Clarifications JCI’s latest changes and updates to its accreditation standards

Current Clarifications for Joint Commission International Accreditation Standards for Hospitals, Third Edition

Note: These clarifications have not been updated since 13 May 2008, and are the same as they appeared in the July 2008 and October 2008 issues of Joint Commission International eZine.   Previous update: 12 February 2008   New text is underlined Deleted text is struck through

Page 5:  Under heading “Accreditation Denied”, fourth bullet (p.6), update text as follows:

One or more International Patient Safety Goals requirements is scored less than a “0” “5”;

 

Page 6:  Under heading “Accreditation Awards”, delete text as follows:

To gain accreditation, organizations must demonstrate acceptable compliance with all core and non-core standards and achieve a minimal numerical score on these standards.

 

Page 7:  Near top of page, update text as follows:

Lisa Stahly

Manager, International Accreditation Services

Fax: +1-630-268-3743

E-mail: lstahly@jcrinc.comJCIAccreditation@jcrinc.com

 

Page 8:  Under heading “Focused Survey Fee”, insert text as follows:

Focused surveys are conducted when JCI becomes aware of potentially serious standards noncompliance, patient care or safety issues, or when JCI has other valid reasons for surveying an accredited organization.

 

Page 19:  Under heading “Information on Accreditation Status Available to the Public”, update text as follows:

Please refer to the section on confidentiality in this chapter (page 89) for specific information on this issue.

 

Page 24:  In the Table of Changes, alter the text as follows:

AOP.5.38 and AOP.5.9 —now address point-of-care testing as part of the laboratory director’s responsibilities

 

Page 24:  In the Table of Changes, alter the text as follows:

AOP.5.109.1 —clarified to indicate that only “specialty” laboratory tests, not all tests, are included in the proficiency testing process.

 

Page 27:  In the Table of Changes, alter the text as follows:

PCI.10.56 —now requires action on reports from relevant public health agencies related to infections.

 

Page 33:  Under heading “Intent of Goal 3”, alter the text as follows:

…potassium phosphate, sodium chloride [0/9% or more concentratedgreater than 0.9% concentration], and magnesium…

 

Page 41: Near bottom of page, under heading “Standard”, insert text as follows:

ACC.1.1 The organization has a process for admitting inpatients and for registering outpatients.

 

Page 42: ACC.1.1, ME 2, delete text as follows:

❒ 2. Policies and procedures are used to standardize the inpatient admitting process.

  (Also see PFR.10.2, ME 4)

 

Page 42: ACC.2.1, ME 1, delete text as follows:

❒ 1. The individual responsible for the patient’s care is identified. (Also see PFR.6.1, ME 6)

 

Page 47: ACC.3.2, ME 3, delete text and update as follows:

❒ 1. A discharge summary is prepared at discharge by a qualified individual.

❒ 2. All discharge summaries contain the items a) through h) identified in the intent.

❒ 3. The summary contains follow-up instructions.

❒ 4 3. A copy of the discharge summary is placed in the patient record.

❒ 5 4. Unless contrary to organization policy, laws, or culture, patients are given a copy of the discharge summary.

❒ 65 . A copy of the discharge summary is provided to the practitioner responsible for the patient’s continuing or follow-up care.

 

Page 48: ACC.4, ME 4, update text as follows:

❒ 4. The process addresses criteria that define when transfer is appropriate. (Also see GLSD.6.1, ME 3)

 

Page 51, ACC.6, Intent statement, update text as follows:

Organizations that own andoperate transport services…

 

Page 75, AOP.1.3 and AOP.1.3.1, Intent statement, update text as follows:

Also, when there is no time to record the complete history and physical examination of an emergency patient requiring surgery, a note onand the preoperative diagnosis is recorded before surgery.

 

Page 92, AOP.6.8, Intent statement, update text as follows:

Quality control procedures include

• validation of the test methods used for accuracy and precision;

• daily surveillance of imaging results by qualified laboratoryradiology staff;

 

Page 92, AOP.6.8, ME 1, update text as follows:

❒ 1. There is a quality control program for the radiology and diagnostic imaging services, and it is implemented.

 

Page 97: COP.1, ME 1, delete text as follows:

❒ 3. Uniform care is provided that meets requirements #1 through #5 in the intent statement. ( Also see ASC.3.1, ME 1)

 

Page 104: Intent of COP.6, letter c), update text as follows:

c) communicating with and educating patients and families about pain and symptom management in the context of their personal, cultural, and religious beliefs ( Also see PRF FR.1.1, ME 1); and

 

Page 125: MMU.4.3, ME 1, update text as follows:

❒ 1. Medications prescribed or ordered are recorded for each patient. (Also see MCI.19.1, ME 4)

 

Page 126: Measurable Elements of MMU.5.1, delete text as follows:

❒ 2. Each prescription or order is reviewed for appropriateness and includes elements a) through g) in the intent. Thus, each prescription or order is evaluated for appropriateness review.

 

Page 147: center of page, above heading “Measurable Elements of QPS.2.1”, update text as follows:

Organizations are expected to have gone through the process described in a) through fg ) for at least one clinical practice guideline and one clinical pathway per year.

 

Page 147: QPS.2.1, ME 4, update text as follows:

❒ 4. The process is used to adapt, adopt, or update at leaste one guideline and one pathway per 12-month period.

 

Page 178: GLD.5.2, Intent statement, add text as follows:

While the directors make recommendations regarding human and other resource needs, those needs sometimes change or are not fully met.

 

Page 210, near top of page, Intent of SQE.14, update text as follows:

The nursing staff’s essential clinical role requires them to actively participate in the organization’s clinical quality improvement program. If at any point during clinical quality monitoring, evaluation, and improvement, a nursing staff member’s performance is in question, the organization has a process to evaluate that individual’s performance. The results of reviews, actions taken, and any impact on privilegesjob responsibilities are documented in the medical staff member’snurse’s credentials or other file.

 

Page 222: Middle of page, under heading “Standard”, delete text as follows:

MCI.1.15 Appropriate clinical and managerial staff participate in selecting, integrating, and using information management technology.

 

Page 225: Intent of MCI.19.1 and MCI.19.1.1, update text as follows:

The organization determines the specific data and information recorded in the clinical record of each patient assessed or treated on an outpatient, emergency, or inpatient basis. The record of each patient receiving emergency care includes the specific information identified in standard MCI.2019.1.1.

 

Page 228: MCI.20.3, ME 3, delete text as follows:

❒ 3. The organization compares its performance using external reference databases. ( Also see QPS.4.2, ME 2; MCI.20.3, ME 3; and PCI.10.4, ME 1)

 

Page 229: Glossary, update text as follows:

validation survey An evaluation of the survey process subsequent to an organization’s initial or triennial re-survey, assessing standards compliance in health care organizations, as part of JCI’s internal quality improvement efforts. Similar in scope to an initial or triennial survey, the validation survey is voluntary and in no way affects the results of an organization’s initial or triennial survey.

 

focused survey Narrow, limited evaluation of an organization subsequent to an initial or triennial survey, which concentrates solely on issues deemed noncompliant during the initial or triennial survey.