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					Joint Commission International Accreditation

HOSPITAL
Survey Process Guide




                                      Effective January 2008
                                      3rd Edition Standards
TABLE OF CONTENT
Contact Directory................................................................................................................. 1
Introduction .......................................................................................................................... 2
The Value of Joint Commission International Accreditation........................................ 2
Joint Commission International —Who Are We? .......................................................... 3
Who Is Eligible for a Hospital Survey? ............................................................................. 4
How to Request a Hospital Survey.................................................................................... 5
Survey Scheduling, Postponements and Cancellation .................................................... 6
The Standards Manual ......................................................................................................... 7
The Scoring Process........................................................................................................... 10
Accreditation Decision Rules - Effective January 2008................................................ 11
International Patient Safety Goals ................................................................................... 15
Accreditation Preparation ................................................................................................. 17
  Preparation Timeline ........................................................................................................... 18
  Accreditation Process Timeline ............................................................................................. 20
Survey Application ............................................................................................................. 21
The On-Site Survey ........................................................................................................... 40
Sample Survey Agendas..................................................................................................... 41
The Accreditation Decision .............................................................................................. 46

                           Survey Agenda - Detailed Description

Opening Conference ......................................................................................................... 48
Orientation to the Organization and Quality Improvement Plan............................... 50
Surveyor Planning Session ................................................................................................ 51
Document Review.............................................................................................................. 53
  Documents Available in English.......................................................................................... 54
Daily Briefing ...................................................................................................................... 59




                                                                                                                                     i
Facility Tour ........................................................................................................................ 61
    Facility Inspection Report – Sample Outline..................................................................... 64
Individual Patient Tracer Activity .................................................................................... 65
System Tracer – Medication Management...................................................................... 68
System Tracer – Infection Control .................................................................................. 71
System Tracer – Data Use................................................................................................. 74
System Tracer – FMS with Emergency Management Tracer ..................................... 76
Staff Qualifications and Education.................................................................................. 80
  Competency Assessment Process Review Forms ..................................................................... 82
Closed Medical Record Review........................................................................................ 85
Medical Review Tool ......................................................................................................... 87
GLD Interview Session ..................................................................................................... 90
Patient Safety Systems Evaluation ................................................................................... 92
Surveyor Team Meeting..................................................................................................... 94
Surveyor Report Preparation ............................................................................................ 95
Leadership Briefing Conference....................................................................................... 96
Organization Exit Conference.......................................................................................... 97



                                 Survey Planning Reference Lists

Required Quality Monitors ............................................................................................... 99
Required Organization Plans .......................................................................................... 100
Required Policies, Procedures, Written Documents, or Bylaws................................ 102
Standards that Reference Law and Regulation............................................................. 111
  Law and Regulation Worksheet ...................................................................................... .112




Revised: 08 2008




                                                                                                                                    ii
Dear Colleague,

Joint Commission International recognizes that hospital care is a constant, ongoing, important force in health
care.

With that in mind, Joint Commission International Accreditation offers an accreditation program for hospitals.
Joint Commission International recognizes that health care organizations want a mechanism for comparing their
performance with recognized, internationally accepted, standards. The standards that have been created to
facilitate accreditation are patient-centered. These standards are written so as to apply to many different types of
hospital organizations. For example, a single specialty oncology hospital or a multi-specialty acute care hospital
could use the same set of standards to achieve international hospital accreditation.

The hospital accreditation process provides organizations with a mechanism to demonstrate the quality and safety
that are being provided in their hospitals. Also, recognizing that in many countries health care systems are judged
by the type of hospital care that is provided, there are many incentives for accreditation.

With this in mind, Joint Commission International Hospital Standards have been developed by an international
task force whose members were drawn from many different types of hospitals. Using The Joint Commission
Hospital Accreditation standards as a foundation and with input from the international hospital community, these
standards and the survey process have been carefully and thoughtfully created.

It is important for the reader to understand that the accreditation activity exists in a constantly changing
environment. The demonstration of quality and safety is becoming more necessary in order to attract patients,
insurers, and other stakeholders. Therefore, it is important to understand why the focus of accreditation is
shifting in those countries where accreditation, at least for hospitals, has been present for some time.

The focus of accreditation is shifting:
    from viewing accreditation as a snapshot, to seeing it more like a movie or film
    from viewing the survey as a contest to seeing it as a validation of a continuous process, and to welcoming
    surveyor findings as opportunities for improvement
    from preparing for the "exam" to continuously using the standards as a means to achieve and maintain
    excellent operational systems, and deriving significant internal benefits
    from a view that the survey process is too focused on policies and procedures, to one where the evaluation is
    clearly understood as an intensive review of the actual delivery of care
    from a process of potential consequences within the organization if there are recommendations made on
    survey to a process of appreciation when opportunities that were not recognized by the organization are
    recognized on survey.

As part of this change in approach to accreditation, there are expectations for both you and Joint Commission
International that this guide will help explain. If you have additional questions after reading this guide, please turn
to page 1 for a directory of resources where you can get the answers.

Yours truly,



David Jaimovich, MD
Chief Medical Officer
Joint Commission International




                                                                                                                     iii
Contact Directory
JCI Accreditation Office
1515 West 22nd Street, Suite 1300W
Oak Brook, Illinois 60523 USA
Phone: +1.630.268.4800
Fax: +1.630.268.2932
E-mail: jciaccreditation@jcrinc.com

         Inquire about your completed Application for Survey, survey date or schedule, or assistance
         with specific problems related to your accreditation.
         Request information about interpreting and applying specific standards.
         Register for, or receive information about education programs, and to purchase, or inquire
         about publications.

Joint Commission International (JCI) Web Site ........................ www.jointcommissioninternational.org
       General information about accreditation
       JCI news
       Information about accreditation status for specific organizations
       Application for Survey
       Frequently asked questions (FAQs)
       JCI eZine newsletter
       Revisions to standards
       Standards

Joint Commission Resources Web Site ................................................................................ www.jcrinc.com
       Upcoming education programs
       Catalog of publications
       Access to official JCI publications and e-books
       International Self-Assessment System (ISAS)

Joint Commission International Center for Patient Safety Web Site .............www.jcipatientsafety.org
A focal point for additional research and related efforts to develop and provide patient safety-related
solutions. The Center will get input, feedback and guidance from an advisory group of patient safety
experts, five global regional advisory councils, and strategic domestic and international partnerships
with other patient safety-focused organizations. The Center will:
         Collaborate with other leading patient safety organizations around the globe to achieve its
         goals, including the identification, development and sharing of patient safety solutions.
         Be a credible source of valid and meaningful information and education about patient safety.
         Engage patients and families in improving patient safety.
         Engage practitioners and providers in improving patient safety.
         Advocate for public policy that promotes patient safety.
         Conduct research related to patient safety.


JCIA Hospital Survey Process Guide ~ 2008                                                                                   1
Introduction
The Joint Commission International (JCI) Accreditation Hospital Survey Process Guide is designed to help you
learn about The Joint Commission International Hospital standards and survey process. This
overview will provide important information about Joint Commission International, the hospital
standards manual, eligibility for accreditation, how to request accreditation, survey preparation, the
on-site survey, and the accreditation decision.

Please do not hesitate to contact the JCI Office by telephone or e-mail using the contact directory at
the beginning of this guide for any other information your organization may need.


The Value of JCI Accreditation
Accreditation may benefit your organization by:
. . . giving you a competitive advantage
      Accreditation provides evidence of quality patient care that helps level the playing field
      for organizations doing the same types of procedures.
. . . strengthening community confidence
      Achieving accreditation is a visible demonstration to patients and the community that
      your organization is committed to providing the highest quality services.
. . . assisting recognition from insurers, associations, employers, and other
      stakeholders
      Increasingly, accreditation is becoming a prerequisite for eligibility for reimbursement,
      for association membership, for community awareness, and for contracts or grants.
. . . validating quality care to patients
      Joint Commission International standards are focused on one goal: raising the safety and
      quality of care to the highest possible level. Achieving accreditation is a strong
      validation that you have taken the extra steps to meet a high level of safety and quality.
. . . helping you organize and strengthen your improvement efforts
      Accreditation encompasses state-of-the-art performance improvement concepts that
      help you continuously improve quality.
. . . enhancing staff education
      The survey process is designed to be educational, not punitive. JCI surveyors are trained
      to help you improve your internal procedures and day-to-day operations.
. . . improving risk management
      By enhancing risk management efforts, accreditation may improve access to, or reduce
      the cost of liability coverage. It can also assist in lowering adverse events or outcomes
      for the organization, and, more importantly, for the patient
. . . facilitating staff recruitment
      As staff recruitment becomes more difficult, achieving accreditation as a demonstration
      of your organization’s commitment to quality and patient safety will enhance recruitment
      efforts.
. . . promoting team building skills for staff




JCIA Hospital Survey Process Guide ~ 2008                                                                  2
    The process of obtaining and maintaining accreditation demands a team approach to
    good patient care. Establishing processes and systems that support this demonstration is
    achieved through good team activities.


Joint Commission International—Who Are We?
Joint Commission International (JCI) is a division of Joint Commission Resources (JCR), the
subsidiary of The Joint Commission. For more than 80 years, The Joint Commission and its
predecessor organization have been dedicated to improving the quality and safety of health care
services. Today the largest accreditor of health care organizations in the United States, The Joint
Commission surveys nearly 20,000 health care programs through a voluntary accreditation process.
The Joint Commission and its subsidiary are both not-for-profit corporations.

The mission of The Joint Commission is to improve the quality of care provided to the public
through the provision of health care accreditation and related services that support performance
improvement in health care organizations.

The Joint Commission was founded in 1951 under the auspices of the American Hospital
Association, the American Medical Association, the American College of Physicians, and the
American College of Surgeons, with the later addition of the American Dental Association, to act as
an independent accrediting body for hospitals nationwide. As such, The Joint Commission currently
accredits nearly 80% of U.S. hospitals. Because of the changing nature of health care in America,
The Joint Commission has, over the years, broadened its scope to include accreditation of many
non-hospital settings, beginning in 1975.

JCI extends The Joint Commission’s mission worldwide. Through international consultation,
accreditation, publications and education, Joint Commission International helps to improve the
quality of patient care in many nations. Joint Commission International has extensive international
experience working with public and private health care organizations and local governments in more
than 60 countries.

JCI established the Hospital Accreditation Program to encourage quality patient care in all types of
hospital facilities. Today’s health care environment is changing rapidly, and hospital providers are
experiencing new competitive pressures in the health care marketplace. Providing safe, high quality
care to patients and continually improving performance are benchmarks of success. Joint
Commission International accreditation of a hospital is a widely recognized standard for high quality
services.

Why Choose JCI Over Other Options
JCI is the leader in accreditation, with more than 10 years of experience across the full spectrum of
health care organizations. JCI accreditation represents the “Gold Seal of Approval TM” in health
care and provides the most comprehensive evaluation process.




JCIA Hospital Survey Process Guide ~ 2008                                                           3
The JCI Patient-Centered Accreditation Process
Significant changes were made to The Joint Commission International accreditation process in 2006
to make the process more focused on the patient’s experience of care. To understand the changes in
the process, a new term, Tracer Methodology, was introduced. The patient-centered process also shifts
accreditation away from survey preparation to continuous standards compliance. The survey
becomes just the on-site evaluation piece of a continuous quality improvement process.

Our Standards Represent an International Consensus
In July 2007, a revised set of Standards was being published for implementation January 1, 2008.
This 3rd Edition of the International Standards for Hospitals was accomplished through the
following processes:

JCI Standards Committee, Accreditation Committee, and Board of Directors
Our standards undergo extensive field review prior to their publication. We have established an
International Standards Committee, composed of experts in the healthcare quality and patient safety
field. This Committee provides advice and assistance in the development of new and revised
standards, and recommends improvements to the accreditation process for Accreditation
Committee review and approval by the Board of Directors. This committee has overseen the
revision of the standards and their introduction to the health care community.

Regional International Advisory Groups
On a regular basis, Regional International Advisory Groups representing ministries of health,
professional healthcare associations, and national accrediting organizations, meet to discuss ongoing
issues and potential future improvements to the JCI accreditation process.

Field Review Process
When periodic revisions or changes are made to the standards, health care organizations, whether
accredited or not, are given an opportunity to comment on those changes. Field review
announcements were posted on the JCI web site and sent to the JCI list serve to elicit
individual/organization’s comments to develop the 3rd edition of the hospital standards. To join the
JCI list serve, please contact the JCI Accreditation Office or sign up on the JCI web site.

Standards Interpretation
JCI will answer specific questions about any JCI standards and how they are interpreted. This is a
no-cost service that you can access by telephone, e-mail, or through the JCI web site. Please direct
standards-related inquiries to Paul vanOstenberg by phone at +1.630.268.7481 or by e-mail to
pvanostenberg@jcrinc.com.


Who Is Eligible for an International Hospital Survey?
Any hospital may apply for JCI hospital accreditation if it meets the following requirements:
     The organization is currently in operation as a health care provider in the country, and licensed
     (if required)



JCIA Hospital Survey Process Guide ~ 2008                                                            4
       The organization assumes, or is willing to assume, responsibility for improving the quality of
       its care and services
       The organization provide services addressed by JCI standards


How to Request an International Hospital Accreditation Survey
Organizations that wish to be accredited by JCI may obtain an Application for Survey by contacting
the JCI Accreditation Office (see contact directory on page 1), from the JCI web site at
www.jointcommissioninternational.org, or from this Survey Process Guide.

The Application for Survey should be submitted to JCI at least six months prior to your
organization’s preferred on-site accreditation survey dates. Applications can be submitted in
electronic format by e-mail attachment to jciaccreditation@jcrinc.com or by fax to +1 630 268 2921
 (see application on page 21).

The Application for Survey is valid for six months from the date submitted, which means your
organization can submit your application, and still have time to complete your preparations before
the on-site survey takes place. It is best to submit your application when you are confident you will
be able to demonstrate a four-month track record of compliance with the standards at the time
of the on-site survey (see the Preparation Timeline on page 18).

On your Application for Survey, you may indicate three months when you would like the survey to
take place, and also, please specify any time periods during the year for which you would not like the
survey to take place. JCI will make every effort to accommodate your time request, if possible. The
earlier you submit your request, the more likely it is that your specific request can be accommodated.

Once the Application for Survey is received, you will be contacted by the Manager for JCI
Accreditation Services, who will:
       Answer your questions about survey preparation, and help you through each step of the
       accreditation process
       Analyze your Application for Survey, and contact you if there are any questions or items
       requiring clarification
       Update changes to your demographic information, including address, contact name(s), etc.
       Assist you with locating other resources or JCI contacts to answer your questions
       Coordinate scheduling the on-site survey
       Forward the proposed contract agreement to the organization for review and authorization.

JCI schedules on-site surveys based on information provided in your Application for Survey. Based
on the information provided, JCI determines the number of days required for a survey, the
composition of the survey team and the services to be reviewed.

Four to six months before the survey, the proposed accreditation survey contract agreement will be
sent to the organization. Until the signed contract agreement and the down payment of the first 50%
of the survey fees are received, the scheduled survey can not be confirmed. You will also receive


JCIA Hospital Survey Process Guide ~ 2008                                                            5
notification of the surveyors’ names before your survey. The survey team leader will contact the
person responsible for the survey at your organization approximately four to eight weeks before the
survey to finalize the agenda, coordinate the availability of certain staff for key survey activities, as
well as provide information regarding the surveyor’s travel arrangements and logistics.

Handling Changes During the Application Process
Once your organization has submitted the application, your organization must notify JCI within 30
days if it undergoes a change that modifies the information reported in the Application for Survey.
Information that must be reported includes:
         A change in organization name and/or ownership
         A significant increase or decrease in the volume of services
         The addition of a new type of health service
         The deletion of an existing health service
         A significantly altered building/physical plant
         New construction or acquisition of a new structure in which patient care or services will be
         provided

It may be necessary for JCI to schedule an additional survey for a later date if its survey team arrives
at the organization and discovers that a change was not reported. JCI may also review any
unreported services addressed by its standards. In either event, there may be additional fees
assessed. JCI will make the final accreditation decision for the organization only after reviewing all
services provided by the organization for which The Joint Commission International has standards.


Survey Scheduling, Postponements and Cancellation
Initial Schedules for Surveys
Joint Commission International (JCI) schedules surveys systematically and efficiently to keep
accreditation fees to a minimum. Therefore, organizations are encouraged to accept scheduled
survey dates. Initial surveys, that is, an organization’s first full accreditation survey, should be
scheduled within six months from the time the JCI receives the organization’s Application for
Survey.

JCI tries to honor specifically requested weeks during which an organization prefers not to be
surveyed. The organization should include these specific dates with the completed Application for
Survey, whenever possible. There may, however, be circumstances that prevent JCI from
accommodating these dates.

Definition of Postponement
JCI also provides for the postponement of initial surveys or resurveys. A postponement is an
organization’s request to alter an already-scheduled survey date or request to push back the survey
date before it is actually scheduled. An organization should direct a request for a postponement to
the Manager for JCI Accreditation Services as soon as possible.




JCIA Hospital Survey Process Guide ~ 2008                                                               6
Accepted Reasons for Postponement
An organization may postpone scheduled surveys when one or more of the following events
happen:
        A natural disaster or another major unforeseen event occurs that totally or substantially
        disrupts operations
        The organization is involved in a major strike, has ceased accepting patients, and is
        transferring patients to other facilities
        Patients, the organization, or both are being moved to another building during the scheduled
        survey
JCI reserves the right to conduct an on-site survey if the organization continues to provide patient
care services under such circumstances.

Cancellation
The survey may be canceled by either party without penalty or damages in the event acts of GOD,
war, terrorism, government regulation, disaster, strikes, civil disorders or other emergencies of a
similar nature that make it impossible, illegal or unreasonable to go forward provided notice of the
event requiring cancellation is communicated in writing as soon as practically possible. Further, JCI
may follow the advice of relevant ministries concerned with evaluating political and military
circumstances with regard to scheduling surveys.

If the organization cancels the survey fewer than thirty (30) prior to the first date of the survey for
any reason or reasons other than those previously stated, JCI accreditation may require payment of
one-half of the survey fees to recover costs JCI accreditation has incurred.


The Standards Manual
The Joint Commission International Accreditation Standards for Hospitals, 3rd Edition is the place to begin
when preparing for accreditation. Even if you do not immediately pursue accreditation, the manual
is an excellent tool to help your organization evaluate current practices and structures. The manual
contains functional standards that are organized around the way care is provided in a hospital
setting. The standards address patient-focused performance and are organized around functions and
processes, including both clinical and organizational functions, common to all health care
organizations.

The manual is designed for use in self-assessment activities and is the basis for an accreditation
survey. The standards manual is divided into two sections: patient-focused functions and
organization functions.




JCIA Hospital Survey Process Guide ~ 2008                                                                 7
PATIENT-FOCUSED FUNCTIONS

Access to Care and Continuity of Care
These standards address which patient needs can be met by the health care organization; the
efficient flow of services to the patient; and the appropriate transfer or discharge of the patent to his
or her home or to another care setting.

Patient and Family Rights
These standards address issues such as promoting consideration of patient’s values; recognizing the
organization’s responsibilities under law; informing patients of their responsibilities in the care
process. Standards regarding patient rights with respect to informed consent, resolution of
complaints and confidentiality are included.

Assessment of Patients
This chapter addresses the assessment of patients at all points of care within the organization. This
includes collecting information and data on the patient’s physical and psychosocial history; analyzing
the data and information to identify the patient’s health care needs; and developing a plan of care to
meet those identified needs.

Care of Patients
This chapter discusses the activities basic to patient care. It includes processes of planning for and
coordinating care, monitoring results, modifying care, and planning for follow-up. The chapter also
includes nutrition care, pain management and end of life care.

Anesthesia and Surgical Care
This chapter addresses sedation and anesthesia use as well as surgical care. It includes processes of
preparing, monitoring and planning for after-care for patients receiving sedation or anesthesia
and/or having surgery.

Medication Management and Use
This chapter addresses the systems and processes for selecting, procuring, storing,
ordering/prescribing, transcribing, distributing, preparing, dispensing, administering, documenting,
and monitoring of medication therapies.

Patient and Family Education
This chapter contains standards that address the effectiveness of education being provided and what
modalities are being used to succeed with education. This chapter also looks at patients’ readiness to
learn by considering language needs and how they learn best.


ORGANIZATION FUNCTIONS
This manual also includes chapters related to how well the management system works for the
benefit of the patient. Pertinent to that management system is the importance of core processes that


JCIA Hospital Survey Process Guide ~ 2008                                                               8
support good management. For example, leadership requirements, infection control, and ongoing
emphasis on infection control.

Quality Improvement and Patient Safety
These standards focus on how well a hospital designs processes; measures its performance; assesses
its performance; and, ultimately, improves its performance. Examples of improvement efforts
include: designing a new service; flowcharting a clinical process; measuring outcomes; comparing
performance with other like organizations; and selecting areas for priority attention.

Prevention and Control of Infections
These standards address how the hospital identifies and reduces the risk of acquiring and
transmitting infections. Areas covered include how infections are reported and what ongoing
surveillance activities are in place.

Governance, Leadership, and Direction
Effective leadership depends on the performance of the following processes:
     Planning and designing services, including defining a clear mission with a vision of the future
     and the values which underlie day to day activities
     Directing services, including responsibility for developing and maintaining policies, providing
     adequate number of staff and determining qualifications and competence
     Integrating and coordinating services
     Improving performance, including the leaders’ critical roles in initiating performance and
     maintaining an organization’s performance improvement activities

Facility Management and Safety
These standards measure how well a safe, functional and effective environment for patients, staff
members, and other individuals in the organization is being maintained. The following areas are
addressed: emergency preparedness, security, life safety, medical equipment, utility systems,
hazardous materials and waste management.

Staff Qualification and Education
This chapter includes sections on human resources planning; orientation, training and education of
staff; competence assessment; handling staff requests; and credentialing and privileging of licensed
independent practitioners and nursing.

Management of Communication and Information
These standards address how well the hospital obtains, manages and uses information to provide,
coordinate and integrate services. The principles of good information management apply to all
methods, whether paper-based or electronic, and Joint Commission International standards are
equally compatible with either method.




JCIA Hospital Survey Process Guide ~ 2008                                                          9
The Scoring Process
The Intent Statement expands on the standard and what it is intended to achieve through the
measurable elements. Measurable Elements (MEs) are the components of the standard that are
scored by the surveyor on site. MEs clearly present the requirements that are assessed during the
on-site review, and are identical to the scoring elements the surveyors use in their laptop systems.
MEs will be scored on a three-point scale of “0” =Non-Compliance or Not Met; “5” = Partial
Compliance or “Partially Met”, and “10” = Satisfactory Compliance .or “Fully Met”

The following guidelines are intended to provide a basis for scoring compliance with the standards.
They do not supersede the judgment of the surveyors.

1. Each measurable element of a standard is scored “Fully Met”, “Partially Met”, “Not Met”, or
   “Not Applicable”;

2. Score “Fully Met” if the answer is “Yes” or “Always” to the specific requirements of the
   measurable element and:

         A. 12 month look-back period of compliance for triennial surveys;
                      or
         B. 4 month look-back period of compliance for initial surveys

3. Score “Partially Met” if the answer is “Usually ” or “Sometimes” to the specific requirements of
   the measurable element and :
       A. 5-11 month look-back period of compliance for triennial surveys
                      or
       B. 1-3 month look-back period of compliance for initial surveys

4. Score “Not Met” if the answer is “Rarely ” or “Never” to the specific requirements of the
   measurable element and:
      A. 0-4 month look-back period of compliance for triennial surveys
                     or
      B. Less than 1 month look-back period of compliance for initial surveys

5. Score “Not Applicable” if the requirements of the measurable element do not apply.




JCIA Hospital Survey Process Guide ~ 2008                                                         10
                                    Joint Commission International
                                    Hospital Accreditation Program
                         Accreditation Decision Rules
                                            Effective Date 1 January 2008

I        ACCREDITATION DECISIONS

         INTRODUCTION
         The Accreditation Committee considers all information from the full survey and any
         required follow-up report and/or focused survey in making its decision regarding
         accreditation. The outcome is that the organization meets the criteria for accreditation or
         does not meet the criteria and is denied accreditation. The criteria for these two potential
         outcomes are as follows:

         A. ACCREDITED
         This decision results when an organization meets all the following conditions.
            1. The organization demonstrates acceptable compliance with each standard.
                Acceptable compliance is:
                • A score of at least “5” on each standard.

              2. The organization demonstrates acceptable compliance with the standards in each
                 chapter. Acceptable compliance is:
                 • An aggregate score of at least “7” for each chapter of standards.

              3. The organization demonstrates overall acceptable compliance.
                 Acceptable compliance is:
                 • An aggregate score of at least “8.5” on all standards.

              4. The organization demonstrates acceptable compliance with all International Patient
                 Safety Goal requirements. Acceptable compliance is:
                 • A score of at least “5” on each International Patient Safety Goal.

         B. ACCREDITATION DENIED
            This decision results when an organization meets one or more of the following
            conditions at the end of any 30 day follow-up period to a full accreditation survey.

              1.   One or more standard is scored less than a “5”.
              2.   The aggregate score of one or more chapter of standards is less than a “7”.
              3.   The aggregate score for all standards is less than “8.5”.
              4.   One or more International Patient Safety Goal is scored less than a “5”.
              5.   A required follow-up focused survey has not resulted in acceptable compliance with
                   the applicable standards and/or International Patient Safety Goal requirements.



JCIA Hospital Survey Process Guide ~ 2008                                                               11
         This decision results when JCI withdraws the accreditation of an organization or when the
         organization voluntarily withdraws from the accreditation process.

II       ASSIGNMENT OF FOLLOW-UP REQUIREMENTS AS A RESULT OF A FULL
         SURVEY.

         INTRODUCTION
         Full surveys are conducted at the time of initial accreditation and at the time of re-
         accreditation, every three years. When a full survey results in one or more of the conditions
         for accreditation considered not met or partially met, the organization is provided a period
         of time to come into acceptable compliance, the follow-up period. Acceptable compliance
         can then be demonstrated by submitting a written report, or by a visit from one or more
         surveyors to the organization. A visit is named a Focused Survey, as only the standards
         and/or International Patient Safety Goal in non-compliance are the focus of the survey.
         The follow-up period is not to exceed 1 month.

         A. PROCESS
            Based on the documented findings of the accreditation survey team, the JCIA Central
            Office determines those standards and International Patient Safety Goal requirements
            for which a focused survey will be required and those standards and International Patient
            Safety Goals for which the written report has sufficiently demonstrated compliance.

         B. FOCUSED SURVEY
            • A focused survey is required within 2 months for standards and International Patient
              Safety Goals that require surveyor observation, staff or patient interviews, or the
              inspection of the physical facility to determine compliance.
            • Focused survey requirements must be completed prior to a decision by the Accreditation
              Committee.

         C. WRITTEN REPORT
            • A written report is required for standards and International Patient Safety Goals that
              require a plan, policy or procedure, or other documentation that can be sent to the
              JCI Accreditation Central office.
            • During 2008, a written report is required within 30 days when any new 3rd Edition
              standard or measurable element, as identified in Appendix A to these Rules, is scored
              less than a “5”.
            • Written report requirements can be satisfied at the time of a focused survey when
              both are required.




JCIA Hospital Survey Process Guide ~ 2008                                                            12
                                            APPENDIX A
                         HOSPITAL ACCREDITATION DECISION RULES
                          EFFECTIVE 1 JANUARY – 31 DECEMBER 2008

                         TABLE OF APPLICABLE STANDARDS
                           MEASURABLE ELEMENT
                                        (ME)                CONTENT of MEASURABLE
STANDARD
                                            Number of                   ELEMENTS
                            ME Name
                                              MEs
PFR.11                       ME#1-5            5      Harvesting & transplanting organs
                                                      Patient/family informed of unanticipated
COP.2.4                       ME#2             1
                                                      outcome of care & treatment
                                                      Outside sources of anesthesia services based
                                                      on director recommendation, acceptable
ASC.1                         ME#4             1
                                                      record performance & compliance with law
                                                      & regulation
                                                      Qualified individual(s) responsible for
                                                      management of anesthesia services (P/P,
ASC.2                        ME#1-7            7      oversight, QC program, recommending
                                                      outside sources, monitoring/reviewing
                                                      anesthesia services)
                                                      Policies/procedures guide care of moderate
ASC.3                       ME#1, 3, 4         3
                                                      & deep sedation
                                                      Plan/policy or document how medication use
                                                      is organized & managed; documented review
MMU.1                        ME#1, 4           2
                                                      of medication management system in past 12
                                                      months
                                                      Process to monitor patient response to
MMU.2.1                      ME#5-6            2      medications added to the list; annual review
                                                      medication list
                                                      Each prescription order reviewed for
MMU.5.1                     ME#2, 6,           2      appropriateness; review facilitated by record
                                                      (profile) for all patients
                                                      Process used to adapt, adopt or update at
QPS.2.1                       ME#4             1      least one guideline and one pathway per 12
                                                      months
                           ME#1 Near                  Clinical monitoring of near misses
QPS.3.6                                        1
                            misses only




JCIA Hospital Survey Process Guide ~ 2008                                                      13
                                                 Defined process for identification & analysis
QPS.7                          ME#1-3       3
                                                 of near misses
                                                 Program for identifying & reducing
                                                 unanticipated adverse events & safety risks,
QPS.10                         ME#1-4       4    including use of a proactive risk-deduction
                                                 tool annually on one or more priority risk
                                                 processes
                                                 Adequate staffing & resources allocated to
PCI.4                          ME#1, 2      2
                                                 the PCI program
                                                 Policy for reuse of single-use devices &
PCI.7.1                         ME#3        1    materials, based on elements in intent
                                                 statement
                                                 One documented performance evaluation of
GLD.1                           ME# 4       1
                                                 governance & senior management
                                                 Governance regularly receives & acts on the
GLD.1.6                         ME# 2       1
                                                 reports of the quality & safety program
                                                 Leaders process for reviewing & approving,
GLD.3.2                         ME# 4       1    before used in care, experimental procedures,
                                                 technologies, & pharmaceutical agents
                                                 Diagnostic, consultative, & treatments
                                                 services provided by independent contractors
GLD.3.3                         ME#5        1
                                                 outside the organizations are privileged by the
                                                 organization
                                                 Product/equipment recall system in place,
FMS.8.2                        ME#1-3       3    including the use of any equipment under
                                                 recall
                                                 Organization provides a staff health & safety
SQE.8.4                        ME#1-5       5
                                                 program
                                                 Policies demonstrate how privileging
                                                 decisions are reached; considers sources of
SQE.10                         ME#2, 3      2
                                                 information in intent statements as relevant &
                                                 also findings of annual performance review
                                                 Ongoing professional practice evaluation of
SQE.11                          ME#1        1    each member of the medical staff, based on
                                                 findings of quality improvement activities
                                                 Verification of credentials from original
SQE.15                          ME#3        1
                                                 source for other health profession staff
                                            51   Total MEs Capped




JCIA Hospital Survey Process Guide ~ 2008                                                  14
International Patient Safety Goals
The purpose of The Joint Commission International Patient Safety Goals is to promote specific
improvements in patient safety. The Goals highlight problematic areas in health care and describe
evidence and expert-based solutions to these problems. Recognizing that sound system design is
fundamental to the delivery of safe, high quality health care, these Goals focus on system-wide
solutions, wherever possible.

Joint Commission International (JCI) introduced the International Patient Safety Goals in 2006. JCI
surveyors evaluated compliance with these goals during accreditation surveys in 2006, but these
findings did not affect the accreditation decision. Effective 1 January 2007, hospitals were required
to demonstrate compliance with the International Patient Safety Goals in order to achieve and
maintain accreditation. Effective 1 January 2008, the International Patient Safety Goals are
published with intent statements and measurable elements similar to other JCI standards.
Organizations that design alternative approaches to meeting a Goal are required to request JCI
consideration and approval of such alternatives.




JCIA Hospital Survey Process Guide ~ 2008                                                          15
                           International Patient Safety Goals

Goal #1                 Identify Patients Correctly
                        The organization develops an approach to improve accuracy of patient
Requirement             identifications.
                        (See Intent and Measurable Elements on page 32 of 3rd Edition Standards)
Goal #2                 Improve Effective Communication
                        The organization develops an approach to improve the effectiveness of
Requirement             communication among caregivers.
                        (See Intent and Measurable Elements on page 32 of 3rd Edition Standards)
Goal #3                 Improve the Safety of High-Alert Medications
                        The organization develops an approach to improve the safety of high-alert
Requirement             medications.
                        (See Intent and Measurable Elements on page 33 of 3rd Edition Standards)
Goal #4                 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery
                        The organization develops an approach to ensuring correct-size, correct-
Requirement             procedure, and correct-patient surgery.
                        (See Intent and Measurable Elements on page 34 of 3rd Edition Standards)
Goal #5                 Reduce the Risk of Health Care–acquired Infections
                        The organization develops an approach to reduce the risk of health care-
Requirement             associated infections.
                        (See Intent and Measurable Elements on page 35 of 3rd Edition Standards)
Goal #6                 Reduce the Risk of Patient Harm Resulting from Falls
                        The organization develops an approach to reduce the risk of patient harm
Requirement             resulting from falls.
                        (See Intent and Measurable Elements on page 35 of 3rd Edition Standards)




JCIA Hospital Survey Process Guide ~ 2008                                                           16
Accreditation Preparation
After Joint Commission International (JCI) accepts the organization’s Application for Survey, both
parties make preparations for the on-site survey. To help organizations prepare for accreditation,
Joint Commission International offers seminars, custom education, numerous publications,
International Self-Assessment System (ISAS), and this Hospital Survey Process Guide. These resources
provide specific information on JCI standards and teach concepts related to hospital care. Go to
The Joint Commission Resources web site www.jcrinc.com for up-to-date information on available
educational resources.

JCI organizes a team of surveyors to match the organization’s needs and unique characteristics. JCI
will make every effort to provide surveyors fluent in the language(s) used at the organization. If JCI
surveyors with the appropriate language capabilities are not available, it is the organization’s
responsibility to provide interpreter services throughout the survey. The interpreter(s) must be fluent
in English and the language(s) used at the organization, experienced in concurrent verbal
translation, knowledgeable of medical terminology, follow recognized Medical Interpreting
Standards of Practice and abide by the confidentiality policies and regulations set up by the hospital.
The interpreter(s) should not be a member of the organization staff.

The survey follows actual patient care through the facility, and includes interviews with key
personnel, observation of the organization’s administrative and clinical activity, assessment of the
physical facilities and patient care equipment, and review of documentation. A sample survey
agenda appears on page 39-43. The actual agenda will be customized by the survey team to fit the
needs and services of your organization.

The JCI survey team leader will contact your organization approximately four to eight weeks prior to
the survey to discuss and coordinate a workable and mutually agreeable agenda. The survey team
leader identifies those services/areas which need to be included in the review and suggests the staff
who should be involved in each survey activity.

                                            Suggested “Ready to Go” List
 It would facilitate the survey process if the following items could be readily available to the
 surveyors at the time of the survey:
 • High-level organization chart
 • Accurate list of the patients currently receiving care in the hospital
 • Required Quality Monitors;
 • Required Organization Plans; and
 • Required Policies and Procedures, Written Documents, or Bylaws
 • Operative procedures schedule for the day (for main Operating Theater and Day Surgery)
 • Current map of the hospital campus
 • Sample of all medical record forms

 The list of required policies and procedures, as well as plans, appears on pages 96-102


JCIA Hospital Survey Process Guide ~ 2008                                                            17
PREPARATION TIMELINE
Organizations Requesting an Initial Survey
                                                  JCI Activity                                  Your Activity
  6 months before                                                                   Submit your Application for Survey to
  preferred month of                                                                          the
  survey                                                                            JCI Accreditation Office (electronically
                                                                                              or
                                                                                    by mail).
  Upon receipt of your              JCI Manager for Accreditation Services          Staff member(s) with knowledge of
  Application for Survey            reviews the application.                        your organization’s services, sites, and
                                    You will be e-mailed a complimentary copy of    patient volume will need to complete
                                    this Hospital Survey Process Guide.             and submit the Application for Survey
                                                                                    (electronically or by mail). The
                                                                                    application should be received by JCI
                                                                                    no later than 4-6 months before the
                                                                                    preferred survey dates.



Organizations Requesting Re-accreditation
                                JCI Activity                                        Your Activity
  6-9 months before the         An Application for Survey is e-mailed to prepare
  due date of your next         for the next on-site survey.
  triennial survey
  Within two months of                                                              Staff member(s) with knowledge of
  receiving the Application                                                         your organization’s services, sites, and
  for Survey from JCI                                                               patient volume will need to complete
                                                                                    and submit the Application for Survey
                                                                                    (electronically or by mail). The
                                                                                    application should be received by JCI
                                                                                    no later than 4-6 months before the
                                                                                    preferred survey dates.

   All Organizations Requesting Accreditation
                              JCI Activity                                          Your Activity
4–6 months before             A proposed contract agreement is e-mailed to the      The signed contract should be e-mailed
survey                        organization.                                         or faxed to JCI no later than 60 days
                                                                                    prior to the survey date. Notify your
                                                                                    accounts payable staff to expect an
                              An invoice for down payment of the first 50% of the   invoice and remit payment with the
                              survey fees is e-mailed by the Finance Department     wire transfer form (found in the
                              when the signed contract is received.                 application) no later than 45 days prior
                                                                                    to survey date.
8 weeks before survey         Verification of survey date(s) and names of
                              surveyor(s) are e-mailed to the organization.
4 - 8 weeks before survey     The survey team leader contacts your organization’s   Appropriate staff member(s) will need
                              survey coordinator to finalize your survey agenda     to discuss the proposed survey agenda
                              and to request pre-survey information.                and determine whether times are
                                                                                    feasible for your organization, given



JCIA Hospital Survey Process Guide ~ 2008                                                                              18
                             JCI Activity                                            Your Activity
                                                                                     patient needs and availability of staff.
Survey                       Surveyor(s) arrives for on-site survey. At the          During the survey, staff should be
                             conclusion of the survey, you receive a copy of the     available as outlined on the survey
                             exit report, which details partial or non-compliant     agenda.
                             areas identified during survey. This report is not
                             final until the JCI central office staff has reviewed
                             the report and discussed each of the findings with
                             the survey team and JCIA leadership.
Within 60 days after         JCI reviews and approves official report of survey      For any standards scored as non-
survey                       findings. A follow-up written report or focused         compliant, submit the follow-up written
                             survey may be required prior to an accreditation        report as requested to JCI.
                             decision determination. If the accreditation is
                             granted, the award letter, report, and accreditation    The CEO of the surveyed organization
                             certificate are mailed when all the survey fees and     should encourage members of the
                             expenses have been paid. The gold seal guidelines       leadership team to provide input into
                             and publicity kit will also be posted to the            completion of the JCIA Satisfaction
                             Accredited Organization Resource Center at the JCI      Survey.
                             website
                             (www.jointcommissioninternational.org/accredited.

                             The CEO of the surveyed organization will be sent a
                             Satisfaction Survey to assist JCIA in performance
                             improvement activities.
Within 2 weeks after the     Your organization’s name, location, and date of
certificate is mailed        accreditation is added or updated for public viewing
                             on the JCI web site at:
                             www.jointcommissioninternational.org

Ongoing                      Each accredited organization will have access via the   Staff should review all changes featured
                             JCI website Accredited Organization Resource            in the newsletter to keep abreast of
                             Center to the JCI newsletter, e-zine, as well as many   changes and developments in the
                             other resources, publications and services that will    standards and survey process.
                             assist in achieving continuous compliance with the      Compliance with new standards and
                             standards.                                              survey processes for accredited
                                                                                     organizations is required.
                                                                                     Staff should review the new
                                                                                     accreditation manual or supplement to
                                                                                     act on any new and modified standards,
                                                                                     scoring guidelines, policies, and
                                                                                     procedures.
Within 30 days of any                                                                The organization must notify JCI (via
significant                                                                          letter, fax, or e-mail) of any significant
organizational changes                                                               change in the organization (as defined
                                                                                     in the “Joint Commission International
                                                                                     Accreditation Policies and Procedures”
                                                                                     chapter of the hospital standards
                                                                                     manual).
6-9 months before the        An Application for Survey is mailed to the
due date of your next        organization to prepare for the next on-site survey.
triennial survey




JCIA Hospital Survey Process Guide ~ 2008                                                                                19
                                                    Accreditation Process Timeline
Obtain JCI Standards
 manual and begin                                                                                             Submit revised
                                   Receive and complete JCI                                                   application and
 preparing for JCI                    Survey Contract and                       JCI                        schedule triennial JCI
   Accreditation                    invoices for survey fees               Accreditation                       Accreditation
                                                                           survey occurs                         resurvey




                                                                                                                                     Continuous
  12-24 Months          6-9 Months         4-6 Months       2 Months                        Within 2        6-9 Months Prior
                                                                               Survey                                                  quality
     Prior to             Prior to           Prior to        Prior to                      Months After     to Triennial Due        improvement
                                                                                Dates
     Survey               Survey             Survey          Survey                          Survey               Date                journey




                   Submit application                    JCI Survey Team                  Receive Accreditation
                    for survey to JCI,                  Leader contacts your              Decision and Survey
                                                          organization to               Findings Report from JCI
                      and schedule
                                                         determine survey
                    survey dates with
                           JCI                          agenda and logistics




     JCIA Hospital Survey Process Guide ~ 2008                                                                                            20
Joint Commission International
Accreditation




 Survey Application

 for
 HOSPITALS




                                   September 2008


Survey Application for Hospitals            21
      JOINT COMMISSION INTERNATIONAL ACCREDITATION
                                   Application for Survey of a Hospital
             INIITAL ACCREDITATION                               TRIENNIAL ACCREDITATION
                (Please check one)

 I.     APPLICANT INFORMATION
        1.   Organization Name:
             (The entry text below, as entered, will be used for your certificates. A maximum length of 60-
             characters is allowed.)



        2.      Address:

                         [street number]


                         [city/province and/or state]


                         [postal code]


                         [country]

                Website:


        3.      Main Telephone Number:

                 [country code]      [city code]    [number]

        4.      Ownership:

                [Owner Name/Parent Company]


                [Ownership Type]
                (e.g. private-non governmental, governmental-military)




Survey Application for Hospitals                                                                      22
                Ownership Address: (if different from above)

                [street number]


                [city/province and/or state]


                [postal code]


                [country]

        5.      Ownership Primary Contact:
                Name:
                                    [Mr./Mrs./Miss/Ms./Dr.]

                Title:

                E-mail:

                Tel:
                            [country code]     [city code]         [number]

                Mobile:
                              [country code]         [city code]       [number]

                Fax:
                            [country code]     [city code]         [number]

        6.      Staff Information:
                Chief Executive Officer: (or equivalent)
                Please note that this person will receive the Customer Satisfaction Survey
                Name:
                                               [Mr./Mrs./Miss/Ms./Dr.]

                Title:

                E-mail:

                Tel:
                                    [country code]       [city code]          [number]




Survey Application for Hospitals                                                             23
                Mobile:
                            [country code]          [city code]       [number]

                Fax:
                                   [country code]       [city code]          [number]

                Chief Medical Director: (or equivalent)
                Name:
                              [Mr./Mrs./Miss/Ms./Dr.]

                Chief Nursing Director: (or equivalent)
                Name:
                              [Mr./Mrs./Miss/Ms./Dr.]

                Representative of Governing Board: (or equivalent group)
                Name:
                              [Mr./Mrs./Miss/Ms./Dr.]


                Survey Coordinator or equivalent: (provide contact information)
                Name:
                              [Mr./Mrs./Miss/Ms./Dr.]

                Title:

                E-mail:

                Tel:
                          [country code]     [city code]          [number]

                Mobile:
                            [country code]          [city code]       [number]

                Fax:
                          [country code]     [city code]          [number]



        7.      Name and Title of Individual Responsible for Application:
                Name:
                [                  Mr./Mrs./Miss/Ms./Dr.]

                Title:

                E-mail:



Survey Application for Hospitals                                                        24
                Tel:
                          [country code]   [city code]   [number]

                Mobile:
                          [country code]   [city code]   [number]

                Fax:
                          [country code]   [city code]   [number]




Survey Application for Hospitals                                    25
 II.      ORGANIZATIONAL DESCRIPTION

    8.     Number of Inpatient Beds (currently in operation):

    9.     Average Daily Inpatient Census:

    10.    Ambulatory/Outpatient Annual Visits:
            (Includes clinics, outpatient surgery, radiology, etc.)

    11.    Emergency Room Visits:

    12.    List the Clinical Medical Services currently provided by the Organization:
            (e.g., obstetrical, surgical, radiology, laboratory, pediatrics, psychiatry)




    13.    List the Clinical Medical Services licensed that the Organization is currently
           licensed to provide:




    14.    List any additional Clinical Medical Services or structure changes that will occur
           within the next 12 months.




Survey Application for Hospitals                                                           26
    15.   List the Top Five Patient Discharge Diagnoses and the Top Five Surgical
          Procedures Performed:
          (This can be used to prepare the patient record list in advance without taking time from the document review session.)

                    Top Five Diagnoses                              Top Five Surgical Procedures




    16.   List Hospital Departments or Services: (non-clinical services that support hospital
          services) (e.g., human resources, housekeeping, dietary, information systems, finance)




    17.   List any Contracted Services:




Survey Application for Hospitals                                                                                           27
    18.   Do you own and operate a medical transport service?
                 Yes If you answered “yes”, continue to #19 and #20 below.
                   No      If you answered “no”, please skip to question #21.

    19.   Number of medical transports per year?

    20.   Does your medical transport services use advanced life support/paramedics?



    21.   In what language is the medical record documentation written?


    22.   In what language is the patient care conducted?


    23.   In what language are the policies, procedures and committee minutes?




Survey Application for Hospitals                                                       28
    24.   Site Demographics. List the buildings /locations in which care is provided to patients.
          List sites separately wherever there is a distinct street address. Buildings with the same
          address or connected site should be considered as one site. (Use separate sheet if needed)

 Building Name /                   Location       Main or Additional Site           How many
     Number                                                                      kilometers from
                                                                                    main site?




Survey Application for Hospitals                                                                29
    25.   Inpatient Care Units/Wards. List Inpatient Care Units/Wards, the Number of
          Beds, and The Type of Care Given on each Unit/Ward. (See examples below. Use
          separate sheet if needed.)
          NOTE: Do not include/combine more than one patient unit/ward. It is critical that the team
          knows each area that houses patients in order to randomly select those areas that will be visited
          when utilizing tracer methodology. The team must be knowledgeable of all patient care areas on-
          site as well as the areas separate from the hospital. Please list “Yes” in the anesthesia / sedation
          column if any level of sedation is administered on the unit/ward.

   Name of         Number               Type of           Floor       Facility/Site        Anesthesia /
  Unit/Ward        of Beds             Care Given                                            Sedation
                                                                                           Administered
  Ward A               32          Intensive Care            3     Main site                   Yes
  Ward B7              10          Mental Health             2     Building C                  No




Survey Application for Hospitals                                                                         30
    26.   List the number of surgical/operating room theaters located in the organization.
          (Include all buildings where care is provided. E.g., main operating theater, obstetrics operating theater,
          cardiac operating theater, pediatric surgery operating theater.)


                    Operating Room Theater                             Building Name




Survey Application for Hospitals                                                                               31
    27.   Ambulatory/Outpatient Units/Clinic. List Ambulatory/Outpatient Units, the
          Number of Visits and the Type of Service Provided (See examples below. Use separate
          sheet if needed.)
          NOTE: It is essential that all outpatient settings on-site and off-campus are listed so that
          the total out-patient areas are known. Include specific information for each of the areas.
          For example, if the area would require visits on specific days or if the clinic hours would
          not fall within the survey hours of 8:00 a.m. and 5:00 p.m. Please list “Yes” in the
          anesthesia / sedation column if any level of sedation is administered in the
          ambulatory/outpatient unit.

     Name of           Number          Type of          Floor                          Anesthesia /
  Ambulatory/          of Annual      Care Given                    Facility/Site        Sedation
 Outpatient Unit         Visits                                                        Administered
     or Clinic
Surgery Center             225      Podiatry              1      Building G                  Yes
Behavioral Health          175      Mental Health         1      Main Site                   No
Outpatient Clinic




Total Number of
Annual Visits




Survey Application for Hospitals                                                                   32
       28.    Please provide your usual hours of operation, such as for Outpatient/Ambulatory
              Clinics, and provide information on any daily religious observances, staff functions,
              etc. that will need to be part of or affect the survey agenda and activities of the
              survey team.




III.         HOME CARE SERVICES

             29.   Does your organization provide services in the patient’s home:
                      Yes If you answered “yes”, please complete #30 and #31 below.
                      No If you answered “no”, please skip to question #32 in the next section.

             30.   Average number of patients visited in the home per day by all staff:



             31.   Please indicate the type of care provided in the patient’s home:
                          Home Health (nursing service)
                          Personal Care and support
                          Home Medical Equipment
                          Home Pharmacy
                          Hospice Service/Palliative Care in the home
                          Other (please describe)




Survey Application for Hospitals                                                                  33
 IV.    SCHEDULING AND TRAVEL                  (Section must be completed in full)

        32.     Please indicate three months in which the organization could have the survey
                scheduled:

                                       Month               Year




        33.     Please specify any time periods during the year for which you would not like
                the survey to take place., if the preferred months cannot be accommodated.

                                 From                            To
                               DD/MM/YY                       DD/MM/YY




        34.     Travel Instructions:*
                Air Transportation:
                Please indicate the airport(s) nearest to your organization that the surveyors should
                fly into:




Survey Application for Hospitals                                                                   34
                Ground Transportation:
                Please provide the following instructions to assist the surveyors in making
                their ground transportation arrangements.

                Travel directions from airport to hotel:




                Travel directions from hotel to organization:




                Recommended method of transport (taxi, car service):




                Assembly point at organization when surveyors arrive:




                Recommended Hotel Accommodations:
                (internet access is required)

            Please recommend two to three business oriented hotels near your organization that have
            internet access. Internet access is required for the surveyors to complete the survey report
            each evening. If possible, please include the Marriott, Hilton or Intercontinental hotel nearest
            to your organization, as these hotels provide preferred rates for the surveyors. If your
            organization has a preferred rate with business hotels near your organizations, please include
            the specific information and directions for obtaining the preferred rates for surveyors.




Survey Application for Hospitals                                                                       35
    Hotel Name                   Address                       Telephone/Fax             E-mail / Web Site
                                                               (please include country
                                                               and city code)




*For insurance/security purposes the survey team is required to make travel reservations through JCI's travel agent.

             35.    Please enter any comments or other information you feel may be pertinent to
                    your survey.




     Survey Application for Hospitals                                                                           36
 V.     FINANCE
        36.  Name and title of individual responsible for processing invoices and
             payments:

                 Name:
                                   [Mr./Mrs./Miss/Ms./Dr.]

                 Title:

                 E-mail:

                 Tel:
                                   [country code]    [city code]       [number]

                 Fax:
                                   [country code]    [city code]       [number]

        37. Does your organization have any special billing requirements?
            For example, (if you will be billed for the surveyors’ travel and maintenance expenses)




        38. Does your organization require an itemized statement of charges in addition to
            the standard invoice?
                  Yes          No

        39. Does your organization require receipts for the expenses?
                 Yes           No

        40. All invoices are sent to the billing contact by email. Does your organization also
            require an original copy sent by mail/courier?
                  Yes            No

        **All invoices are due upon receipt. Payments should be made by wire transfer. Included
        with your contract will be a wire transfer form with the detailed information to transfer funds
        to our bank. VERY IMPORTANT - Please complete and submit the wire transfer form to
        the fax number or email address listed on the form so we can properly credit your account
        once the payment is received.




Survey Application for Hospitals                                                                      37
                 (THIS PAGE/SECTION WILL NEED TO BE PRINTED AND FAXED TO JCI.)
                                               WIRE TRANSFER FORM

                Please complete the following information and fax or email this form to JCI
                prior to the wire transfer so we can properly credit your account once the
                payment is received.

                                          JCI’s fax number is +1-630-792-2992
                                         e-mail: AccountsReceivable@jcrinc.com

             Organization:

             Name:

             Telephone Number:
                                             Country Code      City Code       Number


             Fax Number:
                                             Country Code      City Code       Number


             Amount of Transfer:             USD$

             Date transfer will occur:

             Service dates from:                                       (to)

             Transfer description
             (invoice number):


                The wire transfer, in U.S. dollars, should be sent to JCI’s account at:

                                                The Northern Trust Bank
                                                 One Oakbrook Terrace
                                         Oakbrook Terrace, Illinois 60181, U.S.A.

                                            JCI's account number is: 1054386
                                             JCI’s Swift Code: CNORUS44
                                            JCI’s ABA number is: 071000152

                Any fees incurred for the wire transfer will be the responsibility of the payor.
                If you have any questions concerning the wire transfer please contact Bonnie Quinn
                at JCI phone +1-630-268-7492 and fax +1-630-268-2992




Survey Application for Hospitals                                                             38
 VI.    AUTHORIZATION

        The undersigned makes request to Joint Commission International for an accreditation
        survey of the Applicant Organization named below. By signing this document we hereby
        provide accurate and truthful information within this application. I am authorized to make
        this agreement on behalf of:

        Name of Applicant Organization:



        Name:

        Title:

        Signature:

        Date:




           Return Completed Application by FAX or EMAIL To:
                          Joint Commission International Accreditation
                                   Fax: +1 630 268 2921
                           E-mail: jciaccreditation@jcrinc.com




Survey Application for Hospitals                                                              39
The On-Site Survey

The purpose of a Joint Commission International (JCI) accreditation survey is to assess the extent of
an organization’s compliance with applicable JCI standards. Organizations undergoing their first
survey need to demonstrate a track record of four months of compliance with the standards.
Organizations being resurveyed need to demonstrate twelve months of compliance with the
standards. Understanding the organization and assessing compliance is accomplished through a
number of methods including the following:
     receipt of verbal information concerning implementation of standards, or examples of their
     implementation, enabling analysis of compliance;
     on-site observation by JCI surveyors; and
     review of documents that demonstrate compliance and assistance in orienting surveyors to the
     organization’s operations.

The on-site survey uses the “tracer methodology” to follow a sample of active patients through their
experiences of care in the organization and to evaluate individual components of care and systems
of care.

An important characteristic of the JCI survey process is on-site evaluation education conducted by
the surveyors. This support occurs throughout the survey as surveyors’ offer suggestions for
approaches and strategies that may help the organization better meet the intent of the standards and,
more importantly, improve performance.

The on-site evaluation consists of the following steps:
       Opening conference and orientation to the organization
       Survey planning meeting
       Leadership interview
       Patient care and service area visits guided by patient and system tracer activities
       Competence assessment
       Facilities management reviews and building tour(s)
       Exit conference

Front-Line Staff Ownership of the Process
Involving staff in the accreditation process and continuing to involve them through ongoing
assessments and review of processes and systems enhance ownership, which results in
continued safe and quality care for patients and their families.




JCIA Hospital Survey Process Guide ~ 2008                                                          40
                                                  Sample Survey Agenda
                                                 Joint Commission International
                                                        Name of Hospital
                                                         Date of Survey

                                                      (5 Day-3 Surveyors)



                                                         DAY ONE

                              Physician                            Nurse                      Administrator


08:00 - 08:30                                                Opening Conference


08:30 – 10:30                                                 Document Review


10:30 – 11:00                                             Surveyor Planning Session


11:00 - 12:00               Hospital’s Overview of Organization Services and Quality Improvement Plan
                      [Orientation of Surveyors to the Organization (Organization Chart) and the Quality
                   Improvement Process. A brief (10 minutes) Quality Improvement example may be included
                      demonstrating the Organization’s methodology as well as sustained improvement.]


12:00 - 13:00                                                Lunch and Tracer Planning
                                        (Surveyors will eat alone as this time is used for planning)


13:00 - 16:00         Individual Tracer Activity            Individual Tracer Activity          Facility Tour


16:00 - 16:30                            Survey Integration/Document Review/Tracer Planning




     JCIA Hospital Survey Process Guide ~ 2008                                                                  41
                                    Joint Commission International
                                           Name of Hospital
                                            Date of Survey


                                                       DAY TWO

                              Physician                          Nurse                        Administrator



08:00 - 08:30                                                 Daily Briefing
                        (Time for surveyors to share with the organization observations from previous day)


08:30 - 10:30                                           Infection Control System               Facility Tour
                                                                  Tracer
                     Individual Patient Tracer

10:30 -12:00                                            Individual Patient Tracer        Review of Selected FMS
                                                                                              Documents


12:30 - 13:00                                               Lunch and Tracer Planning
                                        (Surveyors will eat alone as this time is used for planning)


13:00 - 16:00        Individual Patient Tracer          Individual Patient Tracer       Individual Patient Tracer


16:00 – 16:30                               Survey Integration/Document Review/Tracer Planning




JCIA Hospital Survey Process Guide ~ 2008                                                                  42
                                    Joint Commission International
                                           Name of Hospital
                                            Date of Survey



                                                      DAY THREE

                              Physician                          Nurse                        Administrator



08:00 - 08:30                                                 Daily Briefing
                         (Time for surveyors to share with the organization observations from previous day)


08:30 - 11:00       Medication System Tracer                                            Individual Patient Tracer
                                                        Individual Patient Tracer

11:00 - 12:00        Individual Patient Tracer                                             FMS System Tracer


12:00 - 13:00                                               Lunch and Tracer Planning
                                        (Surveyors will eat alone as this time is used for planning)


13:00 - 14:00        Individual Patient Tracer          Individual Patient Tracer       Individual Patient Tracer


14:00 – 16:00          Staff Qualifications &             Staff Qualifications &         Staff Qualifications &
                      Education Interview for            Education Interview for      Education Interview for other
                            Medical Staff                  Nursing Personnel               hospital Personnel


16:00 – 16:30                               Survey Integration/Document Review/Tracer Planning




JCIA Hospital Survey Process Guide ~ 2008                                                                 43
                                    Joint Commission International
                                           Name of Hospital
                                            Date of Survey


                                                       DAY FOUR

                              Physician                          Nurse                        Administrator



08:00 – 08:30                                                  Daily Briefing
                         (Time for surveyors to share with the organization observations from previous day)


08:30 – 10:00        Individual Patient Tracer          Individual Patient Tracer       Individual Patient Tracer


10:00 – 11:00         Patient Safety Systems              Patient Safety Systems          Patient Safety Systems
                            Evaluation                          Evaluation                      Evaluation

11:00 – 12:00       Review of Selected Closed           Review of Selected Closed       Individual Patient Tracer
                         Patient Records                     Patient Records


12:00 – 13:00                                               Lunch and Tracer Planning
                                        (Surveyors will eat alone as this time is used for planning)


13:00 – 16:00        Individual Patient Tracer          Individual Patient Tracer       Individual Patient Tracer


16:00 – 16:30                               Survey Integration/Document Review/Tracer Planning




JCIA Hospital Survey Process Guide ~ 2008                                                                 44
                                     Joint Commission International
                                            Name of Hospital
                                             Date of Survey


                                                    DAY FIVE

                              Physician                       Nurse                       Administrator



08:00 - 09:00                                          GLD Interview Session


09:00 - 10:30       Individual Patient Tracer        Individual Patient Tracer      Individual Patient Tracer


10:30 - 12:00                                              Data System Tracer


12:00 - 13:00                                                     Lunch
                                   (Surveyors will eat alone as this time is used for Integration)


13:00 - 15:00                                Surveyors Complete Integration of Findings
                                                         (Surveyors Only)


15:00 - 16:00                                     Leadership Briefing Conference


16:00 – 16:30                                      Organization Exit Conference
                    (Leaders can decide who participates in this session; the size of the group is not limited.)




 JCIA Hospital Survey Process Guide ~ 2008                                                               45
The Accreditation Decision
The final accreditation decision is based on your organization’s compliance with Joint Commission
International (JCI) standards. Organizations do not receive a numeric score as part of the final
accreditation decision. When an organization successfully meets the JCI requirements, it will be
awarded an accreditation decision of:

•   Accredited
    This decision indicates that an organization is in compliance with all applicable standards at the
    time of the on-site survey or has successfully addressed all survey requirements for improvement
    in its written report within 60 days after survey for re-surveys, or within six months for initial
    surveys.

Promoting Your Accreditation
After you have received official notification of the accreditation decision, publicize your
achievement of international accreditation by notifying patients, the public, the local media, third-
party payers, and resident referral sources. JCI provides a free publicity kit to accredited
organizations that includes:
    • Suggestions for celebrating your accreditation
    • Guidelines for publicizing your JCI accreditation
    • Frequently asked questions
    • Sample news release
    • Fact sheet

Information about your accreditation status will be posted on JCI web site,
www.jointcommissioninternaitonal.org. The web site allows anyone to locate JCI accredited
organizations within a country.

The Continuing Accreditation Cycle
The accreditation process does not end when the on-site survey is completed. In the three years
between on-site surveys, Joint Commission International will continue to monitor for compliance
with all of the JCI hospital standards on an ongoing basis throughout the three year accreditation
cycle. For this reason, it is very important that the organization maintain compliance with the
standards between on-site surveys.

Continuous survey compliance means less focus on the “ramp up” for survey every three years.
Instead, organizations can and should continually improve their systems and operations, eliminating
the need for intense survey preparation. Continuous compliance with the JCI standards directly
contributes to the maintenance of safe, quality care and improved organizational performance.




JCIA Hospital Survey Process Guide ~ 2008                                                           46
                             SURVEY AGENDA

                           Detailed Descriptions




JCIA Hospital Survey Process Guide ~ 2008          47
Opening Conference
PURPOSE:
During the opening conference, the surveyor(s) describes the structure and content of the survey to
the organization

LOCATION:            At the discretion of the hospital

HOSPITAL PARTICIPANTS:
  Chief Executive Officer
  Individual responsible for coordinating the hospital’s survey agenda
  Others at the discretion of the organization

SURVEYORS:             All surveyors

STANDARDS / ISSUES TO BE ADDRESSED:
Introduction and coordination of the survey

DOCUMENTS/MATERIALS NEEDED:
Final survey agenda

WHAT WILL OCCUR:

    •    Introduction of surveyors
    •    Introduction of hospital leadership
    •    Review and modify agenda
    •    Surveyors will answer questions about the survey agenda; explain the scoring of compliance
         to the standards, and pertinent decision rules pertaining to the submission of the preliminary
         report to the Accreditation Committee. The team leader will explain that scoring of
         compliance to the standards will be limited to those processes that have been implemented
         prior to the beginning of the survey. The survey team will not be able to score compliance
         to a standard if new or revised policies, procedures, or practices are made during the
         survey, since the team would not have sufficient time to determine the effectiveness of
         these activities.
    •    Surveyors will explain the use of the Tracer Methodology during the survey process
         activities.
    •    Surveyors will advise leaders the only presentation allowed during the survey is scheduled on
         the survey agenda for the session entitled, Hospital Overview of Organization Services and
         Quality Improvement Plan. The surveyor will follow the planned survey agenda when
         conducting the tracer activities. Staff should be prepared to answer questions. The surveyor
         will also obtain pertinent information through various other methods.
    •    Surveyors will explain the concept of “drilling down” as an interviewing technique/
         approach that has the aim of gathering specific information about a process or outcome.
         Staff members involved in “drilling down” inquiries should not perceive this approach as


JCIA Hospital Survey Process Guide ~ 2008                                                            48
         personal or necessarily an indication of non-compliance. It is an indication that the
         surveyor(s) are evaluating the establishment of systems to support a process.
    •    Surveyors will explain the staff involvement in the patient record review process.
    •    Surveyors will explain the staff involvement in the staff qualifications and education
         interview.
    •    Surveyors will explain the purpose and the leaders’ involvement in the daily briefing sessions.
    •    The hospital staff will be encouraged to ask questions and seek clarification from surveyors
         throughout the survey process.
    •    Hospital staff will notify the surveyors where lunch will be served or where they can
         purchase lunch.
    •    Hospital staff will identify country-specific information that would ensure that the survey
         team observes significant customs and values of the organization during the survey process,
         especially if observance of customs impacts the survey agenda. For example, how would the
         organization prefer that surveyors conduct survey sessions during times that staff members’
         participate in prayer activities? Hospital staff should indicate how staff members would
         prefer to be addressed and discuss the use of interpreters, when needed.
    •    Hospital staff will show the surveyors where they can meet with each other. This should be
         the same room where documents are gathered for surveyor review.
    •    Hospital staff will introduce the surveyors to the staff member who will provide assistance
         throughout the day. This staff person will help the surveyor move quickly between hospital
         locations and maintain the planned schedule. This staff person is usually a leader of the
         organization or the survey coordinator.

HOW TO PREPARE:

•   Identify a meeting or conference room large enough for the surveyors to meet with the key
    hospital leaders and survey coordinator(s).
•   Confirm that computers with high-speed internet connectivity and a document printer are in the
    room and available for the surveyors to use.
•   Notify hospital receptionists so they can direct the surveyors to the appropriate room when they
    arrive.
•   Have copies of the survey agenda available for all participants in the opening conference.
•   Prior to the survey, decide which hospital leader or staff member will accompany each surveyor
    throughout the survey day.
•   Arrange for surveyors to be served or purchase lunch.
•   Notify hospital staff of the survey agenda.
•   Each surveyor will wear a name badge that will identify him or her as a JCIA surveyor. If the
    organization requires additional organization identification, prepare and make it available to
    surveyors in the opening conference.




JCIA Hospital Survey Process Guide ~ 2008                                                             49
Orientation to the Organization’s Services and the Quality
Improvement Plan

PURPOSE:
The organization orients the surveyor(s) to the services the organization provides and its Quality
Improvement process. This provides the surveyor(s) with baseline information about the
organization and the quality and safety program that can help focus subsequent survey activities.

LOCATION:            At the discretion of the hospital

HOSPITAL PARTICIPANTS:
  Chief Executive Officer
  Individual responsible for coordinating the hospital’s survey agenda
  Medical Staff Leadership
  Nursing Leadership
  Staff responsible for Quality Management and Patient Safety Program, if applicable
  Others at the discretion of the organization

SURVEYORS:             All surveyors

STANDARDS / ISSUES TO BE ADDRESSED:
Overview of the organization’s services
Overview over the Quality and Safety Program and Process

DOCUMENTS/MATERIALS NEEDED:
Organization chart
Quality improvement example

WHAT WILL OCCUR:
  1. The organization will give a presentation about the structure and methods of the quality
     Improvement and patient safety program.
  2. The presentation should show how quality and safety information flows through the
     organization/committee structure
  3. The presentation should describe
         a. how quality and safety measures have been chosen
         b. how the measures were prioritized for data collection
         c. how data are collected, aggregated and analyzed
         d. how findings from data analysis are communicated and used for planning
            improvements.
  4. The organization may choose to present a quality improvement example to demonstrate the
     organization’s methodology as well as sustained improvement.




JCIA Hospital Survey Process Guide ~ 2008                                                            50
Surveyor Planning Session

PURPOSE:
During this session, the surveyor(s) reviews data and information about the organization and plans
the survey agenda. The surveyor(s) also selects initial tracer patients/residents/clients.

LOCATION:
The organization is asked to have space available for this activity, usually the room designated as the
“surveyor headquarters.” This space should have the following:
    • conference table
    • power outlets
    • telephone
    • Computers with high speed internet connection/access
    • printer

HOSPITAL PARTICIPANTS:

Organization Survey Coordinator (as needed by team)

SURVEYORS:             All surveyors on site

WHAT OCCURS:
This time is set aside for the surveyor(s) to review and discuss pertinent data and plan the survey
agenda. The surveyor(s) review the following (as applicable to the setting):
Note: These materials should remain available to the surveyors for the entire duration of the survey.
•   Performance improvement data
•   Infection control surveillance data
•   Facility Management and Safety Plan annual reviews. Surveyors should review in preparation for the
    Facility Tour session
•   Facility Management and Safety multidisciplinary team meeting minutes for the 12 months prior to
    survey. Surveyors should review in preparation for the Facility Tour session.
•   List of departments/units/areas/programs/services within the organization (if applicable)
•   An organization chart and map of the organization
•   List of scheduled home visits for the duration of the survey including type of service, disciplines, date
    of admission, and location. Includes branch locations (if applicable).
•   Key contact person (e.g., supervisor, scheduler) who can assist surveyors in planning tracer selection

Selection of Individual Tracers
•   Surveyors review the information from the survey application and the list of patients currently
    receiving care in the hospital to guide their selection of patients to trace.



JCIA Hospital Survey Process Guide ~ 2008                                                                   51
•   Surveyors identify a clinical/service group and some general information about the patient population
    receiving care and services.
•   Surveyors describe to the organization the type of patient that they are seeking to trace and request
    staff’s assistance in identifying an individual.
•   In surveys exceeding one day, the surveyor(s) informs the organization during the morning daily
    briefing about the types of tracers he or she wants to perform that day to facilitate activity planning.
    This does not mean that the surveyor(s) will identify a specific patient from the list supplied by the
    organization. For example, the surveyor(s) may choose to trace:
    o A hospital orthopedic surgery patient who is receiving physical therapy
    o A home care patient who is receiving surgical wound care
    o An ambulatory patient who visited the internal medicine clinic and had laboratory services
    o A patient with limited mobility, who smokes, who uses oxygen, or has cognitive impairment
    o An intensive care patient who is receiving blood gas testing
    o A patient with developmental disabilities
•   In team surveys, tracer selection should be coordinated to avoid overlap of visits to various units to
    the extent possible.
•   In organizations with multiple sites, individual tracers will include patients who move between
    locations and services addressed by the represented accreditation programs.
•   The Individual Tracer Activity Guide provides more detailed information on tracer selection.




JCIA Hospital Survey Process Guide ~ 2008                                                                      52
Document Review

PURPOSE:
The purpose of the document review is to survey standards that require some written evidence of
compliance, such as an emergency preparedness plan or a patient rights document. Additionally, the
purpose of the document review is to orient the survey team to the organizational structure and
management structure of the hospital.

LOCATION:
A meeting room or office that will be used throughout the duration of the survey as a meeting place
and work area for the survey team.

HOSPITAL PARTICIPANTS:
Participants should include hospital staff members that are familiar with the documents, can
translate them, and respond to questions that the surveyors may have during the session. At the
discretion of the team, surveyors may designate a limited number of staff members to attend and
participate in the document review session. The session may be conducted as an interview of staff
about the documents. This approach has been very effective when language barriers exist and the
survey activities necessitate the use of professional interpreters.

SURVEYORS:                  All members of the survey team

STANDARDS/ISSUES TO BE ADDRESSED:
Almost all standards chapters make reference to plans, policies, procedures, etc. that are to be
written. The next section and the back of this guide will assist in understanding the particular
documents that are a part of the accreditation survey.

DOCUMENTS/MATERIALS NEEDED:
The documents that should be available to the survey team for their review or reference during the
survey process are listed at the back of this guide. The lists are:

    1. Required Quality Monitors
    2. Required Organization Plans
    3. Required Policies and Procedures, Written Documents, or Bylaws
    4. Accurate list of the patients currently receiving care in the hospital
    5. Operative procedures schedule for the day (for main Operating Theater and Day Surgery)
    6. Current map of the hospital campus
    7. Sample of all medical record forms




JCIA Hospital Survey Process Guide ~ 2008                                                            53
In addition, the organization should complete and have available for the survey teams the worksheet
related to relevant national or local health care related laws and regulations. The Law and Regulation
Worksheet is located at the back of this guide.


The documents that must be available to the surveyors in ENGLISH are listed below:

    1. The policies and/or procedures require the use of two patient identifiers, not including the
       use of the patient’s room number or location. (IPSG 1)

    2. A collaborative process is used to develop policies and/or procedures that will establish
       uniform processes to ensure the correct site, correct procedure, and correct patient,
       including procedures done in settings other than the operating theatre. (IPSG 4)

    3. The organization has established entry and/or transfer criteria for its intensive and
       specialized services or units, including research and other programs to meet special patient
       needs (ACC.1.4)

    4. There is policy guiding the appropriate transfer of patients (ACC.4)

    5. The organization has listed those procedures and treatments that require separate consent.
       (PFR.6.4.1)

    6. Policies and procedures guide the procurement and donation process. (PFR.11)

    7. Organization policy and procedure define the assessment information to be obtained for
       inpatients. (AOP.1)

    8. Organization policy and procedure define the assessment information to be obtained for
       outpatients. (AOP.1)

    9. Organization policy identifies the information to be documented for the assessments.
       (AOP.1)

    10. The scope and content of assessments by each clinical discipline are defined in policies.
        (AOP.1.1)

    11. The scope and content of assessments performed in inpatient and outpatient settings are
        defined in policies. (AOP.1.1)

    12. The handling, use, and administration of blood and blood products is guided by
        appropriate policies and procedures. (COP.3.3)

    13. The care of comatose patients is guided by appropriate policies and procedures. (COP.3.4)

    14. The care of patients who are on life support is guided by policies and procedures. (COP.3.4)


JCIA Hospital Survey Process Guide ~ 2008                                                             54
    15. The care of patients on dialysis is guided by appropriate policies and procedures. (COP.3.6)

    16. The care of patients receiving chemotherapy or other high-risk medications is guided by
        appropriate policies and procedures. (COP.3.9)

    17. Policies and procedures guide the safe prescribing, ordering and transcribing of
        medications in the organization. (MMU.4)

    18. Policies and procedures address actions related to illegible prescriptions and orders.
        (MMU.4)

    19. Acceptable medication orders or prescriptions are defined in policy(s) and at least
        elements a) through i) are addressed in the policy(s). (MMU.4.1)

    20. A medication error and near miss are defined. (MMU.7.1)

    21. The hospital leaders have established a definition of a sentinel event that at least includes a)
        through c) found in the intent statement. (QPS.5)

    22. Other events defined by the organization are analyzed (QPS.6)

    23. The organization establishes a definition of a near miss and the type of events to be
        reported. (QPS.7)

    24. There is a comprehensive program and plan to reduce the risk of health care– associated
        infections in patients. (PCI.5)

    25. There is a comprehensive program and plan to reduce the risk of health care– associated
        infections in health care workers. (PCI.5)

    26. Risk-reduction goals and measurable objectives are established and regularly reviewed.
        (PCI.5)

    27. When single-use devices and materials are reused, there is a policy that includes items a)
        through e) in the intent statement, and the policy is implemented. (PCI.7.1)

    28. The organization’s governance structure is described in written documents. (GLD.1)

    29. Governance responsibilities and accountabilities are described in the documents. (GLD.1)

    30. The documents describe how the performance of the governing entity and managers will be
        evaluated and any related criteria. (GLD.1)

    31. There is an organization chart or document. (GLD.1)



JCIA Hospital Survey Process Guide ~ 2008                                                              55
     32. There is a written policy or protocol that defines the requirements for developing and
         maintaining policies and procedures including at least items a) through h) in the intent, and it
         is implemented. (MCI.18)

     33. There is a written protocol that outlines how policies and procedures that originated outside
         the organization will be controlled, and it is implemented. (MCI.18)

     34. There is a written policy or protocol that defines retention of obsolete policies and
         procedures for at least the time required by law and regulation, while ensuring that they will
         not be mistakenly used, and it is implemented. (MCI.18)

     35. There is a written policy or protocol that outlines how all policies and procedures in
         circulation will be identified and tracked, and it is implemented. (MCI.18)

WHAT WILL OCCUR:

1.       The documents should be made available to the survey team in the meeting room that has
         been designated for their use throughout the duration of the survey.

2.       At the beginning of the session, one staff person should briefly orient the survey team to the
         organization of the documents.

3.       During the remainder of the session, there should be a staff member readily available, in
         person or by telephone that can respond to any questions the surveyors may have during this
         session.

4.       The materials should remain available to the survey team throughout the survey for
         reference purposes. However, if documents are required for use by organization staff, they
         can, of course, be removed. Surveyors may schedule a second document review session
         during the course of the survey. The review generally is scheduled for hospitals that have a
         survey of longer than three (3) days, and may be scheduled on surveys of a shorter duration,
         based on need. The survey team may also request additional documents throughout the
         survey to clarify or to become knowledgeable of the organization’s policies and procedures
         or performance. Hospital staff should be as proactive as possible in complying with requests
         for documents.

5.       Some of them will have been translated into English. For other required documents, an
         interpreter should be available.


HOW TO PREPARE:
It is very likely that many of the required documents will be part of other larger documents. It is not
necessary to remove or photocopy pertinent sections of these documents. Guidelines for cross-
referencing this information are provided below. The organization can identify the required sections
by using bookmarks or tabs.


JCIA Hospital Survey Process Guide ~ 2008                                                              56
Other documents, such as minutes, reports, etc. may be freestanding or individual documents. It is
the hospital’s decision whether to provide the original document or to provide a photocopy. It is
always good to have several examples of these documents, such as the minutes of a committee from
the last few meetings.

If the hospital has a large quantity of examples or a large volume of materials on a given topic, select
the most representative or the most pertinent. There will not be time for surveyors to review large
amounts of material on any given topic.


ORGANIZATION OF THE MATERIALS:
Because the issues identified in the document review list may be addressed in different documents
from one organization to another, the following guidelines for the organization of the material for
use by the surveyors are provided:

Group the freestanding or individual documents according to the three lists provided in this guide:

         •    Required Quality Monitors
         •    Required Organizational Plans
         •    Required Policies and Procedures, Written Documents, or Bylaws

When possible, please indicate the standards that the document addresses. The documents may be
grouped in binders, folders, or other means of separating major topical areas.

Gather in one place such existing documents. Identify where in the document the specific
information required by the standard may be found. There are several ways the information may be
identified:
         • A guide or index
         • Bookmarks or tabs

Note: When computer-based information is provided through use of monitors rather than
      through paper versions:
      • Each member of the survey team should be provided with a monitor;
      • A printer should be available in case a member of the survey team wishes to print a
          paper copy of a given document;
      • Printed copies should be available of bylaws and longer documents that may require
          extensive reading or scanning by surveyors.


EVALUATION OF THE POLICIES AND PROCEDURES BY THE SURVEY TEAM:

The documents reviewed by the survey team provide an overview of what they expect to see in
actual practice during the survey process. Thus, they would expect to find that when, for example, a
new procedure on the disposal of infectious waste is developed:


JCIA Hospital Survey Process Guide ~ 2008                                                             57
•   Appropriate staff have been educated about the new procedure;
•   Any special skills or other needed training has taken place;
•   It can be observed that waste is actually being disposed of according to the new procedure; and
•   If any documentation is required by the procedure, it is available for review.

The presence of a policy or procedure alone does not usually determine the score of the standard.
Rather, it is also the daily practice (implementation) of what is in the policy or procedure. The survey
team will be seeking evidence that the practice related to the policy or procedure is well
implemented and thus sustainable. In the event that the implementation appears incomplete to the
survey team or that implementation occurred in a manner that is not sustainable, the survey team
will make a recommendation that more time is allowed for better evidence of sustainable
implementation, and to incorporate that recommendation into the survey follow-up requirements.

In general, the length of time a policy has been implemented is often referred to as a “track record”.
The survey team will look for a four-month “track record” for policy-related standards during an
initial survey and for a twelve-month “track record” during a triennial survey. For a policy related
standard to be scored “fully met” the “track record” requirement must be met. When the “track
record” period has not been met, but the survey team finds that the policy has been implemented in
a sustainable manner, the team has the prerogative to score the standard as “fully met”.




JCIA Hospital Survey Process Guide ~ 2008                                                             58
Daily Briefing

PURPOSE:
To facilitate understanding of the survey process and the findings that contributes to the
accreditation decision.

LOCATION:            At the discretion of the hospital.

HOSPITAL PARTICIPANTS:
Organization Survey Coordinator (as needed by team)

SURVEYORS:                  All surveyors on site

WHAT OCCURS:
The daily briefing occurs every morning of a multi-day survey, with the exception of the first day.
The session is intended to be brief; 60 minutes is suggested.

When multiple surveyors are on site, the briefing is conducted jointly with the JCIA Team Leader as
facilitator.

During the daily briefing with the organization the surveyor(s) will:
• Offer a concise summary of the survey process activities completed on the previous day.
• Make general comments regarding significant issues resulting from the previous day’s activities.
• Note any specific positive findings.
• Emphasize patterns or trends of significant concern that could lead to non-compliance
   determinations.
• Inform the organization that final findings for any given standard will be possible only when all
   activities are complete and results are aggregated.
• Allow the organization to provide information that may have been missed during the previous
   survey day.
• Address organization requests for consultation on findings and indicate when such consultation
   can take place.
• Schedule time for more extensive discussion or review of additional evidence of compliance on
   issues that arise.
• Review the agenda for the survey day ahead (including the identification of individual patient
   tracers) and make any necessary adjustments based on organization needs or the need for more
   intensive assessment of an issue.
• Conclude the briefing and transition to the next activity(s) according to the agenda.

Do not expect the surveyor(s) to:
• Repeat observations made at a previous daily briefing unless it is in the context of identifying a
   systemic issue.



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•   Discuss in detail each survey activity, specific records, and discussions held with individuals
    during tracers.
•   Delay scheduled activities for the current day to have an in-depth discussion of issues from the
    previous day.


Special Situations
There may be instances when a surveyor(s) will be scheduled for activity that is not taking place at
the same location where a daily briefing would normally occur, especially when surveying with a
team. There may also be situations where a surveyor(s) is brought in for a day or two and departs
earlier than the rest of the team. If one or more surveyors cannot be physically present for the daily
briefing, the surveyor(s) will:

•   Try to make arrangements to join via conference call when at a different location.
•   Share details of previous day’s activities and findings with another surveyor for the daily briefing
    presentation, even if a conference call is anticipated.




JCIA Hospital Survey Process Guide ~ 2008                                                              60
Facility Tour
PURPOSE:
The purpose of the facility tour is to address issues related to:

     •    The physical facility
     •    Medical and other equipment
     •    Patient and visitor safety
     •    Infection control.

LOCATION:
Selected patient care settings, inpatient and ambulatory units, treatment areas and other areas
including admitting, kitchen, pharmacy, central storage, laundry and power plant (if applicable). It is
recommended that the tour begins on the roof, working downward in the building. The surveyor
will be looking to see that the corridors and exit paths of travel are free for safe exit of the facility in
an emergency.

HOSPITAL PARTICIPANTS:

         Chief Engineer
         Safety Officer and/or Facility Manager
         Directors of Admitting, Pharmacy and Dietary (when the surveyor is present in their areas)

SURVEYORS:
Administrator surveyor (physician and/or nurse surveyor when team does not include an
administrator)

STANDARDS/ISSUES TO BE ADDRESSED:

         Facility Management and Safety (FMS)
         Prevention and Control of Infections (PCI)
         Staff Qualifications and Education (SQE)

DOCUMENTS/MATERIALS NEEDED:

1.        Documents (such as plans, policy and procedures, test and maintenance reports (FMS.2 a
          through f)) that describes the plans for
            (a)safety and security (FMS.4),
            (b)hazardous materials (FMS.5),
            (c)emergencies (FMS.6),
            (d)fire safety (FMS.7),
            (e)medical equipment (FMS.8) and
            (f)utility systems (FMS.9)

2.        Facility inspection report (FMS.4.1)


JCIA Hospital Survey Process Guide ~ 2008                                                                 61
WHAT WILL OCCUR:
Prior to the facility tour, the surveyors will have reviewed the above mentioned facility management
and safety plans (FMS.2). The surveyors will also review selected portions of the facility inspection
report prepared by the organization and visit patient care areas as well as non-patient care areas of
the facility. In all areas the surveyors will observe the facility and interview staff to learn how the
organization manages the facility to:

•   Reduce and control hazards and risks
•   Prevent accident and injuries
•   Maintain safe conditions

NOTE: In some survey agendas, two surveyors will visit separate sections of the facility at the
      same time. The organization should be prepared to have staff available to guide and assist
      each surveyor on the tour of the facility.

The non-patient areas visited by the surveyors include:
   • The boiler room
   • The emergency power generator
   • The loading/receiving dock
   • Central storage areas or warehouse
   • The laundry, if applicable
   • Food service/kitchen
   • Oxygen storage rooms
   • Areas designated as hazardous, such as locker rooms, clean and soiled linen rooms, and
      oxygen storage rooms
   • The bottoms of laundry and garbage chutes
   • Heating and air conditioning equipment rooms to evaluate storage practices and utility
      systems maintenance

HOW TO PREPARE:

•   Prior to survey, the organization leaders and facility manager(s) should carefully read the relevant
    standards.
•   The facility manager(s) should tour the facility, conduct an inspection according to the
    standards, and attempt to address any deficiencies prior to survey.
•   FMS.4.1 requires that the organization conduct its own inspection of the facility. This
    information should be available to the surveyors. All buildings in which patients are housed or
    treated are included in the inspection and the report.
•   The organization should be aware of relevant laws, regulations and facility inspections and be
    able to share this information with the surveyors (FMS.1).
•   Representatives of the organization should be prepared to show the surveyors how their facility
    management plans are be implemented. For example, how hazardous materials are stored and
    disposed.


JCIA Hospital Survey Process Guide ~ 2008                                                             62
•   Prior to survey, the organization should check that all medical equipment has current
    inspections, testing and maintenance and that this is documented (FMS.8 and 8.1).
•   Representatives of the organization should be prepared to explain or demonstrate how potable
    water and electrical power are consistently available 24 hours a day (FMS.9).
•   The organization should have the following items available for the surveyor(s) to use when
    conducting the facility tour:

         -Flashlight
         -Master key
         -Ladder (to look above ceiling tiles)




JCIA Hospital Survey Process Guide ~ 2008                                                     63
Sample Outline of a Facility Inspection Report
I.     The building(s) included in the report:

       A.     The patient care activities that take place in each building
       B.     Any local codes, laws, or classifications for the buildings based on the activities
       C.     The approximate age of each building

II.    The building by building results of the inspection:

       A.     Any general conditions of the building that relate to local codes, laws, regulations, etc.
       B.     Specific findings related to law, regulation, codes, and accreditation standards. For
              example, Building 1, second floor west, fire exit door does not close properly; Building 1,
              room 210, broken chair next to bed; Building 3, 2nd floor laboratory, hazardous materials
              stored on the floor near an exit.

III. The plan to correct the findings:

       A.     Timetable
       B.     Estimated budget (short range and longer range, if appropriate)

IV.    The plan for monitoring the facility improvement process and for the continuing monitoring
       and improvement of the facility to ensure that facility safety concerns are prevented or
       eliminated through an ongoing planning and inspection process.

       NOTE:      The facility inspection report can be in any format that makes it an effective management
                  tool for the hospital. The inspection can be conducted by knowledgeable hospital staff or by
                  outside consultants. The report should be as comprehensive as possible to demonstrate that
                  the hospital is aware of all conditions in its buildings, and has plans to improve the safety of
                  its buildings




JCIA Hospital Survey Process Guide ~ 2008                                                                      64
Individual Patient Tracer Activity
PURPOSE:
A tracer follows the experiences of an individual patient in order to evaluate the organization’s
performance against international standards. One approach to conducting a tracer is to sequentially
follow the course of care and services received by the patient from pre-admission through post-
discharge. During an individual tracer, the surveyor will:
•   Follow the course of care, treatment, or service provided to the patient by and within the
    organization using current records whenever possible.
•   Assess the interrelationships between and among disciplines and departments, programs,
    services, or units, and the important functions in the care and services being provided
•   Evaluate the performance of relevant processes, with particular focus on the integration and
    coordination of distinct but related processes
•   Identify potential concerns in the relevant processes

HOSPITAL PARTICIPANTS:
During a tracer, surveyors will converse with a wide variety of staff involved in the patient’s care,
treatment or services. This could include nurses, physicians, therapists, case managers, aides,
pharmacy and lab personnel, and support staff.

SURVEYORS: Nurse, physician or administrator surveyor

STANDARDS TO BE ADDRESSED:
All standards chapters may be addressed during this visit

DOCUMENTS /MATERIALS NEEDED:
The clinical records of patients currently receiving care in the unit/setting

WHAT WILL OCCUR:
Using the information from the application, the surveyor(s) will select patients from an active patient
list to “trace” their experience throughout the organization. Patients typically selected are those who
have received multiple or complex services and therefore, more contact with various parts of the
organization. This will provide the opportunity to assess continuity of care issues. To the extent
possible, the surveyor(s) will make every effort to avoid selecting tracers that occur at the same time
and may overlap in terms of sites within the organization.

The surveyor will follow the patient's experience, looking at services provided by various individuals
and departments within the organization, as well as “hand-offs” between them. This type of review
is designed to uncover systems issues, looking at both the individual components of an organization,
and how the components interact to provide safe and quality patient care.

The number of patients followed under the Tracer Methodology will depend on the size and
complexity of the organization, and the length of the on-site survey.



JCIA Hospital Survey Process Guide ~ 2008                                                            65
The tracer starts in the patient care setting or unit in which the patient and the clinical record are
currently located. This is where the surveyor begins to trace the entire care or service process from
preadmission through post-discharge. The surveyor has approximately two hours to conduct a
tracer, although it may be shorter or longer depending upon complexity and other circumstances.
Multiple patient records may be reviewed during a single designated tracer activity.

As appropriate to the provision of care being reviewed, the tracer will include the following
elements:
• Review of the record with the staff person responsible for the patient’s care, treatment, or
    service provided to the patient. If the responsible staff person is not available, the surveyor may
    speak with other staff members. Supervisor participation in this part of the tracer should be
    limited. Additional staff involved in the patient’s care will meet with the surveyor as the tracer
    proceeds. For example, the surveyor will speak to a dietician if the patient being traced has
    nutritional issues.
• Observation of direct patient care.
• Observation of medication process.
• Observation of infection control issues.
• Observation of care planning process.
• Discussion of data use in individual units – quality improvement measures being used, what has
    been learned, improvements made using data, data dissemination.
• Observation of the impact of environment on safety and staff roles in minimizing environmental
    risk.
• Interview with the patient and/or family (if it is appropriate and permission is granted by the
    patient and/or family). The discussion will focus on the course of care, and, as appropriate,
    attempt to verify issues identified during the tracer.
• When visiting the emergency department, the surveyor will also address emergency management
    and explore patient flow issues. Patient flow issues may also be explored in ancillary care areas
    and other patient care units as relevant to the patient being traced. For example, if the patient
    received a blood transfusion, the surveyor may visit the blood bank.
• The surveyor(s) may pull and review two to three additional records to verify issues that may
    have been identified. The surveyor(s) may ask staff in the unit, program, or service to assist with
    the review of the additional records. The following criteria can be used to guide the selection of
    additional records depending on the situation:
        o Similar or same diagnosis or tests
        o Patient close to discharge
        o Same diagnosis but different physician/practitioner
        o Same test but different location
        o Same age or sex
        o Length of stay
•   Interview with staff.
•   Review of minutes and procedures as needed.

A surveyor(s) may arrive in a patient care setting or unit and need to wait for staff to become
available. In these cases, the surveyor(s) will use this time productively (e.g., to tour the unit,


JCIA Hospital Survey Process Guide ~ 2008                                                            66
program, or service and to address environment of care issues, or observe care/treatment/service
processes).

Surveyors will avoid visiting an area at the same time, and will minimize multiple visits to the same
location.

TRACER SELECTION CRITERIA
Patient tracer selection may be based on, but not limited to the following criteria:
• A patient on dialysis.
• A psychiatric patient.
• A pediatric patient.
• A patient receiving imaging services.
• A patient receiving rehabilitation services.
• Patients related to system tracers such as infection control and medication management.
• Patients who cross programs (e.g. patients scheduled for a follow-up in ambulatory care, home
    care
• Patients received from the hospital, long term care patients transferred from the hospital, mental
    health care clients receiving ambulatory services, and patients receiving home care services).
• Patients due for discharge that day or the next day
• Patients who cross programs such as hospital to care continuum.

Linkages to Other Survey Activities
Issues identified from the tracer activities may lead to further exploration in the systems tracers or
other survey activities such as the Facilities Tour and GLD Interview.
Findings from tracer visits provide focus for other tracers and may influence the selection of other
tracers. They may also identify issues related to the coordination and communication of information
relevant to the safety and quality of care services.




JCIA Hospital Survey Process Guide ~ 2008                                                           67
System Tracer – Medication Management

PURPOSE:
This session explores the organization’s medication management as well as potential risk points in
the system.

HOSPITAL PARTICIPANTS:
Individuals selected by the organization to participate in the group session should, as a group, be
able to speak to the full spectrum of medication management processes from medication
procurement through monitoring the effects of administered medications.

As applicable, appropriate participants might include a direct care or service representative from
the following areas:
• Clinical staff that have a role in medication management processes as part of the direct care,
    treatment, or services they render, such as a nurse, physician, therapist, dieticians, or others.
• Clinician from the pharmacy or consultant pharmacist who is knowledgeable about the selection
    of medications available for use and medication monitoring
• Staff member responsible for medication education of both staff and patients.
• A clinical staff member who may add a unique perspective about any identifiable or specific
    patient.
• A person who can speak to performance improvement if any performance improvement
    initiatives associated with medication management have been conducted or are being conducted.
     Note: A separate representative from quality improvement is not necessary if other participants
    can speak to medication management improvements e.g., therapist on a medication QI team.
• Clinician from the lab
• Environmental safety personnel involved in the maintenance of pumps

In order to facilitate a beneficial exchange between the surveyor(s) and the organization, the
organization should identify a relatively small group of active participants for discussions and
interviews. Other staff may attend as observers

During the focused-tracer activity the surveyor(s) will visit areas relevant to medication management
processes and talk to staff that is available in these areas about their role in medication management.

SURVEYORS:
Nurse or physician surveyor.

WHAT WLL OCCUR:
Various methodologies are used to evaluate an organization’s medication management system
including a group discussion session; a medication management, focused-tracer; and information
from individual patient tracers. The medication processes that are evaluated include: Selection and
Procurement, Storage, Ordering and Transcribing, Administration, and Monitoring.




JCIA Hospital Survey Process Guide ~ 2008                                                            68
Group Discussion
The discussion session explores medication management processes in the organization and hand-off points
between processes.

During the group discussion, the surveyor(s) and organization staff:

  1. Explore each applicable medication management process. Participants in the group share the
     organization’s approach to medication management based on their experience.

  2. For each medication management process discuss:
      • Areas of concern, “symptoms”
      • Immediate or proximal causes for an area of concern
      • Potential solutions

  3. Explore the continuity of medication management processes and their relationship to other
     supporting processes and systems.
  4. Identify potential areas of concern in the organization’s medication management system and
     actions that might be taken.
  5. Identify any specific medication management issues requiring further exploration as part of
     subsequent tracers and other survey activities.
  6. Review the International Patient Safety Goals (IPSGs) related to medication management

Specific aspects of medication management that may be addressed during the discussion and
focused-tracer include:
    • Medication selection, procurement and storage including IPSG #3
    • Ordering, order entry, and transcription and IPSG #2
    • Preparation and dispensing
    • Administration and IPSG #1
    • Monitoring and IPSGs #5 and #6
    • Reporting of errors/system breakdowns/near misses
    • Data collection, analysis, evaluation of systems and actions taken including any performance
        improvement initiatives related to medication management
    • Medication education – patients and staff
    • Information management related to medication management
    • Patient involvement as part of a medication management team

The influence of other organization systems for planning, data use, performance improvement,
communication and staff competence/effectiveness may be explored with respect to medication
management system and processes.

Focused-Tracer Activity
The focused-tracer activity may take place prior to or after the group discussion. The surveyor
explores the path of a selected medication in the organization using a current medical record. The



JCIA Hospital Survey Process Guide ~ 2008                                                            69
surveyor then focuses on medication management processes informed by prior survey activities such
as the medication management group discussion or observations made during previous patient
tracers.

Notes:
In organizations with more than one program accredited by The Joint Commission International
and in organizations with multiple sites, only one Medication Management Session is scheduled. If
it is not feasible for staff to participate from all programs/sites, the organization may need to
teleconference individuals from distant locations into the group discussion.

In shorter surveys, when a separate Medication Management system tracer is not scheduled, the
surveyors will address medication management in patient tracers and during the Data Use system
tracer.




JCIA Hospital Survey Process Guide ~ 2008                                                      70
System Tracer – Infection Control
PURPOSE:
During the discussion of the infection control program, the surveyor(s) and organization will be able
to:
    • Identify strengths and potential areas of concern in the infection control program.
    • Begin to determine actions necessary to address any identified risks in infection control
       processes.
    • Begin the assessment or determine the degree of compliance with relevant standards.
    • Identify infection control issues requiring further exploration.

Note:
When a separate Infection Control System Tracer is not noted on the agenda (for example, on
shorter surveys), the surveyor(s) will address infection control throughout individual patient tracers
and during the Data Use System Tracer.

HOSPITAL PARTICIPANTS:
Individuals from the organization selected for participation should be able to address issues related
to the infection control program in all major departments or areas within the organization. This
group should include, but not be limited to, representation from, as applicable to the organization:
    • Clinical staff, including physicians, nurses, pharmacists, laboratory personnel
    • Clinicians who are knowledgeable about the selections of medications available for use and
        pharmacokinetic monitoring
    • Clinicians from the laboratory (when applicable) who are knowledgeable about microbiology
    • Clinical staff including those individuals involved in infection control and a sample of
        individuals involved in the direct provision of care, treatment and services.
    • Staff responsible for the physical plant.
    • Organization leadership.

NOTE:
In order to facilitate a beneficial exchange between the surveyor(s) and the organization, the
organization should identify a relatively small group of active participants for discussions and
interviews. Other staff may attend as observers.

SURVEYORS:
Nurse or physician surveyor.

WHAT WILL OCCUR:
The session will open with introductions and a review of the goals for the infection control systems
tracer, which includes:
    •    Exploration, critical thinking, and potential problem solving about the infection control
         program.




JCIA Hospital Survey Process Guide ~ 2008                                                            71
    •    Identification of potential areas of concern in the infection control program, areas for
         improvement, and actions that could be taken.

Process
   • Activity will begin in a patient care area identified by the surveyor(s).
   • The surveyor(s) may move to other settings as appropriate and applicable to tracing
      infection control processes across the organization.
   • The surveyor(s) will observe staff and engage them in discussion focused on infection
      control practices in any setting that is visited during this system tracer activity.
   • Activity will end in a short group meeting with individuals responsible for the organization’s
      infection control program. During this time the surveyor(s) will identify potential areas of
      concern and gain a better understanding of the IC system for further discussion and
      exploration with staff knowledgeable about the organization’s infection control program.

Discussion
The surveyor(s) will draw from tracer activity experience, organization infection control surveillance
data, and other infection control related data, to inspire scenarios for discussion with the
organization. Participants will be asked to discuss the following aspects of the organization’s
infection control program as it relates to the scenarios:
    • How patients with infections are identified by the organization
    • How patients with infections are considered within the context of the infection control
        program
    • Current and past surveillance activity—taking place in the last 12 months or more for re-
        surveys and four months or more for initial surveys
    • Type of analysis being conducted on infection control data, including comparisons
    • Reporting of infection control data—frequency and audience
    • Prevention and control activities (e.g., staff training, education of patient/resident/client
        population, housekeeping procedures)
    • Physical facility changes, either completed or in progress, that have an impact on infection
        control
    • Actions taken as a result of surveillance and the outcomes of those actions

Organizations may use infection control data during this part of the activity if it is relevant to the
discussion.

Discussion can revolve around patients already included in IC surveillance and reporting activities,
or those not yet confirmed as meeting a definition or criteria for entry into and monitoring through
the infection control surveillance system. In addition to surveyor-identified scenarios, the
organization is encouraged to present examples of cases that will highlight various aspects of the
infection control program. Some of the scenarios the surveyors will want to discuss, as applicable to
the organization, may include but are not limited to:
    • Patients seen with fever of unknown origin
    • Patients with a post operative infection
    • Patients admitted to the organization post-operatively


JCIA Hospital Survey Process Guide ~ 2008                                                           72
    •    Patients placed on an antibiotic new to the list of available medications (preferably one with
         corresponding culture and sensitivities, blood levels, and/or other labs used for dosing)
    •    Patients placed on some form of isolation or precaution because of diagnosis of infectious
         disease. If not easily identifiable, consider patients with any of the following diagnoses (this
         is not an exhaustive list): varicella, pulmonary tuberculosis, invasive haemophilus influenzae,
         meningococcal disease, drug-resistant pneumococcal disease, pertussis, mycoplasma,
         mumps, rubella, MRSA, VRE, Clostridium difficile, RSV, enteroviruses, skin infections
         (impetigo, lice, scabies)
    •    Infection control practices related to emergency management.
    •    Patients placed on some form of isolation or precaution because of being
         immunocompromised
    •    Recent changes in physical facilities that have an impact on infection control.
    •    Patients with known case of active tuberculosis

Conclusion
The surveyor(s) and organization will summarize identified strengths and potential areas of concern
in the infection control program. The surveyor(s) will provide education as applicable.

Note: Usually, a single infection control system tracer session will be scheduled. This session is
intended to review infection control for all services provided by the organization. Participants in
this system tracer should include individuals that are able to address infection control in all services
offered by the organization.




JCIA Hospital Survey Process Guide ~ 2008                                                              73
System Tracer – Data Use
PURPOSE:
This session is focused on the organization’s use of data in improving safety and quality of care.

HOSPITAL PARTICIPANTS:
Individuals from the organization selected for participation should be able to address issues related
to the use of data in all major departments or areas within the organization. This group should
include but is not limited to representation from the following services:
• Clinical staff, including individuals involved in performance improvement and a sample of
    individuals involved in the direct provision of care, treatment, and services
• Representation from physicians, nurses, and pharmacists
• Individuals who are knowledgeable about the information systems available for data collection,
    analysis, and reporting
• A representative from the organization’s leadership

In order to facilitate a beneficial exchange between the surveyor(s) and the organization, the
organization should identify a relatively small group of active participants for discussions and
interviews. Other staff may attend as observers.

SURVEYORS:
Nurse, physician or administrator surveyor.

WHAT WILL OCCUR:
During the session, the surveyor(s) and organization will discuss:
1. The measures that are being used for improvement.
•   Improvements that have been made as the result of data collection and analysis.
•   How performance improvement methods are used throughout the organization.
•   The basics of data gathering and preparation, including:
    o Selection of measures
    o Data collection and aggregation
    o Data analysis and interpretation
    o Dissemination/transmission of findings
    o Taking action
    o Monitoring performance/improvement

These issues will be explored in the context of each of the specific data discussion topics described
below.

The surveyor(s) may incorporate examples obtained from previous individual patient tracer findings
of the survey team.




JCIA Hospital Survey Process Guide ~ 2008                                                            74
When system tracer time has not been scheduled for Medication Management and Infection
Control, the use of data in these areas can be covered during this session.

Medication Management Data Issues
Medication management data collection issues are addressed here in shorter surveys where only one
System Tracer (Data Use) is scheduled. Discussion explores:
1. Data collected on the performance of the organization’s medication management system and
    processes, including trends or issues that have been identified, and changes made as a result of
    that review
2. Medication data the organization is collecting. Medication management data collection should
    be relevant to the services provided by the organization and patients served. The organization
    should be collecting data related to the “risk points” it has identified in its medication
    management system evaluation. Examples of such data based on an assessed risk point might
    include but are not limited to:
            Number of pharmacy interventions
            Turn-around times from order to administration
            Adverse drug events (ADEs)
            Use of high risk medications
            All suggested measures in QPS.3.5 and 3.6 (use of antibiotics)

Infection Control Data Issues
Applicable in smaller surveys where only one System Tracer (Data Use) is scheduled. Discussion
explores:
1. Surveillance methods for health care-associated and non-health care-associated infections.
2. Types of data collected
    • Whether infection-related data are collected
    • Whether the organization has developed and implemented a system for measuring
        improvements
3. Use of standardized definitions.
4. Control methods (includes data dissemination to physicians, staff, leaders, external entities).
5. Prevention based on data findings.
6. The organization’s plans to collect data relevant to the JCI prevention and control of infection
    standards.

Conclusion
As a result of this session, the surveyor and the organization will:
1. Identify strengths and weaknesses in the organization’s use of data, areas for improvement, and
    actions that could be taken.
2. Identify specific data use issues requiring further exploration as part of subsequent survey activities.
3. Provide appropriate education, as applicable.

Note:
In hospitals with multiple sites, only one Data Use Session is usually scheduled. If it is not feasible
for staff to participate from all programs/sites, the organization may need to teleconference
individuals from distant locations into the group discussion.



JCIA Hospital Survey Process Guide ~ 2008                                                                     75
Facility Management and Safety System Tracer
PURPOSE:
The purpose of this session is to provide guidance for evaluating the organization’s system and
performance for managing risk within the facility management and safety program (FMS). The
surveyor and the organization will:
       Identify areas of concern and strengths in the organization’s processes.
       Identify or determine the action(s) necessary to address any identified areas of concern.
       Assess or determine the organization’s actual degree of compliance with relevant standards.

HOSPITAL PARTICIPANTS:
Individuals from the organization selected for participation should be able to address issues related
to FMS in all major departments or areas within the organization. This group should include
representation from the following services (in some organizations, individuals may be responsible
for multiple roles):
       Person(s) designated by leadership who coordinates safety management activities.
       Person(s) designated by leadership who coordinates security management activities.
       Person who manages the organization’s facility (ies).
       Person responsible for the organization’s emergency management activities.
       Person who manages the organization’s building utility systems.
       Person responsible for maintaining the organization’s medical/laboratory equipment.
       Leader of the environment of care team or safety committee.
       Organizational leadership.

In complex organizations that have decentralized FMS management activities at remote sites, those
persons responsible for managing the activities listed above at those sites should be available (i.e., in
person, by conference call, etc.).

SURVEYORS:
Administrative Surveyor

WHAT WILL OCCUR:
The duration of the session lasts about 60-90 minutes. The group discussion (Part I) section activity
represents approximately 30% of the session and occurs after the surveyor has had the opportunity
to review the following documents:

         The annual evaluations of the FMS management plans that deal with risks in the
         environment
         The FMS multidisciplinary team meeting minutes (previous twelve months).

It is also important that observations related to FMS made by other members of the survey team (if
applicable) and any FMS-related issues and information identified from previous surveys be
discussed during this session.




JCIA Hospital Survey Process Guide ~ 2008                                                               76
Introduction
The surveyor reviews the objectives of the FMS session with the organization’s participants.

Discussion Guidelines
During this time the surveyor should draw discussion from the organization that will give insight
into the following aspects of its environment of care management processes, as shown in the FMS
Risk Management Cycle below.


                            IMPROVE
                                                           PLAN



            MONITOR
                                         FMS Risk
                                      Management Cycle

                                                            TEACH

                 RESPOND


                                               IMPLEMENT

Plan
         What specific risks related to its environment of care have been identified by the
         organization?

Teach
         How have roles/responsibilities for staff/volunteers been communicated by the
         organization (Human Resources).

Implement
      What procedures and controls (both human and physical components) does the organization
      implement to minimize the impact of risk to patients, visitors, and staff?

Respond
      What procedures does the organization implement to respond to an FMS incident/ failure?
      How, when, and to whom are FMS problems, incidents, and/or failures reported within the
      organization.

Monitor
      How is FMS performance (both human activities and physical components) monitored by
      the organization
      What monitoring activities have taken place within the last 12 months?




JCIA Hospital Survey Process Guide ~ 2008                                                           77
  Improve
        What facility management and safety issues are currently being analyzed.
        What actions have been taken as a result of FMS monitoring activities?

  The organization should discuss how the six FMS risk categories (*1) and construction activities
  have been addressed in each of the management processes listed above. The following matrix is
  provided to assist in determining patterns of management process or risk category areas of concern
  and strengths.

  The following matrix is a screening tool for use in selecting a particular management process or risk
  category to explore in the second part of this session. Selection of a particular management process
  or risk category should be based upon information gathered from the following: the discussion
  phase of this session, FMS-related information from previous surveys, and any unusual observations
  made during survey prior to this session.

  Note: The six FMS risk categories include: general safety and security, hazardous materials and waste, emergency management, fire safety,
  medical/laboratory equipment, and utilities.
                                                    HAZARDOUS                           MED/LAB                             EMERGENCY
                   SAFETY SECURITY                                          FIRE                           UTILITIES
                                                      MATERIAL                       EQUIPMENT                            MANAGEMENT
PLAN
TEACH
IMPLEMENT
RESPOND
MONITOR
IMPROVE


  *During this session, the organization’s performance in addressing the emergency management
  requirements of standards FMS.6 and FMS.6.1 will be reviewed including its performance in:
         Identifying and analyzing potential environmental risks in the organization;
         Identifying its role in relation to the community’s, county’s, or region’s emergency
         management program;
         Identifying processes for the timely sharing of information with other healthcare
         organizations that provide services within the contiguous geographic area;
         Identifying an structure used during emergencies that links with the community’s incident
         response structure; and
         Making any necessary improvements to its emergency management based on critiques of
         emergency management drills.

  Discussion should focus around the management processes and not the FMS risk categories.
  Surveyors should not be the primary speakers during this time, but rather listeners to the
  discussion. This is not intended to be an interview.

  Observation Guidelines (Part Two)
  The surveyor then observes and evaluates the organization’s performance in managing FMS risk.
  This activity represents approximately 70% of the session and occurs after the group discussion
  portion of the session.



  JCIA Hospital Survey Process Guide ~ 2008                                                                                      78
The particular management process or risk selected for observation and further evaluation is based
upon the following:
       FMS documents previously reviewed.
       Observations by other survey team members.
       Knowledge gained during the group discussion portion of this session.

The surveyors will observe the implementation of those particular management processes
determined to be potentially vulnerable or, will trace a particular risk(s) in one or more of the FMS
risk categories the organization manages by:

         Beginning where the risk is encountered or first occurs. (i.e., a starting point might be where
         a particular safety or security incident occurs, a particular piece of medical equipment is
         used, or a particular hazardous material enters the organization).
         Having staff describe or demonstrate their roles and responsibilities for minimizing the risk,
         what they are to do if a problem or incident occurs, and how to report the problem or
         incident.
         Assessing any physical controls for minimizing the risk (i.e., equipment, alarms, building
         features).
         Assessing the emergency management plan for mitigation, preparedness, response, and
         recovery strategies, actions and responsibilities for each priority emergency.
         Assess the emergency plan for responding to utility system disruptions or failures (e.g.,
         alternative source of utilities, notifying staff, how and when to perform emergency clinical
         interventions when utility systems fail, and obtaining repair services)
         If equipment, alarms, or building features are present for controlling the particular risk,
         reviewing implementation of relevant inspection, testing, or maintenance procedures.
         If others in the organization have a role in responding to the particular problem or incident,
         having them describe or demonstrate that role, and reviewing the condition of any
         equipment they use in responding.

If the risk moves around in the organization’s facility (i.e., a hazardous material or waste), the
surveyor will follow the risk from “cradle to grave.”

Conclusion (Part Three)
The surveyor summarizes any potential areas of concern in the management process or risk category
observed. Staff responsible for managing that particular process or risk reviewed provides
information regarding their role in addressing any areas of concern observed.
The organization should provide information regarding processes that have been developed to
address any potential areas of concern observed. The organization should provide information
regarding existing activities that have been implemented to address any potential areas of concern
observed.

NOTE:
In order to facilitate a beneficial exchange between the surveyor and the organization, the
organization should identify a relatively small group of active participants for discussions and
interviews. Other staff may attend as observers.



JCIA Hospital Survey Process Guide ~ 2008                                                               79
Staff Qualifications and Education Session
PURPOSE:
The purpose of this interview is to address the hospital’s process to recruit, orient, educate and
evaluate all hospital staff. In addition, the interview addresses the hospital’s process for evaluating
the credentials of the medical staff, nursing staff, and other health professional staff and their ability
to provide clinical services consistent with their qualifications.

LOCATION:              Small meeting rooms at the discretion of the hospital’s leaders

HOSPITAL PARTICIPANTS FOR EACH INTERVIEW WHEN HELD SEPARATELY:
Generally, two separate interviews will be conducted. Each should be conducted separately and in
different locations. The physician surveyor will conduct the medical staff interview and the nurse
and administrator surveyors will jointly conduct the interview for nursing staff and all other staff.
The survey team may elect to conduct up to four separate interviews, depending on the size of the
organization and the types of hospital and health care professional staff present in the organization.

Medical Staff:
• Elected or appointed senior leader of the medical staff and/or Medical Director (if applicable)
• Representatives of the medical staff involved in credential collection and review

Nursing Staff:
• Manager of the Human Resources/Personnel department
• Chief nurse
• Other representatives of the nursing staff involved in the orientation, education and training of
  nursing staff

Other Health Professional Staff:
• Manager of the Human Resource/Personnel department
• Representatives of group(s) involved in the orientation, education and training of health
   professional staff

Other Hospital Staff:
• Manager of the Human Resource/Personnel department
• Representatives of group(s) involved in the orientation, education and training of hospital staff

SURVEYORS:
Medical Staff – Physician surveyor
Nursing Staff and Other Health Professional Staff: – Nurse surveyor
Other Hospital Staff – Administrator and/or nurse surveyor


STANDARDS ISSUES TO BE ADDRESSED:
Staff Qualifications and Education (SQE) standards


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DOCUMENTS/MATERIALS NEEDED:

    Policy and procedures related to Human Resources/Personnel management, and staff
    credentials.
    A sample of hospital personnel files and of health professional staff credential files.

Surveyors will provide instructions on the first day of the survey, generally during the document
review session, regarding this interview and the preparation of the files for review. The survey team
will provide the Director of Human Resources with a list that identifies the type and number of
personnel and medical staff files selected for review later in the survey during the staff qualifications
and education interview. Sample request and review forms are shown on the next few pages. The
survey team will provide copies of the current survey tool on the first day of the survey. It is
important to know that the surveyors’ tools that are used throughout the survey may change at any
time to continually improve the survey team’s abilities to fairly and accurately score the
organization’s compliance with standards. The tool merely reflects current JCIA standards.

HOW TO PREPARE:
The organization should include a list of all current personnel and medical staff in the document
review session on the first day. The list should identify the specific discipline, hire date, and
department or service assigned (for example: Registered Nurse; Hired July 20, 2001; Intensive Care
Unit). These documents should be in ENGLISH, when possible.

Closely review all personnel and credential files using the Competence Assessment Process
Review Form. Be sure all required elements are in the files.




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                                                               MEDICAL STAFF
                                                  Competence Assessment Process Review
                                                       Request and Review Form

                                                   1                       2                     3                      4                         5
                                           Licensure, education,     Copies of any      Reevaluated at least   Authorized to admit      Staff providing patient
  Name or Category of Staff              training, and experience   required license    every three years or    and treat patients      care /other designated
                                          documented. Verified      certification, or    more frequently,      and provide clinical        staff trained and
                                       from original source, when     registration       when required by           services.         competent in resuscitative
                                                 possible.             (current).       organization policy.                                  techniques.
                                                SQE.9 #2              SQE.9 #4              SQE.9 #5                 SQE.10                    SQE.8.1




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                                                               NURSING STAFF
                                                  Competence Assessment Process Review
                                                       Request and Review Form

                                              1                      2                   3                   4                   5                   6
                                     Licensure, education,    Record contains     Responsibilitie     Ability to carry       At least one     Staff providing
  Name or Category of               training and experience     copies of any     s are defined in          out             documented         patient care or
  Staff                                 are documented;       required license,    a current job     responsibilities in   evaluation each        others, as
                                      Information verified    certification, or     description.      job description       year or more     designated, trained
                                     from original source,       registration.                          evaluated at        frequently, if   and competent in
                                         when possible.                                                appointment.          required by        resuscitative
                                                                  SQE.12             SQE.1.1                                organization.        techniques.
                                            SQE.12                                                      SQE.3 #2             SQE.3 #5             SQE.8.1




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                                            OTHER HEALTH PROFESSIONAL STAFF
                                                  Competence Assessment Process Review
                                                       Request and Review Form

                                            1                   2                   3                    4                     5                       6
                                      Licensure,         Record contains     Responsibilities   Ability to carry out       At least one      Staff providing patient
 Name or Category of              education, training,     copies of any     are defined in a   responsibilities in       documented           care, or designated
 Staff                            and experience are     required license,     current job       job description         evaluation each       others, trained and
                                   documented and        certification, or     description.        evaluated at           year or more            competent in
                                       verified.            registration.                         appointment.            frequently, if           resuscitative
                                                                                                                       required by policy.          techniques.
                                     SQE.15 #2 #3          SQE.15 #5            SQE.1.1             SQE.4 #2               SQE.4 #5                  SQE.8.1




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CLOSED MEDICAL RECORD REVIEW (OPTIONAL*)
*Session is held at the request of the surveyors in order to validate the organization’s compliance
with the documentation track record (4-months for initial surveys and 12-months for triennial
surveys)

Closed Patient Record Review Form: Instructions for Use

Purpose of the form:

The purpose for using the form is to gather and document compliance with the standards that
require documentation in the patient’s record based on additional closed record review beyond the
open records that are evaluated during the tracer activities.

Organization of the form:

The form is organized by topic headings (e.g., consents, assessments) and includes the specific
standard number and the standard requirement (e.g., blood consent, medical assessment). This form
will be provided by the survey team and used for the review. The form may be revised periodically
to reflect approved changes in the standards.

Review process:

1. The surveyor enters the number of the record being reviewed and the type of record (requested
   recorded by diagnosis) on the top of the form. (Example: Record # 5554 Congestive Heart
   Failure)
2. The record is reviewed briefly to decide what type of patient or care was received (e.g. surgery,
   medical, emergency, rehabilitation).

Use of the form during the accreditation survey:

1. The team leader may request five to ten (5-10) closed records for review. The records will be
   requested if the surveyors want to validate the organization’s documentation track record (4-
   month or 12-month) and/or ensure compliance with documentation or patient care process
   requirements due to situations or information identified during the tracer activities.
2. The survey team will also indicate the time period for selecting the records, typically the past
   four months or past year. Hospital staff should acquaint the survey team with the organization’s
   practice and expectation regarding the completion of a patient record following discharge of a
   patient.
3. To conduct the closed patient record review, the hospital leaders should provide one staff
   member with a translator, if needed for each surveyor involved in the closed record review. The
   selected staff person(s) should be knowledgeable about both the medical record and the clinical
   care processes in order to assist the surveyor(s).




JCIA Hospital Survey Process Guide ~ 2008                                                             85
4. The surveyor will review the selected records with the assistance of the hospital representative,
   as needed, to complete the form; one column of the form is completed for each record
   reviewed. If more that five records are reviewed, the surveyor will use another form.
5. For each documentation requirement, the surveyor will check the form to indicate if the
   required element is present, “yes”; if the element is not present, the surveyor will either check
   not present, “no” or not applicable to this patient’s record, “NA”.
6. The survey team aggregates the completed review forms to score the standards. The findings
   from the active or open review of patient records are integrated into aggregation and scoring.
7. The team leader retains the forms to support the survey findings.




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                                                                          MEDICAL RECORD REVIEW TOOL
                                                                                Medical          Medical            Medical      Medical Record    Medical Record
   STD                         Documentation                                    Record 1         Record 2           Record 3           4                 5
                                                                           #______________   #______________   #______________   #______________   #______________    TOTAL
                                Requirement                                DX:               DX:               DX:               DX:               DX:
                                                                            Y      N   NA    Y      N   NA      Y      N   NA     Y     N     NA   Y     N     NA         Y/N
CONSENTS
PFR.6.3            General consent

PFR.6.4            Surgical or Invasive Procedures Consent
                   Anesthesia and Moderate and Deep Sedation Consent
                   Blood and blood Products Consent
                   High-risk Procedures and Treatments Consent
ASC.5.1            Risks, benefits and alternatives of anesthesia

ASC.7.1            Risks, benefits, potential complications and
                   alternatives of surgery
PFR.8              Clinical research, investigation, and trials consent

ASSESSMENTS
AOP.1.4.1; Medical assessment in 24 hours; Updated if less than
                   30 days old
                   Nursing assessment in 24 hours
AOP 1.5            Assessment findings are documented within 24 hours
                   of admission (Medical & Nursing)
AOP.1.5.1          Medical assessment documented prior to surgery

AOP.1.6            Nutritional and functional screening

AOP.1.8.1          Early screening for discharge planning

AOP.1.8.2          Screening for pain on admission

AOP.2              Physician reassessment daily for acute patients

PFE.2              Education needs assessment




          JCIA Hospital Survey Process Guide ~ 2008                                                                                                                  87
                                                                               Medical           Medical            Medical      Medical Record    Medical Record
  STD                          Documentation                                   Record 1          Record 2           Record 3           4                 5
                                                                           #______________   #______________   #______________   #______________   #______________    TOTAL
                                Requirement                                DX:               DX:               DX:               DX:               DX:
                                                                           Y      N   NA     Y      N   NA      Y      N   NA     Y     N     NA   Y     N     NA         Y/N
ASC.3              Pre-sedation assessment

ASC.4              Pre-anesthesia assessment

OTHER
ASC.5              Anesthesia Plan

ASC.7.2            Written Surgical Report
                   -Description of the surgical procedure, findings, and
                   any surgical specimens
                   -A postoperative diagnosis
                   -The names of the surgeon and surgical assistants
                   -Available before the patient leaves the post-
                   anesthesia recovery area.
ASC.6              Arrival and discharge times for post anesthesia care.

MMU.4              List of current medications taken prior to admission

MMU.4.3            Medications prescribed or ordered and administered
                   are recorded
PFE.2.1            Assessment includes:
                   -The patient’s and family’s beliefs and values;
                   -Their literacy, educational level, and language;
                   -Emotional barriers and motivations;
                   -Physical and cognitive limitations; and
                   -The patient’s willingness to receive information.
MCI.19.3           The author, date and time (When required) of every
                   entry
ACC.3.2            Discharge Summary Contains:
                   -Reason for admission
                   -Significant physical and other findings
                   -Significant diagnoses and co-morbidities
                   -Diagnostic and therapeutic procedures performed
                   -Significant medications and other treatments



          JCIA Hospital Survey Process Guide ~ 2008                                                                                                                  88
                                                                          Medical           Medical            Medical      Medical Record    Medical Record
  STD                     Documentation                                   Record 1          Record 2           Record 3           4                 5
                                                                      #______________   #______________   #______________   #______________   #______________    TOTAL
                           Requirement                                DX:               DX:               DX:               DX:               DX:
                                                                      Y      N   NA     Y      N   NA      Y      N   NA     Y     N     NA   Y     N     NA         Y/N
               -The patient’s condition at the time of discharge
               -Discharge medications, all of the medications to be
               taken at home
               -Follow-up instructions
ACC.4.4        Transferred Patients:
               -Name of the health care organization and the
               individual agreeing to receive the patient
               -The reason(s) for transfer
               -Any special conditions related to transfer
               -Any change of patient condition or status during
               transfer




      JCIA Hospital Survey Process Guide ~ 2008                                                                                                                 89
GLD Interview Session

PURPOSE:
The purpose of the leadership interview is to assess communication among senior leaders of the
organization and how they address organizational performance issues.

LOCATION:              At the discretion of the hospital’s leaders

HOSPITAL PARTICIPANTS:

         Chief Executive Officer
         Chief Operating Officer, when applicable
         Chairman, Governing body or similar representative
         Elected or appointed leader of the medical staff
         Medical Director, when applicable
         Nurse Executive
         Quality Improvement Coordinator
         Other senior leaders, at the discretion of the hospital

To foster an interactive process, a large group is not recommended for this interview.

SURVEYORS:
All surveyors on site

STANDARDS/ISSUES TO BE ADDRESSED:
Collaborative involvement of the senior leaders of the organization in governing, managing and
directing the organization will be evaluated. The standards to be addressed are:

         Governance, Leadership and Direction (GLD)
         Staff Qualifications and Education (SQE)
         Patient and Family Rights (PFR)
         Care of Patients (COP)
         Anesthesia and Surgical Care (ASC)
         Medication Management and Use (MMU)
         Management of Communication and Information (MOI)

DOCUMENTS/MATERIALS NEEDED:
No documents are required to be available during the leadership interview. However, during the
document review session, the surveyors may have reviewed the following documents in preparation
for the leadership interview:
• Organizational chart
• Mission statement
• Budget and resource allocation


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•   Strategic planning documents
•   Information management plan
•   Quality Management plan
•   Worksheet of applicable laws and regulations

WHAT WILL OCCUR:
The surveyors will ask questions related to leadership activities and the decisions that have been
made. Everyone present should participate in answering the questions.

The surveyors will assess compliance with certain standards from the Governance, Leadership and
Direction (GLD) chapter as well as other standards. Surveyors will also identify issues during the
leadership interview that they will pursue in later survey activities.

HOW TO PREPARE:
Identify the participants in the leadership interview. While leaders should be familiar with all of the
standards, have the organization's leaders closely read the GLD chapter prior to survey. In
preparation for this interview, it would be useful to turn the standards into questions. Mock
interviews could then be conducted with participants so they can feel more comfortable with
possible questions.

Some sample questions are:

GLD.1.2 – Please explain the process you, as leaders, use to approve the policies and plans used to
operate your organization.
Measurable element #3 - What are your strategies and programs for health care professional
education and research?

GLD.1.6 – What is a recent example of how the governance of this organization has supported and
promoted quality management and improvement efforts?

GLD.3.3 – How do you monitor the services offered by an outside organization with which you
have a contract to provide services?

GLD.5.1 – What is your process for identifying in writing the services provided by each
department? How do you know the documents are current?




JCIA Hospital Survey Process Guide ~ 2008                                                            91
Patient Safety Systems Evaluation
PURPOSE:
The purpose of the Patient Safety Systems Evaluation session is to assess the organizations process
for identifying and implementing organization wide systems to improve quality and patient safety.


LOCATION:              At the discretion of the hospital’s leaders

HOSPITAL PARTICIPANTS:

Key members of the organization who have responsibilities for the various aspects of patient safety,
include RCA, Proactive risk assessments (FMEA), International Patient Safety Goal, risk
management, etc.

To foster an interactive process, a large group is not recommended for this session.

SURVEYORS:
Physician, nurse and administrator surveyors

STANDARDS/ISSUES TO BE ADDRESSED:
Collaborative involvement of key members of the organization who have responsibilities for the
various aspects of patient safety. The standards to be addressed are:

         Governance, Leadership and Direction (GLD)
         Quality Improvement and Patient Safety (QPS)
         Prevention and Control of Infection (PCI)
         Medication Management and Use (MMU)
         Facilities Management and Safety (MCI)

DOCUMENTS/MATERIALS NEEDED:
• Failure Mode Effects Analysis (FMEA) and/or other proactive risk assessment
• Root Cause Analyses (RCA)
• Infection Control Risk Assessment and plan
• Medication Management System evaluation
• Facilities Management Risk Assessment plan


WHAT WILL OCCUR:
o Discussion about specific elements of the various activities which interface to develop a
  organization-wide systems approach to patient safety
o Review examples that highlight this process and demonstrate how improvements have been
  achieved



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o Assign surveyors to accompany selected hospital staff to clinical area(s) to demonstrate how the
  process is working currently to increase patient safety.

The surveyors will ask questions related to risk assessment activities and the decisions that have been
made. Everyone present should participate in answering the questions.


HOW TO PREPARE:
Identify key members of the organization who have responsibilities for the various aspects of patient
safety, include RCA, Proactive risk assessments (FMEA), International Patient Safety Goal, risk
management, etc. The participants in the Patient Safety Systems Evaluation session should be
familiar with all of the standards and the organizations internal processes regarding risk assessment,
identifying and responding to sentinel events. Have the organization's leaders closely review the
related chapter requirements and the relevant internal process documents.




JCIA Hospital Survey Process Guide ~ 2008                                                            93
Surveyor Planning Meeting

PURPOSE:
On surveys being conducted by more than one surveyor, scheduled team meetings provide an
opportunity for surveyors to share information and observations, plan for upcoming survey
activities, and plan for communication and coordination with the organization.

HOSPITAL PATICIPANTS                        None

SURVEYORS:                All surveyors on site

LOCATION:                 Surveyor headquarters

WHAT WILL OCCUR:
For surveys lasting more than one day, a 45-minute session is scheduled at the end of each day to
allow surveyors an opportunity to debrief and plan for subsequent survey days and activities.
Surveys lasting longer than two days will include an additional 30-minute session before or after
lunch to allow for mid-day activity planning and observation sharing. During these sessions
surveyors will:
       Identify areas that have been visited during tracer activity
       Coordinate locations, services, etc. that will be visited during continuing tracer activity
       Share observations on organization performance
       Identify key findings that have surfaced
       Ask other surveyors to follow up on potential issues
       Identify issues/areas that all surveyors should be exploring during individual patient and
       system tracers

When surveyors are in different locations at the times scheduled for Team Meetings, they may
request assistance from the organization in facilitating communication among the members of the
team (e.g., availability of a speaker phone or phone with conference call functionality, etc.).

Note: When only one surveyor is present, this time is an opportunity to plan upcoming survey
      activities, including the selection of additional tracers.




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Survey Report Preparation

PURPOSE:
Surveyor(s) will use this time to compile, analyze and organize the data he or she has collected
throughout the survey into a report reflecting the organization’s compliance with standards.

HOSPITAL PARTICIPANTS: None

SURVEYORS:                  All surveyors

LOCATION:                   Designated surveyor conference room and a predetermined off-site location.

WHAT WILL OCCUR:
This time is reserved on the agenda for the surveyor(s) to review their observations and determine if
there are any findings that reflect issues of standards compliance. When offsite, the surveyor(s) will
be using their laptop computers to prepare the report and plan for the Leadership Briefing
Conference.

The surveyor(s) may ask organization representatives for additional information during this session
to confirm or disprove a finding.




JCIA Hospital Survey Process Guide ~ 2008                                                            95
Leadership Briefing Conference
Leadership Briefing Conference
PURPOSE:
The purpose of this conference is to report
• Distribute the final report to the leaders and review the findings and scores
• Discuss the outcome of the Decision Rules
• Review the process for recording and submitting evidence of standards compliance into the
   Corrective Action Plan submitted to JCIA within 30 days
• Facilitate leaders in a discussion to identify appropriate
     o strategies for ensuring compliance with the findings identified in the survey report


LOCATION: At the discretion of the hospital’s leaders

HOSPITAL PARTICIPANTS:

         Chief Executive Officer
         Chief Operating Officer
         Chairman, Governing body, or similar representative
         Medical staff leadership
         Nursing leadership
         Others at the discretion of the hospital’s leaders

SURVEYORS: Physician, nurse and administrator surveyors

STANDARDS/ISSUES TO BE ADDRESSED: Survey findings

DOCUMENTS/MATERIALS NEEDED:                            None

WHAT WILL OCCUR:
The surveyors will open the conference and cover the following:

    •    Purpose of the conference
    •    Summary of compliance findings related to standards
    •    Discussion of any compliance findings for which there are questions or differences of
         perspective
    •    The content of the survey findings report
    •    The expected follow-up to the survey findings
    •    Education, as time permits, on areas indicated for follow-up within the 30 days.

The surveyors will explain the survey follow-up process regarding communication of the
accreditation decision by the JCI Central Office.


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Organization Exit Summary

PURPOSE:
At the discretion of hospital leadership the purpose of this conference is to communicate the survey
findings to the hospital staff.


LOCATION: At the discretion of the hospital’s leaders

HOSPITAL PARTICIPANTS:

         Chief Executive Officer
         Chief Operating Officer
         Chairman, Governing body, or similar representative
         Medical staff leadership
         Nursing leadership
         Others at the discretion of the hospital’s leaders

SURVEYORS: Physician, nurse and administrator surveyors

STANDARDS/ISSUES TO BE ADDRESSED: Survey findings

DOCUMENTS/MATERIALS NEEDED:                            None

WHAT WILL OCCUR:
The surveyors will open the conference and cover the following:

•   Describe the organization’s journey to accreditation as a milestone toward the ultimate goal of
    continuous improvement in quality and patient safety
•   Summarize the key positive organizational characteristics discovered during the survey activities
    which recognize success in their effort toward quality and patient safety
•   Summarize the high-level findings from the survey report activities
•   Assist the participants to understand where the organization fits into the timeline and next
    steps in the journey to achieving accreditation and beyond




JCIA Hospital Survey Process Guide ~ 2008                                                           97
                         SURVEY PLANNING

                                     Reference Lists




JCIA Hospital Survey Process Guide ~ 2008              98
JOINT COMMISSION INTERNATIONAL ACCREDITATION
Required Quality Monitors
The organization chooses which clinical and managerial processes and outcomes are most important
to monitor based on its mission patient needs and services provided. The organization’s leaders
identify key measures (indicators) to monitor the organization’s clinical and managerial structures,
processes and outcomes.

Required Clinical monitoring includes structure, process or outcomes data selected by the leaders on
aspects of:

         QPS.3.1      patient assessment
         QPS.3.2      laboratory safety
         QPS.3.3      radiology and diagnostic imaging safety
         QPS.3.4      surgical procedures
         QPS.3.5      antibiotics and other medication use
         QPS.3.6      monitoring of medication errors and near misses
         QPS.3.7      anesthesia and sedation use
         QPS.3.8      use of blood and blood products
         QPS 3.9      availability, content and use of patient records
         QPS.3.10     infection control, surveillance and reporting
         QPS.3.11     clinical research

Required Managerial monitoring includes structure, process or outcomes data selected by the leaders
on aspects of:

         QPS.3.12 procurement of routinely required supplies and medications essential to meet
                  patient needs
         QPS.3.13 reporting of activities as required by law and regulation
         QPS.3.14 risk management
         QPS.3.15 utilization management
         QPS.3.16 patient and family expectations and satisfaction
         QPS.3.17 staff expectations and satisfaction
         QPS.3.18 patient demographics and clinical diagnoses
         QPS.3.19 financial management
         QPS.3.20 surveillance, control and prevention of events that jeopardize the safety of
                  patients, families and staff including the International Patient Safety Goals

Required General measures to be monitored:

Clinical and managerial monitoring data are used to study targeted areas for improvement (QPS.3.1
through QPS.3.20 ME 2) and to monitor and evaluate the effectiveness of the improvements
(QPS.3.1 through QPS.3.20 ME 3).




JCIA Hospital Survey Process Guide ~ 2008                                                         99
JOINT COMMISSION INTERNATIONAL ACCREDITATION
Required Organization Plans
The following standards identify requirements that relate to a written plan. A plan is usually more
comprehensive in content than a policy or procedure. A plan can also be more long range, or
strategic in content. Frequently a plan also sets priorities for the entire organization. For example,
the quality management and improvement plan may address the organizations commitment to
quality, how quality improvement efforts will be organized. It will also identify priorities for the
short and long-range, and how those priorities will be achieved.

QUALITY IMPROVEMENT AND PATIENT SAFETY:

There is a written plan for an organization-wide quality improvement and patient safety program.
[QPS.1]

GOVERNANCE, LEADERSHIP, AND DIRECTION:

Organization plans (strategic or other documents) describe the care and services to be provided
consistent with the mission. [GLD 3.2]

Directors of each clinical department or service identify in writing the current and planned services
to be provided by the department or service. [GLD 5.1]

FACILITY MANAGEMENT AND SAFETY:

The organization has a master plan to reduce evident risks in the environment [FMS.2] or individual
plans that include, as appropriate to the facility and activities of the organization, the following areas:
[FMS.4 through FMS.10]:

         1. Safety and Security (FMS.4.2)
            • Safety – buildings, grounds, and equipment do not pose a risk to patients, staff and
                 visitors
            • Security – protect the facility and occupants from loss, destruction, tampering, and
                 unauthorized access or use
         2. Hazardous materials – handling, storage and use of radioactive and other materials
            (FMS.5)
         3. Emergencies – response to epidemics, disasters and emergencies (FMS.6)
         4. Fire safety –property and occupants are protected from fire and smoke (FMS.7)
         5. Medical equipment – equipment selected, maintained and used in a manner to reduce
            risks (FMS.8)
         6. Utility systems – electric, water and other utility systems maintained to minimize risk of
            failure (FMS.9.1)




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STAFF QUALIFICATION AND EDUCATION:

There is a plan for staffing the organization, developed collaboratively by the clinical and managerial
leaders, that identifies the number, types and desired qualifications of staff. [SQE 6]

MEDICATION MANAGEMENT AND USE

There is a plan (policy or other document) that identifies how medication use is organized and
managed throughout the organization (MMU.1).

PREVENTION AND CONTROL OF INFECTIONS

There is a comprehensive program and plan to reduce the risk of health care-associated infections in
patients, health care workers and visitors (PCI.5).




JCIA Hospital Survey Process Guide ~ 2008                                                           101
             JOINT COMMISSION INTERNATIONAL ACCREDITATION
             Required Policies and Procedures, Written Documents, or Bylaws
    Each of the following standards identify a requirement for a written document. In some cases
    document is in the form of a policy and procedure. In other cases, the document is less formal, but
    addresses the issue identified in the standard. In many cases a number of standard requirements can
    be combined into one policy and procedure. For example, many of the patient assessment
    requirements are interconnected and can be contained in one policy.

    The surveyors may not need to review all these documents in detail. It is however best to gather all
    these documents into one book or alternatively, identify the document by standard number in the
    traditional location of the document for easy location. NOTE: Please refer to the guidelines for
    document review for detailed suggestions on the presentation of documents for the surveyors.

    A select few of these documents need to be in English. The documents that need to be in English
    are identified below in caps. Other documents do not need to be translated. For documents that are
    not in English, the survey team will have one member able to read the documents or alternatively,
    the survey team may request that one or more individuals are available to describe the contents of
    the document and answer questions concerning the document.



   International Patient Safety Goals
 Goal                            Measurable Element(s)                                              Page
                                                                                                   Number
Goal 1     1. A collaborative process is used to develop policies and/or procedures that address     32
              the accuracy of patient identification.
           2. The policies and/or procedures require the use of two patient identifiers, not
              including the use of the patient’s room number or location. (ENGLISH)
Goal 2     1. A collaborative process is used to develop policies and/or procedures that address     33
              the accuracy of verbal and telephone communications.
Goal 3     1. A collaborative process is used to develop policies and/or procedures that address     33
              the location, labeling, and storage of concentrated electrolytes.
Goal 4     1. A collaborative process is used to develop policies and/or procedures that will        34
              establish uniform processes to ensure the correct site, correct procedure, and
              correct patient, including procedures done in settings other than the operating
              theatre. (ENGLISH)
Goal 5     1. A collaborative process is used to develop policies and/or procedures that address     35
              reducing the risk of health care–associated infections.
Goal 6     1. A collaborative process is used to develop policies and/or procedures that address     35
              reducing the risk of patient harm resulting from falls in the organization.




    JCIA Hospital Survey Process Guide ~ 2008                                                        102
     Access to Care and Continuity of Care (ACC)
Standard                          Measurable Element(s)                                              Page
                                                                                                    Number
ACC.1       5. Policies identify which screening and diagnostic tests are standard before             41
               admission.
            7. Policies define how patients are informed when there will be a wait or delay in
               care and treatment and the reasons for the delay or wait, and how the information
               will be documented.
ACC.1.1     1. Policies and procedures are used to standardize the outpatient registration            42
               process.
            2. Policies and procedures are used to standardize the inpatient admitting process.
            4. The policies and procedures address admitting emergency patients to inpatient
               units.
            5. The policies and procedures address holding patients for observation.
            6. The policies and procedures address managing patients when bed space is not
               available on the desired service or unit or elsewhere in the facility.
ACC.1.4     1. The organization has established entry and/or transfer criteria for its intensive      44
               and specialized services or units, including research and other programs to meet
               special patient needs. (ENGLISH)
ACC.2       2. Established criteria or policies determine the appropriateness of transfers within     45
               the organization.
ACC.3       1. There is a policy guiding the appropriate referral and/or discharge of patients.       46
            6. Organization policy guides the process of patients “on pass” for a defined period
               of time.
ACC.4       1. There is policy guiding the appropriate transfer of patients. (ENGLISH)                48




    JCIA Hospital Survey Process Guide ~ 2008                                                        103
     Patient and Family Rights (PFR)
Standard                          Measurable Element(s)                                              Page
                                                                                                    Number
PFR.1        5. Policies and procedures guide and support patient and family rights in the            56
                organization.
PFR.2        1. Policies and procedures are developed to support and promote patient and family       59
                participation in care processes.
PFR.2.3      3. Policies and procedures are implemented to guide the process for patients to          61
                make their decisions known to the organization and for modifying decisions
                during the course of care.
PFR.3        4. Policies and procedures identify participants in the process.                         63
             5. Policies and procedures identify how the patient and family participate.
PFR.6        1. The organization has a clearly defined informed consent process described in          64
                policies and procedures.
PFR.6.4.1    1. The organization has listed those procedures and treatments that require separate     66
                consent. (ENGLISH)
PFR.7        7. Policies and procedures guide the information and decision process.                   67
PFR.9        2. The organization develops a clear statement of purpose for the oversight              68
                activities.
PFR.11       1. Policies and procedures guide the procurement and donation process.                   69
                (ENGLISH)
             2. Policies and procedures guide the transplantation process.




     JCIA Hospital Survey Process Guide ~ 2008                                                       104
     Assessment of Patients (AOP)
Standard                          Measurable Element(s)                                                   Page
                                                                                                         Number
AOP.1        1. Organization policy and procedure define the assessment information to be                  74
                obtained for inpatients. (ENGLISH)
             2. Organization policy and procedure define the assessment information to be
                obtained for outpatients. (ENGLISH)
             3. Organization policy identifies the information to be documented for the
                assessments. (ENGLISH)
AOP.1.1      1. The scope and content of assessments by each clinical discipline are defined in            74
                policies. (ENGLISH)
             2. The scope and content of assessments performed in inpatient and outpatient
                settings are defined in policies. (ENGLISH)
AOP.1.4.1    1. The initial medical assessment is conducted within the first 24 hours of admission         77
                as an inpatient or earlier as indicated by the patient’s condition or hospital policy.
             2. The initial nursing assessment is conducted within the first 24 hours of admission
                as an inpatient or earlier as indicated by the patient’s condition or hospital policy.
AOP.1.6      1. Qualified individuals develop criteria to identify patients who require further            78
                nutritional assessment.
             4. Qualified individuals develop criteria to identify patients who require further
                functional assessment.
AOP.3        5. Those qualified to conduct patient assessments and reassessments have their                81
                responsibilities defined in writing.
AOP.5.1      3. Written policies and procedures address the handling and disposal of infectious            83
                and hazardous materials.
AOP.5.3      1. The organization has established the expected report time for results.                     84
AOP.5.6      1. Procedures guide the ordering of tests.                                                    85
             2. Procedures guide the collection and identification of specimens.
             3. Procedures guide the transport, storage, and preservation of specimens.
             4. Procedures guide the receipt and tracking of specimens.
AOP.5.11     1. A roster of experts for specialized diagnostic areas is maintained.                        88
AOP.6.2      3. Written policies and procedures address compliance with applicable standards,              89
                laws, and regulations.
             4. Written policies and procedures address handling and disposal of infectious and
                hazardous materials.
AOP.6.10     1. The organization maintains a roster of experts for specialized diagnostic areas.           93




    JCIA Hospital Survey Process Guide ~ 2008                                                             105
     Care of Patients (COP)
Standard                                        Measurable Element(s)                                 Page
                                                                                                     Number
COP.1       2. Policies and procedures guide uniform care and reflect relevant laws and                97
               regulations.
COP.3       1. The organization’s leaders have identified the high-risk patients and services.        100
            2. The leaders use a collaborative process to develop applicable policies and
               procedures.
COP.3.1     1. The care of emergency patients is guided by appropriate policies and procedures.       101
COP.3.2     1. The uniform use of resuscitation services throughout the organization is guided        101
               by appropriate policies and procedures.
COP.3.3     1. The handling, use, and administration of blood and blood products is guided by         102
               appropriate policies and procedures. (ENGLISH)
COP.3.4     1. The care of comatose patients is guided by appropriate policies and procedures.        102
               (ENGLISH)
            2. The care of patients who are on life support is guided by policies and procedures.
               (ENGLISH)
COP.3.5     1. The care of patients with a communicable disease is guided by appropriate policies     102
               and procedures.
            2. The care of immune-suppressed patients is guided by appropriate policies and
               procedures.
COP.3.6     1. The care of patients on dialysis is guided by appropriate policies and procedures.     102
               (ENGLISH)
COP.3.7     1. The use of restraint is guided by appropriate policies and procedures.                 102
COP.3.8     1. The care of frail, dependent elderly patients is guided by appropriate policies and    102
               procedures.
            3. The care of young, dependent children is guided by appropriate policies and
               procedures.
            5. Patient populations at risk for abuse are identified and their care is guided by
               appropriate policies and procedures.
COP.3.9     1. The care of patients receiving chemotherapy or other high-risk medications is          102
               guided by appropriate policies and procedures. (ENGLISH)
COP.6       2. Patients in pain receive care according to pain management guidelines.                 104




    JCIA Hospital Survey Process Guide ~ 2008                                                         106
     Anesthesia and Surgical Care (ASC)
Standard                          Measurable Element(s)                                                Page
                                                                                                      Number
ASC.3       1. Appropriate policies and procedures, addressing at least elements a) through f)          111
               found in the intent statement, guide the care of patients undergoing moderate and
               deep sedation. (ENGLISH)




     Medication Management and Use (MMU)
Standard                        Measurable Element(s)                                                  Page
                                                                                                      Number
MMU.1       1. There is a plan or policy or other document that identifies how medication use is        119
               organized and managed throughout the organization.
            3. Policies guide all phases of medication management and medication use in the
               organization.
MMU.2       2. There is a list of medications stocked in the organization or readily available from    120
               outside sources.
MMU.31      1. Organization policy defines how appropriate nutrition products are stored.              122
            2. Organization policy defines how radioactive, investigational and similar
               medications are stored.
            3. Organization policy defines how sample medications are stored and controlled.
            4. Organization policy defines how emergency medications are stored and
               maintained.
MMU.3.3     2. Policies and procedures address any use of medications known to be expired or           123
               outdated.
            3. Policies and procedures address the destruction of medications known to be
               expired or outdated.
MMU.4       1. Policies and procedures guide the safe prescribing, ordering and transcribing of        123
               medications in the organization. (ENGLISH)
            2. Policies and procedures address actions related to illegible prescriptions and
               orders. (ENGLISH)
MMU.4.1     1. Acceptable medication orders or prescriptions are defined in policy(s) and at least     124
               elements a) through i) are addressed in the policy(s). (ENGLISH)
MMU.7.1     1. A medication error and near miss are defined. (ENGLISH)                                 129




    JCIA Hospital Survey Process Guide ~ 2008                                                          107
     Quality Improvement and Patient Safety (QPS)
Standard                          Measurable Element(s)                                                 Page
                                                                                                       Number
QPS.1        1. The organization’s leadership participates in developing the plan for the quality        143
                improvement and patient safety program.
QPS.3        1. The leaders identify key measures to monitor clinical areas.                            149
             2. The leaders identify key measures to monitor managerial areas.
QPS.5        1. The hospital leaders have established a definition of a sentinel event that at least    151
                includes a) through c) found in the intent statement. (ENGLISH)
QPS.6        7. Other events defined by the organization are analyzed. (ENGLISH)                        152
QPS.7        1. The organization establishes a definition of a near miss and the type of events to      152
                be reported. (ENGLISH)




     Prevention and Control of Infections (PCI)
Standard                            Measurable Element(s)                                               Page
                                                                                                       Number
PCI.5          1. There is a comprehensive program and plan to reduce the risk of health care–           159
                  associated infections in patients. (ENGLISH)
               2. There is a comprehensive program and plan to reduce the risk of health care–
                  associated infections in health care workers. (ENGLISH)
               6. Risk-reduction goals and measurable objectives are established and regularly
                  reviewed. (ENGLISH)
PCI.7.1        3. When single-use devices and materials are reused, there is a policy that includes     161
                  items a) through e) in the intent statement, and the policy is implemented.
                  (ENGLISH)
PCI.8          1. Patients with known or suspected contagious diseases are isolated in accordance       163
                  with organization policy and recommended guidelines.
               2. Policies and procedures address the separation of patients with communicable
                  diseases from patients and staff who are at greater risk due to immunosuppression
                  or other reasons.




     JCIA Hospital Survey Process Guide ~ 2008                                                          108
     Governance, Leadership, and Direction (GLD)
Standard                          Measurable Element(s)                                                Page
                                                                                                      Number
GLD.1        1. The organization’s governance structure is described in written documents.              170
                (ENGLISH)
             2. Governance responsibilities and accountabilities are described in the documents.
                (ENGLISH)
             3. The documents describe how the performance of the governing entity and
                managers will be evaluated and any related criteria. (ENGLISH)
             5. There is an organization chart or document. (ENGLISH)
GLD.1.1      1. Those responsible for governance approve the organization’s mission.                   171
GLD.3.2      1. Organization plans describe the care and services to be provided.                      174
GLD.5.1      2. The departmental or service documents describe the current and planned services        177
                provided by each department or service.
GLD.5.3      1. The director develops criteria related to the needed education, skills, knowledge,     178
                and experience of the department’s professional staff.
GLD.6.1      3. The organization provides clear admission, transfer, and discharge policies.           180




     Facility Management and Safety (FMS)
Standard                          Measurable Element(s)                                                Page
                                                                                                      Number
FMS.2        1. There are written plan(s) that address the risk areas a) through f) in the intent       185
                statement.
FMS.4.1      1. The organization has a documented, current, accurate inspection of its physical        186
                facilities.
FMS.5        1. The organization identifies hazardous materials and waste and has a current list of    187
                all such materials within the organization.
FMS.8        2. There is an inventory of all medical equipment.                                        190




    JCIA Hospital Survey Process Guide ~ 2008                                                          109
     Staff Qualifications and Education (SQE)
Standard                            Measurable Element(s)                                                Page
                                                                                                        Number
SQE.6        1. There is a written plan for staffing the organization.                                    210
SQE.8.4      4. There is a policy on the provision of staff vaccinations and immunizations.               204
             5. There is a policy on the evaluation, counseling, and follow-up of staff exposed to
                infectious diseases that is coordinated with the infection prevention and control
                program.




     Management of Communication and Information (MCI)
Standard                       Measurable Element(s)                                                     Page
                                                                                                        Number
MCI.7        1. Policy establishes those care providers who have access to the patient’s record(s).       219
MCI.10       1. There is a written policy for addressing the privacy and confidentiality of               220
                information that is based on and consistent with law and regulation.
MCI.11       1. The organization has a written policy for addressing information security,               221
                including data integrity, that is based on or consistent with law or regulation.
MCI.12       1. The organization has a policy on retaining patient clinical records and other data       221
                and information.
MCI.18       1. There is a written policy or protocol that defines the requirements for developing       224
                and maintaining policies and procedures including at least items a) through h) in
                the intent, and it is implemented. (ENGLISH)
             2. There is a written protocol that outlines how policies and procedures that
                originated outside the organization will be controlled, and it is implemented.
                (ENGLISH)
             3. There is a written policy or protocol that defines retention of obsolete policies and
                procedures for at least the time required by law and regulation, while ensuring that
                they will not be mistakenly used, and it is implemented. (ENGLISH)
             4. There is a written policy or protocol that outlines how all policies and procedures
                in circulation will be identified and tracked, and it is implemented. (ENGLISH)
MCI.19.2     1. Those authorized to make entries in the patient clinical record are identified in        226
                organization policy.




    JCIA Hospital Survey Process Guide ~ 2008                                                            110
         JOINT COMMISSION INTERNATIONAL ACCREDITATION
                Standards that Reference Laws and Regulations
The International Standards for Hospitals were designed to be surveyed in the context of relevant,
country-specific local and national laws and regulations. The survey process takes into account the
laws and regulations under which a hospital operates and provides patient care in one of two ways:

    1. If a relevant law and/or regulation set a less stringent expectation than the accreditation
       standard, then the expectation of the accreditation standard is surveyed and scored.
    2. If, on the other hand, the law and/or regulation set a more stringent expectation than the
       accreditation standard, then the survey team will expect to find that the hospital is in
       compliance with the relevant law and/or regulation.

A senior manager or director is responsible for operating the organization and for complying with
applicable laws and regulations (GLD.2). The survey team will expect that this individual:

    •    Is knowledgeable concerning the applicable laws and/or regulations;
    •    Is aware of how the organizations complies with such laws and/or regulations; and
    •    Has satisfactorily responded to any citations or reports from agencies responsible for the
         enforcement of the laws and/or regulations.

The Law and Regulation Worksheet that follows is designed to familiarize the organization with
those particular standards that reference country-specific laws and/or regulations, and to provide a
summary of relevant applicable laws and/or regulations to the survey team for appropriate
evaluation of the accreditation standards. Note: Use the worksheet to indicate when there are laws
and/or regulations that are in conflict with each other, and when there are laws and/or regulations
that are in conflict with the standard.

Please complete this worksheet and provide it to the survey team at the document review session.
The worksheet contains additional space to include other laws and regulations that may be
applicable to the accreditation survey process, but may not be referenced in the standards.




JCIA Hospital Survey Process Guide ~ 2008                                                        111
                                Law and Regulation Worksheet
                                                                  IS LAW/REGULATION
                                                                    MORE STRINGENT
     STANDARD                   APPLICABLE          NAME OF         THAN STANDARD?
      NUMBER                 LAW/REGULATION?     LAW/REGULATION        note conflicts
                                 (YES/ NO)            IF YES           (YES / NO)
   ACCESS (ACC)
      ACC.6

   RIGHTS (PFR)
       PFR.1
      PFR.1.6
      PFR.2.3
       PFR.6
      PFR.6.2
      PFR.11

   ASSESSMENT
       (AOP)
      AOP.1.1
      AOP.1.7
       AOP.3
       AOP.5
      AOP.5.8
       AOP.6
      AOP.6.1
      AOP.6.2
      AOP.6.7

     CARE (COP)
       COP.1

  ANESTHESIA/
  SURGERY (ASC)
      ASC.1
      ASC.2

  MEDICATIONS
     (MMU)
     MMU.1
     MMU.3
    MMU.4.2
     MMU.5
     MMU.6


JCIA Hospital Survey Process Guide ~ 2008                                       112
                                                                IS LAW/REGULATION
                                                                  MORE STRINGENT
     STANDARD                   APPLICABLE        NAME OF         THAN STANDARD?
      NUMBER                 LAW/REGULATION?   LAW/REGULATION        note conflicts
                                 (YES/ NO)          IF YES           (YES / NO)

EDUCATION (PFE)
    NONE
 QUALITY (QPSI)
     QPS.2
        QPS.3.13


INFECTIONS (PCI)
     PCI.3
        PCI.10.6


  GOVERNANCE
     (GLD)
     GLD.2
         GLD.6


  FACILITY (FMS)
      FMS.1
        FMS.4.2
         FMS.5


    STAFF (SQE)
       SQE.1
         SQE.9
        SQE.13
        SQE.15
        SQE.16



 COMMUNICATIO
       N&
  INFORMATION
      (MCI)



JCIA Hospital Survey Process Guide ~ 2008                                     113
                                                                IS LAW/REGULATION
                                                                  MORE STRINGENT
     STANDARD                   APPLICABLE        NAME OF         THAN STANDARD?
      NUMBER                 LAW/REGULATION?   LAW/REGULATION        note conflicts
                                 (YES/ NO)          IF YES           (YES / NO)
         MCI.10
         MCI.12
         MCI.18
       MCI.19.4




JCIA Hospital Survey Process Guide ~ 2008                                     114

				
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Description: Hospital Forms, Request Family to Assist in Discharge document sample