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Joint Commission International Accreditation Standards for

Hospitals

6th Edition | Effective 1 July 2017

Including Standards for Academic Medical Center Hospitals

Updated 8 January 2018 to correct typographical and other errors

Joint Commission International Accreditation Standards for

Hospitals

6th Edition | Effective 1 July 2017

Including Standards for Academic Medical Center Hospitals

Updated 8 January 2018 to correct typographical and other errors

Joint Commission international aCCreditation standards for Hospitals, 6tH edition

Joint Commission International A 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 of education, publications, consultation, and evaluation services. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of Joint Commission International. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process.

© 2017 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

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Permissions Editor Department of Publications Joint Commission Resources 1515 W. 22nd Street Suite 1300W Oak Brook, IL 60523 permissions@jcrinc.com

ISBN: 978-1-59940-989-4

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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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http://www.jointcommissioninternational.org
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Contents

Standards Advisory Panel ................................................................................................. v Introduction .................................................................................................................... 1 General Eligibility Requirements ..................................................................................... 7 Summary of Changes to the Manual ............................................................................... 9

Section I: Accreditation Participation Requirements ...............................................31 Accreditation Participation Requirements (APR) ................................................ 33

Section II: Patient-Centered Standards ....................................................................41 International Patient Safety Goals (IPSG) .......................................................... 43 Access to Care and Continuity of Care (ACC) ................................................... 57 Patient and Family Rights (PFR) ........................................................................ 77 Assessment of Patients (AOP) ............................................................................. 91 Care of Patients (COP) .................................................................................... 119 Anesthesia and Surgical Care (ASC) ................................................................. 141 Medication Management and Use (MMU) ...................................................... 155 Patient and Family Education (PFE) ................................................................ 173

Section III: Health Care Organization Management Standards .............................177 Quality Improvement and Patient Safety (QPS) ............................................... 179 Prevention and Control of Infections (PCI) ..................................................... 191 Governance, Leadership, and Direction (GLD) ................................................ 207 Facility Management and Safety (FMS) ............................................................ 237 Staff Qualifications and Education (SQE) ........................................................ 257 Management of Information (MOI) ................................................................ 285

Section IV: Academic Medical Center Hospital Standards .....................................301 Medical Professional Education (MPE) ............................................................ 303 Human Subjects Research Programs (HRP) ..................................................... 309

Summary of Key Accreditation Policies ....................................................................... 317 Glossary ...................................................................................................................... 327 Index ........................................................................................................................... 339

Joint Commission international aCCreditation standards for Hospitals, 6tH edition

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v

Standards Advisory Panel

John Øvretveit, BSc(hons), MPhil, PhD, CPsychol, CSci, MHSM (Chairperson) Stockholm, Sweden

Abdullah Mufareh Assiri, MD Riyadh, Saudi Arabia

María del Mar Fernández, MSc, PhD Madrid, Spain

Brigit Devolder, MS Leuven, Belgium

Samer Ellahham, MD, FACP, FACC, FAHA, FCCP, ASHCSH Abu Dhabi, UAE

Paul Hofmann, DrPH, FACHE California, USA

Johan Kips, MD, PhD Brussels, Belgium

Manish Kohli, MD, MPH, MBA Abu Dhabi, UAE

Lee Chien Earn, PhD Singapore

Harish Pillai, MD Kerala, India

Abdul Latif Sheikh, MS, RPh Karachi, Pakistan

Abha Shroff, MBBS, MD, DCP Mumbai, India

José Valverde Filho, MD Rio De Janeiro, Brazil

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1

Introduction

Joint Commission International (JCI) is proud to publish the 6th edition of the Joint Commission International Accreditation Standards for Hospitals. Each of the five previous editions have sought to reflect the most current thinking in patient safety practices and concepts to help accredited and nonaccredited organizations uncover their most pressing safety risks and advance their goals for continuous quality improvement. This tradition carries on with the 6th edition as it seeks to continue the work of making health care as safe as possible.

The Joint Commission International Accreditation Standards for Hospitals contain the standards, intents, measurable elements (MEs), a summary of changes for this edition of the JCI hospital standards, a summary of key accreditation policies and procedures, a glossary of terms, and an index. This introduction is designed to provide information on the following topics:

• The origin of these standards • How the standards are organized • How to use this standards manual • What is new in this edition of the manual

If, after reading this publication, you have questions about the standards or the accreditation process, please contact JCI:

+1-630-268-7400 JCIAccreditation@jcrinc.com

How were the standards developed and refined for this 6th edition? The JCI standards development process is a collaboration between JCI, accredited organizations, and experts in quality and safety. This new edition takes into account developments in the science of quality improvement and patient safety as well as the experiences of the organizations that used the 5th edition hospital standards to improve the safety and quality of care in their organizations.

The development process included the following: • Focus groups with JCI–accredited organization leaders and other health care experts. These focus

groups were conducted in 16 countries, in regions around the world. • Review of the literature for current evidence-based practice and processes, and authoritative sources

for industry guidelines, to support new and revised standards • Input from experts and others with specific and relevant content knowledge, including JCI surveyors

and consultants • Discussion and guidance on the development and revision of the standards with the Standards

Advisory Panel, a 13-member international panel composed of experts with extensive experience in various health care fields

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• An online field review of the draft 6th edition standards sent to all accredited hospitals and JCI field staff and promoted through social media and the JCI website.

How are the standards organized? The standards are organized around the important functions common to all health care organizations. This approach is now the most widely used around the world and has been validated by scientific study, testing, and application.

The standards are grouped into three major areas: those related to providing patient care; those related to providing a safe, effective, and well-managed organization; and, for academic medical center hospitals only, those related to medical professional education and human subjects research programs. The standards apply to the entire organization as well as to each department, unit, or service within the organization. The survey process gathers standards compliance information throughout the entire organization, and the accreditation decision is based on the organization’s overall level of compliance.

What are the Academic Medical Center hospital standards and do they apply to my organization? The Academic Medical Center (AMC) hospital standards were developed and first published in 2012 to recognize the unique resource such centers represent for health professional education and human subjects research in their community and country. This section of standards contains two chapters: Medical Professional Education (MPE) and Human Subjects Research Programs (HRP). Unless deliberately included in the quality framework, education and research activities often are the unnoticed partners in patient care quality monitoring and improvement. To address this concern, the standards in these two chapters present a framework for including medical education and research into the quality and patient safety activities of academic medical center hospitals.

Many health care organizations may consider themselves to be academic medical centers. However, only organizations that meet JCI’s definition are required to comply with the standards present in the AMC section of the manual. Academic medical center hospital applicants must meet each of the following three criteria:

1. The applicant hospital is organizationally or administratively integrated with a medical school. 2. The applicant hospital is the principal site for the education of both medical students (undergraduates)

and postgraduate medical specialty trainees (for example, residents or interns) from the medical school noted in criterion 1.

3. At the time of application, the applicant hospital is conducting medical research with approval and oversight by an Institutional Review Board (IRB) or research ethics committee.

All hospitals meeting the eligibility criteria must comply with the requirements in these two chapters (as well as the other requirements detailed in this manual) in order to be accredited by JCI.

Organizations with questions about their eligibility for Academic Medical Center hospital accreditation should contact JCI Accreditation’s Central Office at jciaccreditation@jcrinc.com.

Are the standards available for the international community to use? Yes. These standards are available in the international public domain for use by individual health care organizations and by public agencies seeking to improve the quality of patient care. To assist such organizations, JCI has provided a document that lists the standards (but not the intent statements and MEs) that can be downloaded at no cost from the JCI website. The translation and use of the standards as published by JCI requires written permission.

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IntroductIon

When there are national or local laws related to a standard, what applies? When a concept is addressed by the JCI standards and by the laws or regulations of a national or local authority, JCI requires that an organization follow whichever body has set the higher or stricter requirement. For example, JCI requires that organizations use two patient identifiers in a variety of processes. If the hospital’s national standard requires the use of three identifiers, the hospital must consequently use three identifiers to meet the national standard which is stricter than JCI’s standard. However, if that same national standard allows the use of bed number as an identifier—a practice JCI explicitly prohibits—the organization is prohibited from doing so. In this case, the organization would need to use three identifiers (the stricter national requirement) and would be prohibited from using bed number as an identifier (the stricter JCI requirement).

How do I use this standards manual? This international standards manual can be used to accomplish the following:

• Guide the efficient and effective management of a health care organization • Guide the organization and delivery of patient care services and efforts to improve the quality and

efficiency of those services • Review the important functions of a health care organization • Become aware of those standards that all organizations must meet to be accredited by JCI • Review the compliance expectations of the standards as well as those of the additional requirements

found in the associated intent • Become aware of the accreditation policies and procedures and the accreditation process • Become familiar with the terminology used in the manual

JCI requirements by category are described in detail below. JCI’s policies and procedures are also summarized in this manual. Please note that these are neither the complete list of policies nor every detail of each policy. Current JCI policies are published on JCI’s public website, www.jointcommissioninternational.org.

JCI Requirement Categories JCI requirements are described in these categories:

• Accreditation Participation Requirements (APR) • Standards • Intents • Measurable Elements (MEs)

Accreditation Participation Requirements (APR) The Accreditation Participation Requirements (APR) chapter is composed of specific requirements for participation in the accreditation process and for maintaining an accreditation award. Hospitals must be compliant with the APRs at all times during the accreditation process. However, APRs are not scored like standards during the on-site survey; hospitals are considered either compliant or not compliant with the APRs. When a hospital is not compliant with a specific APR, the hospital will be required to become compliant or risk losing accreditation.

Standards JCI standards define the performance expectations, structures, or functions that must be in place for a hospital to be accredited by JCI. JCI’s standards are evaluated during the on-site survey.

Intents A standard’s intent helps explain the full meaning of the standard. The intent describes the purpose and rationale of the standard, provides an explanation of how the standard fits into the overall program, sets

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parameters for the requirement(s), and otherwise “paints a picture” of the requirements and goals. The bulleted lists in the intent statement are considered advisory and serve as a helpful explanation of practices that might meet the standard. Numbered or lettered lists in the intent statement include required elements that must be in place in order to meet the standard.

Measurable Elements (MEs) Measurable elements (MEs) of a standard indicate what is reviewed and assigned a score during the on-site survey process. The MEs for each standard identify the requirements for full compliance with the standard. The MEs are intended to bring clarity to the standards and help the organization fully understand the requirements, educate leadership, department/service leaders, health care practitioners, and staff about the standards, and guide the organization in accreditation preparation.

Other Sections Included in This Manual • General Eligibility Requirements • Summary of Changes to the Manual • Summary of Key Accreditation Policies • Glossary • Index

What is new in this 6th edition of the manual? There are many changes to this 6th edition of the hospital manual. A thorough review is strongly recommended. This 6th edition of the hospital manual includes a summary of changes to the manual immediately preceding the Accreditation Participation Requirements chapter. This summary identifies new standards, new measurable elements, an explanation of the changes, as well as text that has been edited from the 5th edition for the purpose of providing increased clarity and additional examples. Other changes to the hospital manual include:

• Updated and additional evidence-based references to support the new and revised standards. With this feature, JCI is continuing to provide support for its standards by citing important evidence that provides assistance with compliance. References of various types—from clinical research to practical guidelines—are cited in the text of the standard’s intent and are listed at the end of the applicable standard chapter.

• Modifications to the APR chapter. • A P icon added after the standard text in some standards, such as some new standards in the 6th

edition. As in the 5th edition, some standards require the hospital to have a policy, procedure, or other type of written document for specific processes. Those standards are indicated by a P icon after the standard text. All written policies, procedures, and programs will be scored together at MOI.8 and MOI.8.1.

• More examples added to many standards’ intents to better illustrate expectations for compliance. To make the examples more apparent to the user, the term for example is printed in bold text.

• Definitions of key terms used throughout the manual have been created or updated, and text including those terms has been reevaluated and revised to ensure that terminology is correct and clear. Many terms are defined within intents; look for these key terms in italics (for example, leadership). All key terms are defined in the glossary in the back of this edition.

• Chapter overviews and lists of “standards only” have returned to this edition and are presented at the beginning of each chapter.

5

IntroductIon

How frequently are the standards updated? Information and experience related to the standards will be gathered on an ongoing basis. If a standard no longer reflects contemporary health care practice, commonly available technology, quality management practices, and so forth, it will be revised or deleted. It is current practice that the standards are revised and published approximately every three years.

What does the “effective” date on the cover of this 6th edition of the standards manual mean? The “effective” date found on the cover means one of two things:

1. For hospitals accredited under the 5th edition of the standards, this is the date by which they now must be in full compliance with all the standards in the 6th edition. Standards are published at least six months in advance of the effective date to provide time for organizations to come into full compliance with the revised standards by the time they are effective.

2. For hospitals seeking accreditation for the first time, the effective date indicates the date after which all surveys and accreditation decisions will be based on the standards of the 6th edition. Any survey and accreditation decisions before the effective date will be based on the standards of the 5th edition.

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7

General Eligibility Requirements

Any hospital may apply for Joint Commission International (JCI) accreditation if it meets all the following criteria:

• The hospital is located outside of the United States and its territories. • The hospital is currently operating as a health care provider in the country, is licensed to provide care

and treatment as a hospital (if required), and, at minimum, does the following: 0 Provides a complete range of acute care clinical services—diagnostic, curative, and rehabilitative. 0 In the case of a specialty hospital, provides a defined set of services, such as pediatric, eye, dental,

and psychiatry, among others. 0 For all types of hospitals, provides services that are available 365 days per year; ensures all direct

patient care services are operational 24 hours per day, 7 days per week; and provides ancillary and support services as needed for emergent, urgent, and/or emergency needs of patients 24 hours per day, 7 days per week (such as diagnostic testing, laboratory, and operating theatre, as appropriate to the type of acute care hospital).

• The hospital provides services addressed by the current JCI accreditation standards for hospitals. • The hospital assumes, or is willing to assume, responsibility for improving the quality of its care and

services. • The hospital is open and in full operation, admitting and discharging a volume of patients that will

permit the complete evaluation of the implementation and sustained compliance with all current JCI accreditation standards for hospitals.

• The hospital meets the conditions described in the current Accreditation Participation Requirements (APRs).

Academic medical center hospital applicants must meet each of the criteria above in addition to the following three criteria:

1) The applicant hospital is organizationally or administratively integrated with a medical school. 2) The applicant hospital is the principal site for the education of both medical students (undergraduates)

and postgraduate medical specialty trainees (for example, residents or interns) from the medical school noted in criterion 1.

3) At the time of application, the applicant hospital is conducting medical research with approval and oversight by an Institutional Review Board (IRB) or research ethics committee.

Definitions Full operation

• The hospital accurately identifies the following in its electronic application (E-App) at the time of application: 0 All clinical services currently provided for inpatients and outpatients. (Those clinical services that

are planned and thus not identified in the E-App and begin operations at a later time will require a separate extension survey to evaluate those services.)

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0 Utilization statistics for clinical services showing consistent inpatient and outpatient activity levels and types of services provided for at least four months or more prior to submission of the E-App

• All inpatient and outpatient clinical services, units, and departments identified in the E-App are available for a comprehensive evaluation against all relevant JCI standards for hospitals currently in effect, consistent with JCI’s normal survey process for the size and type of organization (see, for example, the current JCI hospital survey process guide), such as 0 patient tracer activities, including individual patient and system tracers; 0 open and closed medical record review; 0 direct observation of patient care processes; 0 interviews with patients; and 0 interviews with medical students/trainees.

Contact JCI Accreditation prior to submitting an E-App to discuss the criteria and validate whether the hospital meets the above criteria for “in full operation” at least four months or more prior to submitting its E-App and at its initial survey. JCI may request documentation of the hospital’s utilization statistics prior to accepting the E-App or conducting the on-site survey. In addition, JCI will not begin an on-site survey, may discontinue an on-site survey, or may cancel a scheduled survey when it determines the hospital is not “in full operation.”

Principal site Principal site means the hospital provides the majority of medical specialty programs for postgraduate medical trainees (for example, residents or interns) and not just one specialty, as in a single-specialty hospital (for example, an ophthalmologic hospital, dental hospital, or orthopedic hospital).

Medical research Medical research conducted at the academic medical center hospital represents varied medical areas or specialties within the institution and includes basic, clinical, and health services research. Such research may include clinical trials, therapeutic interventions, development of new medical technologies, and outcomes research, among others. Hospitals that primarily conduct non–human subjects research and/or research exempt from review by an IRB or research ethics committee, such as medical record review studies, case studies, and research involving data/specimens without individually identifiable information, do not meet criterion 3 of the academic medical center hospital eligibility criteria.

Note: If in its reasonable discretion JCI determines that the applicant does not meet the eligibility criteria for the Hospital/Academic Medical Center Hospital accreditation program, JCI will not accept the application or will not process the application for accreditation from the hospital and will notify the hospital of its decision.

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Summary of Changes to the Manual

The following table summarizes key changes to standards in the 6th edition of the Joint Commission International Accreditation Standards for Hospitals. Several of the standards in the table have requirement changes (compared to their 5th edition versions), some standards are new to the 6th edition, and many standards have no requirement changes but were revised for the purpose of clarifying expectations, combining similar requirements, and/or providing additional examples in the intents.

The table includes each standard’s current number in the 6th edition as well as its number from the 5th edition. In some cases, the number has changed (for example, a standard may have moved to a new location in the 6th edition or two standards may now be combined into one). In addition, a description of changes is provided, and if the standard has new measurable elements or is a new standard, a checkmark appears in one of the last two columns.

The changes to this 6th edition of the hospital standards were influenced and guided by several sources, including

• suggestions from JCI-accredited organizations, JCI surveyors and consultants, and the JCI Standards Advisory Panel for patient safety and quality of care issues not addressed in the 5th edition hospital standards;

• communications with JCI-accredited organizations, JCI surveyors and consultants, and JCI staff regarding the need for clarification of requirements and expectations for specific standards; and

• evolving health care practices and the changing health care environment.

6th Edition Standard(s)

Number

Previous 5th Edition Standard(s)

Number Description of Changes New

Standard New

ME(s) IPSG.1 IPSG.1 • Adds language to the intent to clarify that

the two identifiers used in the outpatient departments may be different from those used in the inpatient departments

• Combines the requirements of ME 2 and ME 3 from the 5th edition into ME 2 (6th edition)

• Changes ME 3 to clearly identify the requirement for hospitals to ensure the correct identification of patients in special circumstances

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6th Edition Standard(s)

Number

Previous 5th Edition Standard(s)

Number Description of Changes New

Standard New

ME(s) IPSG.2 through IPSG.2.2

IPSG.2 through IPSG.2.2

• Clarifies in IPSG.2.2, ME 2 that standardized forms, tools, or methods are used to support the handover process

• Adds language to IPSG.2.2, ME 3 to specify that adverse event data are tracked and used to identify improvements for handover communications

IPSG.3 and IPSG.3.1

IPSG.3 and IPSG.3.1

• Revises language in the intent to clarify the definition of high-alert medications

• Revises MEs in IPSG.3 to separate requirements for high-alert medications from look-alike/sound-alike medications for clarification purposes