication management processes in the hospital and handoff points between processes.

During the group discussion, the surveyor(s) and hospital staff will do the following:• Explore each applicable medication management process. Participants in the group share the hospital’s approach to

medication management based on their experience.• For each medication management process discuss the following:

– Areas of concern or symptoms– Immediate or proximal causes for an area of concern– Potential solutions

• Explore the continuity of medication management processes and their relationship to other supporting processes andsystems

• Identify potential areas of concern in the hospital’s medication management system and actions that might be taken• Identify any specific medication management issues requiring further exploration as part of subsequent tracers and other

survey activities• Review the IPSGs related to medication management

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

• Medication selection, procurement, and storage, including IPSG 3• Ordering, order entry, and transcription and IPSG 2• Preparation and dispensing• Administration and IPSG 1• Monitoring of and compliance with IPSGs 5 and 6• Reporting of errors/system breakdowns/near misses• Data collection, analysis, and evaluation of systems and actions taken, including any performance improvement initiatives

related to medication management• Medication education for patients and staff• Information management related to medication management• Patient involvement as part of a medication management team

The influence of other hospital systems for planning, data use, performance improvement, communication, and staffcompetence/effectiveness may be explored with respect to the medication management system and processes.

Note: In hospitals with more than one program accredited by JCI and in hospitals with multiple sites, only one medicationmanagement session is scheduled. If it is not feasible for staff from all programs/sites to participate, the hospital may need toteleconference individuals from distant locations into the group discussion.

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System Tracer: Infection ControlPURPOSEDuring the discussion of the infection prevention and control program, the surveyor(s) and hospital will be able to accomplishthe following:

• Identify strengths and potential areas of concern in the infection prevention and control program• Begin determining actions necessary to address any identified risks in infection prevention and control processes• Begin assessing or determining the degree of compliance with relevant standards• Identify infection prevention and control issues requiring further exploration

Note: When a separate Infection Control System Tracer is not noted on the agenda (for example, on shorter surveys), thesurveyor(s) will address infection prevention and control throughout individual patient tracers and during the Improvement inQuality and Patient Safety System Tracer.

HOSPITAL PARTICIPANTSIndividuals from the hospital selected for participation should be able to address issues related to the infection prevention andcontrol program in all major departments or areas within the hospital. This group should include, but not be limited to,representatives from the following departments, as applicable:

• Clinical staff, including physicians, nurses, pharmacists, and laboratory personnel• Clinicians who are knowledgeable about the selections of medications available for use and pharmacokinetic monitoring• Clinicians from the laboratory who are knowledgeable about microbiology• Clinical staff, including all individuals involved in infection prevention and control and a sample of individuals involved in

the direct provision of care, treatment, and services• Staff responsible for the physical plant• Hospital leadership

Note: To facilitate a beneficial exchange between the surveyor(s) and the hospital, the hospital should identify a relatively smallgroup of active participants for discussions and interviews. Other staff may attend as observers.

SURVEYOR(S)All surveyors available to participate

WHAT WILL OCCURThe session will open with introductions and a review of the goals for the Infection Control System Tracer, which include thefollowing:

• Exploration, critical thinking, and potential problem solving about the infection prevention and control program• Identification of potential areas of concern in the infection prevention and control program and areas for improvement and

actions that could be taken to address these

Process• The tracer may begin with a short group meeting with individuals responsible for the hospital’s infection prevention and

control program or in a patient care area identified by the surveyor(s) for the focused-tracer activity.• During the group meeting, the surveyor(s) will gain a better understanding of the infection prevention and control system

and will identify potential areas that could be explored during the patient care area visit and potential areas of concern thatrequire further discussion with staff knowledgeable about the hospital’s infection prevention and control program.

• The surveyor(s) may move to other settings as appropriate and applicable to tracing infection prevention and controlprocesses across the hospital.

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

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DiscussionThe surveyor(s) will draw from his or her tracer activity experience, hospital infection prevention and control surveillance data,and other infection prevention and control–related data to inspire scenarios for discussion with the hospital. Participants will beasked to discuss the following aspects of the hospital’s infection prevention and control program as they relate to the scenarios:

• How patients with infections are identified by the hospital• How patients with infections are considered within the context of the infection prevention and control program• Current and past surveillance activity that took place in the previous 12 months or more for re-surveys and 4 months or

more for initial surveys• Type of analysis being conducted on the infection prevention and control data, including comparisons• Reporting of infection prevention and control data, including frequency and audience• Process for handling an influx of infectious patients• Process used to perform an infection prevention and control risk assessment, including the reasons for conducting the

assessment and the results of the analysis• Prevention and control activities (for example, staff training, education of patient/resident/client population, and

housekeeping procedures)• Physical facility changes, either completed or in progress, that have an impact on infection prevention and control• Actions taken as a result of surveillance and the outcomes of those actions• Effectiveness of implementation of IPSGs 5 and 6 and the hand-hygiene guidelines

Hospitals may use infection prevention and control data during this part of the activity if the data are relevant to the discussion.

Discussion can revolve around patients already included in infection prevention and control surveillance and reporting activitiesor around those not yet confirmed as meeting the definition or criteria for entry into and monitoring through the infectionprevention and control surveillance system. In addition to surveyor-identified scenarios, the hospital is encouraged to presentexamples of cases that will highlight various aspects of the infection prevention and control program. Some of the scenarios thesurveyor(s) will want to discuss, as applicable to the hospital, may include, but are not limited to, the following:

• Patients with fever of unknown origin• Patients with a postoperative infection• Patients admitted to the hospital postoperatively• Patients placed on an antibiotic that is new to the list of available medications (preferably one with corresponding culture

and sensitivities, blood levels, and/or other laboratories used for dosing)• Patients placed in isolation due to an 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, meningococcaldisease, drug-resistant pneumococcal disease, pertussis, mycoplasma, mumps, rubella, multidrug-resistant Staphylococcusaureus (MRSA), vancomycin-resistant Enterrococcus (VRE), Clostridium difficile, respiratory syncytial virus (RSV),enteroviruses, and skin infections (impetigo, lice, and scabies).

• Infection prevention and control practices related to emergency management• Patients placed in isolation because they are immunocompromised• Recent changes in physical facilities that have an impact on infection prevention and control• Patients with a known case of active tuberculosis

ConclusionThe surveyor(s) and hospital will summarize identified strengths and potential areas of concern in the infection prevention andcontrol 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 infectionprevention and control for all services provided by the hospital. Participants in this system tracer should include individuals whoare able to address infection prevention and control in all services offered by the hospital.

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System Tracer: Improvement in Quality and Patient SafetyPURPOSEThis session focuses on the hospital’s activities to improve quality and patient safety through the use of data to manage risk.

HOSPITAL PARTICIPANTSIndividuals from the hospital selected for participation should be able to address issues related to using data in all majordepartments or areas within the hospital. The individuals should include representatives from the following services:

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

• Physicians, nurses, and pharmacists• Individuals who are knowledgeable about the information systems available for data collection, analysis, and reporting• Hospital leadership

Note: To facilitate a beneficial exchange between the surveyor(s) and the hospital, the hospital should identify a relatively smallgroup of active participants for discussions and interviews. Other staff may attend as observers.

SURVEYOR(S)All surveyors available to participate

STANDARDS/ISSUES TO BE ADDRESSED

Quality Improvement and Patient Safety (QPS)All standards in the “Quality Improvement and Patient Safety” chapter may be discussed; however, specific attention will be paidto how measures were selected (QPS.3.1 and QPS.3.2), the process used to validate data internally (QPS.5), and whatimprovements have been achieved and sustained as a result of data analysis (QPS.9 through QPS.11).

In addition, the hospital may be asked about the process for identifying and managing sentinel events and near-miss events(QPS.6 through QPS.8).

The surveyor(s) will also expect to see data regarding implementation of the IPSGs (IPSG.1 through IPSG.6). As part ofIPSG.5, PCI.9 may be included in the discussion.

Prevention and Control of Infections (PCI)Specifically, PCI.7 through PCI.7.5, identifying processes and procedures associated with the risk of infection are addressed. Inaddition, the surveyor(s) will discuss how the infection prevention and control program is integrated with quality improvementand patient safety (PCI.10 through PCI.10.6).

Governance, Leadership, and Direction (GLD)Standards addressed during this activity include how governance approves the hospital’s plan for quality and patient safety(GLD.1.5) and how leaders are educated in the concepts of quality improvement (GLD.3.4).

Medication Management and Use (MMU)Standards addressed during this activity include how the effects of medications on patients are monitored (MMU.7) andmonitoring and reporting medication errors and near misses (MMU.7.1).

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DOCUMENTS/MATERIALS NEEDEDHospitals should have all of the following documents available for review during this session or for the document review sessionon day one (see pages 37 to 40).

• Clinical and managerial measures reports for each measure identified by hospital leaders; for example, charts and graphs(including reviews of all QPS.3 measures, indicators chosen, data collected, data analyzed, and findings used to makechanges/improvements)

• Root cause analysis for any sentinel events and/or near misses, including definitions of sentinel event and near miss and themethods and processes for performing a root cause analysis. If possible, include a real-world example of a near miss event forwhich a root cause analysis was performed.

• Proactive risk assessments, such as failure mode and effects analysis (FMEA), hazard vulnerability analysis (HVA), andinfection control risk assessment (ICRA), including a proactive risk analysis and redesign of at least one process per year.During this session, the hospital will show at least one example of a process that was analyzed and redesigned to preventpossible problems.

• Clinical practice guidelines and clinical pathways for the five areas selected as priority focus areas in order to explain theguidelines and pathways that are in use, the guidelines developed in the past 12 months, how the guidelines’ and pathways’use was monitored, how the data on the use and usefulness/effectiveness of specific guidelines and pathways are collected,and which changes in practice were affected

• Committee manuals, including committee minutes (for example, minutes from the Quality Improvement and PatientSafety, Infection Prevention and Control, Medication Use, Risk Management, and Complaint Management committees).This session is designed to identify how the decision for the measures was made; how the data were collected; how thefindings were used; and how data, findings, and problems are communicated throughout the hospital.

WHAT WILL OCCURThe session is organized to better understand the processes related to quality monitoring and improvement. Some of the activities forthis session will be discussions and document review; for example, clinical and managerial measures that are being used forimprovement can be reviewed. Other activities can include the surveyor(s) conducting focused tracers in the departments/services toevaluate the effectiveness of the hospital’s implementation of the overall quality plan; quality standards; and patient safety actionplans, processes, and programs. The surveyor(s) will perform the following activities and use the following methods:

• The basics of data gathering and preparation, including the following:– Selecting measures– Data collection and aggregation– Data analysis and interpretation– Disseminating/transmitting findings– Taking action– Monitoring performance/improvement

• Review the hospital’s monitoring data for each of the clinical and managerial measures selected for QPS.3.1 and QPS.3.2 toevaluate compliance. The surveyor will review measures selected from the JCI Library of Measures to ensure that thehospital is using five measures (see page 82). The surveyor will also determine how these monitoring data have been used toidentify potential areas for improvement, to implement action plans, and to demonstrate sustained performance.

• Validate the implementation and use of selected performance improvement strategies throughout the hospital to ensure thatthe improvements are effective and consistently implemented across the hospital. For example, IPSGs or plans implementedin response to a performance measure that does not meet the target threshold will be checked. The surveyor(s) will conductselected focused-tracer activities during this session and throughout the remainder of the survey.

• Evaluate the hospital’s consistent implementation and use of the clinical practice guidelines and clinical pathways selected bythe hospital to determine compliance with the guidelines and integration of the guideline requirements into the clinical carepathways of patients. The surveyor(s) will trace the care process of appropriate patients on various departments/services.

• Determine the effectiveness in implementing the hospital’s action plans developed as improvements following root causeanalyses for sentinel events or near misses, proactive risk assessments (such as FMEA and HVA), and managing quality andsafety complaints.

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• Review and discuss the measures validation process. Surveyors will review one of the measures the hospital used in order tosee how it was validated, how the analysis was conducted, and how a process changed as a result.

• Evaluate the root cause analysis action plan to validate the findings

The surveyor(s) may incorporate examples from observations obtained from previous individual patient tracers. During thissession, the surveyor(s) will review only the monitoring measures that have not been reviewed previously during the survey aspart of the individual or system tracers. When system tracer time has not been scheduled for medication management andinfection control, the use of data and improvements in these areas can be covered during this session.

Medication Management Data Issues (also see “System Tracer: Medication Management” on pages 49–51)Medication management data–collection issues are addressed in this section for shorter surveys in which only one system tracer(Improvement in Quality and Patient Safety) is scheduled. Discussion explores the following issues:

• Monitoring data collected on the performance of the hospital’s medication management system and processes, includingtrends or issues that have been identified and changes made as a result of that review

• Medication measures the hospital is collecting. Medication management data collection should be relevant to the servicesprovided by the hospital and to the patients served. The hospital should be collecting data related to the risk points it hasidentified in its medication management system evaluation. Examples of such data based on an assessed risk point mightinclude, but are not limited to, the following:– Number of pharmacy interventions– Turnaround times from order to administration– Adverse drug events/adverse drug reactions– Use of high-risk or high-alert medications– All suggested measures in QPS.3.1 (such as the use of antibiotics)

Infection Prevention and Control Data Issues (also see “System Tracer: Infection Control” on pages 52–53)Applicable in smaller surveys in which only one system tracer (Improvement in Quality and Patient Safety) is scheduled.Discussion explores the following topics:

• Risk assessment process and findings• Surveillance methods for health care–associated and non–health care–associated infections• Types of monitoring measures and data collected:

– Whether infection-related data are collected– Whether the hospital has developed and implemented a system for measuring improvements

• Using standardized definitions• Control methods (includes data dissemination to physicians, staff, leaders, and external entities)• Prevention based on data findings• The hospital’s plans to collect data relevant to the JCI Prevention and Control of Infections standards

ConclusionAs a result of this session, the surveyor(s) and the hospital will be able to do the following:

• Identify strengths and weaknesses in the hospital’s implementation of the quality plan, including monitoring of performancemeasures, data use, areas identified for improvement, and actions that could be taken

• Identify specific data-use issues requiring further exploration as part of subsequent survey activities• Provide appropriate education, as applicable

Note: In hospitals with multiple sites, only one medication management session and one infection control session are usuallyscheduled. If it is not feasible for staff to participate from all programs/sites, the hospital may need to teleconference individualsfrom distant locations into the group discussion.

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Quality Improvement and Patient Safety (QPS) Monitoring Plan: Measures Documentation ToolPurpose

This Quality Improvement and Patient Safety (QPS) Monitoring Plan: Measures Documentation Tool is a sample form on which hospitals can record the method that will be

used to evaluate the effectiveness of ongoing compliance with the clinical and managerial measures selected by the leaders for the QPS monitoring plan. This tool will

provide a consistent process for documenting each element of the selected QPS clinical and managerial measures. The following information should be identified before

collecting and measuring data to ensure that the process is clear and transparent:

• Category of the measure (clinical or managerial)

• Name, source, and definition of the measure for the QPS monitoring requirement

• Rationale for selecting the measure

• Methodology for data collection (retrospective or concurrent)

• Type of measure (structure, process, outcome, or process and outcome)

• Reporting time period and frequency of assessment of data

• Target sample size and threshold/target to demonstrate the expected performance outcome

• Data aggregation and analysis plan (to transform the data collected into useful information to reach conclusions and make necessary decisions in response to the

results)

• Communication plan for reporting results to staff

• Name or file name for the audit tool used

Procedure

The Quality Committee or other key leadership group can appoint a team of stakeholders (senior leaders, managerial leaders, and clinical leaders within the hospital) and

assign the task of developing the QPS measurement plan for each measure. The JCI Library of Measures is a good source for selecting valid and reliable measures to use.

The team completes one form for each measure selected. Each clinical/managerial area being monitored can have more than one measure. After all the measures are

selected, one approach is for the leadership team to designate an “owner” for each measure. The owner is an individual(s) with knowledge and experience in the process

being monitored, for example, assessment of patients, blood and blood products, anesthesia and sedation, risk management, and patient and family satisfaction. In addition,

the owner should understand the principles of quality monitoring and have demonstrated skills in using measurement tools needed to collect, aggregate, analyze, and report

data effectively. This assigned owner is responsible for ensuring that these data are collected, aggregated, analyzed, and reported consistently to the Quality Committee or

other appropriate group for ongoing analysis and improvement. Committee minutes or other documents should demonstrate a multidisciplinary approach and process.

Documentation should demonstrate that data results are acted on and improvement plans are implemented and sustained over time or that new strategies are used when

the results are not met.

(continued)

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System Tracer: Facility Management and Safety SystemPURPOSEThis session provides guidance for evaluating the hospital’s facility management and safety (FMS) system and performance formanaging risk. The surveyor(s) and the hospital will do the following:

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

HOSPITAL PARTICIPANTSIndividuals from the hospital selected for participation should be able to address issues related to FMS in all major departmentsor areas within the hospital. This group should include representatives from the following services (in some hospitals, individualsmay be responsible for multiple roles):

• A person(s)—designated by leadership—who coordinates safety management activities• A person(s)—designated by leadership—who coordinates security management activities• A person(s) who manages the hospital’s facility(ies)• A person(s) responsible for the hospital’s emergency management activities• A person(s) who manages the hospital’s building utility systems• A person(s) responsible for maintaining the hospital’s medical/laboratory equipment• A leader(s) of the environment of care team or safety committee• Hospital leadership

In complex hospitals that have decentralized FMS management activities at remote sites, those persons responsible for managingthe activities listed above at those sites should be available (either in person, by conference call, or through other means).

Note: To facilitate a beneficial exchange between the surveyor(s) and the hospital, the hospital should identify a relatively smallgroup of active participants for discussions and interviews. Other staff may attend as observers.

SURVEYOR(S)Administrative surveyor(s)

WHAT WILL OCCURThe duration of the session will be about 60 to 90 minutes. The group discussion activity (first part of the session) representsapproximately 30% of the session and occurs after the surveyor(s) has had the opportunity to review the following documentsfor orientation purposes:

• The annual evaluations of the FMS plans that deal with risks in the environment• The FMS multidisciplinary team meeting minutes (previous 12 months)

It is also important that observations related to FMS made by other members of the survey team (if applicable) and anyFMS–related issues and information identified from previous surveys be discussed during this session.

IntroductionThe surveyor(s) reviews the objectives of the FMS session with the hospital’s participants.

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Discussion GuidelinesDuring this time, the surveyor(s) should initiate and lead a discussion that will give insight into the following aspects of thehospital’s environment of care management processes, as shown in the FMS risk management cycle below.

Plan• What specific environment of care risks have been identified by the hospital?

Teach• How have roles/responsibilities for staff/volunteers been communicated by the hospital (human resources)?

Implement• What procedures and controls (human and physical) does the hospital implement to minimize the impact of risk to

patients, visitors, and staff?

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

Monitor• How is FMS performance (human activities and physical components) monitored by the hospital?• What monitoring activities have taken place within the past 12 months?

Improve• What FMS issues are currently being analyzed?• What actions have been taken as a result of FMS monitoring activities?

The hospital should discuss how six FMS risk categories* and construction activities have been addressed in each of themanagement processes listed above. The following matrix assists in determining patterns of management process, risk categoryareas of concern, and strengths.

* The six FMS risk categories are general safety and security, hazardous materials and waste, fire safety, medical/laboratory equipment, utilities, and emergencymanagement.

PLAN

TEACH

IMPLEMENT

RESPOND

MONITOR

IMPROVE

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The matrix below is a screening tool for selecting a particular management process or risk category to explore in the second partof the FMS–tracer session. Selection of a particular management process or risk category should be based on informationgathered from the following: the discussion phase of this session, FMS–related information from previous surveys, and anyunusual observations made during survey prior to this session.

During this session, the hospital’s performance in addressing the emergency management requirements of Standards FMS.6 andFMS.6.1 will be reviewed, including its performance in the following areas:

• Identifying and analyzing potential environmental risks in the hospital• Identifying the hospital’s role in relation to the community’s, country’s, or region’s emergency management program• Identifying processes for the timely sharing of information with other health care organizations that provide services within

the contiguous geographic area• Identifying a structure used during emergencies that links with the community’s incident response structure• Making any necessary improvements to the hospital’s emergency management based on critiques of emergency management

drills

Discussion should focus on the management processes and not the FMS risk categories. The surveyor(s) should not be theprimary speaker(s) during this time but rather a listener(s) to the discussion. This is not intended to be an interview.

Observation GuidelinesThe surveyor(s) then observes and evaluates the hospital’s performance in managing FMS risk. This activity representsapproximately 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 on the following:• FMS documents previously reviewed• Observations by other survey team members• Knowledge gained during the group discussion portion of this session

The surveyor(s) will observe the implementation of those particular management processes determined to be potentially vulnerable orwill trace a particular risk(s) in one or more of the FMS risk categories that the hospital manages by doing the following:

• Beginning where the risk is encountered or first occurs (that is, a starting point might be where a particular safety or securityincident occurs, a particular piece of medical equipment is used, or a particular hazardous material enters the hospital)

• Having staff describe or demonstrate their roles and responsibilities for minimizing the risk, the actions they should take if aproblem or incident occurs, and how to report the problem or incident

• Assessing any physical controls for minimizing the risk (for example, equipment, alarms, and building features)

Safety Security

Hazardous Materials

and Waste Fire Safety

Medical/Laboratory

Equipment Utilities Emergency Management

Plan

Teach

Implement

Respond

Monitor

Improve

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• Assessing the emergency management plan for mitigation, preparedness, response, and recovery strategies and actions andresponsibilities for each priority emergency (see FMS.6 and FMS.6.1 for more information on the emergency managementplan)

• Assessing the emergency management plan for responding to utility system disruptions or failures (such as having analternative source of utilities, notifying staff how and when to perform emergency clinical interventions when utility systemsfail, and obtaining repair services)

• Reviewing the implementation of relevant inspection, testing, or maintenance procedures of any equipment, alarms, orbuilding features that are available for controlling the particular risk

• Asking others in the hospital who have a role in responding to the particular problem or incident to describe or demonstratetheir role and reviewing the condition of any equipment they use when responding

If the risk moves around in the hospital’s facility (for example, a hazardous material or waste), the surveyor(s) will follow the riskfrom “cradle to grave.”

ConclusionThe surveyor(s) summarizes any potential areas of concern in the management process or risk category observed. Staffresponsible for managing the particular process or risk that was reviewed provide information regarding their roles in addressingany areas of concern observed. The hospital should provide information regarding processes that have been developed to addressany potential areas of concern that were observed. The hospital should also provide information regarding existing activities thathave been implemented to address any potential areas of concern that were observed.

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Undetermined Survey ActivitiesPURPOSETracer methodology is used as the primary tool to assess standards compliance. However, other tools or a focused approach canbe used to gather additional information to evaluate standards compliance that is not directly related to a specific patient tracer.Each of these focused activities is listed on the survey agenda as an “Undetermined Survey Activity.”

Undetermined survey activities are broadly defined and encompass a variety of activities customized to the particular needs ofeach hospital. Undetermined survey activities are selected by the survey team to allow a more intensified assessment of a targetedarea when information from any survey activity, such as tracers or discussions, identifies a need to focus on a specific concern orto increase the sample size of a review item.

HOSPITAL PARTICIPANTSParticipants will be identified by the surveyor(s) depending on the activity being evaluated.

STANDARDS/ISSUES TO BE ADDRESSEDStandards related to the specific activity that is being addressed. For example, if the survey activity is focused on hazardousmaterials, one of the standards that would be addressed is FMS.5.

WHAT WILL OCCURExamples of undetermined survey activities include, but are not limited to, the following:

• Focused tracers that are not patient tracers:– Patient education processes– Access to medical information– Financial disclosure to patients– Disinfection processes– Blood product infusion processes

• Focused process tracer:– Hazardous materials management– Medical transport– Laboratory specimen handling in clinics– Assessing a specific standard/issue using patient records and document review to evaluate, for example, ACC.1.1 related to

admitting or registering patients• Specific site or department visits to review applicable standards:

– Pharmacy and others, for example, traditional Chinese medicine and chemotherapy– Noninvasive diagnostic areas, such as pulmonary laboratory, electrocardiogram (EKG), and electroencephalogram (EEG)– Hyperbaric treatment area– Wound clinics

• Specific patient safety and quality activities:– Failure mode and effects analysis– Root cause analysis review– Sentinel event review

• Focused document/policy review to close gaps in the usual document review exercise• Other items as appropriate to the needs of the team

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Education Session: Hospital Decision Rules, ScoringGuidelines, and Strategic Improvement PlanPURPOSEThe purpose of this session is to provide education to hospital leadership to help them understand the decision rules, thesurveyor scoring guidelines, and the SIP.

LOCATIONAt the discretion of the hospital leaders

HOSPITAL PARTICIPANTS• Chief executive officer• Chief operating officer• Chairman, governing body, or similar representative• Medical staff leadership• Nursing leadership• Survey coordinator and core quality leadership group• Others at the discretion of the hospital leaders

STANDARDS/ISSUES TO BE ADDRESSED• Hospital decision rules• JCI surveyor’s scoring guidelines• SIP tool

DOCUMENTS/MATERIALS NEEDEDNone

WHAT WILL OCCURThe surveyor(s) will cover the following topics:

• Explanation of each of the decision rules for hospitals• Scoring criteria for “fully met,” “partially met,” “not met,” and “not applicable” logic based on the JCI surveyor’s scoring

guidelines• The survey team leader or designee will select one or two of the surveyors’ observations that were reported at the daily

debriefing to use as examples in illustrating how the findings would be scored based on the scoring guidelines.• The survey team leader or designee will provide education on developing a postsurvey SIP to address compliance issues

identified in the “not met” findings in the survey report.

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Staff Qualifications and Education SessionPURPOSEThe objective of this interview is to address the hospital’s processes to recruit, orient, educate, and evaluate all hospital staff. Inaddition, the interview addresses the hospital’s process for evaluating the credentials of the medical, nursing, and other healthcare professional staff and their ability to provide clinical services consistent with their qualifications.

LOCATIONSmall meeting rooms at the discretion of the hospital’s leaders

HOSPITAL PARTICIPANTS FOR EACH INTERVIEW WHEN HELD SEPARATELYGenerally, two interviews will be conducted. Each should be conducted separately and in different locations. The physiciansurveyor(s) will conduct the medical staff interview, and the nurse and administrator surveyor(s) will jointly conduct theinterview for nursing staff and all other staff. The survey team may elect to conduct up to four separate interviews, depending onthe size of the hospital and the types of hospital and health care professional staff present in the hospital. Staff who may beinterviewed are as follows:

• Medical Staff:– Elected or appointed senior leader of the medical staff and/or the 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 resources/personnel department– Representatives of the group(s) involved in the orientation, education, and training of health professional staff

• Other Hospital Staff:– Manager of the human resources/personnel department– Representatives of the group(s) involved in the orientation, education, and training of hospital staff

SURVEYOR(S)• Medical staff: physician surveyor(s)• Nursing staff: nurse surveyor(s)• Other hospital staff: administrator and/or nurse surveyor(s)

STANDARDS/ISSUES TO BE ADDRESSEDStaff Qualifications and Education (SQE) standards

DOCUMENTS/MATERIALS NEEDED• Policies and procedures related to human resources/personnel management, staff credentials, and staff orientation and

education• A sample of hospital personnel files and health care practitioner staff credential files• A sample of medical staff files

The surveyor(s) will provide instructions on the first day of the survey, generally during the document review session, regardingthis interview and the preparation of the files for review. The survey team will provide the director of human resources with a listthat identifies the type and number of personnel and medical staff files selected for review later in the survey during the staff

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qualifications and education interview. Sample request and review forms are shown on the next few pages. The survey team willprovide copies of the current survey tool on the first day of the survey. It is important to know that the tools used by thesurveyor(s) throughout the survey may change at any time to continually improve the survey team’s abilities to score thehospital’s compliance with standards fairly and accurately. The tool merely reflects current JCI standards.

HOW TO PREPAREThe hospital should include a list of all current personnel and medical staff in the document review session on the first day. Thelist should identify each staff member’s specific discipline, hire date, and department or service assigned (for example,“Registered Nurse; Hired 20 July 2001; Intensive Care Unit”). These documents should be in English, when possible.

The hospital should closely review all personnel and credential files using the Competency Assessment Process Review Form onpages 68–69. Hospitals should ensure that all required elements are in the files.

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Medical Staff Qualifications Worksheet

Medical Specialty: _______________________ Initial Start Date: ______________________________

Name: ________________________________ Degree/Credential: ____________________________

Standard Measurable Element

Compliance

Yes/No Comments

SQE.9 1. Those permitted by law, regulation, and organization policy to provide patient care

without supervision are identified.

2. Required credentials (education, licensure, registration, among others) as determined

by regulation and organization policy for each medical staff member are copied by

the organization and maintained in the personnel file or in a separate credential file

for each medical staff member.

3. All credentials (education, licensure, registration, among others) are verified with the

source that issued the credential before the individual begins providing services to or

for patients.

4. All credentials on file (education, licensure, registration, among others) are current

and updated as required.

5. At initial appointment an informed determination is made about the current

qualifications of the individual to provide patient care services.

SQE.9.1 1. There is a process described in policy for the review of each staff member’s

credential file at uniform intervals at least once every three years.

3. The renewal decision is documented in the staff member’s credential file.

SQE.10 1. The organization uses a standardized process that is documented in official

organization policy for granting privileges to each medical staff member to provide

services on initial appointment and on reappointment.

2. The decision to grant reappointment to provide patient services is guided by items (a)

through (f) in the intent statement and the annual performance review of the

practitioner.

3. The patient services to be provided by each staff member are clearly delineated and

communicated by organization leaders across the organization and to the medical

staff member.

4. Each medical staff member provides only those services that have been specifically

permitted by the organization.

SQE.11 1. An ongoing professional practice evaluation of the quality and safety of patient

services provided by each medical staff member is reviewed and communicated to

the medical staff member at least annually.

5. Information from the professional practice evaluation process is documented in the

medical staff member’s credentials file and other relevant files.

SQE.8.1 1. Staff members who provide patient care and other staff identified by the organization

to be trained in cardiac life support are identified.

3. There is evidence to show if a staff member passed the training.

4. The desired level of training for each individual is repeated based on the

requirements and/or time frames established by a recognized training program, or

every two years if a recognized training program is not used.

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Nursing Staff Competency Assessment Process Review Form

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Other Health Care Professional Staff Competency Assessment Process Review Form

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Closed Medical Record ReviewThis session is held to validate the hospital’s compliance with the documentation track record (4 months for initial surveys and12 months for triennial surveys).

PURPOSE OF THE FORMThe purpose of using the closed patient medical record review form on pages 71–75 is to gather and document compliance withstandards that require documentation in the patient’s record based on additional closed record review beyond the open recordsthat are evaluated during the tracer activities.

ORGANIZATION OF THE FORMThe form is organized by topic headings (for example, “Consents” and “Assessments”) and includes the specific standard numberand the standard requirement (for example, blood consent and medical assessment). This form will be provided by the surveyteam and used for the review. The form may be revised periodically to reflect approved changes in the standards.

REVIEW PROCESS• The surveyor(s) 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”).• The record is reviewed briefly to decide what type of patient or care was received (for example, surgery, medical, emergency,

and rehabilitation).

USING THE FORM DURING THE ACCREDITATION SURVEY• The survey team leader may request 5 to 10 closed records for review. The records will be requested if the surveyor(s) wants

to validate the hospital’s documentation track record (4-month or 12-month) and/or to ensure compliance withdocumentation or patient care process requirements due to situations or information identified during the tracer activities.

• The survey team will also indicate the time period for selecting the records, typically the past 4 or 12 months. Hospital staffshould acquaint the survey team with the hospital’s practice and expectation regarding the completion of a patient recordfollowing discharge of the patient.

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

• The surveyor(s) will review the selected records with the assistance of the hospital representative, as needed, to complete theform. One column of the form is completed for each record reviewed. If more that five records are reviewed, the surveyor(s)will use another form.

• For each documentation requirement, the surveyor(s) will check “Y” (yes) on the form to indicate that the required elementis present, “N” (no) if the element is not present, or “NA” if the element is not applicable to that patient’s record.

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

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

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Medical Record Review Tool

(continued)

Standard Documentation Requirement

Medical Record 1 Medical Record 2 Medical Record 3 Medical Record 4 Medical Record 5TOTAL

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

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

PFR.8 Clinical research, investigation, and trials consent

ASC.5.1 Risks, benefits, and alternatives of anesthesia

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

surgery

ASSESSMENTS

AOP.1.3 Patient’s medical needs

Patient’s nursing needs

AOP.1.4.1 Medical assessment in 24 hours; updated if more than 30

days old

Nursing assessment in 24 hours

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Medical Record Review Tool, continued

(continued)

Standard Documentation Requirement

Medical Record 1 Medical Record 2 Medical Record 3 Medical Record 4 Medical Record 5TOTAL

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

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

AOP.1.5 Assessment findings documented within 24 hours of

admission (medical and nursing)

AOP.1.5.1 Medical assessment documented prior to surgery

AOP.1.6 Nutritional and functional screening

AOP.1.7 Screening for pain on admission

AOP.1.9 Assessment and reassessment of dying patients

AOP.1.10 Modification of assessments for special needs

AOP.1.11 Early screening for discharge planning

AOP.2 Physician reassessment daily for acute patients

COP.2.1 Measurable goals from the planned care

PFE.2 Education needs assessment

ASC.3 Presedation assessment

Monitoring during sedation

Recovery criteria

ASC.4 Preanesthesia and preinduction assessments

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Medical Record Review Tool, continued

(continued)

Standard Documentation Requirement

Medical Record 1 Medical Record 2 Medical Record 3 Medical Record 4 Medical Record 5TOTAL

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

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

OTHER

ASC.5 Anesthesia plan

ASC.6 Arrival and discharge times for postanesthesia care

ASC.7 Assessment information that supports the planned procedure

Preoperative diagnosis

Planned surgical procedure

ASC.7.2 Written surgical report contains the following:

• Postoperative diagnosis

• Name of operative surgeon and assistants

• Name of the procedure

• Surgical specimens sent for examination

• Specific mention of complications or the absence of

complications during the procedure, including amount of

blood loss

• Date, time, and signature of responsible physician

ASC.7.4 The medical postsurgical plan

The nursing postsurgical plan of care

Postsurgical plan of care by “others” as appropriate

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Medical Record Review Tool, continued

(continued)

Standard Documentation Requirement

Medical Record 1 Medical Record 2 Medical Record 3 Medical Record 4 Medical Record 5TOTAL

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

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

MMU.4 List of current medications taken prior to admission

MMU.4.3 Medications prescribed or ordered and administered are

written in the patient’s record.

MMU.7 Adverse effects

PFE.2.1 Assessment includes the following:

• The patient’s and family’s beliefs and values

• Their literacy, educational level, and language

• Emotional barriers and motivations

• Physical and cognitive limitations

• The patient’s willingness to receive information

MCI.19.3 The author, date, and time (when required) of every entry

ACC.1.1.3 Any delay in treatment

ACC.2.1 Patient’s plan of care

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Medical Record Review Tool, continued

Standard Documentation Requirement

Medical Record 1 Medical Record 2 Medical Record 3 Medical Record 4 Medical Record 5TOTAL

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

#______________

DX:

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

ACC.3.2.1 Discharge summary contains the following:

• Reason for admission, diagnoses, and comorbidities

• Significant physical and other findings

• Diagnostic and therapeutic procedures performed

• Significant medications, including discharge medications

• The patient’s condition/status at the time of discharge

• Follow-up instructions

ACC.4.4 Record of transferred patients contains the following:

• 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

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Leadership ConferencePURPOSEThe purpose of the leadership conference is to assess communication among senior leaders of the hospital and how they addressorganizational performance issues.

LOCATIONAt 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 conference.

SURVEYOR(S)Physician and nurse surveyor(s) (administrator, when part of the team)

STANDARDS/ISSUES TO BE ADDRESSEDCollaborative involvement of the senior leaders of the hospital in governing, managing, and directing the hospital will beevaluated. The following standards are to be addressed:

• 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 (MCI)

DOCUMENTS/MATERIALS NEEDEDNo documents are required to be available during the leadership conference. However, during the document review session, thesurveyor(s) may have reviewed the following documents in preparation for the leadership conference:

• Organizational chart• Mission statement• Budget and resource allocation• Strategic planning documents• Staffing plans• Information management plan• Quality management plan• Worksheet of applicable laws and regulations

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WHAT WILL OCCURThe surveyor(s) will ask questions related to leadership activities and the decisions that have been made as well as clarify anyleadership issues identified during the survey. Everyone present should participate in answering the questions. This is designed tobe an interactive session.

The surveyor(s) will assess compliance with certain standards from the “Governance, Leadership, and Direction” (GLD) chapteras well as with other standards. During the leadership conference, the surveyor(s) will also identify issues that he or she willpursue in later survey activities.

HOW TO PREPAREHospitals should identify the participants in the leadership conference. Although leaders should be familiar with all thestandards, the hospital’s leaders should read closely the GLD chapter prior to survey. In preparation for this session, it would beuseful to turn the standards into questions. Mock discussions could then be conducted with participants so they feel morecomfortable with possible questions.

The following are a few sample questions:

GLD.1.2: Please explain the process you, as leaders, use to approve the policies and plans used to operate your organization.

GLD.1.2, ME 3: What are your strategies and programs for health care professional education and research?

GLD.1.5: What is a recent example of how the governance of this organization has supported and promoted qualitymanagement and patient safety improvement efforts?

GLD.3.3: How do you monitor the services offered by an outside organization with which you have a contract to provideservices?

GLD.5.1: What is your process for identifying, in writing, the services provided by each department? How do you know thedocuments are current?

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Surveyor Team MeetingPURPOSEFor surveys being conducted by more than one surveyor, scheduled team meetings provide an opportunity for surveyors to shareinformation and observations, plan for upcoming survey activities, and plan for communication and coordination with thehospital.

LOCATIONSurveyor headquarters

HOSPITAL PARTICIPANTSNone

SURVEYOR(S)All surveyors

WHAT WILL OCCURFor surveys lasting more than one day, a 30-minute session is scheduled at the end of each day to allow surveyors an opportunityto debrief and to plan for subsequent survey days and activities. Surveys lasting longer than two days will include an additional30-minute session before or after lunch to allow for midday activity planning and observation sharing. During these sessionssurveyors will do the following:

• Identify areas that have been visited during tracer activity• Coordinate locations, services, and other areas that will be visited during continuing tracer activities• Share observations on hospital 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 thehospital to facilitate communication among the members of the team (such as ensuring availability of a speaker phone or phonewith conference call functionality).

Note: When only one surveyor is present, this time is an opportunity to plan upcoming survey activities, including the selectionof additional tracers.

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Surveyor Report PreparationPURPOSEThe surveyor(s) will use this time to compile, analyze, and organize the data he or she has collected throughout the survey into areport reflecting the hospital’s compliance with standards.

LOCATIONDesignated surveyor conference room with a computer that has an Internet connection and a printer provided for the use of thesurveyor(s) on each day of the survey

HOSPITAL PARTICIPANTSNone

SURVEYOR(S)All surveyors

WHAT WILL OCCURThis time is reserved on the agenda for the surveyor(s) to review his or her observations and to determine if there are anyfindings that reflect issues of standards compliance. The surveyor(s) will be using his or her laptop computer to prepare thereport and to plan for the leadership exit conference.

The surveyor(s) may ask hospital representatives for additional information during this session to confirm or disprove a finding.In addition, the surveyor(s) may request that the hospital photocopy the report, as needed.

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Leadership Exit ConferencePURPOSEThe purpose of this conference is to report the findings of the survey to hospital leadership and to resolve any issues ofinterpretation that may have been identified during the survey.

LOCATIONAt 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

SURVEYOR(S)Physician, nurse, and administrator surveyor(s)

STANDARDS/ISSUES TO BE ADDRESSEDSurvey findings

DOCUMENTS/MATERIALS NEEDEDNone

WHAT WILL OCCURThis session includes the following two components:

1. Discussion with key leaders of the hospital about the survey report and follow-up process, including review of the SIP.The discussion will 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 formal report of findings• The expected follow-up to the survey findings, for example, an SIP or a follow-up focused survey

2. Formal presentations of an overview of the report to hospital staff selected at the discretion of the CEO

The surveyor(s) will provide education to assist the hospital in developing an SIP based on the “not met” findings from thesurvey report. The surveyor(s) will explain the survey follow-up process regarding communication of the accreditation decisionby the JCI Accreditation Central Office.

At the discretion of the CEO, a brief conference will be held with other selected staff in the hospital to provide an overview ofthe report and to complete the survey activities.

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Reference ListsSurvey Planning:

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Required Quality MonitorsThe hospital chooses the clinical and managerial structures, processes, and outcomes that are most important to monitor basedon its mission, patient needs, and services provided. The hospital’s leaders identify key measures (indicators) to monitor thehospital’s clinical and managerial structures, processes, and outcomes.

Hospitals are required to choose five measures from the JCI Library of Measures to help them monitor their clinical andmanagerial structures, processes, and outcomes. The JCI Library of Measures includes the following measure sets:

• Acute myocardial infarction• Heart failure• Stroke• Children’s asthma care• Hospital-based inpatient psychiatric service• Nursing-sensitive care• Perinatal care• Pneumonia• Surgical care improvement project• Venous thromboembolism

Intent of QPS.3 through QPS.3.3. Required clinical monitoring includes structure, process, or outcomes data selected by theleaders on the following 11 clinical areas:

1. patient assessments2. laboratory services3. radiology and diagnostic imaging services4. surgical procedures5. antibiotic and other medication use6. medication errors and near misses7. anesthesia and sedation use8. use of blood and blood products9. availability, content, and use of patient records

10. infection prevention and control, surveillance, and reporting11. clinical research

Intent of QPS.3 through QPS.3.3. Required managerial monitoring includes structure, process, or outcomes data selected by theleaders on the following managerial areas:

a. the procurement of routinely required supplies and medications essential to meet patient needsb. reporting of activities as required by law and regulationc. risk managementd. utilization managemente. patient and family expectations and satisfactionf. staff expectations and satisfactiong. patient demographics and clinical diagnosesh. financial managementi. prevention and control of events that jeopardize the safety of patients, families, and staff

QPS.3.3. The organization’s leaders identify key measures for each of the IPSGs.

Required general measures to be monitored:Clinical and managerial monitoring data are used to study targeted areas for improvement (QPS.3, ME 1) and to monitor andevaluate the effectiveness of the improvements (QPS.3.1, ME 6; QPS.3.2, ME 5; and QPS.3.3, ME 3).

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Required Hospital PlansThe following standards identify requirements that relate to a written plan. A plan is usually more comprehensive in contentthan a policy or procedure. A plan can also be more long range or strategic in content. Frequently, a plan also sets priorities forthe entire hospital. For example, the quality management and improvement plan may address the hospital’s commitment toquality and methods for organizing quality improvement efforts. It will also identify short- and long-range priorities andmethods to achieve those priorities.

A select few of these documents need to be in English. Please refer to the list of the documents that need to be in English onpages 37–39 of this guide. Other documents do not need to be translated. For non-English documents, the survey team willhave one member able to read the documents, or alternatively, the survey team may request that one or more individuals beavailable to describe the contents of the document and answer questions concerning the document.

QUALITY IMPROVEMENT AND PATIENT SAFETYThere is a written plan for an organizationwide quality improvement and patient safety program. (QPS.1)

GOVERNANCE, LEADERSHIP, AND DIRECTIONOrganization plans (strategic or other documents) describe the care and services to be provided consistent with its mission.(GLD.3.2, intent)

The directors of each clinical department identify, in writing, the services to be provided by the department. (GLD.5.1)

FACILITY MANAGEMENT AND SAFETYThe hospital has a master plan to reduce evident risks in the environment (FMS.2) or individual plans that include, asappropriate to the facility and activities of the hospital, the following areas (FMS.4 through FMS.10):

• Safety and security (FMS.4)– Safety—buildings, grounds, and equipment do not pose a risk to patients, staff, and visitors– Security—facility and occupants are protected from loss, destruction, tampering, and unauthorized access or use

• Hazardous materials—handling, storage, and use of radioactive and other materials (FMS.5)• Disaster preparedness—response to epidemics, disasters, and emergencies (FMS.6)• Fire safety—property and occupants protected from fire and smoke (FMS.7)• Medical equipment—equipment selected, maintained, and used in a manner to reduce risks (FMS.8)• Utility systems—electric, water, and other utility systems maintained to minimize risk of failure (FMS.9.1)

STAFF QUALIFICATIONS AND EDUCATIONA staffing plan for the organization, developed collaboratively by the leaders, identifies the number, types, and desiredqualifications of staff. (SQE.6)

MEDICATION MANAGEMENT AND USEThere is a plan or policy or other document that identifies how medication use is organized and managed throughout theorganization. (MMU.1, ME 1)

PREVENTION AND CONTROL OF INFECTIONSThe organization designs and implements a comprehensive program to reduce the risks of health care–associated infections inpatients and health care workers. (PCI.5)

ASSESSMENT OF PATIENTSAll equipment used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records aremaintained for these activities. (AOP.5.4)

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Quality control procedures are in place, followed, and documented. (AOP.5.9)

A radiation safety program is in place that addresses potential safety risks and hazards encountered within or outside of thedepartment. (AOP.6.2, ME 1)

All equipment used to conduct radiology and diagnostic imaging studies are regularly inspected, maintained, and calibrated, andappropriate records are maintained for these activities. (AOP.6.5)

Quality control procedures are in place, followed, and documented. (AOP.6.8)

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Required Policies and Procedures, Written Documents, orBylawsThe standards in the tables on pages 86–99 identify a requirement for a written document. In some cases, that document is inthe form of a policy and procedure. In other cases, the document is less formal but addresses the issue identified in the standard.The document that is required is specified in the “Type of Documentation” column in the tables. In many cases, a number ofstandards requirements or MEs can be combined into one policy and procedure. Organizations may find it useful to group allrelated policies and procedures. For example, many of the patient assessment requirements are interconnected and can becontained in one policy; for example, AOP.1 and AOP.1.1 can be combined, as can MCI.18, MEs 1 through 4.

The surveyor(s) may not need to review all these documents in detail. It is, however, best to gather all these documents into onebook or, alternatively, to identify the document by standard number in the traditional location of the document for easylocation.

Note: Hospitals should refer to the guidelines for document review for detailed suggestions on the presentation of documents forthe surveyor(s).

A select few of these documents need to be in English, and these are indicated in the “English” column in the tables. Please referto the list of the documents that need to be in English on pages 38–39 of this guide. Other documents do not need to betranslated. For non-English documents, the survey team will have one member able to read the documents, or alternatively, thesurvey team may request that one or more individuals be available to describe the contents of the document and answerquestions concerning the document.

The “Page Number(s)” column in the tables refers users to the page in the Joint Commission International Accreditation Standardsfor Hospitals, Fourth Edition, where the standard is discussed.

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International Patient Safety Goals

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

IPSG.1 5. Policies and procedures support consistent practice in all situations and locations. (See ME 1 through ME 4 for policy

inclusions.)36

X Policy and Procedure

IPSG.2 4. Policies and procedures support consistent practice in verifying the accuracy of verbal and telephone communications.

(See ME 1 through ME 3 for policy inclusions.) 36–37X Policy and Procedure

IPSG.3 1. Policies and/or procedures are developed to address the identification, location, labeling, and storage of high-alert

medications.37–38

X Policy and Procedure

IPSG.4 4. Policies and procedures are developed that will support uniform processes to ensure the correct site, correct procedure,

and correct patient, including medical and dental procedures done in settings other than the operating theatre. 38–39X Policy and Procedure

IPSG.5 3. Policies and/or procedures are developed that support continued reduction of health care–associated infections. 39 X Policy and Procedure

IPSG.6 4. Policies and/or procedures support continued reduction of risk of patient harm resulting from falls in the organization. 40 X Policy and Procedure

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Access to Care and Continuity of Care

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

ACC.1 5. Policies identify which screening and diagnostic tests are standard before admission. 43 Policy

ACC.1.1 6. Written policies and procedures support the processes for admitting inpatients and registering outpatients. Includes:

• Outpatient registration

• Admitting inpatients

• Admitting emergency patients

• Holding patients for observation

43–44

Policy and Procedure

ACC.1.1.3 4. Written policies and/or procedures support consistent practice [on the process for managing inpatients and outpatients

when there is a delay in treatment]. 45Policy and Procedure

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.46

X Criteria

ACC.2 2. Established criteria or policies determine the appropriateness of transfers within the organization. 47 Criteria or Policies

ACC.2.1 5. The transfer of responsibility from individual to individual of the patient’s care is described in organization policy. 48 Policy

ACC.3 5. Organization policy guides the process for patients being permitted to leave the organization during the planned course

of treatment on an approved pass for a defined period of time.48–49

Policy

ACC.3.2 6. Policy and procedure define when the discharge summary must be completed and in the record. 50 Policy and Procedure

ACC.3.3 5. Clinical records contain the completed summary list per organization policy. 51 Policy

ACC.4.4 2. The records of transferred patients contain documentation or other notes as required by the policy of the transferring

organization.54

Policy and Procedure

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Patient and Family Rights

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

PFR.1 5. Policies and procedures guide and support patient and family rights in the organization. 60 Policy and Procedure

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

2. Policies and procedures address the patient’s right to seek a second opinion without fear of compromise to their care

within or outside the organization.

63

Policy and Procedure

Policy and Procedure

PFR.2.3 5. Policies and procedures support consistent practice [on resuscitative practices]. 65 Policy and Procedure

PFR.3 5. Policies and procedures support consistent practice [in the complaint process]. 66–67 Policy and Procedure

PFR.6 1. The organization has a clearly defined informed consent process described in policies and procedures. 68 X Policy and Procedure

PFR.6.4.1 1. The organization has listed those procedures and treatments that require separate consent. 70 X Policy and Procedure

PFR.7 7. Policies and procedures guide the information and decision process [for research]. 70–71 Policy and Procedure

PFR.11 1. Policies and procedures guide the procurement and donation process.

2. Policies and procedures guide the transplantation process.73

Policy and Procedure

Policy and Procedure

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Assessment of Patients

(continued)

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

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

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

3. Organization policy identifies the information to be documented for the assessments.

78

X

X

X

Policy and Procedure

Policy and Procedure

Policy and Procedure

AOP.1.1 3. The minimum content of assessments performed in inpatient settings is defined in policies.

4. The minimum content of assessments performed in outpatient settings is defined in policies.78

X

X

Policy and Procedure

Policy and Procedure

AOP.1.2 1. All inpatients and outpatients have an initial assessment(s) that includes a health history and physical examination

consistent with the requirements defined in hospital policy.79

Policy and Procedure

AOP.1.3 5. Policies and procedures support consistent practice in all areas [related to identifying patient medical and nursing needs]. 79–80 Policy and Procedure

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 fist 24 hours of admission as an inpatient or earlier as indicated by

the patient’s condition or hospital policy.

81

Policy and Procedure

Policy and Procedure

AOP.1.8 1. The organization defines criteria, in writing, that identify when additional, specialized, or more in-depth special-needs

assessments are performed.83–84

Criteria

AOP.2 3. Patients are reassessed at intervals based on their condition and when there has been a significant change in their

condition, plan of care, and individual needs or according to organization policies and procedures.

5. For nonacute patients, the organization policy defines the circumstances in which, and the types of patients or patient

populations for which, a physician’s assessment may be less than daily and identifies the minimum reassessment interval

for these patients.

85–86

Policy and Procedure

Policy and Procedure

AOP.3 5. Those qualified to conduct patient assessments and reassessments have their responsibilities defined in writing. 86 Policy and Procedure

AOP.5.1 3. Written policies and procedures address the handling and disposal of infectious and hazardous materials. 88 X Policy and Procedure

AOP.5.4 1. There is a laboratory equipment management program and it is implemented. 90 Program

AOP.5.5 4. The laboratory has and follows written guidelines for evaluation of all reagents to provide for accuracy and precision of

results. 90–91Guideline

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Assessment of Patients, continued

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

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.

91

Procedure

Procedure

Procedure

Procedure

AOP.5.9 1. There is a quality control program for the clinical laboratory. 92–93 Program

AOP.6.2 1. A radiation safety program is in place that addresses potential safety risks and hazards encountered within or outside the

department.

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.

95

X Program

Policy and Procedure

Policy and Procedure

AOP.6.5 1. There is a radiology and diagnostic imaging equipment management program, and it is implemented. 97 Program

AOP.6.8 1. There is a quality control program for the radiology and diagnostic imaging services, and it is implemented. 98–99 Program

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Care of Patients

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

COP.1 2. Policies and procedures guide uniform care and reflect relevant laws and regulations. 103 Policy and Procedure

COP.2.2 1. Orders are written when required and follow organization policy. 105 Policy

COP.3.1 1. The care of emergency patients is guided by appropriate policies and procedures. 107–108 Policy and Procedure

COP.3.2 1. The uniform use of resuscitation services throughout the organization is guided by appropriate policies and procedures. 107–108 X Policy and Procedure

COP.3.3 1. The handling, use, and administration of blood and blood products are guided by appropriate policies and procedures. 107–108 X Policy and Procedure

COP.3.4 1. The care of comatose patients is guided by appropriate policies and procedures.

2. The care of patients who are on life support is guided by policies and procedures.107–108

Policy and Procedure

Policy and Procedure

COP.3.5 1. The care of patients with communicable diseases is guided by appropriate policies and procedures.

2. The care of immune-suppressed patients is guided by appropriate policies and procedures.107–108

Policy and Procedure

Policy and Procedure

COP.3.6 1. The care of patients on dialysis is guided by appropriate policies and procedures. 107–108 Policy and Procedure

COP.3.7 1. The use of restraint is guided by appropriate policies and procedures. 107–108 Policy and Procedure

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.

107–108

Policy and Procedure

Policy and Procedure

Policy and Procedure

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

procedures.107–108

Policy and Procedure

COP.6 2. Patients in pain receive care according to pain management guidelines. 110 Guideline

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Anesthesia and Surgical Care

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

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.

3. There is a pre-sedation assessment performed that is consistent with organization policy to evaluate risk and

appropriateness of the sedation for the patient.

6. Established criteria are developed and documented for the recovery and discharge from sedation.

116–117

X

X

X

Policy and Procedure

Policy

Criteria

ASC.5.3 1. Policy and procedure address the minimum frequency and type of monitoring during anesthesia and are uniform for

similar patients receiving similar anesthesia wherever anesthesia is provided.

2. Physiological status is monitored according to policy and procedure during anesthesia administration.

119

Policy

Policy and Procedure

ASC.6 1. Patients are monitored according to policy during the postanesthesia recovery period. 119–120 Policy

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Medication Management and Use

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

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

organization.125

X Plan or Policy

MMU.2 1. There is a list of medications stocked in the organization or readily available from outside sources. 126 List

MMU.3 5. Organization policy defines how medications brought in by the patient are identified and stored. 128 Policy

MMU.3.1 1. Organization policy defines how appropriate nutrition products are stored.

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

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

128–129

Policy

Policy

Policy

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.129

Policy and Procedure

Policy and Procedure

MMU.4 1. Policies and procedures guide the safe prescribing, ordering, and transcribing of medications in the organization.

2. Policies and procedures address actions related to illegible prescriptions and orders.130

X

X

Policy and Procedure

Policy and Procedure

MMU.7 3. The organization has a policy that identifies those adverse effects that are to be recorded in the patient’s record and

those that must be reported to the organization. 135Policy

MMU.7.1 1. A medication error and near miss are defined through a collaborative process. 136 X Document

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Quality Improvement and Patient Safety

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

QPS.1 1. The organization’s leadership participates in developing the plan for the quality improvement and patient safety program. 148 X Plan/Program

QPS.2.1 1. On an annual basis, clinical leaders determine at least five priority areas on which to focus the use of guidelines, clinical

pathways, and/or clinical protocols.151–152

Priority Areas

QPS.5 2. The organization has an internal data validation process that includes a) through f) in the intent statement. 156–157 Process

QPS.6 1. The hospital leaders have established a definition of a sentinel event that at least includes a) through d) found in the intent

statement.157–158

X Policy Definition

QPS.8 1. The organization establishes a definition of a near miss. 159 X Policy Definition

QPS.11 1. The organization’s leaders adopt a risk management framework to include a) through f) in the intent. 160–161 Framework

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Prevention and Control of Infections

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

PCI.5 5. The program is guided by appropriate policies and procedures [to reduce risks of health care–associated infections]. 168 X Policy and Procedure

PCI.6 4. The organization assesses these risks [of the infection prevention and reduction program] at least annually, and the

assessment is documented.169

Risk Assessment

PCI.7 1. The organization has identified those processes associated with infection risk.

3. The organization identifies which risks require policies and/or procedures, staff education, practice changes, and other

activities to support risk reduction.

169–170

Processes

Policy and Procedure

PCI.7.1.1 1. There is a policy and procedure consistent with national laws and regulations and professional standards in place that

identifies the process for managing expired supplies.

2. When single-use devices and materials are reused, the policy includes items a) through e) in the intent statement.

170–171

X

Policy and Procedure

Policy

PCI.7.3 3. The disposal of sharps and needles is consistent with infection prevention and control polices of the organization. 171 Policy

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.

3. Policies and procedures address how to manage patients with airborne infections for short periods of time when negative

pressure rooms are not available.

172–173

Policy

Policy and Procedure

Policy and Procedure

PCI.9 5. The organization has adopted hand-hygiene guidelines from an authoritative source. 173 Guideline

PCI.11 1. The organization develops an infection prevention and control program that includes all staff and other professionals and

patients and families.175–176

X Program

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Governance, Leadership, and Direction

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

GLD.1 1. The organization’s governance structure is described in written documents, and those responsible for governance and

managing are identified by title or name.

2. Governance responsibilities and accountabilities are described in the documents.

3. The documents describe how the performance of the governing entity and managers will be evaluated and any related

criteria.

180

X Document

Document

Document

GLD.1.2 2. When approval authority is delegated, it is defined in governance polices and procedures. 180–181 Policy and Procedure

GLD.3.2 1. Organization plans describe the care and services to be provided. 184 Plans

GLD.3.3 2. The organization has a written description of the nature and scope of services provided through contractual agreements. 185 X Document

GLD.5.1 2. The departmental or service documents describe the current and planned services provided by each department or

service.

3. Each department’s or service’s policies and procedures guide the provision of identified services.

4. Each department’s or service’s policies and procedures address the staff knowledge and skills needed to assess and

meet patient needs.

188–189

Document

Policy and Procedure

Policy and Procedure

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

professional staff. 189–190Criteria

GLD.5.4 1. The director has established a documented orientation program for department staff. 190 Program

GLD.6 2. The leaders establish a framework for the organization’s ethical management. 191–192 Framework

GLD.6.1 3. The organization provides clear admission, transfer, and discharge policies. 191–192 Policy

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Facility Management and Safety

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

FMS.2 1. There are written plans that address the risk areas a) though f) in the intent statement.

a) Safety and security (Also see FMS.4 ME 1 through ME 4)

b) Hazardous materials (Also see FMS.5 ME 2 through ME 7)

c) Emergencies (Also see FMS.6, ME 1)

d) Fire Safety (Also see FMS.7.1 ME 1 through ME 5)

e) Medical equipment (Also see FMS.8 MEs 1 through ME 3 and FMS.8.1 ME 1 and ME 2)

f ) Utility systems (Also see FMS.9.1, ME 3)

196–197

X Plans

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

2. The organization has a plan to reduce evident risks based on the inspection.198–199

Document

Plan

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

organization.199–200

List

FMS.7.2 5. Inspection, testing, and maintenance of equipment and systems are documented. 201–202 Documented Inspections

FMS.7.3 1. The organization has developed a policy and/or procedure to eliminate or to limit smoking. 202–203 Policy and Procedure

FMS.8.2 2. Policy or procedure addresses any use of any product or equipment under recall. 204 Policy

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Staff Qualifications and Education

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

SQE.6 1. There is a written plan for staffing the organization. 215–216 Plans

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.

219

Policy

Policy

SQE.9.1 1. There is a process described in policy for the review of each medical staff member’s credential file at uniform intervals at

least once every three years.220–222

X Policy

SQE.10 1. The organization uses a standardized process that is documented in official organization policy for granting privileges to

each medical staff member to provide services on initial appointment and on reappointment. 222–223

X Policy

SQE.11 2. The ongoing professional practice evaluation and annual review of each medical staff member are accomplished by a

uniform process that is defined by organization policy. 223–224X Policy

SQE.12 1. The organization has a standardized procedure to gather the credentials of each nursing staff member. 224–225 Procedure

SQE.15 1. The organization has a standardized procedure to gather the credentials of each health professional staff member. 226–227 Procedure

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Management of Communication and Information

STANDARD MEASURABLE ELEMENT(S)

PAGE

NUMBER(S) ENGLISH

TYPE OF

DOCUMENTATION

MCI.7 1. Policy establishes those health care practitioners who have access to the patient’s record(s). 235 Policy

MCI.10 1. There is a written policy for addressing the privacy and confidentiality of information that is based on and consistent with

laws and regulations.

2. The policy defines the extent to which patients have access to their health information and the process to gain access when

permitted.

236–237

Policy

Policy

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.

2. The policy includes levels of security for each category of data and information identified.

237

Policy

Policy

MCI.12 1. The organization has a policy on retaining patient clinical records and other data and information. 237 Policy

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.

2. There is a written protocol that outlines how policies and procedures that originated outside the organization will be

controlled, and it is implemented.

3. There is a written policy or protocol that defines retention of obsolete policies and procedures for at least the time required

by laws and regulations, while ensuring that they will not be mistakenly used, and it is implemented.

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.

240

X

X

X

X

Policy

Protocol

Policy or Protocol

Policy or Protocol

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

2. The format and location of entries are determined by organization policy.

5. Those authorized to have access to the patient clinical record are identified in organization policy.

6. There is a process to ensure that only authorized individuals have access to the patient clinical record.

242

Policy

Policy

Policy

Policy

Page 104: JCI 2nd Edition

Standards That Reference Laws and RegulationsThe Joint Commission International Accreditation 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 laws and regulations under whicha hospital operates and provides patient care in one of the following two ways:

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

2. If on the other hand, the law and/or regulation sets a more stringent expectation than the accreditation standard, then thesurvey 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 hospital 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 hospital 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 on pages 101–105 is designed to familiarize the hospital with those particular standards thatreference country-specific laws and/or regulations, to provide a summary of relevant applicable laws and/or regulations, and toprovide information regarding the results of any on-site audits or inspections required by local/regional laws or regulations (forexample, ministry of health and fire brigade) or by another invited accrediting body (such as the College of Pathologists [CAP]and the ISO) to the survey team to facilitate appropriate evaluation of the accreditation standards.

Hospitals can use the Law and Regulation Worksheet to indicate when there are laws and/or regulations that are in conflict witheach other and with a JCI standard. The Law and Regulation Worksheet contains additional space to include other laws andregulations that may be applicable to the accreditation survey process but that may not be referenced in the standards.

Hospitals can use the External Auditing Body Recommendation Worksheet on page 106 to provide information regarding theresults of on-site evaluations conducted by a government-authorized department, a regulatory agency, or an invited evaluatorwithin the past 12 months. An executive summary (in English) of the outcome of on-site evaluations should be provided to thesurvey team at the document review session.

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Law and Regulation Worksheet

STANDARD

NUMBER

APPLICABLE

LAW/REGULATION

(YES/NO)

IF YES:

NAME OF

LAW/REGULATION

SUMMARY OF

LAW/REGULATION

HOW DOES IT APPLY TO

THE STANDARD?

IS LAW/REGULATION MORE

STRINGENT THAN STANDARD?

(note conflicts)

(YES/NO)

Does any regulatory agency

conduct on-site inspections to

evaluate compliance with the

applicable law/regulation?

(YES/NO)

Access to Care and Continuity of Care

ACC.3.5

ACC.5

Patient and Family Rights

PFR.1

PFR.1.6

PFR.2.3

PFR.6

PFR.6.2

PFR.11

(continued)

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Joint Commission International Accreditation Hospital Survey Process Guide

Law and Regulation Worksheet, continued

STANDARD

NUMBER

APPLICABLE

LAW/REGULATION

(YES/NO)

IF YES:

NAME OF

LAW/REGULATION

SUMMARY OF

LAW/REGULATION

HOW DOES IT APPLY TO

THE STANDARD?

IS LAW/REGULATION MORE

STRINGENT THAN STANDARD?

(note conflicts)

(YES/NO)

Does any regulatory agency

conduct on-site inspections to

evaluate compliance with the

applicable law/regulation?

(YES/NO)

Assessment of Patients

AOP.1.1

AOP.1.8

AOP.3

AOP.5

AOP.5.8

AOP.6

AOP.6.1

AOP.6.2

AOP.6.7

Care of Patients

COP.1

COP.4.1

(continued)

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Joint Commission International Accreditation Hospital Survey Process Guide

Law and Regulation Worksheet, continued

STANDARD

NUMBER

APPLICABLE

LAW/REGULATION

(YES/NO)

IF YES:

NAME OF

LAW/REGULATION

SUMMARY OF

LAW/REGULATION

HOW DOES IT APPLY TO

THE STANDARD?

IS LAW/REGULATION MORE

STRINGENT THAN STANDARD?

(note conflicts)

(YES/NO)

Does any regulatory agency

conduct on-site inspections to

evaluate compliance with the

applicable law/regulation?

(YES/NO)

Anesthesia and Surgical Care

ASC.1

ASC.2

Medication Management and Use

MMU.1

MMU.2

MMU.3

MMU.4.2

MMU.5

MMU.6

Quality Improvement and Patient Safety

QPS.2

QPS.3

QPS.4.2

QPS.6

(continued)

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Joint Commission International Accreditation Hospital Survey Process Guide

Law and Regulation Worksheet, continued

STANDARD

NUMBER

APPLICABLE

LAW/REGULATION

(YES/NO)

IF YES:

NAME OF

LAW/REGULATION

SUMMARY OF

LAW/REGULATION

HOW DOES IT APPLY TO

THE STANDARD?

IS LAW/REGULATION MORE

STRINGENT THAN STANDARD?

(note conflicts)

(YES/NO)

Does any regulatory agency

conduct on-site inspections to

evaluate compliance with the

applicable law/regulation?

(YES/NO)

Prevention and Control of Infections

PCI.3

PCI.7.1

PCI.7.3

PCI.10.6

Governance, Leadership, and Direction

GLD.2

GLD.6

Facility Management and Safety

FMS.1

FMS.4.2

FMS.5

FMS.9.2

(continued)

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Law and Regulation Worksheet, continued

STANDARD

NUMBER

APPLICABLE

LAW/REGULATION

(YES/NO)

IF YES:

NAME OF

LAW/REGULATION

SUMMARY OF

LAW/REGULATION

HOW DOES IT APPLY TO

THE STANDARD?

IS LAW/REGULATION MORE

STRINGENT THAN STANDARD?

(note conflicts)

(YES/NO)

Does any regulatory agency

conduct on-site inspections to

evaluate compliance with the

applicable law/regulation?

(YES/NO)

Staff Qualifications and Education

SQE.1

SQE.1.1

SQE.9

SQE.12

SQE.13

SQE.15

SQE.16

Management of Communication and Information

MCI.10

MCI.11

MCI.12

MCI.18

MCI.19.4

MCI.20.2

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External Auditing Body Recommendation Worksheet

If an on-site evaluation was conducted by a government-authorized department, a regulatory agency, or any other invited evaluator within the past 12 months, please

complete and provide this form with an executive summary of the outcome of each on-site evaluation (in English) to the survey team at the document review session.

Name of the governmental

department, regulatory

agency, or invited evaluator

that conducted the on-site

audit/inspection

Date of the

on-site audit

Were any

recommendations

or citations noted?

(Yes/No)

If Yes, what department(s) or

service(s) was identified in the

report (for example, laboratory,

operating theatre, kitchen, and

pharmacy)?

How much time was

allotted to achieve

compliance (for example,

90 days, 6 months)?

On what date was

full compliance

achieved by the

organization?

Has the auditor

returned to validate

compliance?

(Yes/No)

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IndexAAccess to care and continuity of care (ACC)

laws and regulations worksheet for, 101purpose of, 6standards, 74, 75, 87

Accreditationbenefits of, 2cycle, continuing, 30decision rules, 14–15hospitals requesting, 18–19preparation timeline, 16–19process timeline, 20promoting, 30

Accreditation Committeedecision rules by, 14–15standards review by, 3

Accreditation Hospital Resource Center, 18, 19Accreditation survey

agendas, 22–26contract agreement, 4, 18eligibility for, 4how to request, 4–5medical record review tool and, 70–75other considerations, 9–13scoring guidelines for, 8–9

American College of Physicians, 2American College of Surgeons, 2American Dental Association, 2American Hospital Association, 2American Medical Association, 2Anesthesia and surgical care (ASC)

laws and regulations worksheet for, 103purpose of, 7standards, 11, 71–73, 92

Application for surveyhandling changes during, 5initial survey and, 17postponement and cancellation of, 4–5for reaccreditation, 17scheduling of, 4–5validity for, 4

Assessment of patients (AOP)laws and regulations worksheet for, 102purpose of, 6standards, 10, 71–72, 89–90

At Risk for Denial of Accreditation, 14–15

BBylaws, 85

CCancellation of on-site surveys, 6Care of patients (COP)

laws and regulations worksheet for, 102purpose of, 7standards, 10–11, 72, 91

Clinical and managerial measures, 55Clinical practice guidelines, 55Closed medical record review

accreditation survey and, 70medical record review tool and, 71–75organization of the form, 70purpose of, 70review process, 70

Committee manuals, 55Competency assessment process review forms, 68–69Consents, 71Contract agreement, 4, 18Criticality

defined, 9of finding, 10scoring process and, 10

DDaily briefing

documents needed for, 76hospital participants in, 41location, 41purpose of, 41special situations, 42standards to be addressed in, 76surveyors, 41what will occur in, 41

Data issuesinfection prevention, 56medication management, 56improvement in quality and patient safety system tracer, 55

Decision rules, 14–15Denied Accreditation status, 15Document review

documentation, 37evaluation of policies and procedures and, 40hospital participants in, 37

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how to prepare for, 39location, 37organization of materials for, 39–40purpose of, 37surveyors, 37standards to be addressed in, 37what will occur in, 39

Documentsfor ACC standards, 87for AOP standards, 89–90for ASC standards, 92available in English, 37–39consents, 71for COP standards, 91for document review, 37for education session: hospital decision rules, scoring guidelines,

and strategic improvement plan, 64for facility tour, 43for FMS standards, 97–98for GLD standards, 96for improvement in quality and patient safety system tracer, 55for individual patient tracer activity, 46for IPSG standards, 86for leadership exit conference, 80for leadership interview, 76for MCI standards, 99for MMU standards, 93needed by surveyors, 37, 43for opening conference, 32for orientation to the hospital’s services and the quality

improvement plan, 34for PCI standards, 95for PFR standards, 88for QPS standards, 94for SQE standards, 98for staff qualifications and education session, 65–66written, 85

EEducation session: hospital decision rules, scoring guidelines, and

strategic improvement plandocuments needed for, 64hospital participants in, 64location, 64purpose of, 64standards to be addressed in, 64what will occur in, 64

Emergency management plan, 62External auditing body recommendation worksheet, 106

FFacility management and safety (FMS)

laws and regulations worksheet for, 104purpose of, 7

Facility management and safety system tracerhospital participants in, 59hospital plans and, 83purpose of, 29, 59risk categories, 60–61standards, 13, 97–98surveyors, 59what will occur in, 59–62

Facility tourdocuments needed for, 43hospital participants in, 43how to prepare for, 44inspection report for, 45location, 43purpose of, 43standards to be addressed in, 43surveyors, 43what will occur in, 43–44

Field review process standards, 3FMS risk management cycle, 60Focused-tracer activity

medication management and, 50undetermined survey activities and, 63

Follow-up focused surveysaccreditation decision and, 14–15, 18look-back period for, 9

Full surveys, conducting, 15“Fully met” score, 8

GGold Seal, 3, 18Governance, leadership, and direction (GLD)

hospital plans and, 83laws and regulations worksheet for, 104purpose of, 7standards, 13, 54, 77, 83, 96

Group discussion, 50–51

HHealth care professional staff competency assessment process review

form, 69Hospital participants

daily briefing and, 41document review and, 37education session: hospital decision rules, scoring guidelines, and

strategic improvement plan, 64

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109

facility management and safety system, 59facility tour, 43improvement in quality and patient safety system tracer and, 54individual patient tracer activity, 46infection control and, 52leadership exit conference, 80leadership interview, 76medication management and, 49opening conference, 32orientation to the hospital’s services and the quality improvement

plan, 34staff qualifications and education session, 65surveyor planning session and, 35surveyor team meeting and, 78surveyor report preparation and, 79undetermined survey activities and, 63

Hospitalsaccreditation benefits for, 2Accreditation Program, 3accreditation request by, 18–19decision rules, 64initial survey request by, 17plans, 83publicity kit for, 18, 30quality monitors and, 82reaccreditation, 17services, orientation to, 34

IImpact

defined, 9scoring process and, 10

Improvement in quality and patient safety system tracerdocuments needed for, 55hospital participants in, 54purpose of, 29, 54standards to be addressed in, 54surveyors, 54what will occur in, 55–56

Individual-based system tracer activity, 28–29Individual patient tracer activity

documents needed for, 46hospital participants in, 46elements of, 28, 47other survey activities and, 48purpose of, 27, 46selection criteria for, 27–28, 47–48standards to be addressed in, 46survey agenda, 46–48

surveyors, 46what will occur in, 46–47

Individual tracers, 35–36Infection control system tracer

data issues, 56hospital participants in, 52purpose of, 29, 52surveyors, 52what will occur in, 52–53

Initial survey, 17International Patient Safety Goals

purpose of, 6standards, 86

JJCI accreditation

satisfaction survey, 18value of, 2

JCI Library of Measures, 57Joint Commission International

accreditation office, 1description of, 2–3standards consensus, 3Web site, 1why to choose, 3

Joint Commission International Accreditation: Getting Started, 6, 16

LLaws and regulations

standards and, 100worksheet, 101–105

Leadership exit conferencedocuments needed for, 80hospital participants in, 80location, 80purpose of, 80standards to be addressed in, 80surveyors, 80what will occur in, 80

Leadership interviewdocuments needed for, 76hospital participants in, 76how to prepare for, 77location, 76purpose of, 76standards to be addressed in, 76surveyors, 76what will occur in, 77

Look-back period, 9

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MManagement of communication and information (MCI)

laws and regulations worksheet for, 105purpose of, 8standards, 13, 99

Measurable element (ME)of ACC standards, 87of AOP standards, 89–90of ASC standards, 92of COP standards, 91of FMS standards, 97–98of GLD standards, 96of IPSG standards, 85–86of MCI standards, 99of MMU standards, 93with multiple expectations, 10–13number of, 14of PCI standards, 95of PFR standards, 88of QPS standards, 94of SQE standards, 99of standards, 8, 10–13, 86–99

Medical record review tool, 71–75Medical staff. See StaffMedication management and use (MMU)

hospital plans and, 83laws and regulations worksheet for, 103purpose of, 7standards, 11–12, 54, 93

Medication management system tracerdata issues, 56hospital participants in, 49purpose of, 29, 49surveyors, 49what will occur in, 49–51

Mock interviews, 77

NNon-patient care areas, 44“Not applicable” score, 9“Not met” score, 8–9Nursing staff competency assessment process review form, 68

OOfficial Survey Findings Report

accreditation and, 18process, 15

On-site surveysapplication for, 17, 19cancellation of, 6preparation for, 16–19ready to go list for, 16

scheduling of, 4–5steps in, 21survey team for, 40team leader for, 16, 18

Opening conferencedocumentation, 32hospital participants, 32how to prepare for, 33location, 32purpose of, 32standards to be addressed in, 32surveyors, 32what will occur in, 32–33

Organization functions, 7–8Orientation to the hospital’s services and the quality improvement

plandocumentation, 34hospital participants, 34location, 34purpose of, 34standards to be addressed in, 34surveyors, 34what will occur in, 34

P“Partially met” score, 8Patient(s)

care areas, 44safety, 54–58standards related to assessment of, 89–90under tracer methodology, 27–28

Patient and family education (PFE)purpose of, 7standards, 12, 72, 74

Patient and family rights (PFR)laws and regulations worksheet for, 101purpose of, 6standards, 10, 71, 88

Patient-centered functions, 6–7Patient safety. See Quality improvement and patient safety (QPS)Performance improvement. See Improvement in quality and patient

safety system tracerPolicies and procedures, 40, 85Postponement, defined, 5Preliminary Survey Findings Report, 15Prevention and control of infections (PCI)

hospital plans and, 83laws and regulations worksheet for, 104purpose of, 7standards, 12–13, 54, 83, 95

Proactive risk assessments, 55Publicity kit, 18, 30

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QQualifications worksheet, 67Quality Committee, 57Quality improvement and patient safety (QPS)

hospital plans and, 83laws and regulations worksheet for, 103measures documentation tool, 57–58purpose of, 7standards, 12, 54, 82, 94

Quality improvement plan and hospital’s services, 34Quality monitors, 82

RReaccreditation, hospitals requesting, 17Regional International Advisory Groups, 3Report preparation, 79Root cause analysis, 55

SScoring guidelines/process

for accreditation survey, 8–9survey agenda and, 64

Staffeducation session, 65–66nursing, 68other professional staff, 69qualifications, 65–67role in on-site surveys, 21role in tracer methodology, 29

Staff qualifications and education (SQE)hospital plans and, 83laws and regulations worksheet for, 105purpose of, 8standards, 13, 98

Staff qualifications and education sessioncompetency assessment process review forms, 68–69documents needed for, 65–66hospital participants in, 65how to prepare for, 65location, 65medical staff qualifications worksheet, 67purpose of, 65standards to be addressed in, 65surveyors, 65

StandardsAccess to care and continuity of care (ACC), 74, 75, 87Anesthesia and surgical care (ASC), 11, 71–73, 92Assessment of patients (AOP), 10, 71–72, 89–90Care of patients (COP), 10–11, 72, 91in document review, 37in education session: hospital decision rules, scoring guidelines,

and strategic improvement plan, 64

Facility management and safety (FMS), 13, 97–98in facility tour, 43field review process, 3Governance, leadership, and direction (GLD), 13, 54, 77, 83, 96to be addressed in improvement in quality and patient safety

system tracer, 54to be addressed in individual patient tracer activity, 46international consensus, 3interpretation, 3laws and regulations and, 100–105in leadership interview, 76in leadership exit conference, 80look-back period for, 9Management of communication and information (MCI), 13, 99manual, 6–8measurable element of, 8, 10–13, 86–99Medication management and use (MMU), 11–12, 54, 93in opening conference, 32in orientation to the hospital’s services and the quality

improvement plan, 34Patient and family education (PFE), 12, 72, 74Patient and family rights (PFR), 10, 71, 88Prevention and control of infections (PCI), 12–13, 54, 83, 95Quality improvement and patient safety (QPS), 12, 54, 82, 94Staff qualifications and education (SQE), 13, 98in staff qualifications and education session, 65track record for, 40in undetermined survey activities, 63

Strategic Improvement Plan (SIP), 15, 18, 19, 64, 80Survey agenda

closed medical record review, 70–75daily briefing, 41–42document review, 37–40education session: hospital decision rules, scoring guidelines, and

strategic improvement plan, 64facility management and safety system, 59–62facility tour, 43–45individual patient tracer activity, 46–48improvement in quality and patient safety system tracer, 54–56infection control system tracer, 52–53leadership exit conference, 80leadership interview, 76–77medication management system tracer, 49–51opening conference, 32–33orientation to the hospital’s services and the quality improvement

plan, 34staff qualifications and education session, 65–69surveyor planning session, 35–36surveyor report preparation, 79surveyor team meeting, 78undetermined survey activities, 63

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Surveyor planning sessionhospital participants, 35location, 35purpose of, 35selection of individual tracers, 35–36standards to be addressed in, 34surveyors, 35what will occur in, 35

Surveyor report preparationhospital participants in, 79location, 79purpose of, 79surveyors, 79what will occur in, 79

Surveyors. See also Accreditation surveyin daily briefing, 41in document review, 37documents needed by, 32, 34, 37–39, 43, 46, 55, 65, 76, 85–99in facility management and safety system, 59in facility tour, 43in improvement in quality and patient safety system tracer, 54in individual patient tracer activity, 46in infection control system tracer, 52in leadership exit conference, 80in leadership interview, 76in medication management system tracer, 49multiple, 41non-patient care areas visited by, 44for on-site surveys, 16, 18in opening conference, 32in orientation to the hospital’s services and the quality

improvement plan, 34in staff qualifications and education session, 65in surveyor planning session, 35in surveyor report preparation, 79in surveyor team meeting, 78tracer methodology and, 27–29

Surveyor team meetinghospital participants in, 78location, 78purpose of, 78surveyors, 78what will occur in, 78

Survey planningexternal auditing body and, 106for hospital plans, 83laws and regulations and, 100–105for policies and procedures, 85–99for quality monitors, 82

System tracerfacility management and safety system, 59–62infection control, 52–53medication management, 49–51improvement in quality and patient safety system tracer, 54–58

TTracer methodology

introduction of, 3for on-site surveys, 21patients under, 27–28purpose of, 27role of staff in, 29

“Track record”, 40

UUndetermined survey activities

hospital participants in, 63purpose of, 63standards to be addressed in, 63what will occur in, 63

Unit of analysisfor AOP standards, 10for ASC standards, 11for COP standards, 10–11for FMS standards, 13for GLD standards, 13for MCI standards, 13for MMU standards, 11for PCI standards, 12–13for PFE standards, 12for PFR standards, 10for QPS standards, 12for SQE standards, 13

WWritten documents, 85

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Surveyor planning sessionhospital participants, 35location, 35purpose of, 35selection of individual tracers, 35–36standards to be addressed in, 34surveyors, 35what will occur in, 35

Surveyor report preparationhospital participants in, 79location, 79purpose of, 79surveyors, 79what will occur in, 79

Surveyors. See also Accreditation surveyin daily briefing, 41in document review, 37documents needed by, 32, 34, 37–39, 43, 46, 55, 65, 76,

84–100in facility management and safety system, 59in facility tour, 43in improvement in quality and patient safety system tracer, 54in individual patient tracer activity, 46in infection control system tracer, 52in leadership exit conference, 80in leadership interview, 76in medication management system tracer, 49multiple, 41non-patient care areas visited by, 44for on-site surveys, 16, 18in opening conference, 32in orientation to the hospital’s services and the quality

improvement plan, 34in staff qualifications and education session, 65in surveyor planning session, 35in surveyor report preparation, 79in surveyor team meeting, 78tracer methodology and, 27–29

Surveyor team meetinghospital participants in, 78location, 78purpose of, 78surveyors, 78what will occur in, 78

Survey planningexternal auditing body and, 107for hospital plans, 83laws and regulations and, 101–106for policies and procedures, 84–100for quality monitors, 82

System tracerfacility management and safety system, 59–62infection control, 52–53medication management, 49–51improvement in quality and patient safety system tracer, 54–58

TTracer methodology

introduction of, 3for on-site surveys, 21patients under, 27–28purpose of, 27role of staff in, 29

“Track record”, 40

UUndetermined survey activities

hospital participants in, 63purpose of, 63standards to be addressed in, 63what will occur in, 63

Unit of analysisfor AOP standards, 10for ASC standards, 11for COP standards, 10–11for FMS standards, 13for GLD standards, 13for MCI standards, 13for MMU standards, 11for PCI standards, 12–13for PFE standards, 12for PFR standards, 10for QPS standards, 12for SQE standards, 13

WWritten documents, 84