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STANDARDS INTERPRETATIONS

Hospital Accreditation Program

151 June 2004

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15 West 22nd Street, Suite 1300W Oakbrook, IL 60523 USA

Tel: 01-630-268-2900 Fax: 01-630-268-7405

E-mail: mpotter@jcrinc.com

NOTE: ALL CHANGES TO INTERPRETATIONS AND NEW INTERPRETATIONS THIS QUARTER ARE SHOWN IN RED TYPEFACE. THE CHANGES SHOWN IN THIS DOCUMENT ARE EFFECTIVE ON 1 JUNE 2004.

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HOSPITALS ACCESS AND CONTINUITY OF CARE (ACC) STANDARD: ACC.3.3 Patient records contain a copy of the discharge summary. ISSUE: To be in compliance with this standard, must the discharge summary include a list of all medicines utilized during the hospitalization, including for example, Tylenol given for a headache, vitamins and medications regularly used by the patient? INTERPRETATION: The medications included in the discharge summary are those used as part of the primary treatment of the patient or ordered in association with the patients treatment. Thus, the summary would include antibiotics for an infection or pain medications following surgery. In addition, the standard requires that the medications given to the patient or prescribed for the patient at discharge be noted in the discharge summary. Thus, the occasional Tylenol for a headache or daily vitamin given a patient do not need to be included in the discharge summary as they were not directly associated with the treatment planned for the patient. Date: December 1999 Modified: STANDARD: ACC.3.3 Patient records contain a copy of the discharge summary. ISSUE: Who can complete the discharge summary, for which patients, in what timeframe and what content to be considered complete? INTERPRETATION: Any qualified individual can compile the discharge summary. If completing a discharge summary is simply a process of transferring information from the patients record to the discharge summary, a health professional may not be required. If completing a discharge summary involves the interpretation of patient data and information, then an appropriately qualified health professional is required. All in-patients have a discharge summary. The summary is completed at the time of discharge. All seven elements described in the standard will be looked for during survey however, only those elements relevant to a particular patient, will be expected to be present in the summary. The process can be made easy by using preprinted forms with check off boxes and spaces to fill in details. Date: August 2003 Modified:

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HOSPITALS PATIENT AND FAMILY RIGHTS (PFR) STANDARD: PFR.2.4 The organization supports the patients right to appropriate assessment and management of pain. ISSUE: For hospitals that publish or post the rights of patients, does the right to appropriate assessment and management of pain need to be on the list of rights? INTERPRETATION: A list, or other identification of patient rights, does not need to be exhaustive, for example, include all the rights found in the PFR standards. Also, not all patients have the same clinical needs and hospital experience. Thus, information about pain management and the right of the patient to have adequate pain assessment and management, may be better accomplished through other educational means than the list of rights. Date: September 2002 Modified:

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HOSPITALS ASSESSMENT OF PATIENTS (AOP) STANDARDS: AOP.1 All patients cared for by the organization have their health care needs identified through an established assessment process. AOP.1.1 The organization has determined the scope and content of assessments, based on applicable laws and regulations. ISSUE: The physical assessment process, in terms of the scope of the assessment, and in terms of a process that uses different practitioners for different portions of the assessment. INTERPRETATION: Hospital policy needs to be clear as to the content of a physical assessment, what portions may be deferred to a later time, or deferred to another practitioner. For example, if permitted by hospital policy, an admitting consultant can defer pulmonary system assessment to the anesthesia assessment conducted by the anesthesiologist. The overall process must result in a complete assessment, per hospital policy, recorded on the patients record before surgery and anesthesia, or within 24 hours of admission. Date: August 2003 Modified: STANDARD: AOP.1.1 The organization has determined the scope and content of assessments, based on applicable laws and regulations. ISSUE: AOP.1.1 is included in the list of required policies, procedures, written documents or bylaws in the Survey Process Guide. Thus, does the scope and content of assessments need to be contained in a policy, or can various assessment forms identify, for different settings (e.g., ambulatory or in-patient) or different patients (e.g., adult, pediatric), the required scope and content of the assessment? INTERPRETATION: The list in the Survey Process Guide covers all types of written documents, including forms. The most important issue is that, as the measurable elements require, the scope and content of each type of assessment is defined in writing. To satisfy this requirement, a form would need to be clear as to;

the health professional(s) responsible for completing the form or each section, and the minimal content for the form to be considered complete in terms of the

required assessment scope and content. Thus, a form will usually require guidelines for completion. Such guidelines can be on the form, or in a separate policy. The form, with guidelines, is needed to fully meet the standards. Date: June 2004 Modified:

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STANDARDS: AOP.2 Each patients initial assessment includes an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history. Measurable Element #8 The initial assessment results in an initial diagnosis. AOP.2.1.2 The initial medical assessment is documented before anesthesia or surgical treatment. Measurable Element #4 Surgical patients have a preoperative diagnosis recorded before surgery. COP.10 Each patients surgical care is planned and documented, based on the results of the assessment. Measurable Element #4 A preoperative diagnosis is recorded. COP.10.2 The surgery performed is written in the patient record. Measurable Element #1 A postoperative diagnosis is documented. Measurable Element #2 A description of the surgical procedure, findings, and any surgical specimens is documented. ISSUE: It is clear from the standards that both surgical and non-surgical patients need an initial diagnosis entered in their record. As the preoperative diagnosis and postoperative diagnosis are, in most cases, the same, are there any options for recording a postoperative diagnosis, such as an exception process when only a different diagnosis is recorded? INTERPRETATION: The options related to recording the postoperative diagnosis along with the surgical findings include:

1. write out the preoperative diagnosis, now as a postoperative diagnosis, 2. write same along with the findings of the surgery, 3. use preprinted template forms for common surgeries and only note exceptions to

what appears on the form, or 4. develop a hospital policy and procedure that permits documentation by exception

in the absence of preprinted template forms. With an exception process, and whenever there is a preliminary or tentative diagnosis, hospital procedure identifies how a final diagnosis is recorded, in particular when the results of pending laboratory or other tests change an admitting or preoperative diagnosis. Finally, whichever option a hospital implements, there is need for an effective monitoring process that provides evidence that the process is uniformly implemented, is consistent with hospital policy and consistent with good medical practice. Date: June 04 Modified:

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STANDARDS: AOP.2. Each patients initial assessment includes an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history. AOP.2.1.1 The initial medical assessment is documented in the patients record within the first 24 hours after the patients entry or earlier as indicated by the patients condition or hospital policy.

Measurable Element #2 Initial medical assessments conducted outside the organization are no older than 30 days.

ISSUES:

a) Does the 30-day time limit apply to initial medical assessments conducted within and by the organization as well as those assessments conducted outside the organization?

b) Does a patients initial medical assessment that is older than 30 days have to be repeated or can it be updated?

The content of the initial medical assessment is identified in AOP.2 and includes an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history. This assessment is conducted in conjunction with an admission to a hospital. Not infrequently the actual admission is delayed, at times for several weeks or even months for some elective surgery procedures. The initial medical assessment is intended to answer two questions:

Is there clinical evidence that an admission and procedure are indicated and appropriate, and

Is the candidate an acceptable risk at this time? The answer to the first question is not likely to change in the short term. The answer to the second question may change significantly, even in the short term. Measurable Element #2 sets a 30-day threshold after which both of the above questions must be answered again on the basis of repeating the initial medical assessment. Due to the fact that the 30-day threshold may be considered arbitrary, and that repeating medical assessments may significantly add time and cost to health care delivery, this threshold has been extensively debated within the JCI staff and among accredited organizations. The over-arching consideration is that any interpretation of the standard or setting of a new threshold time period must continue to be proactive and consistent with good professional judgment and good patient safety. INTERPRETATION:

a) It is the continued confidence in the content and conclusions of the initial medical assessment that is the primary issue, not where it was conducted. Thus the same conditions apply to an assessment conducted outside of the hospital and to an assessment conducted within the hospital in anticipation of a future admission.

b) An initial medical assessment 6 months or older must be completely repeated and newly documented. Most medical staff would agree that confidence in the

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findings and conclusions are no longer justified. The 30-day threshold is thus set aside until supported by clinical evidence as to the appropriateness of this threshold.

c) An initial medical assessment of less than 6 months must have the two questions related to continued clinical indication and candidate risk updated at the time of admission with a confirmatory note. Professional judgment and good clinical practice determines when all or a part of the assessment must be repeated. Medical staff or hospital policy may set any associated criteria or conditions.

Date: June 2004 Modified: STANDARD: AOP.3 All patients are reassessed at appropriate intervals to determine their response to treatment and to plan for continued treatment or discharge. ISSUE: Physicians are to assess acute care patients on a daily basis. What patients are considered acute? INTERPRETATION: Each organization must determine which types of patients are considered acute, and place that decision in a policy to ensure that all staff are aware. This determination should be made for both medical patients and for psychiatric patients, when present in the organization. While there is rarely a clear transition point from acute care to a less acute phase, it would be logical to consider that patients still undergoing initial assessment, and patients for whom the course of care has not yet been determined, are still in need of daily physician attention. There are other patients, such as an OBGYN patient admitted to the hospital for a normal delivery, or an individual admitted for elective oral and maxillo-facial surgery, and others, that the organizations may determine that the physician does not need to provide daily oversight. Surveyors will examine both the policy and practice. In particular, the evaluation of patient records is useful to determine that the required physician oversight occurred. Date: September 2002 Modified: STANDARD: AOP.3 All patients are reassessed at appropriate intervals to determine their response to treatment and to plan for continued treatment or discharge. ISSUE: Frequency of the reassessment process for acute and non-acute patients. INTERPRETATION: All patients are reassessed daily during the acute phase of their care. Hospital policy identifies those patient groups considered acute. Non-acute patients are assessed at a frequency consistent with good clinical practice. Hospital policy can define a specific frequency for reassessment of these patients, or can set a range, consistent with what the Medical Advisory Board considers good practice. Each

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physician can then decide the frequency of reassessment based on this range, and consistent with the condition of his or her patient. Date: August 2003 Modified: STANDARD: AOP.5.11 The organization regularly reviews quality control results for all outside sources of laboratory services. ISSUES: If the outside source of the laboratory service (or radiology or other service) is a JCI accredited facility, must quality control results be collected and reviewed? Also, under proficiency testing (AOP.10.1) which uses outside sources by design, must quality control data be collected and reviewed? INTERPRETATION: Quality control results must always be collected and reviewed, even when the outside source is a JCI accredited facility. The JCI accredited facility can share all or part of its internal quality control review with the contracting organization, or if significant services are under contract, someone from the laboratory service at the contracting organization can be included in the quality control group at the other facility. Proficiency testing is a quality control process by design and the process always results in a report and analysis. Two other considerations are relevant: the use of the results from the outside source in the patient care process (e.g., laboratory results in patient assessment) or a process directly related to patient safety (e.g., biomedical equipment maintenance), and secondly, what is the volume of use of the outside source. Thus, quality control results from the contractor for grounds maintenance are not very critical, nor are quality control results from a clinical laboratory used every several months for a rare test that the hospital does not perform. Date: August 2003 Modified:

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HOSPITALS CARE OF PATIENTS (COP) STANDARDS: COP.5.1 through COP.5.9 Policies and procedures for high-risk patients. ISSUE: The intent statement for COP.5.1 through COP.5.8 identifies the six important elements of a good policy or procedure related to the high-risk group. Standard COP.5.9 also addresses high-risk patients, those undergoing moderate or deep sedation, however the intent does not mention the six important elements of the relevant policy. Do these six elements also apply to COP.5.9. INTERPRETATION: The six elements of a good policy or procedure for a high-risk patient as identified in the intent statement are not required within the measurable elements and thus are more for guiding the organization in developing the policy or procedure, or for guiding the evaluation of the appropriateness of the policy or procedure by the surveyor, rather than representing absolute requirements. It is reasonable to also use the six elements in evaluating the policies and procedures related to care of patients undergoing moderate and deep sedation. Date: August 2003 Modified: STANDARDS: COP.5.9 Policies and procedures guide the care of patients undergoing moderate and deep sedation. COP.6 A qualified individual conducts a pre-anesthesia assessment. ISSUE: Pre-anesthesia assessment for patients undergoing moderate and deep sedation. INTERPRETATION: Patients undergoing moderate and deep sedation do not need a pre-anesthesia assessment and anesthesia plan unless required by hospital policy. The pre-anesthesia assessment and plan are intended to support the use of general anesthesia as described in COP.7-COP.9. Date: August 2003 Modified:

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STANDARD: COP.8 Each patients postanesthesia status is monitored and documented, and a qualified individual discharges the patient from the recovery area using established criteria. ISSUE: When an anesthesiologist discharges the patient from the postanesthesia recovery area, does there have to be evidence they used the established criteria? INTERPRETATION: The established criteria are for the use of nursing and other qualified staff in discharging patients from the recovery area. If the anesthesiologist discharges the patient, Measurable Elements #3 and #4 would be scored not applicable. It is presumed that the anesthesiologist will use clinical criteria that are the same or similar to the criteria established for other staff to apply. Date: September 2002 Modified: STANDARD: COP.11.4.2 Medication prescriptions or orders are verified. ISSUE: What is meant by verified, and who may perform the verification of the medication prescriptions or orders? INTERPRETATION: The verification of medication orders involves a review of an order for medication for its appropriateness and accuracy before the administration of the medication. This review process applies to any setting that a patient will be receiving a medication during the care or treatment in that setting (including inpatient and outpatient settings). The review and verification process may vary with each organization, depending on medication use system. For example, the verification can occur during the prescribing or ordering process, at the time orders are transcribed, during preparation and dispensing, or just prior to administration. Medication orders should be reviewed by a qualified person* (an individual who is knowledgeable of the appropriate use of the medication, dose, frequency, and route of administration) prior to the administration of the medication to a patient unless a physician controls the prescribing or ordering, preparation and administration of the medication, such as in the operating room or other procedural areas, or in emergencies when the resulting delay would harm the patient. The individual who performs the review may be the same individual involved in receiving, transcribing, preparing, and administering the medication. The review process should include checking the appropriateness and accuracy of the drug, dose, frequency, and mode of administration. *Qualified person may include a pharmacist, physician, nurse, or others, as determined by the organization. Date: September 2002 Modified: January 2003

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STANDARD: COP.11.4.4 A system is used to dispense medications in the right dose to the right patient at the right time. ISSUE: When a hospital does not have a central pharmacy, and medications are prepared, dispensed, and administered on each ward/care unit, what sort of dispensing system will the surveyors look for? INTERPRETATION: To be considered a system the medication dispensing process should be implemented uniformly throughout the hospital, should be guided by appropriate policies and procedures, and should be designed to prevent incorrect doses, administration to the wrong patient, or administration at the wrong time. This standard is closely related to safe medication practices and thus will be closely examined by the survey team. Hospitals should design the system so that the process has the least number of steps and the fewest staff involved. For example, if medications are prepared on the patient unit by one staff member, dispensed by another, and administered by yet another staff member, there are multiple points where error can occur. Also, there should be a system in place to identify both the medication as well as the intended patient. This does not mean that medication preparation should be performed at bedside; rather, medication preparation should be performed in a clean, safe, and organized place. This is usually done in a separate room or a portion of the nursing station. Date: March 2003 Modified:

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HOSPITALS QUALITY AND PATIENT SAFETY (QPS) STANDARD: QPS.3.5 Clinical monitoring includes the use of anesthesia. ISSUE: Does this monitoring requirement refer to only anesthesia or does it also include monitoring the use of conscious sedation as identified in COP.5.9? INTERPRETATION: The monitoring requirement found in QPS.3.5 only refers to the use of anesthesia as described in standards COP.6 through COP.9. However, surveyors will look to see if the policy and procedure required for moderate and deep sedation requires monitoring, and will also see if the risk management monitoring required in QPS.3.12 includes sedation as a high risk procedure. Date: September 2002 Modified: STANDARD: QPS.3.15 Managerial monitoring includes staff expectations and satisfaction. ISSUE: Is employee satisfaction the same as client and other satisfaction surveys? INTERPRETATION: Understanding the expectations and satisfaction of hospital staff is part of managerial quality monitoring. Employees are considered a group of "clients" in some hospitals. For purposes of scoring standard QPS.3.15, there are different types of employee satisfaction surveys and different purposes that would satisfy the requirement. Two examples follow. An employee survey can be a component of a particular process improvement effort. For example, the process of transport, storage and disposal of soiled bed linens may need to be improved as there is poor separation of clean and dirty linen, and staff find the many containers for types of soiled linen to be confusing. As part of gathering data on how the current process works, a questionnaire is given to staff to identify how satisfied they are with different elements of the current process and to obtain their opinions or their perceptions of how the process can be improved. Once the process is improved, staff are again surveyed to measure their satisfaction with the new process.

Staff satisfaction may be evaluated on a more global level and apply to all staff of the hospital or to all staff in a particular category (e.g., nurses). This type of survey commonly relates to such things as working conditions (e.g., air quality, room temperature), benefits (e.g., health coverage, vacation days), ability to participate in improvement teams, if their opinion is valued by their manager, would they recommend the hospital to a friend as a good place to work, etc. This type of survey is more for overall Human Resource management rather than clinical process improvement.

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Both of these types of employee satisfaction surveys would satisfy the standard. Date: December 1999 Modified: STANDARD: QPS.3.17 Managerial monitoring includes financial management. ISSUE: What is meant by financial monitoring. INTERPRETATION: QPS.3.17 requires that there be data to support financial decisions in an organization or even to support required financial reporting to governmental agencies or insurance companies. It is important that the financial monitoring indicators make sense to an organization and are useful. The indicator can range from collecting and reporting revenue per patient admission, cost per dialysis treatment, cost for disposable supplies per operation, staff cost per patient day, or cost of outdated medications if that is an issue to track. There are usually many such financial measures already present in most hospitals that would meet the requirement of this standard. Date: December 1999 Modified:

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HOSPITALS GOVERNANCE, LEADERSHIP AND DIRECTION (GLD) STANDARD(S): GLD standards related to organization leaders. ISSUE: Do the JCIA standards for hospitals require a nurse executive? INTERPRETATION: The standards do not make reference to a nurse executive. Rather, the standards repeatedly reference clinical leaders and nursing leaders. The standards reference leader, as the term nurse executive is not universally used, and the assignment of nursing responsibilities and authority may be at more than one level, or with more than one individual in many hospitals. The expectation of the standards is that there is at least one senior nursing leader who determines nursing practice in the hospital and is responsible for the quality of nursing services. This individual is usually within the hospital to provide such oversight of policy and practice. The standards refer to this internal nursing leadership. Each hospital defines who has such responsibility and authority for nursing and the title of such individual(s). There may, in addition, at times be an external nurse leader, such as in a public hospital system, who has authority and responsibility over nursing services in many hospitals. The hospital clinical leader(s) for nursing: plans the type of nursing services required to meet the needs of patients (GLD.3.2); provides oversight of any contracts related to nursing services (GLD.3.3); is educated in the concepts of quality management and improvement (GLD.3.4); develops nursing staff recruitment, retention, and the training and education programs

for nursing (GLD.3.5); plans and implements an effective organization structure to support his or her

responsibilities and authority (GLD.4); participates with other clinical leaders in developing the staffing plan for the hospital

(SQE.4); determines the scope and content of nursing assessments (AOP.1.1); and participates in the planning and monitoring of a quality management and

improvement program in the hospital (QMI.1). Date: December 1999 Modified:

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HOSPITALS FACILITY MANAGEMENT AND SAFETY (FMS) STANDARD: FMS.7 The organization plans and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results. ISSUE: On patient care units there are frigobars in every patient room. They are not used for patient food - only for storing food for the companion of the patient required to stay 24/h/d with the patient. The operation of these frigobars is not monitored as part of our equipment inspection, testing, and maintenance program. Do they need to be monitored or would a sticker on the refrigerator stating that it is not controlled (quality) and that no patient food is to be stored in it be sufficient. INTERPRETATION: The frigobars, when only used for family food, do not need to be included in the medical equipment monitoring program. The only related requirements, in both the JCAHO US standards and in the JCIA international standards, relate to the proper storage of medications that must be refrigerated (COP.11.4), and the proper storage of patient food (COP.12.3). There are two possible exceptions to the above: if there are Public Health or other laws or regulations that require quality control checks on these frigobars; or if the hospitals own policies, such as for the equipment management program, require you to do so. Date: December 1999 Modified: STANDARD: FMS.10.3 The organization periodically tests staff knowledge through demonstration, mock events, and other suitable methods. This testing is then documented. ISSUE: Will the surveyors look for any particular tool used by a hospital to test staff knowledge as called for in this standard. INTERPRETATION: JCI accreditation does not have a best practice tool for the testing of staff knowledge on safety or the recording of staff participation. In general, the hospital should make sure that staff receives education on safety as part of their orientation to the hospital. This can be easily documented as to who attended. For ongoing testing, mock events and mock surveys are effective mechanism for the evaluation of staff knowledge as staff understanding of what they should do, can be observed. Another test method is to enter a patient care unit and ask staff what they would do if a patient fell, or they saw smoke coming from under a door, or found a chemical spill, etc., and then document the results, and conduct any retraining needed and

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document the retraining. Whatever method is used should be simple and practical and thus permit more frequent testing. Date: September 2002 Modified:

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HOSPITALS STAFF QUALIFICATIONS AND EDUCATION (SQE) STANDARD: SQE.3.1 Each staff members ability to carry out the responsibilities in his or her job description is evaluated at appointment to the staff and then regularly thereafter. ISSUE: Can the initial review competency be within 90 days rather than before or at the time of starting to perform work as stated in the intent statement, in particular if hospital policy requires a review at the end of a 90 day probationary period. INTERPRETATION: The review process and review cycle is usually set by hospital policy. In general, if a new employee is in a sensitive patient care position (e.g., critical care nurse), you would want to know if the individual had the correct competency level very soon into their employment for reasons of patient safety. This could be established by having the individual work under supervision for the first day or two. Then over the next 90 days, the full scope of their responsibilities is evaluated. If the staff member is not in a patient sensitive area, the review should commence soon after employment however in all practicality may take 90 days to complete. Thus - create a policy that focuses on the patient and patient safety. Such a policy can have variable review cut off points consistent with the level of patient contact for the position. Date: September 2002 Modified: END OF DOCUMENT

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Standards InterpretationsHospital Accreditation Program1 June 2004

HOSPITALS ACCESS AND CONTINUITY OF CARE (ACC)HOSPITALS PATIENT AND FAMILY RIGHTS (PFR)HOSPITALS ASSESSMENT OF PATIENTS (AOP)HOSPITALS QUALITY AND PATIENT SAFETY (QPS)HOSPITALS GOVERNANCE, LEADERSHIP AND DIRECTION (GLD)HOSPITALS FACILITY MANAGEMENT AND SAFETY (FMS)HOSPITALS STAFF QUALIFICATIONS AND EDUCATION (SQE)