Essentials of Joint Commission Readiness Dale Brown, RN, MSN Stephen Dorman, MD Day 2

Essentials of Joint Commission Essentials of Joint Commission ReadinessReadiness

Dale Brown, RN, MSNDale Brown, RN, MSN

Stephen Dorman, MDStephen Dorman, MD

Day 2Day 2

Patient Centered Patient Centered CommunicationCommunication

PC. 02.01.21PC. 02.01.21

The hospital effectively communicates with The hospital effectively communicates with patients when providing care, treatment, and patients when providing care, treatment, and services.services.EP 1- (A)The hospital identifies the patients’ oral EP 1- (A)The hospital identifies the patients’ oral and written communication needs, including the and written communication needs, including the patient’s preferred language for discussing health patient’s preferred language for discussing health care.care.EP 2-(A) The hospital communicates with the EP 2-(A) The hospital communicates with the patient during the provision of care, treatment, and patient during the provision of care, treatment, and services in a manner that meets the patient’s oral services in a manner that meets the patient’s oral and written communication needs.and written communication needs.

33

RI. 01.01.01RI. 01.01.01

The hospital respects, protects, and The hospital respects, protects, and promotes patient rights.promotes patient rights.

EP # 5-(C) the hospital respects the EP # 5-(C) the hospital respects the patient’s right to and need for effective patient’s right to and need for effective communicationcommunication

44

RI. 01.01.03RI. 01.01.03The hospital respects the patient’s right to The hospital respects the patient’s right to receive information in a manner he or she receive information in a manner he or she understands. understands. EP# 2-The hospital provides language EP# 2-The hospital provides language interpreting and translation services.interpreting and translation services.(HR. 01.02.01, EP # 1)(HR. 01.02.01, EP # 1)EP # 3-The hospital provides information to EP # 3-The hospital provides information to the patient who has vision, speech, hearing, the patient who has vision, speech, hearing, or cognitive impairments in a manner that or cognitive impairments in a manner that meets the patient’s needs.meets the patient’s needs.

55

Medication ManagementMedication Management

77

MM.01.01.03MM.01.01.03

The organization safely manages high-The organization safely manages high-alert and hazardous medications.alert and hazardous medications.

88

MM.01.01.03MM.01.01.03

5-A: 5-A: The hospital reports abuses and The hospital reports abuses and losses of controlled substances to the losses of controlled substances to the individual responsible for the pharmacy individual responsible for the pharmacy department or service and to the chief department or service and to the chief executive officer, in accordance with law executive officer, in accordance with law and regulation. and regulation.

99

MM.03.01.01MM.03.01.01

The organization safely stores The organization safely stores medications.medications.

Secure: no unsupervised, Secure: no unsupervised, unauthorized individuals may unauthorized individuals may

access medications.access medications.

1010

MM.03.01.01MM.03.01.01

3-A: 3-A: The hospital stores controlled The hospital stores controlled (scheduled) medications in a locked, (scheduled) medications in a locked, secured area to prevent diversion, in secured area to prevent diversion, in accordance with law and regulation. accordance with law and regulation. Scheduled medications include those Scheduled medications include those listed in Schedules II–V of the listed in Schedules II–V of the Comprehensive Drug Abuse Prevention Comprehensive Drug Abuse Prevention and Control Act of 1970.and Control Act of 1970.

1111

MM.03.01.01MM.03.01.01

19-A: 19-A: The hospital has a pharmacy The hospital has a pharmacy directed by a registered pharmacist or a directed by a registered pharmacist or a supervised drug storage area, in supervised drug storage area, in accordance with law and regulation. accordance with law and regulation.

1212

MM.05.01.07MM.05.01.07

The organization safely prepares The organization safely prepares medication.medication.

1313

MM.05.01.07MM.05.01.07

5-DI,A: 5-DI,A: Medications are prepared and Medications are prepared and administered in accordance with the administered in accordance with the orders of a licensed independent orders of a licensed independent practitioner responsible for the patient's practitioner responsible for the patient's care, and in accordance with law and care, and in accordance with law and regulation. regulation.

1414

MM.05.01.07MM.05.01.07

6-DI,A: 6-DI,A: In-house preparation of In-house preparation of radiopharmaceuticals is done by, or under radiopharmaceuticals is done by, or under the direct supervision of, an appropriately the direct supervision of, an appropriately trained registered pharmacist or doctor of trained registered pharmacist or doctor of medicine or osteopathy.medicine or osteopathy.

Note: Direct defined by CMS as Note: Direct defined by CMS as ““on the on the same campus.same campus.””

1515

MM.07.01.03MM.07.01.03

The organization responds to actual or The organization responds to actual or potential adverse drug events, potential adverse drug events,

significant adverse drug reactions, significant adverse drug reactions, and medication errors.and medication errors.

1616

MM.07.01.03MM.07.01.03

6-DI,A: 6-DI,A: Medication administration errors, Medication administration errors, adverse drug reactions, and medication adverse drug reactions, and medication incompatibilities are immediately reported incompatibilities are immediately reported to the attending physician, and, as to the attending physician, and, as determined by the hospital, to the determined by the hospital, to the organization-wide performance organization-wide performance improvement program. improvement program.

CMS Changes for 2013CMS Changes for 2013

CMS ChangesCMS Changes

1. Removal of requirement for special 1. Removal of requirement for special education for blood and medication education for blood and medication administration. (HR.01.02.01)administration. (HR.01.02.01)

2. Mandate for CEO, nurse leaders and 2. Mandate for CEO, nurse leaders and medical staff leaders to address problems medical staff leaders to address problems identified by infection control (LD.01.02.01).identified by infection control (LD.01.02.01).

3. A podiatrist may serve as a medical staff 3. A podiatrist may serve as a medical staff leader including president (LD.01.05.01).leader including president (LD.01.05.01).


4. Permission to use standing orders 4. Permission to use standing orders (without a requirement for an order) if:(without a requirement for an order) if:– Based on best practice guidelinesBased on best practice guidelines– Approved by the medical staff, nursing and Approved by the medical staff, nursing and

pharmacypharmacy– For a defined patient populationFor a defined patient population– No “choices” in the set.No “choices” in the set.– Maintain required to sign, date and time at Maintain required to sign, date and time at

some point. (MM.04.01.01)some point. (MM.04.01.01)

RestraintRestraint

5. Permission to use orders for care, 5. Permission to use orders for care, treatment of services for outpatients from treatment of services for outpatients from any licensed provider as allowed by laws any licensed provider as allowed by laws and regulation providing there is a and regulation providing there is a supporting hospital policy. (MM.05.01.07)supporting hospital policy. (MM.05.01.07)6. New reporting process for death in 6. New reporting process for death in restraints. Not required for death in wrist restraints. Not required for death in wrist restraints if the death is not related to the restraints if the death is not related to the restraint.restraint.


7. All verbal orders must be authenticated 7. All verbal orders must be authenticated within law and regulation. All time within law and regulation. All time requirements have been removed but it is requirements have been removed but it is clear that unauthenticated orders at 30 clear that unauthenticated orders at 30 days would constitute a delinquent record.days would constitute a delinquent record.

8. Authentications may be performed on 8. Authentications may be performed on behalf of partner physicians.behalf of partner physicians.


9: Single governing body9: Single governing body

10. ONE medical staff per CCN.10. ONE medical staff per CCN.

11. Nursing care plans may be included in 11. Nursing care plans may be included in interdisciplinary care plans.interdisciplinary care plans.

12. Removed requirement for one person 12. Removed requirement for one person responsible for ambulatory and outpatient responsible for ambulatory and outpatient care.care.

2323

Field ReviewField ReviewRadiology StandardsRadiology Standards

Stephen M. Dorman, M.D.Stephen M. Dorman, M.D.

EC.02.01.01EC.02.01.01

The hospital manages safety The hospital manages safety and security risks.and security risks.

2424

EC.02.01.01EC.02.01.01

EP 14:EP 14:

For hospitals that provide magnetic For hospitals that provide magnetic resonance imaging (MRI) services: The resonance imaging (MRI) services: The hospital manages safety risks in the MRI hospital manages safety risks in the MRI environment associated with the following:environment associated with the following:

- Patients who may experience - Patients who may experience claustrophobia, anxiety, or emotional claustrophobia, anxiety, or emotional distressdistress

2525

EC.02.01.01EC.02.01.01

EP 14: EP 14:

Patients who may require urgent or Patients who may require urgent or emergent medical careemergent medical care

- Metallic implants and devices- Metallic implants and devices

- Ferrous objects entering the MRI - Ferrous objects entering the MRI environmentenvironment

2626

EC.02.01.01EC.02.01.01

EP 16:EP 16:

For hospitals that provide magnetic For hospitals that provide magnetic resonance imaging (MRI) services: The resonance imaging (MRI) services: The hospital manages safety risks by doing the hospital manages safety risks by doing the following:following:

- Restricting access of everyone not - Restricting access of everyone not trained screened by staff to an area that trained screened by staff to an area that immediately precedes the entrance to the immediately precedes the entrance to the MRI scanner roomMRI scanner room

2727

EC.02.01.01EC.02.01.01

EP 16:EP 16:

- Making sure that this area is controlled by - Making sure that this area is controlled by and under the direct supervision MRI trained and under the direct supervision MRI trained staffstaff

- Posting signage at the entrance to the - Posting signage at the entrance to the MRI scanner room that conveys that the MRI scanner room that conveys that the magnet is always onmagnet is always on

2828

EC.02.02.01EC.02.02.01

The hospital manages risks The hospital manages risks related to related to hazardoushazardous materials materials

and waste.and waste.

2929

EC.02.02.01EC.02.02.01

EP 17:EP 17:

For hospitals that provide computed For hospitals that provide computed tomography (CT), positron emission tomography (CT), positron emission tomography (PET), or nuclear medicine tomography (PET), or nuclear medicine (NM) services: The hospital monitors (NM) services: The hospital monitors radiation exposure levels for all staff and radiation exposure levels for all staff and licensed independent practitioners who licensed independent practitioners who routinely work in CT, PET, and NM areas.routinely work in CT, PET, and NM areas.

3030

EC.02.02.01EC.02.02.01

EP 17:EP 17:

Note: This is typically done through the Note: This is typically done through the use of exposure meters, such as personal use of exposure meters, such as personal dosimetry badges.dosimetry badges.

3131

EC.02.04.01EC.02.04.01

The hospital manages The hospital manages medical equipment risks.medical equipment risks.

3232

EC.02.04.01EC.02.04.01

EP 7:EP 7:

The hospital identifies activities and The hospital identifies activities and frequencies to maintain the image quality of frequencies to maintain the image quality of the diagnostic images produced. The the diagnostic images produced. The content and frequency of these activities are content and frequency of these activities are in accordance with state regulatory in accordance with state regulatory requirements, manufacturers’ guidelines, requirements, manufacturers’ guidelines, and the recommendations of a medical and the recommendations of a medical physicist.physicist.

3333

EC.02.04.03EC.02.04.03

The hospital inspects, tests, The hospital inspects, tests, and maintains medical and maintains medical

equipment.equipment.

3434

EC.02.04.03EC.02.04.03

EP 15:EP 15:

The hospital maintains the image The hospital maintains the image quality of the diagnostic images quality of the diagnostic images produced.produced.

(See also EC.02.04.01, EP 7)(See also EC.02.04.01, EP 7)

3535

EC.02.04.03EC.02.04.03

EP 17:EP 17:For hospitals that provide computed tomography For hospitals that provide computed tomography

(CT) services: When utilizing standard adult brain, (CT) services: When utilizing standard adult brain, adult abdomen, and pediatric brain protocols, a adult abdomen, and pediatric brain protocols, a qualified medical physicist measures the actual qualified medical physicist measures the actual radiation dose produced by each diagnostic CT radiation dose produced by each diagnostic CT imaging system at least annually and verifies that the imaging system at least annually and verifies that the radiation dose displayed on the system is within 20 radiation dose displayed on the system is within 20 percent of the actual amount of radiation dose percent of the actual amount of radiation dose delivered. The dates of these verifications are delivered. The dates of these verifications are documented.documented.

3636

EC.02.04.03EC.02.04.03

Note: This element of performance is Note: This element of performance is applicable only for systems capable of applicable only for systems capable of calculating and displaying radiation doses.calculating and displaying radiation doses.

3737

EC.02.04.03EC.02.04.03

EP 19:EP 19:For hospitals that provide computed tomography (CT) For hospitals that provide computed tomography (CT)

services: If the hospital does not utilize standard adult services: If the hospital does not utilize standard adult brain, adult abdomen, or pediatric brain protocols, the brain, adult abdomen, or pediatric brain protocols, the hospital uses a qualified medical physicist to measure the hospital uses a qualified medical physicist to measure the actual radiation dose produced by each diagnostic CT actual radiation dose produced by each diagnostic CT imaging system at least annually and verify that the imaging system at least annually and verify that the radiation dose displayed on the system is within 20 percent radiation dose displayed on the system is within 20 percent of the actual amount of radiation dose delivered for the of the actual amount of radiation dose delivered for the three most common CT protocols used by the hospital. The three most common CT protocols used by the hospital. The dates of these verifications are documenteddates of these verifications are documented..

3838

EC.02.04.03EC.02.04.03

Note: This element of performance is Note: This element of performance is applicable only for systems capable of applicable only for systems capable of calculating and displaying radiation dosescalculating and displaying radiation doses

3939

EC.02.04.03EC.02.04.03


(CT) services: At least annually, a medical (CT) services: At least annually, a medical physicist conducts a performance evaluation of all physicist conducts a performance evaluation of all CT imaging equipment. The evaluation results, CT imaging equipment. The evaluation results, along with recommendations for correcting any along with recommendations for correcting any problems identified, are documented. The problems identified, are documented. The evaluations include the use of phantoms to assess evaluations include the use of phantoms to assess the following imaging metrics:the following imaging metrics:

4040

EC.02.04.03EC.02.04.03

EP 20:EP 20:- Image uniformity- Image uniformity

- Slice thickness accuracy- Slice thickness accuracy

- Slice position accuracy- Slice position accuracy

- High-contrast resolution- High-contrast resolution

- Low-contrast resolution- Low-contrast resolution

- Geometric or distance accuracy- Geometric or distance accuracy

- CT number accuracy and uniformity- CT number accuracy and uniformity

- Artifact evaluation- Artifact evaluation4141

EC.02.04.03EC.02.04.03

EP 21:EP 21:For hospitals that provide magnetic resonance For hospitals that provide magnetic resonance

imaging (MRI) services: At least annually, a imaging (MRI) services: At least annually, a medical physicist or MRI scientist conducts a medical physicist or MRI scientist conducts a performance evaluation of all MRI imaging performance evaluation of all MRI imaging equipment. The evaluation results, along with equipment. The evaluation results, along with recommendations for correcting any problems recommendations for correcting any problems identified, are documented. The evaluations identified, are documented. The evaluations include the use of phantoms to assess the include the use of phantoms to assess the following imaging metrics:following imaging metrics:

4242

EC.02.04.03EC.02.04.03


- Slice thickness accuracy- Slice thickness accuracy

- Slice position accuracy- Slice position accuracy

- High-contrast resolution- High-contrast resolution

- Low-contrast resolution (or contrast-to-noise ratio)- Low-contrast resolution (or contrast-to-noise ratio)

- Geometric or distance accuracy- Geometric or distance accuracy

- Magnetic field homogeneity (for MRI)- Magnetic field homogeneity (for MRI)

- Artifact evaluation- Artifact evaluation

4343

EC.02.04.03EC.02.04.03

EP 22:EP 22:For hospitals that provide positron emission For hospitals that provide positron emission

tomography (PET) or nuclear medicine (NM) tomography (PET) or nuclear medicine (NM) services: At least annually, a medical physicist services: At least annually, a medical physicist conducts a performance evaluation of all imaging conducts a performance evaluation of all imaging equipment. The evaluation results, along with equipment. The evaluation results, along with recommendations for correcting any problems recommendations for correcting any problems identified, are documented. The evaluations identified, are documented. The evaluations include the use of phantoms to assess the include the use of phantoms to assess the following imaging metrics:following imaging metrics:

4444

EC.02.04.03EC.02.04.03


- Extrinsic or system uniformity- Extrinsic or system uniformity

- Intrinsic or system spatial resolution- Intrinsic or system spatial resolution

- Low-contrast resolution- Low-contrast resolution

- Sensitivity- Sensitivity

- Energy resolution- Energy resolution

- Count-rate performance- Count-rate performance

- Artifact evaluation- Artifact evaluation4545

EC.02.06.05EC.02.06.05

The hospital manages its The hospital manages its environment during environment during

demolition, renovation, or demolition, renovation, or new construction to reduce new construction to reduce

risk to those in the risk to those in the organization.organization.

4646

EC.02.06.05EC.02.06.05


(CT), positron emission tomography (PET), or (CT), positron emission tomography (PET), or nuclear medicine (NM) services: The hospital nuclear medicine (NM) services: The hospital conducts a shielding integrity survey of rooms conducts a shielding integrity survey of rooms where ionizing radiation will be emitted or where ionizing radiation will be emitted or radioactive materials will be used or stored (for radioactive materials will be used or stored (for example, scan rooms, injection rooms, hot lab).example, scan rooms, injection rooms, hot lab).

4747

EC.02.06.05EC.02.06.05

EP 4:EP 4:

Note: For additional guidance on structural Note: For additional guidance on structural shielding design, see National Council on shielding design, see National Council on Radiation Protection and Measurements Radiation Protection and Measurements Report No. 147 (NCRP-147).Report No. 147 (NCRP-147).

4848

HR.01.02.05HR.01.02.05

The hospital verifies staff The hospital verifies staff qualifications.qualifications.

4949

HR.01.02.05HR.01.02.05

EP 19:EP 19:

For hospitals that provide computed For hospitals that provide computed tomography (CT) services: The hospital tomography (CT) services: The hospital verifies and documents that a radiologic verifies and documents that a radiologic technologist who performs CT exams has technologist who performs CT exams has the following qualifications:the following qualifications:

5050

HR.01.02.05HR.01.02.05

EP 19:EP 19:

- Registered by the American Registry of - Registered by the American Registry of Radiologic Technologists (ARRT)Radiologic Technologists (ARRT)

- Certified by the ARRT in radiography - Certified by the ARRT in radiography and/or computed tomographyand/or computed tomography

- Trained and experienced in operating CT - Trained and experienced in operating CT equipmentequipment

5151

HR.01.02.05HR.01.02.05


(CT) services: Diagnostic medical physicists that (CT) services: Diagnostic medical physicists that support CT services are board certified in support CT services are board certified in diagnostic radiological physics or radiological diagnostic radiological physics or radiological physics by the American Board of Radiology, the physics by the American Board of Radiology, the American Board of Medical Physics, or an American Board of Medical Physics, or an equivalent source. If the diagnostic medical equivalent source. If the diagnostic medical physicist is not board certified, then he or she has physicist is not board certified, then he or she has completed the following:completed the following:

5252

HR.01.02.05HR.01.02.05

EP 20:EP 20:

- A graduate degree in medical physics, - A graduate degree in medical physics, radiologic physics, physics, or another radiologic physics, physics, or another relevant physical science or engineering relevant physical science or engineering disciplinediscipline

5353

HR.01.02.05HR.01.02.05

EP 20:EP 20:

- Formal coursework in the biological - Formal coursework in the biological sciences with at least one course in biology sciences with at least one course in biology or radiation biology, and one course in or radiation biology, and one course in anatomy, physiology, or a similar topic anatomy, physiology, or a similar topic related to the practice of medical physicsrelated to the practice of medical physics

- Three years of documented experience in - Three years of documented experience in a clinical CT environmenta clinical CT environment

5454

HR.01.05.03HR.01.05.03

Staff participate in ongoing Staff participate in ongoing education and training.education and training.

5555

HR.01.05.03HR.01.05.03


(CT) services: The hospital verifies and documents (CT) services: The hospital verifies and documents that radiologic technologists who perform CT that radiologic technologists who perform CT examinations participate in ongoing education. examinations participate in ongoing education. Ongoing education must include annual training on Ongoing education must include annual training on radiation dose reduction awareness and radiation dose reduction awareness and techniques following As Low As Reasonably techniques following As Low As Reasonably Achievable (ALARA), Image Gently, and Image Achievable (ALARA), Image Gently, and Image Wisely concepts.Wisely concepts.

5656

HR.01.05.03HR.01.05.03

EP 25:EP 25:

Staff providing magnetic resonance Staff providing magnetic resonance imaging (MRI) services participate in imaging (MRI) services participate in education and training on safe practices in education and training on safe practices in the MRI environment including the following:the MRI environment including the following:

5757

HR.01.05.03HR.01.05.03

EP 25:EP 25:- Patient screening criteria for ferrous-based items- Patient screening criteria for ferrous-based items

- Proper patient positioning activities to avoid burns- Proper patient positioning activities to avoid burns

- Equipment and supplies that have been determined to - Equipment and supplies that have been determined to be safe for use in MRI areasbe safe for use in MRI areas

- MRI safety response procedures for patients who - MRI safety response procedures for patients who require urgent or emergent medical carerequire urgent or emergent medical care

- MRI equipment emergency shutdown procedures- MRI equipment emergency shutdown procedures

5858

LD.04.04.01 (new standard)LD.04.04.01 (new standard)

The hospital uses clinical practice The hospital uses clinical practice guidelines when providing the following guidelines when providing the following diagnostic imaging services: computed diagnostic imaging services: computed

tomography, magnetic resonancetomography, magnetic resonance

imaging, positron emission imaging, positron emission tomography, and nuclear medicine.tomography, and nuclear medicine.

For Hospitals that use CT, MRI, PET and For Hospitals that use CT, MRI, PET and NM:NM:

5959

LD.04.04.01LD.04.04.01

EP 1:EP 1:

The hospital uses evidence-based The hospital uses evidence-based guidelines and considers the patient’s age guidelines and considers the patient’s age and previous imaging exams when deciding and previous imaging exams when deciding on the most appropriate type of imaging on the most appropriate type of imaging exam.exam.

6060

LD.04.04.01LD.04.04.01

EP 2:EP 2:

The hospital establishes imaging protocols The hospital establishes imaging protocols based on current standards of practice, based on current standards of practice, which address key criteria including, clinical which address key criteria including, clinical indication, patient age, patient positioning, indication, patient age, patient positioning, scan times, radiation dose limits, and scan times, radiation dose limits, and contrast administration.contrast administration.

See (PI.01.01.01, EP 46)See (PI.01.01.01, EP 46)

6161

LD.04.04.01LD.04.04.01

EP 3:EP 3:

Imaging protocols are kept current and Imaging protocols are kept current and adjusted with input from an interpreting adjusted with input from an interpreting radiologist, medical physicist, and chief radiologist, medical physicist, and chief imaging technologist. Imaging protocols are imaging technologist. Imaging protocols are adjusted based on individual patient needs adjusted based on individual patient needs and on changes to standards of practice.and on changes to standards of practice.

6262

MM.06.01.01MM.06.01.01

The hospital safely The hospital safely administers medications.administers medications.

6363

MM.06.01.01MM.06.01.01

EP 13:EP 13:

Before administering a radioactive isotope, Before administering a radioactive isotope, staff verify that the dose to be administered staff verify that the dose to be administered is within 20% of the prescribed dose, or, if is within 20% of the prescribed dose, or, if the dose is prescribed as a range, staff the dose is prescribed as a range, staff verify that the dose to be administered is verify that the dose to be administered is within the prescribed range.within the prescribed range.

6464

PC.01.02.15PC.01.02.15

The hospital provides for The hospital provides for diagnostic testing.diagnostic testing.

6565

PC.01.02.15PC.01.02.15

EP 5:EP 5:

The hospital documents in the patient’s The hospital documents in the patient’s record the radiation dose on every study record the radiation dose on every study produced during a CT examination.produced during a CT examination.

Note 1: This element of performance is Note 1: This element of performance is applicable only for systems capable of applicable only for systems capable of calculating and displaying radiation doses.calculating and displaying radiation doses.

6666

PC.01.02.15PC.01.02.15

EP 5:EP 5:

Note 2: This element of performance does Note 2: This element of performance does not apply to systems used for therapeutic not apply to systems used for therapeutic radiation treatment planning or delivery, or radiation treatment planning or delivery, or for calculating attenuation coefficients for for calculating attenuation coefficients for nuclear medicine studies.nuclear medicine studies.

6767

PC.01.02.15PC.01.02.15

EP 6:EP 6:

For hospitals that provide computed For hospitals that provide computed tomography (CT) services: The interpretive tomography (CT) services: The interpretive report of a diagnostic CT study includes the report of a diagnostic CT study includes the radiation dose. The dose is either recorded radiation dose. The dose is either recorded in the patient's interpretive report or included in the patient's interpretive report or included on the protocol page, which is then attached on the protocol page, which is then attached to the interpretive report. (used to apply to the interpretive report. (used to apply only to California).only to California).

6868

PC.01.02.15PC.01.02.15

EP 7:EP 7:

For hospitals that provide computed For hospitals that provide computed tomography (CT) services: The hospital tomography (CT) services: The hospital electronically sends each CT study and electronically sends each CT study and protocol page that lists the radiation dose protocol page that lists the radiation dose and related technical factors to the hospital’s and related technical factors to the hospital’s electronic picture archiving and electronic picture archiving and communications system (PACS).communications system (PACS).

6969

PC.01.02.15PC.01.02.15

EP 7:EP 7:

Note: This element of performance is only Note: This element of performance is only applicable for systems capable of calculating applicable for systems capable of calculating and displaying radiation doses.and displaying radiation doses.

7070

PC.01.02.15PC.01.02.15

EP 10:EP 10:

For hospitals that provide computed For hospitals that provide computed tomography (CT), magnetic resonance tomography (CT), magnetic resonance imaging (MRI), positron emission imaging (MRI), positron emission tomography (PET), or nuclear medicine tomography (PET), or nuclear medicine (NM) services: Prior to conducting a (NM) services: Prior to conducting a diagnostic imaging study, the hospital diagnostic imaging study, the hospital verifies the following:verifies the following:

7171

PC.01.02.15PC.01.02.15

EP 10:EP 10:

Correct patientCorrect patient

- Correct imaging site- Correct imaging site

- Correct patient positioning- Correct patient positioning

- For CT only: Correct imaging protocol- For CT only: Correct imaging protocol

- For CT only: Correct scanner parameters- For CT only: Correct scanner parameters

7272

PC.01.02.15PC.01.02.15

EP 11: EP 11: For hospitals that provide computed tomography For hospitals that provide computed tomography

(CT), magnetic resonance imaging (MRI), positron (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), or nuclear medicine emission tomography (PET), or nuclear medicine (NM) services: The hospital makes certain that (NM) services: The hospital makes certain that imaging studies are based on an order from a imaging studies are based on an order from a licensed independent practitioner or other qualified licensed independent practitioner or other qualified practitioner in accordance with law and regulation.practitioner in accordance with law and regulation.

7373

PI.01.01.01PI.01.01.01

The hospital collects data to The hospital collects data to monitor its performance.monitor its performance.

7474

PI.01.01.01PI.01.01.01

EP 46:EP 46:

For hospitals that provide computed For hospitals that provide computed tomography (CT) services: The hospital tomography (CT) services: The hospital collects data on incidents where radiation collects data on incidents where radiation dose limits identified in imaging protocols dose limits identified in imaging protocols have been exceeded. have been exceeded.

7575

PI.01.01.01PI.01.01.01

EP 47:EP 47:

For hospitals that provide magnetic For hospitals that provide magnetic resonance imaging (MRI) services: The resonance imaging (MRI) services: The hospital collects data on patient burns that hospital collects data on patient burns that occur during MRI exams.occur during MRI exams.

7676

PI.01.01.01PI.01.01.01

EP 48:EP 48:

For hospitals that provide magnetic For hospitals that provide magnetic resonance imaging (MRI) services: The resonance imaging (MRI) services: The hospital collects data on the following:hospital collects data on the following:

- Incidents when ferrous-based items - Incidents when ferrous-based items entered the MRI scanner roomentered the MRI scanner room

- Injuries resulting from the presence of - Injuries resulting from the presence of ferrous-based items in the MRI scanner roomferrous-based items in the MRI scanner room

7777

PI.02.01.01PI.02.01.01

The hospital compiles and The hospital compiles and analyzes data.analyzes data.

7878

PI.02.01.01PI.02.01.01

EP 6:EP 6:

For hospitals that provide computed For hospitals that provide computed tomography (CT) services: The hospital tomography (CT) services: The hospital analyzes data on CT radiation doses and analyzes data on CT radiation doses and compares it with external benchmarks, when compares it with external benchmarks, when available.available.

7979

Medical Staff OPPE and FPPEMedical Staff OPPE and FPPE

The Joint CommissionThe Joint Commission’’s New s New Approach to Assessing Approach to Assessing Physician PerformancePhysician Performance

The Standard: MS.05.01.01: The Standard: MS.05.01.01: CLINICALCLINICAL

The organized medical staff has a leadership The organized medical staff has a leadership role in organization performance improvement role in organization performance improvement activities to improve quality of care, treatment, activities to improve quality of care, treatment, and services and [patient] safety.and services and [patient] safety.

Relevant information developed from the Relevant information developed from the following processes is integrated into following processes is integrated into performance improvement initiatives and performance improvement initiatives and consistent with [organization] preservation of consistent with [organization] preservation of confidentiality and privilege of information.confidentiality and privilege of information.

8181

The Standard: MS.05.01.01The Standard: MS.05.01.01

1: The organized medical staff provides 1: The organized medical staff provides leadership for measuring, assessing, and leadership for measuring, assessing, and improving processes that improving processes that primarily primarily depend on the activities of one or more depend on the activities of one or more licensed independent practitionerslicensed independent practitioners, and , and other practitioners credentialed and other practitioners credentialed and privileged through the medical staff privileged through the medical staff process. (See also PI.03.01.01, EPs 1-4)process. (See also PI.03.01.01, EPs 1-4)

8282


2: The medical staff is 2: The medical staff is actively involvedactively involved in the measurement, assessment, and in the measurement, assessment, and improvement of the following: improvement of the following: Medical Medical assessment and treatment of patientsassessment and treatment of patients. . (See also PI.03.01.01, EPs 1-4)(See also PI.03.01.01, EPs 1-4)

8383


3: The medical staff is actively involved in 3: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: Use of improvement of the following: Use of information about adverse privileging information about adverse privileging decisionsdecisions for any practitioner privileged for any practitioner privileged through the medical staff process.through the medical staff process.

8484


4: The medical staff is actively involved in 4: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Use of Use of medicationsmedications

8585


5: The medical staff is actively involved in 5: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Use of Use of blood and blood componentsblood and blood components

8686


6: The medical staff is actively involved in 6: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Operative Operative and other procedure(s)and other procedure(s)– Judgment (decision making)Judgment (decision making)– Clinical and Technical SkillsClinical and Technical Skills

8787


7: The medical staff is actively involved in 7: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Appropriateness of clinical practice Appropriateness of clinical practice patterns.patterns.– Utilization Review (LOS, Avoidable days, Utilization Review (LOS, Avoidable days,

denials)denials)

8888


8: The medical staff is actively involved in 8: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: Significant Significant departures from established patterns of departures from established patterns of clinical practice.clinical practice.– All other departments: Pathology, All other departments: Pathology,

radiology, anesthesiology, ERradiology, anesthesiology, ER

8989


9: The medical staff is actively involved in 9: The medical staff is actively involved in the measurement, assessment, and the measurement, assessment, and improvement of the following: improvement of the following: The use of The use of developed criteria for autopsiesdeveloped criteria for autopsies. (CMS . (CMS REQUIREMENT)REQUIREMENT)

9090


10: Information used as part of the 10: Information used as part of the performance improvement mechanisms, performance improvement mechanisms, measurement, or assessment includes the measurement, or assessment includes the following: following: Sentinel event dataSentinel event data. .

9191


11: Information used as part of the 11: Information used as part of the performance improvement mechanisms, performance improvement mechanisms, measurement, or assessment includes the measurement, or assessment includes the following: following: Patient safety dataPatient safety data. .

9292

The Standard: MS.05.01.03: The Standard: MS.05.01.03: CITIZENSHIPCITIZENSHIP

1: The organized medical staff participates 1: The organized medical staff participates in the following activities: in the following activities: Education of Education of patients and families.patients and families.

9393


2: The organized medical staff participates 2: The organized medical staff participates in the following activities: in the following activities: Coordination of Coordination of care, treatment, and services with other care, treatment, and services with other practitioners and hospital personnel, as practitioners and hospital personnel, as relevant to the care, treatment, and relevant to the care, treatment, and services of an individual patient.services of an individual patient.

9494


3: The organized medical staff participates 3: The organized medical staff participates in the following activities: in the following activities: Accurate, Accurate, timely, and legible completion of timely, and legible completion of patientpatient’’s medical records.s medical records.

9595


4: The organized medical staff participates 4: The organized medical staff participates in the following activities: in the following activities: Review of Review of findings of the assessment process findings of the assessment process that are relevant to an individualthat are relevant to an individual’’s s performance. The organized medical performance. The organized medical staff is responsible for determining the staff is responsible for determining the use of this information in the ongoing use of this information in the ongoing evaluations of a practitionerevaluations of a practitioner’’s s competence.competence.

9696


5: The organized medical staff participates 5: The organized medical staff participates in the following activities: Communication in the following activities: Communication of findings, conclusions, of findings, conclusions, recommendations, and actions to improve recommendations, and actions to improve performance to appropriate staff members performance to appropriate staff members and the and the governing bodygoverning body..

9797


Ongoing professional practice evaluation Ongoing professional practice evaluation information is factored into the decision to information is factored into the decision to maintain existing privilege(s), to revise maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege(s), or to revoke an existing privilege prior to or at the time of existing privilege prior to or at the time of renewal.renewal.

9898


1: The process for the ongoing 1: The process for the ongoing professional practice evaluation includes professional practice evaluation includes the following: the following: There is a clearly defined There is a clearly defined processprocess in place that facilitates the in place that facilitates the evaluation of each practitionerevaluation of each practitioner’’s s professional practice. (D means there professional practice. (D means there must be a policy)must be a policy)

9999


2: The process for the ongoing 2: The process for the ongoing professional practice evaluation includes professional practice evaluation includes the following: The the following: The type of datatype of data to be to be collected is determined by individual collected is determined by individual departments and approved by the departments and approved by the organized medical stafforganized medical staff. (Performance . (Performance measures must be defined for CMS in a measures must be defined for CMS in a Medical Staff Plan).Medical Staff Plan).

100100


3: The process for the ongoing 3: The process for the ongoing professional practice evaluation includes professional practice evaluation includes the following: Information resulting from the following: Information resulting from the ongoing professional practice the ongoing professional practice evaluation is evaluation is used to determine whether used to determine whether to continue, limit, or revoke any to continue, limit, or revoke any existing privilege(s).existing privilege(s).

101101

FOCUSED REVIEWFOCUSED REVIEW

While it was a good thing to evaluate While it was a good thing to evaluate providers after they had already been providers after they had already been working 6 months, it was apparent that working 6 months, it was apparent that there was real risk in the there was real risk in the ““unknownunknown””..

Peer Recommendations could not be Peer Recommendations could not be trusted.trusted.

Harm could come to patients soon after Harm could come to patients soon after practice began.practice began.

102102


There were analogous standards in the There were analogous standards in the Human Resources chapter for an Human Resources chapter for an ““initial initial assessment of competencyassessment of competency”” before before hospital staff could carry out job hospital staff could carry out job responsibilities independently.responsibilities independently.

103103


It was clear that something was needed on It was clear that something was needed on the the ““front end.front end.””

Next it was determined that in classic Next it was determined that in classic ““peer reviewpeer review””, cases simply fell off and , cases simply fell off and issues were never closed or casually issues were never closed or casually investigated. There was no accountability investigated. There was no accountability for closure of many significant issues.for closure of many significant issues.

104104


The purpose:The purpose:– Initial assessment competence of all new Initial assessment competence of all new

physicians or new privileges regardless of physicians or new privileges regardless of experience.experience.

– Conduct intensive, planned and Conduct intensive, planned and ““focusedfocused”” investigations when adverse events occurred investigations when adverse events occurred (trigger events).(trigger events).

– Conduct intensive, planned and Conduct intensive, planned and ““focusedfocused”” investigations when ongoing performance investigations when ongoing performance measurement indicated undesirable measurement indicated undesirable performance.performance.

105105

Focused Review: New PrivilegesFocused Review: New Privileges

Goal: To be conducted as rapidly as Goal: To be conducted as rapidly as possible.possible.

““VolumeVolume”” of review defined by the medical of review defined by the medical staff and departments.staff and departments.

Individual plans should be developed to allow Individual plans should be developed to allow the medical staff to know when the review the medical staff to know when the review has concluded.has concluded.

Each provider may warrant a tailored plan.Each provider may warrant a tailored plan.

Some departments are completely uniform.Some departments are completely uniform.

106106

Focused Review: New PrivilegesFocused Review: New Privileges

Should be conducted in a time frame that Should be conducted in a time frame that is too short for rate based performance is too short for rate based performance measurement: data collection would not measurement: data collection would not be statistically significant for short term.be statistically significant for short term.

Evaluation of privilege must be realistic: Evaluation of privilege must be realistic: chart review versus direct observation.chart review versus direct observation.

All requirements defined in a plan.All requirements defined in a plan.

TOP Medical Staff Standard RFI in 2009.TOP Medical Staff Standard RFI in 2009.

107107


The organized medical staff defines the The organized medical staff defines the circumstances requiring monitoring and circumstances requiring monitoring and evaluation of a practitionerevaluation of a practitioner’’s professional s professional performance.performance.

- Initial Appointment (new privileges)- Initial Appointment (new privileges)- New mid-cycle privilege- New mid-cycle privilege- Trigger events- Trigger events- Variant data - Variant data

108108


The focused evaluation process is defined by The focused evaluation process is defined by the organized medical staff. The time period of the organized medical staff. The time period of the evaluation can be extended, and/or a the evaluation can be extended, and/or a different type of evaluation process assigned. different type of evaluation process assigned. Information for focused professional practice Information for focused professional practice evaluation may include chart review, monitoring evaluation may include chart review, monitoring clinical practice patterns, simulation, proctoring, clinical practice patterns, simulation, proctoring, external peer review, and discussion with other external peer review, and discussion with other individuals involved in the care of each patient individuals involved in the care of each patient (e.g., consulting physicians, assistants at (e.g., consulting physicians, assistants at surgery, nursing or administrative personnel).surgery, nursing or administrative personnel).

109109


Relevant information resulting from the Relevant information resulting from the focused evaluation process is integrated focused evaluation process is integrated into performance improvement activities, into performance improvement activities, consistent with the organizationconsistent with the organization’’ss policies policies and procedures that are intended to and procedures that are intended to preserve confidentiality and privilege of preserve confidentiality and privilege of information.information.

110110


1: A period of focused professional 1: A period of focused professional practice evaluation is implemented for all practice evaluation is implemented for all initially requested privileges.initially requested privileges.

111111


2: The organized medical staff develops 2: The organized medical staff develops criteria to be used for evaluating the criteria to be used for evaluating the performance of practitioners when issues performance of practitioners when issues affecting the provision of safe, high quality affecting the provision of safe, high quality patient care are identified. (D means patient care are identified. (D means Plan)Plan)

112112


3: The performance monitoring process is clearly 3: The performance monitoring process is clearly defined and includes each of the following defined and includes each of the following elements: elements: - Criteria for conducting performance monitoring- Criteria for conducting performance monitoring- Method for establishing a monitoring - Method for establishing a monitoring planplan specific to the requested privilegespecific to the requested privilege- Method for determining the duration of - Method for determining the duration of performance monitoringperformance monitoring- Circumstances under which monitoring by an - Circumstances under which monitoring by an external source is requiredexternal source is required

113113


4: Focused professional practice 4: Focused professional practice evaluation is evaluation is consistently implementedconsistently implemented in accordance with the criteria and in accordance with the criteria and requirements defined by the organized requirements defined by the organized medical staff.medical staff.

114114


5: The 5: The triggerstriggers that indicate the need for that indicate the need for performance monitoring are clearly performance monitoring are clearly defined. defined.

Note: Triggers can be single incidents or Note: Triggers can be single incidents or evidence of a clinical practice trend.evidence of a clinical practice trend.

115115


6: The decision to assign a period of 6: The decision to assign a period of performance monitoring to performance monitoring to further assessfurther assess current competence is based on the evaluation current competence is based on the evaluation of a practitionerof a practitioner’’s current clinical competence, s current clinical competence, practice behavior, and ability to perform the practice behavior, and ability to perform the requested privilege.requested privilege.

Note: Other existing privileges in good standing Note: Other existing privileges in good standing should not be affected by this decision.should not be affected by this decision.

116116


7: Criteria are developed that determine 7: Criteria are developed that determine the type of monitoring to be conducted. (D the type of monitoring to be conducted. (D means this has to be in the plan).means this has to be in the plan).

117117


8: The measures employed to resolve 8: The measures employed to resolve performance issues are clearly defined. (D performance issues are clearly defined. (D means it must be in the plan).means it must be in the plan).

118118


9: The measures employed to resolve 9: The measures employed to resolve performance issues are consistently performance issues are consistently implemented.implemented.

119119

ScoringScoring

All of the medical staff standards on these All of the medical staff standards on these issues are issues are ““AA”” meaning 100% compliance meaning 100% compliance is requiredis required

Focused Review: 16% of hospitals citedFocused Review: 16% of hospitals cited

Ongoing Review: 15% of hospitals citedOngoing Review: 15% of hospitals cited

Problems with no or low volume providersProblems with no or low volume providers

Changes to privileges based on dataChanges to privileges based on data

120120

RestraintsRestraints

122122

PC.03.05.03PC.03.05.03

The organization uses restraint or The organization uses restraint or seclusion safely.seclusion safely.

123123

PC. 03.05.03PC. 03.05.03Elements of PerformanceElements of Performance

1-DI, A: The hospital implements restraint or 1-DI, A: The hospital implements restraint or seclusion using safe techniques identified by the seclusion using safe techniques identified by the hospitalhospital’’s policies and procedures in accordance s policies and procedures in accordance with law and regulation.with law and regulation.

2-M, C: The use of restraint and seclusion is in 2-M, C: The use of restraint and seclusion is in accordance with a written modification to the accordance with a written modification to the patient's plan of care.patient's plan of care.

124124

PC. 03.05.05PC. 03.05.05

The organization initiates restraint or The organization initiates restraint or seclusion based on an individual order.seclusion based on an individual order.

125125


3-A: The attending physician is consulted as 3-A: The attending physician is consulted as soon as possible (immediately), in soon as possible (immediately), in accordance with hospital policy, if he or she accordance with hospital policy, if he or she did not order the restraint or seclusiondid not order the restraint or seclusion. .

126126

PC. 03.05.05PC. 03.05.05

4-M, C: Unless state law is more restrictive, orders 4-M, C: Unless state law is more restrictive, orders for the use of restraint or seclusion used for the for the use of restraint or seclusion used for the management of violent or self-destructive behavior management of violent or self-destructive behavior that jeopardizes the immediate physical safety of that jeopardizes the immediate physical safety of the patient, staff, or others may be renewed within the patient, staff, or others may be renewed within the following limits:the following limits:

• 4 hours for adults 18 years of age or older4 hours for adults 18 years of age or older• 2 hours for children and adolescents 9 to 17 2 hours for children and adolescents 9 to 17

years of ageyears of age• 1 hour for children under 9 years of age 1 hour for children under 9 years of age

127127

PC. 03. 05. 05 PC. 03. 05. 05 Elements of PerformanceElements of Performance

5-DI, A: Unless state law is more restrictive, every 5-DI, A: Unless state law is more restrictive, every 24 hours, a physician or other authorized licensed 24 hours, a physician or other authorized licensed independent practitioner primarily responsible for independent practitioner primarily responsible for the patientthe patient’’s ongoing care sees and evaluates the s ongoing care sees and evaluates the patient before writing a new order for restraint or patient before writing a new order for restraint or seclusion used for the management of violent or seclusion used for the management of violent or self-destructive behavior that jeopardizes the self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or immediate physical safety of the patient, staff, or others in accordance with hospital policy and law others in accordance with hospital policy and law and regulation. and regulation.

128128


6-DI, A: Orders for restraint used to protect 6-DI, A: Orders for restraint used to protect the physical safety of the nonviolent or the physical safety of the nonviolent or non-self-destructive patient are renewed non-self-destructive patient are renewed in accordance with hospital policy. in accordance with hospital policy.

129129

PC. 03.05.07PC. 03.05.07

The organization monitors patients who The organization monitors patients who are restrained or secluded.are restrained or secluded.

130130

PC. 03.05.07PC. 03.05.07

1-DI, A: Physicians or other licensed 1-DI, A: Physicians or other licensed independent practitioners or staff who have independent practitioners or staff who have been trained in accordance with 42 CFR been trained in accordance with 42 CFR 482.13(f) monitor the condition of patients in 482.13(f) monitor the condition of patients in restraint or seclusion. (See PC.03.05.17, EP restraint or seclusion. (See PC.03.05.17, EP 3)3)

131131

PC. 03.05.09PC. 03.05.09

The organization has written policies The organization has written policies and procedures that guide the use of and procedures that guide the use of restraint or seclusionrestraint or seclusion..

132132


1-D, A: The hospital1-D, A: The hospital’’s policies and procedures s policies and procedures regarding restraint or seclusion include the regarding restraint or seclusion include the following:following:

• Physician and other authorized licensed Physician and other authorized licensed independent practitioner training independent practitioner training requirementsrequirements

• Staff training requirementsStaff training requirements• The determination of who has authority to The determination of who has authority to

order restraint and seclusionorder restraint and seclusion

133133


1-D, A: The hospital1-D, A: The hospital’’s policies and procedures regarding s policies and procedures regarding restraint or seclusion include the following restraint or seclusion include the following

The determination of who has authority to discontinue the The determination of who has authority to discontinue the use of restraint or seclusionuse of restraint or seclusion

The determination of who can initiate restraint or The determination of who can initiate restraint or seclusionseclusion

The circumstances under which restraint or seclusion is The circumstances under which restraint or seclusion is discontinued.discontinued.

The requirement that restraint or seclusion is discontinued The requirement that restraint or seclusion is discontinued as soon as is safely possibleas soon as is safely possible

134134


The hospitalThe hospital’’s policies and procedures regarding s policies and procedures regarding restraint or seclusion include the following:restraint or seclusion include the following:

• A definition of restraint in accordance with 42 A definition of restraint in accordance with 42 CFR 482.13(e)(1)(i)(A-C)CFR 482.13(e)(1)(i)(A-C)

• A definition of seclusion in accordance with 42 A definition of seclusion in accordance with 42 CFR 482.13(e)(1)(ii)CFR 482.13(e)(1)(ii)

• A definition or description of what constitutes A definition or description of what constitutes the use of medications as a restraint in the use of medications as a restraint in accordance with 42 CFR 482.13(e)(1)(i)(B)accordance with 42 CFR 482.13(e)(1)(i)(B)

135135


The hospitalThe hospital’’s policies and procedures regarding s policies and procedures regarding restraint or seclusion include the following:restraint or seclusion include the following:

• A determination of who can assess and A determination of who can assess and monitor patients in restraint or seclusionmonitor patients in restraint or seclusion

• Time frames for assessing and monitoring Time frames for assessing and monitoring patients in restraint or seclusion patients in restraint or seclusion

136136


2-DI,A: Physicians and other licensed 2-DI,A: Physicians and other licensed independent practitioners authorized to independent practitioners authorized to order restraint or seclusion (through hospital order restraint or seclusion (through hospital policy in accordance with law and policy in accordance with law and regulation) have a working knowledge of the regulation) have a working knowledge of the hospital policy regarding the use of restraint hospital policy regarding the use of restraint and seclusion. and seclusion.

137137

PC. 03.05.11PC. 03.05.11

The organization evaluates and The organization evaluates and reevaluates the patient who is reevaluates the patient who is restrained or secluded.restrained or secluded.

138138


1-D, A: A physician or other licensed independent 1-D, A: A physician or other licensed independent practitioner responsible for the care of the patient practitioner responsible for the care of the patient evaluates the patient in-person within one hour of the evaluates the patient in-person within one hour of the initiation of restraint or seclusion used for the initiation of restraint or seclusion used for the management of violent or self-destructive behavior management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, that jeopardizes the physical safety of the patient, staff, or others. A registered nurse or a physician staff, or others. A registered nurse or a physician assistant may conduct the in-person evaluation within assistant may conduct the in-person evaluation within one hour of the initiation of restraint or seclusion; this one hour of the initiation of restraint or seclusion; this individual is trained in accordance with the individual is trained in accordance with the requirements at PC.03.05.17, EP 3. requirements at PC.03.05.17, EP 3.

139139


2-DI, A: 2-DI, A: When the in-person evaluation When the in-person evaluation (performed within one hour of the initiation (performed within one hour of the initiation of restraint or seclusion) is done by a of restraint or seclusion) is done by a trained registered nurse or trained trained registered nurse or trained physician assistant, he or she consults physician assistant, he or she consults with the attending physician or other with the attending physician or other licensed independent practitioner licensed independent practitioner responsible for the care of the patient as responsible for the care of the patient as soon as possible after the evaluation, as soon as possible after the evaluation, as determined by hospital policy. determined by hospital policy.

140140


3-DI, A: The in-person evaluation, conducted within one 3-DI, A: The in-person evaluation, conducted within one hour of the initiation of restraint or seclusion for the hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior that management of violent or self-destructive behavior that jeopardizes the physical safety of the patient staff or others, jeopardizes the physical safety of the patient staff or others, includes the following:includes the following:

• An evaluation of the patient's immediate situationAn evaluation of the patient's immediate situation• The patient's reaction to the interventionThe patient's reaction to the intervention• The patient's medical and behavioral conditionThe patient's medical and behavioral condition• The need to continue or terminate the restraint or The need to continue or terminate the restraint or

seclusion seclusion

141141

PC.03.05.13PC.03.05.13

The organization continually monitors The organization continually monitors patients who are simultaneously patients who are simultaneously restrained and secluded.restrained and secluded.

142142

PC. 03.05.13PC. 03.05.13

1-DI, A: The patient who is 1-DI, A: The patient who is simultaneously restrained and secluded simultaneously restrained and secluded is continually monitored by trained staff is continually monitored by trained staff either in-person or through the use of either in-person or through the use of both video and audio equipment that is both video and audio equipment that is in close proximity to the patient.in close proximity to the patient.

143143

PC. 03.05.15PC. 03.05.15

The organization documents the use of The organization documents the use of restraint or seclusion.restraint or seclusion.

144144


1-M, C: Documentation of restraint and seclusion 1-M, C: Documentation of restraint and seclusion in the medical record includes the following:in the medical record includes the following:

• Any in-person medical and behavioral Any in-person medical and behavioral evaluation for restraint or seclusion used to evaluation for restraint or seclusion used to manage violent or self-destructive behaviormanage violent or self-destructive behavior

• A description of the patientA description of the patient’’s behavior and s behavior and the intervention usedthe intervention used

• Any alternatives or other less restrictive Any alternatives or other less restrictive interventions attemptedinterventions attempted

145145


1-M, C: Documentation of restraint and seclusion in 1-M, C: Documentation of restraint and seclusion in the medical record includes the following:the medical record includes the following:

• The patientThe patient’’s condition or symptom(s) that s condition or symptom(s) that warranted the use of the restraint or seclusionwarranted the use of the restraint or seclusion

• The patientThe patient’’s response to the intervention(s) s response to the intervention(s) used, including the rationale for use of the used, including the rationale for use of the interventionintervention

• Individual patient assessments and Individual patient assessments and reassessmentsreassessments

• The intervals for monitoringThe intervals for monitoring

146146


1-M,C: Documentation of restraint and seclusion in 1-M,C: Documentation of restraint and seclusion in the medical record includes the following:the medical record includes the following:

• Revisions to the plan of careRevisions to the plan of care• The patientThe patient’’s behavior and staff concerns s behavior and staff concerns

regarding safety risks to the patient, staff, regarding safety risks to the patient, staff, and others that necessitated the use of and others that necessitated the use of restraint or seclusionrestraint or seclusion

• Injuries to the patientInjuries to the patient

147147


1-M, C: Documentation of restraint and seclusion in the 1-M, C: Documentation of restraint and seclusion in the medical record includes the following:medical record includes the following:

• Death associated with the use of restraint or Death associated with the use of restraint or seclusionseclusion

• The identity of the physician or other licensed The identity of the physician or other licensed independent practitioner who ordered the restraint independent practitioner who ordered the restraint or seclusionor seclusion

• Orders for restraint or seclusionOrders for restraint or seclusion• Notification of the use of restraint or seclusion to Notification of the use of restraint or seclusion to

the attending physicianthe attending physician• ConsultationsConsultations

148148

PC. 03.05.17PC. 03.05.17

The organization trains staff to safely The organization trains staff to safely implement the use of restraint or implement the use of restraint or seclusion.seclusion.

149149


2-M, C: The hospital trains staff on the use 2-M, C: The hospital trains staff on the use of restraint and seclusion, and assesses of restraint and seclusion, and assesses their competence, at the following their competence, at the following intervals:intervals:

• At orientationAt orientation

• Before participating in the use of Before participating in the use of restraint and seclusionrestraint and seclusion

• On a periodic basis thereafterOn a periodic basis thereafter

150150


3-M, C: Based on the population served, staff 3-M, C: Based on the population served, staff education, training, and demonstrated knowledge education, training, and demonstrated knowledge focus on the following:focus on the following:

• Safe application and use of all types of Safe application and use of all types of restraint or seclusion used in the hospital, restraint or seclusion used in the hospital, including training in how to recognize and including training in how to recognize and respond to signs of physical and respond to signs of physical and psychological distress (for example, psychological distress (for example, positional asphyxia)positional asphyxia)

• Clinical identification of specific behavioral Clinical identification of specific behavioral changes that indicate that restraint or changes that indicate that restraint or seclusion is no longer necessaryseclusion is no longer necessary

151151


3-M, C: Based on the population served, staff education, 3-M, C: Based on the population served, staff education, training, and demonstrated knowledge focus on the training, and demonstrated knowledge focus on the following:following:

• Monitoring the physical and psychological well-Monitoring the physical and psychological well-being of the patient who is restrained or secluded, being of the patient who is restrained or secluded, including but not limited to respiratory and including but not limited to respiratory and circulatory status, skin integrity, vital signs, and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital any special requirements specified by hospital policy associated with the in-person evaluation policy associated with the in-person evaluation conducted within one hour of initiation of restraint conducted within one hour of initiation of restraint or seclusionor seclusion

152152


3-M, C: Based on the population served, 3-M, C: Based on the population served, staff education, training, and demonstrated staff education, training, and demonstrated knowledge focus on the following:knowledge focus on the following:

• Use of first aid techniques and Use of first aid techniques and certification in the use of certification in the use of cardiopulmonary resuscitation, cardiopulmonary resuscitation, including required periodic including required periodic recertificationrecertification

153153


4-A: Individuals providing staff training in 4-A: Individuals providing staff training in restraint or seclusion have education, restraint or seclusion have education, training, and experience in the techniques training, and experience in the techniques used to address patient behaviors that used to address patient behaviors that necessitate the use of restraint or seclusion.necessitate the use of restraint or seclusion.

154154

PC.03.05.17PC.03.05.17Elements of PerformanceElements of Performance

5-M, D, C: The hospital documents in 5-M, D, C: The hospital documents in staff records that restraint and staff records that restraint and seclusion training and demonstration of seclusion training and demonstration of competence were completed.competence were completed.

CMS Restraint ChangesCMS Restraint Changes

155155

Reporting Restraint-Related Reporting Restraint-Related DeathsDeaths

Restraint-Related Deaths: Restraint-Related Deaths: Replaces the Replaces the requirement that hospitals report deaths requirement that hospitals report deaths related to soft, 2- point restraints, with a related to soft, 2- point restraints, with a requirement that hospitals maintain a log (or requirement that hospitals maintain a log (or other system) that will be made available to other system) that will be made available to CMS if requested. CMS if requested.

156156


Log: Log: The Log is internal to the hospital and The Log is internal to the hospital and the name of the practitioner responsible for the name of the practitioner responsible for the care of the patient may be used in the the care of the patient may be used in the log in lieu of the name of log in lieu of the name of

the attending physician if the patient was the attending physician if the patient was

under the care of a non-MD practitioner. under the care of a non-MD practitioner.

157157

Reporting Restraint DeathsReporting Restraint Deaths

Section 482.13 is amended by a) revising Section 482.13 is amended by a) revising paragraphs (g)(1) through (3) and b) adding paragraphs (g)(1) through (3) and b) adding paragraph (g)(4). The revisions and addition paragraph (g)(4). The revisions and addition read as follows: With the exception of deaths read as follows: With the exception of deaths described under paragraph (g)(2) of this described under paragraph (g)(2) of this section the hospital must report the following section the hospital must report the following information to CMS by telephone, fax or information to CMS by telephone, fax or electronically as determined by CMs no later electronically as determined by CMs no later than the close of next business daythan the close of next business day

158158

CMS Restraint ChangesCMS Restraint Changes

(g) (i) Each death that occurs while a (g) (i) Each death that occurs while a patient is in restraint or seclusionpatient is in restraint or seclusion

(g) (ii) Each death that occurs within 24 (g) (ii) Each death that occurs within 24 hours after that patient has been removed hours after that patient has been removed from restrain or seclusionfrom restrain or seclusion

159159


(g) (iii) Each death known to the hospital (g) (iii) Each death known to the hospital that occurs within 1 week after restraint or that occurs within 1 week after restraint or seclusion where it is reasonable to seclusion where it is reasonable to assume that use of restraint or placement assume that use of restraint or placement in seclusion contributed directly or in seclusion contributed directly or indirectly to the patient’s death, regardless indirectly to the patient’s death, regardless of the type (s) of restraint used on the of the type (s) of restraint used on the patient during this time.patient during this time.

160160


(2) When no seclusion has been used and (2) When no seclusion has been used and when the only restraints used on the when the only restraints used on the patient tare those applied exclusively to patient tare those applied exclusively to the patient’s wrist(s), and which are the patient’s wrist(s), and which are composed solely of soft, non-rigid, cloth-composed solely of soft, non-rigid, cloth-like materials, the hospital staff must like materials, the hospital staff must record in an internal log or other system, record in an internal log or other system, the following information:the following information:

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Internal Restraint Log Internal Restraint Log ComponentsComponents

(i) Any death that occurs while a patient is (i) Any death that occurs while a patient is in restraintsin restraints

(ii) Any death that occurs within 24 hours (ii) Any death that occurs within 24 hours after a patient has been removed from after a patient has been removed from such restraints.such restraints.

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(3) The staff must document in the patient’s (3) The staff must document in the patient’s medical record the date and time the death medical record the date and time the death was:was:– Reported to CMS for deaths described in (g) (1) Reported to CMS for deaths described in (g) (1)

of this section or other systems for deaths of this section or other systems for deaths described in paragraph (g) (2) of this section.described in paragraph (g) (2) of this section.

For deaths described in paragraph (g) 2 of For deaths described in paragraph (g) 2 of this section entries into the internal log or this section entries into the internal log or other system must be documented as other system must be documented as follows:follows:

163163


(ii) The information must be made (ii) The information must be made available in either written or electronic available in either written or electronic form to CMS immediately upon request.form to CMS immediately upon request.

164164


(i) Each entry must be made not later than (i) Each entry must be made not later than 7 days after the date of death of the 7 days after the date of death of the patient. patient.

(ii) Each entry must document the patient’s (ii) Each entry must document the patient’s name, date of birth , date of death, name name, date of birth , date of death, name of attending physician or other LIP who is of attending physician or other LIP who is responsible for the care of the patient , responsible for the care of the patient , medical record number and primary medical record number and primary diagnosis(es)diagnosis(es)

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Patient Flow StandardsPatient Flow Standards

LD 04.03.11LD 04.03.11

The hospital manages the The hospital manages the flow of patients throughout flow of patients throughout the hospital.the hospital.

LD.04.03.11LD.04.03.11

EP # 1EP # 1– The hospital has processes that support the flow of The hospital has processes that support the flow of

patients throughout the hospital.patients throughout the hospital.

EP # 2EP # 2– The hospital plans for the care of admitted patients The hospital plans for the care of admitted patients

who are in temporary bed locations, such as the who are in temporary bed locations, such as the post-anesthesia care unit or the emergency post-anesthesia care unit or the emergency department.department.

EP # 3EP # 3– The hospital plans for care to patients placed in The hospital plans for care to patients placed in

overflow locations.overflow locations.

LD. 04.03. 11LD. 04.03. 11EP # 4EP # 4– Criteria guide decisions to initiate ambulance Criteria guide decisions to initiate ambulance

diversion.diversion.

EP # 5EP # 5– The hospital measures and The hospital measures and sets goals sets goals the the

components of the patient flow process including:components of the patient flow process including:

The available supply of bedsThe available supply of beds

The throughput of areas where patients receive The throughput of areas where patients receive care, treatment, and services ( such as inpatient care, treatment, and services ( such as inpatient units, laboratory, operating rooms, telemetry, units, laboratory, operating rooms, telemetry, radiology and PACU.radiology and PACU.

LD. 04.03.11LD. 04.03.11

EP. # 5 (Continued)EP. # 5 (Continued)– The safety of areas where patients receive The safety of areas where patients receive

care, treatment and servicescare, treatment and services– The efficiency of the non-clinical services that The efficiency of the non-clinical services that

support patient care and treatment (such as support patient care and treatment (such as housekeeping and transportation). housekeeping and transportation).

– Access to support services (such as case Access to support services (such as case management and social work)management and social work)

LD. 04.03.11LD. 04.03.11EP # 6EP # 6– Effective January 1, 2014Effective January 1, 2014– The hospital measures and sets goals for mitigating The hospital measures and sets goals for mitigating

and managing the boarding of patients who come and managing the boarding of patients who come through the emergency department.through the emergency department.

– Note: Boarding is the practice of holding patients in Note: Boarding is the practice of holding patients in the emergency department or a temporary location the emergency department or a temporary location after the decision to admit or transfer has been after the decision to admit or transfer has been made. The hospital should set its goals with made. The hospital should set its goals with attention to patient acuity and best practice; it is attention to patient acuity and best practice; it is recommended that boarding timeframes not exceed recommended that boarding timeframes not exceed 4 hours in the interest of patient safety and quality of 4 hours in the interest of patient safety and quality of care.care.

LD. 04.03.011LD. 04.03.011

EP # 6 (Cross-referenced standard)EP # 6 (Cross-referenced standard)– NPSG. 15.01.01., EP’s 1 & 2, PC.01.01.01 EP’s 4 & 9NPSG. 15.01.01., EP’s 1 & 2, PC.01.01.01 EP’s 4 & 9

PC. 01.02.03, EP 3, PC. 02.01.19, EP 1 & 2PC. 01.02.03, EP 3, PC. 02.01.19, EP 1 & 2

NPSG. 15.01.01NPSG. 15.01.01 EP # 1 EP # 1

Conduct a risk assessment that identifies Conduct a risk assessment that identifies specific patient characteristics and specific patient characteristics and environmental features that may increase environmental features that may increase or decrease the risk for suicide.or decrease the risk for suicide.

LD. 04.03.11LD. 04.03.11

NPSG. 15.01.01. EP # 2NPSG. 15.01.01. EP # 2

Address the patient’s immediate safety needs Address the patient’s immediate safety needs and most appropriate setting for treatment.and most appropriate setting for treatment.

PC.01.01.01PC.01.01.01

The hospital accepts the patient in the care, The hospital accepts the patient in the care, treatment, and services based on its ability to treatment, and services based on its ability to meet the patient’s needs.meet the patient’s needs.

LD. 04.03.11LD. 04.03.11

PC. 01.01.01PC. 01.01.01

EP # 4 Hospitals that do not primarily provide EP # 4 Hospitals that do not primarily provide psychiatric or substance abuse services have a psychiatric or substance abuse services have a written plan that defines the care, treatment and written plan that defines the care, treatment and services or the referral process for patients who services or the referral process for patients who are emotionally ill or suffer the effects of are emotionally ill or suffer the effects of alcoholism or substance abusealcoholism or substance abuse

LD. 04.03.11LD. 04.03.11PC. 01. 01. 01PC. 01. 01. 01EP # 24 If a patient is boarded while awaiting for EP # 24 If a patient is boarded while awaiting for emotional illness and/or the effects of alcoholism emotional illness and/or the effects of alcoholism or substance abuse, the hospital does the or substance abuse, the hospital does the following:following:– Provides for a location for the patient that is safe, Provides for a location for the patient that is safe,

monitored, and clear of items that the patient could monitored, and clear of items that the patient could use to harm himself or herself or others.use to harm himself or herself or others.

– Provides orientation and training to any clinical and Provides orientation and training to any clinical and non-clinical staff caring for such patients in effective non-clinical staff caring for such patients in effective and safe care, treatment, and services.and safe care, treatment, and services.

– Conducts assessments, and reassessments, and Conducts assessments, and reassessments, and provides care consistent with the patients’ identified provides care consistent with the patients’ identified needs.needs.

LD. 04.03.11LD. 04.03.11PC. 01.02.03 EP # 3PC. 01.02.03 EP # 3

Each patient is reassessed as necessary Each patient is reassessed as necessary based on his or her plan for care or changes in based on his or her plan for care or changes in his or her condition. his or her condition.

Note: Reassessments may also be based on Note: Reassessments may also be based on the patient's diagnosis; desire for care, the patient's diagnosis; desire for care, treatment, and services; response to previous treatment, and services; response to previous care, treatment, and services; and/or his or her care, treatment, and services; and/or his or her setting requirements.setting requirements.

LD.04.03.11LD.04.03.11

PC. 02.01.19 EP # 1PC. 02.01.19 EP # 1

The hospital has a process for recognizing and The hospital has a process for recognizing and responding as soon as a patient’s condition responding as soon as a patient’s condition appears to be worsening.appears to be worsening.

PC. 02.01.19 EP # 2PC. 02.01.19 EP # 2

The hospital develops written criteria describing The hospital develops written criteria describing early warning signs of a change or deterioration early warning signs of a change or deterioration in a patient’s condition and when to seek in a patient’s condition and when to seek further assistance.further assistance.

LD. 04.03.11LD. 04.03.11EP # 7EP # 7

The individuals who manage patient flow The individuals who manage patient flow processes review measurement results to processes review measurement results to determine that goals were achieved.determine that goals were achieved.

Cross-referenced standard NR. 02.02.01 EP # Cross-referenced standard NR. 02.02.01 EP # 44

The nurse executive, registered nurses, and The nurse executive, registered nurses, and other designated nursing staff write: Nursing other designated nursing staff write: Nursing standards of patient care, treatment, and standards of patient care, treatment, and services.services.

LD. 04.03.11LD. 04.03.11

EP # 8 EP # 8

Leaders take action when patient flow Leaders take action when patient flow goals are not achieved.goals are not achieved.

Cross-referenced standard PI. 03.01.01, Cross-referenced standard PI. 03.01.01, EP #4EP #4

The hospital takes action when it does The hospital takes action when it does not achieve or sustain planned not achieve or sustain planned improvements.improvements.

LD. 04.03.11LD. 04.03.11Note for EP # 8.Note for EP # 8.

At a minimum, leaders included medical At a minimum, leaders included medical staff and governing body, the chief staff and governing body, the chief executive officer and other senior executive officer and other senior managers, the chief nurse executive, managers, the chief nurse executive, clinical leaders, staff members in clinical leaders, staff members in leadership positions within the leadership positions within the organization.organization.

LD. 04.03.11LD. 04.03.11EP # 9EP # 9

Effective January 1, 2014Effective January 1, 2014

When the hospital determines that it has a When the hospital determines that it has a population at risk for boarding due to population at risk for boarding due to behavioral health emergencies, hospital behavioral health emergencies, hospital leaders communicate with behavioral health leaders communicate with behavioral health providers and/or authorities serving the providers and/or authorities serving the community to foster coordination of care for this community to foster coordination of care for this populationpopulation

Cross-referenced standards LD. 03.04.01 EP’s Cross-referenced standards LD. 03.04.01 EP’s # 3 & 6# 3 & 6

LD. 04.03.11LD. 04.03.11LD. 03. 04. 01LD. 03. 04. 01

EP # 3 EP # 3

Communication is designed to meet the Communication is designed to meet the needs of internal and external users.needs of internal and external users.

EP # 6EP # 6

When changes in the environment occur, When changes in the environment occur, the hospital communicates those the hospital communicates those changes effectivelychanges effectively

LeadershipLeadership

184184

LD.04.03.09LD.04.03.09

Care, treatment, and services provided through contractual

agreement are provided safely and effectively.

185185

LD.04.03.09LD.04.03.09

1-A: 1-A: Clinical leaders and medical staff have an opportunity to provide advice about the sources of clinical services to be provided through contractual agreement.

2-D,A: The hospital describes, in writing, the nature and scope of services provided through contractual agreements.

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LD.04.03.09LD.04.03.09

3-D,A: 3-D,A: Designated leaders approve contractual agreements.

187187

LD.04.03.09LD.04.03.09

4-A: 4-A: Leaders monitor contracted services by establishing expectations for the performance of the contracted services.

5-D,A:Leaders monitor contracted services by communicating the expectations in writing to the provider of the contracted services.Note: A written description of the expectations can be provided either as part of the written agreement or in addition to it.

188188

LD.04.03.09LD.04.03.09

6-A: 6-A: Leaders monitor contracted services by evaluating these services in relation to the hospital's expectations

189189

LD.04.03.09LD.04.03.09

7-A: 7-A: Leaders take steps to improve contracted services that do not meet expectations.Note: Examples of improvement efforts to consider include the following:- Increase monitoring of the contracted services.- Provide consultation or training to the contractor.- Renegotiate the contract terms.- Apply defined penalties.- Terminate the contract.

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LD.04.03.09LD.04.03.09

8-DI,A: 8-DI,A: When contractual agreements are renegotiated or terminated, the hospital maintains the continuity of patient care.

10-D,A: Reference and contract laboratory services meet the federal regulations for clinical laboratories and maintain evidence of the same.

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Contract PrinciplesContract Principles

TJC does not require organizations to manually verify each contract employee file.

If the contracting entity is Joint Commission accredited there is no requirement to request the information on the employee

Full hospital orientation is not required

Orientation to key areas such as emergency preparedness, infection control, safety, and security is critical.

192192


If specified in the contract, the contracting If specified in the contract, the contracting organization can rely on the contract staff organization can rely on the contract staff provider to complete annual in-service provider to complete annual in-service training, many topics of which are the training, many topics of which are the same as those required by the customer same as those required by the customer (such as, infection control, population-(such as, infection control, population-specific health care, cultural diversity, specific health care, cultural diversity, proper lifting techniques, and so forth).proper lifting techniques, and so forth).

193193


Contracts must be in writing.Contracts must be in writing.

The organization must define the expectations of The organization must define the expectations of the contract, including human resource the contract, including human resource expectation.expectation.

The contract should specify that the contracted The contract should specify that the contracted organization will provide only staff who are organization will provide only staff who are qualified in relation to their education, training, qualified in relation to their education, training, licensure, and competence as defined by the licensure, and competence as defined by the contracting organization.contracting organization.

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The contracted organization has the The contracted organization has the responsibility to verify orientation, responsibility to verify orientation, performance evaluations, health status, performance evaluations, health status, background checks, and any applicable background checks, and any applicable references.references.

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The contract should include the following:The contract should include the following: Define within the contract the required Define within the contract the required

qualifications for the contracted staffqualifications for the contracted staff Review the personnel practices of the Review the personnel practices of the

contracted organization to assess contracted organization to assess compliance with its own and Joint compliance with its own and Joint Commission requirements (for example, Commission requirements (for example, who will complete competence who will complete competence assessments)assessments)

196196


If the contracted organizationIf the contracted organization’’s practices s practices are acceptable, the organization can are acceptable, the organization can accept those practices for the provided accept those practices for the provided contracted personnel.contracted personnel.

If the contracted organizationIf the contracted organization’’s practices s practices are not acceptable, the organization can are not acceptable, the organization can define in the contract the specific define in the contract the specific requirements or perform the requirements requirements or perform the requirements itself.itself.

Human ResourcesHuman Resources

198198

Competence Assessment Competence Assessment ActivityActivity

Competence AssessmentCompetence Assessment

10-12 Personnel Records10-12 Personnel Records

Contract Personnel based on list providedContract Personnel based on list provided

Agency StaffAgency Staff

Bring Hospital Orientation curriculumBring Hospital Orientation curriculum

Education Requirements (see handout)Education Requirements (see handout)

Make sure department manager of requested Make sure department manager of requested employee is present for the activity.employee is present for the activity.

2013 Education Requirements2013 Education Requirements

Arranged by Chapter in Joint Commission Arranged by Chapter in Joint Commission ManualManual

Annually means every 12 months, different Annually means every 12 months, different than yearlythan yearly

Ongoing is surveyed as every 3 years or Ongoing is surveyed as every 3 years or soso

At orientation-is before being independentAt orientation-is before being independent

199199

200200

HR.01.02.01HR.01.02.01

The hospital defines staff qualificationsThe hospital defines staff qualifications

Job DescriptionsJob Descriptions

201201

HR. 01.02.05HR. 01.02.05

7-DI, A: Before providing care, treatment, 7-DI, A: Before providing care, treatment, and services, the hospital confirms that and services, the hospital confirms that non-employees who are brought into the non-employees who are brought into the hospital by a licensed independent hospital by a licensed independent practitioner to provide care, treatment, or practitioner to provide care, treatment, or services have the same services have the same qualificationsqualifications and and competenciescompetencies required of employed required of employed individuals performing the same or similar individuals performing the same or similar services at the hospital. services at the hospital.

202202

Human ResourcesHuman Resources

Non-advanced practice employees of Non-advanced practice employees of physiciansphysicians– Equivalent process, orientation safety, Equivalent process, orientation safety,

department, primary source verificationdepartment, primary source verification– Initial competency determinedInitial competency determined– Annual competence determinedAnnual competence determined

Physician employed advance practice Physician employed advance practice personnel ( CRNA, CNM, PA, ARNP)personnel ( CRNA, CNM, PA, ARNP)

203203

HR.01.04.01HR.01.04.01

The hospital provides orientation to staff.The hospital provides orientation to staff.

204204

HR.01.04.01HR.01.04.01

3-A: 3-A: The hospital orients staff on the The hospital orients staff on the following: Relevant hospital-wide and following: Relevant hospital-wide and unit-specific policies and procedures. unit-specific policies and procedures. Completion of this orientation is Completion of this orientation is documented. documented.

205205

HR. 01.04.01HR. 01.04.01

7-M,C:The hospital orients external law 7-M,C:The hospital orients external law enforcement and security personnel on the enforcement and security personnel on the following: following:

– How to interact with patientsHow to interact with patients– Procedures for responding to unusual clinical Procedures for responding to unusual clinical

events and incidentsevents and incidents– The hospitalThe hospital’’s channels of clinical, security, s channels of clinical, security,

and administrative communicationand administrative communication– Distinctions between administrative and Distinctions between administrative and

clinical seclusion and restraint clinical seclusion and restraint

206206

Problematic Human Problematic Human Resources StandardsResources Standards

HR. 01.06.01 Staff CompetenceHR. 01.06.01 Staff Competence

Positions of one--An individual with the Positions of one--An individual with the educational background, experience, or educational background, experience, or knowledge related to the skills being knowledge related to the skills being reviewed assesses competence.reviewed assesses competence.

Performance evaluations (HR. 01.07.01)Performance evaluations (HR. 01.07.01)

Frequency/Measurement/Delinquency (C)Frequency/Measurement/Delinquency (C)

207207

Frequently Cited StandardsFrequently Cited Standards


RC.01.01.01: 55%RC.01.01.01: 55%– Dating, timingDating, timing

LS.02.01.20: 54%LS.02.01.20: 54%– Means of egress, hall clutterMeans of egress, hall clutter

IC.02.02.01: 47%IC.02.02.01: 47%– Instrument processing, sterilization, high level Instrument processing, sterilization, high level

disinfectiondisinfection

208208


EC.02.05.01: 46%EC.02.05.01: 46%– Air pressure differentialsAir pressure differentials

LS.02.01.01: 45%LS.02.01.01: 45%– Fire ratings of walls and penetrationsFire ratings of walls and penetrations

EC.02.03.05: 40%EC.02.03.05: 40%– Fire safety equipment and fire safety featuresFire safety equipment and fire safety features

LS.02.01.30: 39%LS.02.01.30: 39%– Protection of hazardous areasProtection of hazardous areas

209209


EC.02.06.01: 35%EC.02.06.01: 35%– Humidity 35-60% or get waiver 20-60%Humidity 35-60% or get waiver 20-60%

MM.03.01.01: 35%MM.03.01.01: 35%– Medication Security, controlled substancesMedication Security, controlled substances– Vaccine storageVaccine storage

LS.02.01.35: 34%LS.02.01.35: 34%– Sprinklers and Fire ExtinguishersSprinklers and Fire Extinguishers

210210

QUESTIONS??QUESTIONS??

211211

212212

Documents

Essentials of Joint Commission Readiness Dale Brown, RN, MSN Stephen Dorman, MD Day 2