Any health care organization may apply for JCI accreditation if it meets the following requirements:
• The organization is located outside of the U.S. and its territories.
• The organization is currently operating as a healthcare provider in the country and is licensed
to provide care and treatment as a hospital (if required).
• The organization provides services addressed by JCI Hospital standards.
• The organization assumes, or is willing to assume, responsibility for improving the quality of
its care and services.
• The organization provides a complete range of acute care clinical services. These services are: available 365 days per year and all direct patient care services are operational 24 hours per day, 7 days per week; and ancillary and support services are available as needed for emergent, urgent and/or emergency needs of patients 24 hours per day, 7 days per week, such as diagnostic testing, laboratory, operating theater, as appropriate to the type of acute care hospital.
• All current clinical services identified by the organization in the survey application are in full
operation at the time of the on-site accreditation survey; and the clinical services are immediately available for a comprehensive evaluation against all relevant JCI standards, such
as patient tracer activities, open and closed medical record review, direct observation of
patient care processes, and interviews of patients.
9 April 2012
Joint Commission International Accreditation Standards for Hospitals
(4th Edition Updated 20 June 2011)
Page 5,
Introduction:
ACC.1.1.1, Patients with emergent, urgent, or immediate needs are given priority for assessment and treatment.
A new Measurable Element 54 was added to emphasize the need to stabilize emergency patients prior to transfer to another organization using an evidence-based triage process.
Page 27,
Joint Commission International Policies and Procedures At a minimum, an organization must include those events that are subject to review listed below:
• Unanticipated death unrelated to the natural course of the patient’s illness or underlying condition
• Major permanent loss of function unrelated to the natural course of the patient’s illness or underlying condition
• Wrong-site, wrong-procedure, wrong-patient surgery
• Infant abduction or infant who was sent home with the wrong parents
Page 42,
Access to Care and Continuity of Care chapter,
ACC.1.2 (standards-only section)
ACC.1.2 At admission as an inpatient, patients and families receive information on the proposed care, the expected outcomes of that care, and any expected cost to the patient for the care.
Page 50,
Access to Care and Continuity of Care chapter,
ACC.3.2, Measurable Elements
1. A discharge summary is prepared at discharge by a qualified individual.
2. The summary contains follow-up instructions.
32. A copy of the discharge summary is placed in the patient record.
43. Unless contrary to organization policy, laws, or culture, the patient is given a copy of the discharge summary.
54. A copy of the discharge summary is provided to the practitioner responsible for the patient’s continuing or follow-up care.
65. Policy and procedure define when the discharge summary must be completed and in the record.
Page 65,
Patient and Family Rights chapter, PFR.2.3, Measurable Elements
1. The organization has identified its position on withholding resuscitative services and forgoing or withdrawing life-sustaining treatments.
2. The organization’s position conforms to its community’s religious and cultural norms and any legal or regulatory requirements.
3. The organization guides health professionals on the ethical and legal considerations in carrying out such patient wishes.
4. Patient/family decisions about resuscitative services are documented in the clinical record.
5. Policies and procedures support consistent practice.
Page 75,
Assessment of Patients chapter, AOP.1.1 and AOP.1.3.1 (standards-only section)
AOP.1.1 The organization has determined the scope and minimum content of assessments, based on applicable laws and regulations and professional standards.
AOP.1.3.1 The initial medical and nursing assessments of emergency patients is are based on their needs and conditions.
Page 76,
Assessment of Patients chapter, AOP.4 (standards-only section)
AOP.4 Medical, nursing, Physicians, nurses, and other individuals and services responsible for patient care collaborate to analyze and to integrate patient assessments.
Page 79,
Assessment of Patients chapter, AOP.1.3.1
AOP.1.3.1 The initial medical and nursing assessments of emergency patients is are based on their needs and conditions.
Page 110,
Care of Patients chapter, COP.6, Measurable Elements
1. Based on the scope of services provided, the organization has processes to identify patients in pain. (Also see AOP.1.7, ME 1, and AOP.1.8.2, ME 1)
Page 148,
Quality Improvement and Patient Safety chapter,
QPS.1, Intent Statement
The governing body holds ultimate accountability for quality and patient safety in the organization, and, thus, it approves the quality and patient safety plan (also see GLD.1.56); on a regular basis, it receives and actson reports related to the organization’s program to improve quality and patient safety (also see GLD.1.56).
Page 152,
Quality Improvement and Patient Safety chapter,
QPS.2.1, Measurable Element 3
3. The organization implements a clinical guidelines, and a clinical pathway, or clinical protocol for each identified priority area.
Page 160,
Quality Improvement and Patient Safety chapter, QPS.9, Measurable Elements
1. The organization plans and implements improvements in quality and safety.
2. The organization uses a consistent process for identifying priority improvements that are selected by the leaders.
23. The organization documents the improvements achieved and sustained.
Page 178,
Governance, Leadership, and Direction (GLD) chapter,
GLD.3.3
GLD.3.3 The leaders are accountable for provide oversight of contracts for clinical or management services.
Page 181, Governance, Leadership, and Direction (GLD) chapter,
GLD.1.4, Measurable Element 3
3. The evaluation of the senior managerment is performed at least annually.
Page 199,
Facility Management and Safety chapter, FMS.4.2, Measurable Elements
2. The organization plans and budgets for upgrading or replacing systems, buildings, or components needed for the continued operation of a safe and effective facility. (Also see ACC.6.1, ME 5)
Page 200,
Facility Management and Safety chapter, FMS.5, Measurable Elements
2. The plan for safe handling, storage, and use of hazardous materials and waste is established and implemented. (Also see AOP.5.1, intent statement, and ME 3; AOP.5.5, ME 3; AOP.6.2, ME 4; and AOP.6.6, ME 3)
Page 209,
Staff Qualifications and Education chapter, SQE.1.1 (standards-only section)
SQE.1.1 Each staff member’s responsibilities are defined in a current job description.
JCI Hospital Survey Process Guide
(Corrections 31 October 2012 Page 1 of 20 ©2012 JCI)
Page 37:
Document Review
• Required quality monitors with data from the past 4 months (initial surveys) and/or 12 months for triennial surveys
• 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 102)
• A list of the five clinical practice guidelines, clinical pathways, and/or clinical protocols the hospital selected to guide clinical care
Page 38:
Required Hospital Plans:
• There is a plan for an organizationwide quality improvement and patient safety program. (QPS.1)
• Organization plans describe the care and servicesto be provided consistent with the mission.
(GLD.3.2, intent)
Required Hospital Programs:
• All equipment used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. (AOP.5.4)
• 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 the department. (AOP.6.2, ME 1)
• All equipment used to conduct radiology and diagnostic imaging studies are regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. (AOP.6.5)
• Quality control procedures are in place, followed, and documented. (AOP.6.8)
Required Policies and Procedures, Written Documents, or Bylaws
• Policies and procedures support consistent practice in all situations and locations. (IPSG.1, ME 5)
• Policies and procedures support consistent practice in verifying the accuracy of verbal and telephone communications. (IPSG.2, ME 4)
• Policies and/or procedures are developed to address the identification, location, labeling, and storage of high-alert medications. (IPSG.3, ME 1)
• 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. (IPSG.4, ME 4)
• Policies and/or procedures are developed that supportcontinued reduction of health care–associated infections. (IPSG.5, ME 3)
• Policies and/or procedures support continued reduction of risk of patient harm resulting from falls in the organization. (IPSG.6, ME 4)
• The organization uses an instantly recognizable mark for surgical-site identification and involves the patient in the marking process. (IPSG.4, ME 1)
• Policies identify which screening and diagnostic tests are standard before admission. (ACC.1, ME 5)
• The organization has established entry and/or transfer criteria for its intensive and specialized services or units, including research and other programs to meet special patient needs. (ACC.1.4, ME1)
• Established criteria or policies determine the appropriateness of transfers within the organization.(ACC.2, ME 2)
• Policy and procedure define when the discharge summary must be completed and in the record. (ACC.3.2, ME 6)
• The records of transferred patients contain documentation of any change in patient condition or status during transfer. (ACC.4.4, ME 5)
• The organization has a clearly defined informed consent process described in policies and
procedures. (PFR.6, ME 1)
• The organization has listed those procedures and treatments that require separate consent.
(PFR.6.4.1, ME 1)
• Organization policy and procedure define the assessment information to be obtained for inpatients. (AOP.1, ME 1)
• Organization policy and procedure define the assessment information to be obtained for outpatients. (AOP.1, ME 2)
• Organization policy identifies the information to be documented for the assessments. (AOP.1, ME 3)
• The minimum content of assessments performed ininpatient settings is defined in policies.
(AOP.1.1, ME 3)
• The minimum content of assessments performed inoutpatient settings is defined in policies.
(AOP.1.1, ME 4)
• Written policies and procedures address the handling and disposal of infectious and hazardous materials. (AOP.5.1, ME 3)
• The organization’s leaders have identified the high-risk patients and services. (COP.3, ME 1)
• The leaders develop applicable policies and procedures. (COP.3, ME 2)
• The uniform use of resuscitation services throughout the organization is guided by appropriate policies and procedures. (COP.3.2, ME 1)
• The handling, use, and administration of blood and blood products are guided by appropriate
policies and procedures. (COP.3.3, ME 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. (ASC.3, ME 1)
• There is a presedation assessment performed that is consistent with organization policy to evaluate risk and appropriateness of the sedation for the patient. (ASC.3, ME 3)
• Established criteria are developed and documented for the recoveryand discharge from sedation. (ASC.3, ME 6)
• There is a plan or policy or other document that identifies how medication use is organized and managed throughout the organization. (MMU.1, ME 1)
• Policies guide all phases of medication management and medication use in the organization.(MMU.1, ME 3)
• 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 illegible prescriptions and orders. (MMU.4, ME 2)
• A medication error and near miss are defined through a collaborative process. (MMU.7.1, ME 1)
• The organization’s leadership participates in developing the plan for the quality improvement and patient safety program. (QPS.1, ME 1)
• The hospital leaders have established a definition of a sentinel event that at least includes (a) through (d) found in the intent 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 procedures [to reduce risks of health care associated infections]. (PCI.5, ME 5)
• When single-use devices and materials are reused, the policy includes items (a) through (e) in the intent statement. (PCI.7.1.1, ME 2)
• The organization develops an infection prevention and control program that includes all staff and other professionals and patients and families. (PCI.11, ME 1)
• The organization’s governance structure is described in written documents, and those responsible for governance and managing are identified by title or name. (GLD.1, ME 1)
• Organization plans describe the care and services to be provided. (GLD.3.2, ME 1)
• The organization has a written description of the nature and scope 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, ME1)
• There is an inventory of all medical equipment. (FMS.8, ME 2)
• There is a preventive maintenance program. (FMS.8, ME 5)
• There is a product/equipment recall system in place. (FMS.8.2, ME 1)
• The organization plans a program to ensure that all occupants of the organization’s facilities are safe from fire, smoke, or other nonfire emergencies. (FMS.7, ME 1)
• Medical equipment is managed throughout the organization according to a plan. (FMS.8, ME 1)
• Policy or procedure addresses any use of any product or equipment under recall. (FMS.8.2, ME 2)
• 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. (SQE.9.1, ME 1)
• The organization uses a standardized process that isdocumented in official organization policy for granting privileges to each medical staff memberto provide services on initial appointment and on reappointment. (SQE.10, ME 1)
• 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. (SQE.11, ME 2)
• There is a written policy for addressing the privacy and confidentiality of information that is based on and consistent with laws and regulations. (MCI.10, ME 1)
• The policy defines the extent to which patients have access to their health information and the
process to gain access when permitted. (MCI.10, ME 2)
• There is a written policy or protocol that defines the requirements for developing and maintaining policies and procedures including at least items (a) through (h) in the intent, and it is implemented. (MCI.18, ME 1)
• There is a written protocol that outlines how policies and procedures that originated outside the organization will be controlled, and it is implemented. (MCI.18, ME 2)
• 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. (MCI.18, ME 3)
• There is a written policy or protocol that outlineshow all policies and procedures in circulation will be identified and tracked, and it is implemented. (MCI.18, ME 4)
Page 53:
System Tracer: Infection Control
• Process for handling an influxof 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)
Page 55:
System Tracer: Improvement in Quality and Patient Safety
DOCUMENTS/MATERIALS NEEDED
Hospitals should have all of the following documents available for review during this session or for the document review session on day one (see pages 37 to 40).
• Root cause analysisfor any sentinel events and/or nearmisses, including definitions of sentinel eventand near missand the methods and processes for performing a root cause analysis. If possible, include a real-world example of a nearmiss event for which a root cause analysis was performed.
• Proactive risk assessments, such as failure mode and effects analysis (FMEA), hazard vulnerability analysis (HVA), and infection control risk assessment (ICRA), including a proactive
risk analysis and redesign of at least one process per year. During this session, the hospital should willshow at least one example of a process that was analyzed and redesigned to prevent possible problems.
• Clinical practice guidelines and clinical pathwaysfor the five areas selected as priority focus
areas in orderto explain the guidelines and pathways thatare 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
Page 56:
System Tracer: Improvement in Quality and Patient Safety, continued
• Determine the effectiveness in implementing the hospital’s action plans developed as improvements following root cause analyses for sentinel events ornear misses, proactive risk assessments (such as FMEA and HVA), and managing quality and safety complaints.
• Review and discuss the measures validation process. Surveyors will review one of the measures the hospital used in order to see 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
Page 56:
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
Page 67:
Required Quality Monitors (On page 67, within the Medical Staff Qualification Worksheet, three Measurable Elements (MEs) of standard SQE.11 were inadvertently omitted. Those MEs are:)
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.
3. The evaluation considers and uses comparative data in a proactive manner such as benchmarking to literature-based medicine.
4. The evaluation considers and uses the conclusionsof in-depth analysis of known complications as applicable.
(With that correction, all 5 MEs of SQE.11 are thereby included in the worksheet.)
Page 69:
Other Health Care Professional Staff Competency Assessment Process Review Form
(column 3 of form)
Licensure, education, training, and experience are documented; information is verified from an original source when possible. SQE.125 (column 4 of form)
Record contains copies of required license, certification, or registration. SQE.125
Page 82:
Required Quality Monitors
The hospital chooses the clinical and managerial structures, processes, and outcomes that are most important to monitor based on its mission, patient needs, and services provided. The hospital’s leaders identify key measures (indicators) to monitor the hospital’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 and managerial 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
Pages 83–84:
Required Hospital Plans
PREVENTION AND CONTROL OF INFECTIONS
The organization designs and implements a comprehensive program to reduce the risks of health care associated infections in patients and health care workers. (PCI.5)
ASSESSMENT OF PATIENTS
• All equipment used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. (AOP.5.4)
• 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 the department. (AOP.6.2, ME 1)
• All equipment used to conduct radiology and diagnostic imaging studies are regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. (AOP.6.5)
• Quality control procedures are in place, followed, and documented. (AOP.6.8)
Page 85:
Required Policies and Procedures, Written Documents, or Bylaws
The standards in the tables on pages 86–99 identify a requirement for a written document. In some cases, that document is in the form of a policy and procedure. In other cases, the document is less formal but addresses the issue identified in the standard. The document that is required is specified in the “Type of Documentation” column in the tables. In many cases, a number of standards requirements or MEs can be combined into one policy and procedure. Organizations may find it useful to group all related policies and procedures. For example, many of the patient assessment requirements are interconnected and can be contained in one policy; for example, AOP.1 and AOP.1.1 can be combined, as can MCI.18, MEs 1 through
4.
International Patient Safety Goals
IPSG.1
1. Patients are identified using two patient identifiers, not including the use of the patient’s room number or location.
2. Patients are identified before administering medications,blood, or blood products.
3. Patients are identified before taking blood and other specimens for clinical testing.
4. Patients are identified before providing treatments and procedures.
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
1. The complete verbal and telephone order or test result is written down by the receiver of the order or test result.
2. The complete verbal and telephone order or test result 36-37 X Policy and Procedure is read back by the receiver of the order or test result.
3. The order or test result is confirmed by the individual who gave the order or test result.
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.)
IPSG.3
1. Policies and/or procedures are developed to address the identification, location, labeling, and storage of high-alert medications.
2. The policies and/or procedures are implemented.
3. Concentrated electrolytes are not present in patient care units unless clinically necessary and actions are taken to prevent inadvertent administration in those areas where permitted by policy.
4. Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that restricts access.
37-38 X Policy and Procedure IPSG.4
1. The organization uses an instantly recognizable mark for surgical-site identification and involves the patient in the marking process.
2. The organization uses a 38-39 X Checklist (or checklist used as a script to perform)
checklist or other process to verify preoperatively the correct site, correct procedure, and correct patient and that all documents and equipment needed are on hand, correct, and functional.
3. The full surgical team conducts and documents a time-out procedure just before starting a surgical procedure.
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.
IPSG.5
1. The organization has adoptedor adapted currently published and generally accepted hand hygiene guidelines.
2. The organization implements an effective hand hygiene program.
3. Policies and/or procedures are developed that support continued reduction of health care– associated infections.
39 X Checklist (or checklist
used as a script to perform) Policy and Procedure
IPSG.6
1. The organization implements a process for the initial assessment of patients for fall risk and reassessment of patients when indicated by a change in condition, medications, among others.
2. Measures are implemented to 40 X Policy and Procedure reduce fall risk for those assessed to be at risk.
3. Measures are monitored for results, both successful fall injury reduction and any unintended related consequences.
4. Policies and/or procedures support continued reduction of risk of patient harm resulting from falls in the organization.
Page 87:
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 X Policy and Procedure
ACC.1.1.1
1. The organization uses an evidence-based triage process to prioritize patients with immediate needs.44Process ACC.2 2. Established criteria or policies determine the appropriateness of transfers within the organization. 47 XCriteria or Policies ACC.4.4
2. The records of transferred patients contain documentation or other notes as required by the policy of the transferring organization.
5. The records of transferred patients contain documentation of any change in patient condition or statusduring transfer. (ACC.4.4, ME 5) 54 XPolicy and Procedure
Page 89:
Assessment of Patients
STANDARD MEASURABLE ELEMENT(S) PAGE NUMBER(S) ENGLISH TYPE OF
DOCUMENTATION
AOP.5.3.11. A collaborative method is used to develop processes for reporting critical results of diagnostic tests.
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 XProgram
Policy and Procedure
Policy and Procedure
Page 91:
Care of Patients
STANDARD MEASURABLE ELEMENT(S) PAGE NUMBER(S) ENGLISH TYPE OF
DOCUMENTATION
COP.31. The organization’s leaders have
identified the high-risk patients
and services.
2. The leaders develop applicable
policies and procedures.
106
X
X
Identification
Policy and Procedure
Page 93:
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.
3. Policies guide all phases of
medication management and
medication use in the
organization.
125 X Plan or Policy
Policy
MMU.3.1
1. Organization policy defines
how appropriate nutrition
products are stored.
2. Organization policy defines
128–129 Policy
Policy
Policy
Policy
Policy
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how radioactive,
investigational, and similar
medications are stored.
3. Organization policy defines
how sample medications are
stored and controlled.
4. All storage is according to
organization policy.
Policy
Policy
MMU.4.1
2. Medication orders or
prescriptions are complete per
organization policy.
130–131 Policy
MMU.6.2 1. Policies and procedures are
implemented to govern patient
self-administration of
medications.
2. Policies and procedures are
implemented to govern the
documentation and
management of any
medications brought into the
organization for or by the
patient.
3. Policies and procedures are
implemented to govern the
availability and use of
medication samples.
135 Policy and Procedure
Policy and Procedure
Policy and Procedure
MMU.7.1 1. A medication error and near
miss are defined through a
collaborative process.
136 X Written document
Quality Improvement and Patient Safety
STANDARD MEASURABLE ELEMENT(S) PAGE NUMBER(S) ENGLISH TYPE OF
DOCUMENTATION
QPS.106. Policy changes necessary to
plan, to carry out, and to
sustain the improvement are
made.
160 Policy
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Prevention and Control of Infections
STANDARD MEASURABLE ELEMENT(S) PAGE NUMBER(S) ENGLISH TYPE OF
DOCUMENTATION
PCI.7.1
4. There is a coordinated
oversight process that ensures
all cleaning, disinfection, and
sterilization methods are the
same throughout the
organization.
170 Process
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 Written document
GLD.3.1
1. The organization’s leaders meet
with recognized community
leaders to develop and to
revise strategic and operational
plans to address community
needs.
183 Plan
GLD.3.2 1. Organization plans describe the
care and services to be
provided.
184 X Plans
GLD.3.3 2. The organization has a written
description of the nature and
scope of services provided
through contractual
185 X Written Description
Document
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agreements.
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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 Written Plans
FMS.4
1. The organization has a program
to provide a safe and secure
physical facility, including
monitoring and securing areas
identified as security risks.
2. The program ensures that all
staff, visitors, and vendors are
identified, and all security risk
areas are monitored and kept
secure.
3. The program is effective in
preventing injury and
maintaining safe conditions for
patients, families, staff, and
visitors.
4. The program includes safety
and security during times of
construction and renovation.
198–199 Program
Program
Program
Program
FMS.5 1. The organization identifies
hazardous materials and
199–200
List
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waste and has a current list
of all such materials within
the organization.
2. The plan for safe handling,
storage, and use of hazardous
waste is established and
implemented.
3. The plan for reporting and
investigation of spills,
exposures, and other incidents
is established and
implemented.
4. The plan for the proper
handling of waste within the
organization and disposal of
hazardous waste in a safe and
legal manner is established and
implemented.
5. The plan for the proper
protective equipment and
procedures during use, spill, or
exposure is established and
implemented.
6. The plan for documentation
requirements, including any
permits, licenses, or other
regulatory requirements, is
established and implemented.
7. The plan for labeling
hazardous materials
and waste is
established and
implemented.
FMS.6
2. The organization plans its
response to likely disasters
including items a) through g) in
the intent.
200–201 Plan
FMS.7
1. The organization plans a
program to ensure that all
occupants of the organization’s
facilities are safe from fire,
smoke, or other nonfire
emergencies.
201–202X Program
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FMS.8
1. Medical equipment is managed
throughout the organization
according to a plan.
2. There is an inventory of all
medical equipment.
5. There is a preventive
maintenance program.
203–204X
X
X
Plan
Inventory
Program
FMS.8.2 1. There is a product/equipment
recall system in place.
2. Policy or procedure addresses
any use of any product or
equipment under recall.
204
Policy
FMS.9.1
3. The organization plans
alternative sources of power and
water in emergencies.
204–205 Plan
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
Written Plans
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.
223–224 X Policy
Management of Communication and Information
STANDARD MEASURABLE ELEMENT(S) PAGE NUMBER(S) ENGLISH TYPE OF
DOCUMENTATION
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
236–237 X
X
Policy
Policy
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the process to gain access
when permitted.
