ModuleModule
3: Standards
DOREEN FINN, RN, BSN, MBA
Senior Associate Director
Standards Interpretation Group
Division of Healthcare Improvement
1
Faculty Introduction(s)
DOREEN FINN, RN, BSN, MBA
Senior Associate Director
Standards Interpretation Group
Division of Healthcare Improvement
22
Welcome and Introduction
• This module is 1 out of 9 available to help prepare
candidates towards the JCCAP exam. Additional
webinar modules include:
– Understanding the Joint Commission’s Accreditation Process
– Organizational Analysis
– How to Engage Your Medical Staff into The Joint Commission
Accreditation Process
– Environment of Care
– Leadership
– Performance Improvement
– Patient Safety
– Understanding the CMS Regulatory and Survey Process for Hospitals
33
Welcome and Introduction
• Please note that all modules and Exam
Questions related to the JCCAP product line
are specifically related to The Comprehensive
Accreditation Manual for Hospitals, in addition
to CMS related materials
• JCCAP Questions
– Please visit www.jcrinc.com/jccap
– Email questions to: jccap@jcrinc.com
44
JCCAP Module 3: Standards
Disclosure Statement
The following staff and speakers have disclosed that they do not have any
financial arrangements or affiliations with corporate organizations
that either provide educational grants to this program or may be
referenced in this activity:
–
–
–
–
Speaker
Program Manager
Nurse Planner
Other planning team member
The following staff and speakers have verbally disclosed their
arrangements and affiliations: Not Applicable to this presentation
Furthermore, each of the previously named speakers has also attested
that their discussions will not include any unapproved or off-label use
of products.
55
Publications and Record Restrictions
• The program may be electronically recorded by JCR
and is subject to the protection of the copyright laws
of the US. No individual or entity other than JCR may
electronically record any portion of these programs
for any purpose without the written permission of
JCR. Any and all reproduction or publication of these
proceedings and programs for commercial purposes
by anyone other than JCR is prohibited.
6
Learning Objectives
• Describe a Standard and Element of
Performance
• Describe how each chapter supports quality of
care and positively effects health outcomes
• Apply the information learned to continuous
survey readiness
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Tips for Using Module
• Optimize your experience
– Viewers are encouraged to pause your screen at
any time to bring other staff and faculty in to
segments that you find appropriate for team
building and/or communication
– Take advantage of printing out the slides (pdf
available on the left side bar) for easy note taking
– Make sure to review attached links, documents
and references mentioned throughout this
module (available on the left side bar)
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Anatomy of a Chapter
• Overview
• Outline
• Definition of Standards
• Element of Performance (EP)
99
Human Resources (HR)
• Standards and EPs address the following:
• Staffing
• Qualifications
• Orientation
• Training and Education
• Competence
• Evaluation of Performance
10
10
Human Resources (HR)
• Pharmacist requirement HR.01.01.01
• Staff qualifications
HR.01.02.01
• Current license and
Scope of Practice
HR.01.02.07
• Staff competency
HR.01.06.01
• Staff evaluations
HR.01.07.01
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11
HR.01.01.01 Staffing
• Deemed status purposes:
• A full-time, part-time, or consulting
pharmacist develops, supervises, and
coordinates all the activities of the pharmacy
department / services.
12
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HR.01.02.05 Qualifications
• When law or regulation requires care
providers to be currently licensed, certified, or
registered to practice their professions, the
hospital both verifies these credentials with
the primary source and documents this
verification when a provider is hired and
when his or her credentials are renewed.
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HR.01.02.05 Qualifications
• The hospital verifies and documents that the
applicant has the education and experience
required by the job responsibilities.
14
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HR.01.02.05 Qualifications
• The hospital obtains a criminal background
check on the applicant as required by law and
regulation or hospital policy.
• Criminal background checks are documented.
15
15
HR.01.02.05 Qualifications
• The hospital confirms that nonemployees
who are brought into the hospital by a
licensed independent practitioner to provide
care, treatment, or services have the same
qualifications and competencies required of
employed individuals performing the same or
similar services at the hospital.
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HR.01.02.07 Qualifications
• All staff who provide patient care, treatment,
and services:
1. Possess a current license, certification, or
registration
2. Practice within the scope of their license in
accordance with law and regulation
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HR.01.04.01 Orientation
• The hospital orients its staff to key safety
content before staff provide care, treatment
or services.
• Completion of this orientation is documented.
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HR.01.05.03
Training and Education
• Staff participate in ongoing education and
training to maintain or increase their
competency. Staff participation is
documented.
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HR.01.05.03
Training and Education
• The hospital provides education and training
that addresses:
1. How to identify early warning signs of a
change in a patient’s condition
2. How to respond to a deteriorating patient,
including when to contact responsible
clinicians
3. Participation is documented
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HR.01.06.01 Competency
• Staff are competent to perform their
responsibilities.
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HR.01.07.01 Evaluations
• Staff are evaluated based on performance
expectations that reflect job responsibilities
• Evaluation is performed at least every three
years
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Infection Control (IC)
• Standards and EPs address the following:
• Planning
• Implementation
• Evaluation
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IC.01 Planning
•
•
•
•
•
•
Responsibility
Resources
Risks
Goals
Activities
Influx
IC.01.01.01
IC.01.02.01
IC.01.03.01
IC.01.04.01
IC.01.05.01
IC.01.06.01
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IC.01.01.01 Responsibility
• The [organization] identifies the individual(s)
responsible for the infection prevention and
control program.
1. Clinical Authority (Program)
2. Daily management of infection prevention
and control activities
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IC.01.02.01 Resources
• Hospital leaders allocate needed resources for
the infection prevention and control program.
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IC.01.02.01 Resources
• The hospital provides equipment and supplies
to support the infection prevention and
control program.
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IC.01.02.01 Resources
•
•
•
•
Other education
Daily lab services
Adequate number of isolation carts
Available Personal Protective Equipment (PPE)
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IC.01.03.01 Risk Assessment
• The hospital identifies risks for acquiring and
transmitting infections.
• The risk assessment is the cornerstone upon
which the IC program is built.
EXAMPLE: Food and Drink in clinical areas
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IC.01.04.01 Goals
• Based on the identified risks, the hospital sets
goals
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IC.01.04.01 Goals
• The hospital's written infection prevention
and control goals include the following:
1. Improving compliance with hand hygiene
guidelines.
2. Limit the transmission of infections
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IC.01.04.01 Goals
• Limiting unprotected exposure to pathogens
1. Isolation systems
2. Bloodborne pathogens
3. Waste disposal
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Infection Control (IC)
• There is a relationship of Goals to Evaluation
***Remember***
Your evaluation must address success or failure
of goals. Be sure to consider this when
formulating your goals.
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IC.01.05.01 Written IC Plan
• When developing the plan, use evidencebased national guidelines or, in the absence of
such guidelines, expert consensus.
CDC- Center for Disease Control
HICPAC- Healthcare Infection Control Advisory
Committee
NQF- National Quality Forum
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IC.01.05.01 Written Plan
• The surveyor:
– Will ask the ICP how these evidenced base
guidelines have been considered in the design of
interventions
– Will ask about the newest one or two guidelines –
the ICP should be able to discuss them
– May want to reference them in policies and
procedures
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IC.01.05.01 Written Plan
The plan includes a written description of:
1. The activities to minimize, reduce or
eliminate the risk of infection.
2. The process to evaluate the plan.
3. The process of investigating outbreaks of
infectious disease.
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Infection Control (IC)
“The hospital describes, in writing, the process
for investigating outbreaks of infectious
disease.”
• The surveyor might ask– Has this been predetermined?
– Does the method chosen “close the loop”
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IC.02 Implementation
• Plan Implementation
• Medical Equipment,
Devices, and Supplies
• Transmission of Infections
• Influenza Vaccinations
IC.02.01.01
IC.02.02.01
IC.02.03.01
IC.02.04.01
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IC.02.01.01 Implementation
• Surveillance is used to minimize, reduce or
eliminate the risk of infections.
• Examples of findings that are frequently
scored here are:
• dirty ceiling tiles
• dirty carts or wheelchairs,
• ripped or cracked chairs/mattresses
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IC.02.01.01 Implementation
Minimize the risk of
infection when storing
and disposing of
infectious waste.
The surveyor might ask:
“How does IC work with
facilities and housekeeping
to prevent exposure?”
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IC.02.02.01 Medical Equipment,
Devices and Supplies
• The hospital reduces the risk of infections
associated with medical equipment, devices,
and supplies.
• This standard is frequently scored among
non-compliant standards for Hospitals.
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IC.02.02.01 Cleaning and Disinfecting
• The hospital implements IC activities when
doing the following: Cleaning and performing
low-level disinfection of medical supplies and
devices.
• Surveyors might question the staff about low
level disinfection products and how they are
used.
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IC.02.02.01 High-Level
Disinfection & Sterilization
• The hospital implements IC activities when
performing intermediate and high-level
disinfection and sterilization of medical
equipment, devices, and supplies.
• See July 2009 Perspectives (Steam
Sterilization)
• See HICPAC’s “Guideline for Disinfection and
Sterilization in Healthcare Facilities, 2008”
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IC.02.02.01 Storage
• The hospital implements IC activities when
storing medical equipment, devices, and
supplies.
• The surveyor will look for expired supplies,
proper storage of medical equipment (how do
you know equipment is clean)
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IC.02.03.01 Staff Health Screening
• The hospital makes screening for exposure
and/or immunity to infectious disease
available to licensed independent
practitioners (LIP) and staff who may come in
contact with infections at the workplace.
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IC.02.04.01 Influenza Vaccination
• The hospital offers vaccination against
influenza to licensed independent
practitioners and staff annually.
• The hospital includes in its infection control
plan the goal of improving influenza
vaccination rates.
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IC.02.04.01 Influenza Vaccination
• The hospital educates licensed independent
practitioners and staff about, at a minimum,
1. the influenza vaccine
2. non-vaccine prevention measures
3. the diagnosis, transmission, and impact of
influenza
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IC.02.04.01 Influenza Vaccination
• The hospital annually evaluates vaccination
rates and the reasons given for declining the
influenza vaccination.
• The hospital takes steps to increase influenza
vaccination rates.
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IC.03.01.01 Evaluation
• The hospital evaluates the effectiveness of its
IC plan’s risks, activities and goals.
• The organization must ask, “How did we do?”
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IC.03.01.01 Evaluation
• Findings from the evaluation are
communicated at least annually to the
individuals or interdisciplinary group that
manages the patient safety program.
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Information Management (IM)
• Standards and EP’s address the following:
• Planning for the management of information
• Health Information – protecting the privacy,
capturing, storing and retrieving data
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Information Management (IM)
• Plan
IM.01.01.01
• Written plan for
managing interruptions
IM.01.01.03
• Protects the privacy of
health information (HIPAA) IM.02.01.01
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Information Management (IM)
• Security and integrity
of health information
• Manages the collection
of health information
• Retrieves, disseminates,
and transmits health
information in useful
formats
IM.02.01.03
IM.02.02.01
IM.02.02.03
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IM.03.01.01 Knowledge-based
Resources
• The hospital provides access to knowledgebased information resources 24 hours a day, 7
days a week.
• Provides knowledge-based information
resources that are not available on site by
cooperative or contractual arrangements
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Medication Management (MM)
• Standards and EP’s address the following:
• High alert and hazardous medications
• Safe storage
• Ordering
• Labeling
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MM.01.01.03 High Alert/Hazardous
Medication
• Must be identified in writing
• Must have a process for managing and
implement the process
• Must report abuses and losses of controlled
substances, according to law and regulation
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MM.01.02.01 Look-alike/ Sound-alike
Medications
• Develop a look-alike/sound-alike list
• Take action to prevent errors
• Annually reviews and, as necessary, revises
the list
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MM.03.01.01 Safe Storage
• A process exists for ensuring that medications
are stored safely and at the correct
temperature.
• All medications are stored in a secure area,
and locked when necessary, in accordance
with law and regulation.
• This standard is frequently scored.
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MM.03.01.01 Safe Storage
• Define the process to ensure labeling is
occurring as required
Example- multi dose vial (FAQ)
• Refer to BoosterPak® MM.03.01.01
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MM.04.01.01 Orders
• Standing Order
• Must be approved by the Medical Staff
• Criteria to trigger standing order
• Must have an order to implement the
standing order
• RN implements the order
• MD can sign latter
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MM.04.01.01 Orders
• Written policy that defines what action to
take when medication orders are incomplete,
illegible, or unclear
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MM.05.01.13
• There is a process for providing medications
when the pharmacy is closed to meet patient
needs.
• Store and secure medications approved for
use outside the pharmacy.
• Only trained, designated prescribers and
nurses are permitted access to the approved
medications.
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National Patient Safety Goals (NPSG)
• Standards and EP’s address the following:
• Importance of patient identification
• Communication among caregivers
• Safety of using medications
• Medication reconciliation
• Healthcare associated infections
• Identifying patients at risk for suicide
• Universal Protocol
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Goal 1- Improve the Accuracy of
Patient Identification
NPSG.01.01.01
Use two patient identifiers when providing
care, treatment and services.
Acceptable identifiers may be the individual’s:
• name
• assigned identification number
• telephone number, or other person-specific
identifier
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Goal 2 –Improve Communication
Among Staff
NPSG.02.03.01
• Develop, implement and evaluate procedures
for managing critical test results
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Goal 3- Improve the Safety of
Using Medications
NPSG.03.04.01
• Label all medications, containers and other
solutions on and off the sterile field
• The Joint Commission no longer prohibits prelabeling of syringes in the OR
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NPSG.03.06.01
• Document medications the patient is currently
taking when admitted to the hospital or is
seen in an outpatient setting
• Provide the patient or family, with written
information on the medications the patient
should be taking upon discharge
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Goal 7 – Reduce the Risk of
Health Care Associated Infections
• NPSG.07.01.01
• Comply with either the CDC or WHO hand
hygiene guidelines
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NPSG.07.06.01
• Implement evidence-based practices to
prevent health care associated infections due
to MRSA, central line associated bloodstream
infection (CLABSI), prevent surgical site
infections, and prevent indwelling catheter
associated urinary tract infections (CAUTI).
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NPSG.07.06.01
• Evidence-based guidelines for CAUTI located
at:
• http://www.sheaonline.org/GuidelinesResources/Compendium
ofStrategiestoPreventHAIs.aspx
• http://www.cdc.gov/hicpac
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Goal 15 – Identify Safety Risks
Inherent in Patient Population
NPSG.15.01.01
• Identify patients at risk for suicide
• BoosterPak® for NPSG.15.01.01
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Universal Protocol
• UP.01.01.01- Conduct a pre-procedure
verification process
• UP.01.02.01- Mark the procedure site
• UP.01.03.01- A time-out is performed before
the procedure
• Most frequently reported sentinel event
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Provision of Care, Treatment and
Services (PC)
• Standards and EPs address the following:
• Plan
• Implement
• Special Condition
• Discharge and Transfer
• Blood Safety
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PC.01.02.01 Assessment
• The hospital defines, in writing, the scope and
content of screening, assessment, and
reassessment information it collects.
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PC.01.02.03 Assessment
• The hospital defines, in writing, the time
frame for the patient’s initial assessment.
• The hospital assesses and reassesses the
patient and his or her condition according to
defined time frames.
• This standard is frequently scored among
non-compliant standards for Hospitals.
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PC.01.02.03 Assessment
• For an H&P examination that was completed
within 30 days prior to inpatient admission, an
update documenting any changes in the
patient’s condition is completed within 24
hours after inpatient admission, but prior to
surgery or a procedure requiring anesthesia
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PC.01.02.03 Assessment
• If the LIP finds no change in the patient’s
condition since the H&P was completed, he
may indicate in the medical record that the
H&P was reviewed, the patient was
examined and that no change in the patient’s
condition has occurred.
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PC.01.02.07 Pain Assessment
• A comprehensive pain assessment and
reassessment is performed.
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PC.01.02.08 Assessment
• The patient is assessed for a risk of falls and an
intervention is implemented to reduce falls
based on the patient’s identified risk.
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PC.01.02.09 Abuse and Neglect
• The hospital has written criteria to identify
those patients who may be victims of
physical/sexual assault, sexual molestation,
domestic abuse, or elder or child abuse and
neglect.
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PC.01.03.01 Care Plan
• The hospital plans the patient’s care, based
on needs identified by the patient’s
assessment, reassessment, and results of
diagnostic testing.
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PC.02.01.01 Providing Care
• The hospital provides the patient with care,
treatment, and services according to his or her
individualized plan of care.
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PC.02.01.03
• Deemed Status – Prior to providing care,
treatment, and services, the hospital obtains
or renews orders (verbal or written) from a
licensed independent practitioner.
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PC.02.01.11
• Resuscitation services are available
throughout the hospital.
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PC.02.01.19
• The hospital has a process for recognizing and
responding as soon as a patient’s condition
appears to be worsening.
• Based on the hospital’s early warning criteria,
staff seek additional assistance when they
have concerns about a patient’s condition.
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PC.02.01.21
• The hospital identifies the patient’s oral and
written communication needs, including the
patient’s preferred language for discussing
health care.
• Reference Perspectives, January 2012
• A Roadmap for Hospitals - 2010
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PC.02.02.03 Coordinate Care
• The hospital prepares food and nutrition
products using proper sanitation,
temperature, light, moisture, ventilation, and
security.
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PC.03.01.03 Pre-procedure
• Before operative or other high-risk procedures
are initiated, or before moderate or deep
sedation or anesthesia is administered:
• The hospital conducts a presedation or
preanesthesia patient assessment.
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PC.03.01.05 During the Procedure
• The hospital monitors the patient during
operative or other high-risk procedures and/or
during the administration of moderate or
deep sedation or anesthesia.
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PC.03.01.07 Post-procedure
• A postanesthesia evaluation is completed and
documented by an individual qualified to
administer anesthesia no later than 48 hours
after surgery or a procedure requiring
anesthesia services
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Restraints
• For Deemed status Purposes Use PC.03.05.01
- PC.03.05.19
• For Non-Deemed status purposes Use
PC.03.02.01 - PC.03.03.31
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PC.03.05.01
• The hospital uses restraint or seclusion only to
protect the immediate physical safety of the
patient, staff, or others.
• Distinguish between restraints for violent, self
destructive behavior and non-violent, nonself destructive behavior.
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PC.03.05.05 Restraints
• The hospital initiates restraint or seclusion
based on an individual order.
• The hospital does not use standing orders or
PRN (also known as “as needed") orders for
restraint or seclusion.
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PC.03.05.11 Restraints
• An LIP responsible for the care of the patient
evaluates the patient in person within one
hour of the initiation of restraint or seclusion
used for the management of violent or selfdestructive behavior.
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PC.03.05.11 Restraints
• A registered nurse or a physician assistant may
conduct the in-person evaluation within one
hour of the initiation of restraint or seclusion;
this individual is trained in accordance with
the requirements in PC.03.05.17.
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PC.03.05.17 Restraints
• The hospital trains staff to safely implement
the use of restraint or seclusion.
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PC.03.05.19 Restraints
• The hospital reports deaths associated with
the use of restraint and seclusion to Centers
for Medicare and Medicaid Services (CMS).
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PC.04.01.05 Discharge Education
• Before the hospital discharges or transfers a
patient, it informs and educates the patient
about his or her follow-up care.
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Record of Care (RC)
• Standards and EP’s address the following:
• Plan
• Implementation
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RC.01 Plan
•
•
•
•
•
Clinical Record Components
Authentication
Timeliness
Audit
Retention
RC.01.01.01
RC.01.02.01
RC.01.03.01
RC.01.04.01
RC.01.05.01
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RC.01.01.01 Medical Record
• The hospital maintains complete and accurate
medical records for each individual patient.
• All entries in the medical record are dated and
timed.
• This standard is frequently scored among
non-compliant standards for Hospitals.
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RC.01.02.01 Authentication
• Entries in the medical record are
authenticated.
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102
RC.01.04.01 Audits
• The hospital measures its medical record
delinquency rate at regular intervals, but no
less than every three months.
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RC.01.05.01 Retention
• The retention time of the original or legally
reproduced medical record is determined by
its use and hospital policy, in accordance with
law and regulation.
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RC.02 Implementation
• Care, treatment
• Verbal Orders
• Discharge Information
RC.02.01.01
RC.02.03.07
RC.02.04.01
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RC.02.01.01 Care, Treatment
• The medical record contains the patient’s race
and ethnicity. (Perspectives, January 2012)
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RC.02.01.03
• The patient’s medical history and physical
examination are recorded in the medical
record before an operative or other high-risk
procedure is performed.
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RC.02.01.03
• A procedure report is written or dictated upon
completion of the operative or other high-risk
procedure and before the patient is
transferred to the next level of care.
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RC.02.03.07 Verbal Orders
• Documentation of verbal orders includes:
• Date and the names of individuals who
1. Gave
2. Received
3. Recorded
4. Implemented the orders.
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Rights and Responsibilities (RI)
• Standards and EP’s address the following:
• Patient Rights
• Patient Responsibilities
Encourage patients to become more informed
and involved in their care.
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RI.01 Patient Rights
• Developing and Communicating Patient Rights
Organization
RI.01.01.01
Effective Communication RI.01.01.03
• Participation in Patient
Care Decisions
RI.01.02.01
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RI.01 Patient Rights
•
•
•
•
•
Informed Consent
Right to Know
End of Life
Personal Rights
Services to Protect
Patient Rights
RI.01.03.01
RI.01.04.01
RI.01.05.01
RI.01.06.03
RI.01.07.01
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112
RI.02 Patient Responsibilities
• Written policy that defines
patient responsibilities
RI.02.01.01
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RI.01.01.01 Patient Rights
• There is a written policy on patient rights.
• The hospital prohibits discrimination based on
age, race, ethnicity, religion, culture, language,
physical or mental disability, socioeconomic
status, sex, sexual orientation, and gender
identity or expression.
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RI.01.02.01
Participation in Care Decisions
• The hospital involves the patient in making
decisions about her care, treatment and
services
• The patient is provided with written
information about the right to refuse care
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RI.01.03.01 Informed Consent
• The hospital has a written policy on informed
consent
• The informed consent process includes a
discussion about reasonable alternatives to
the patient’s proposed care, treatment, and
services.
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RI.01.03.01 cont.
• The discussion encompasses:
1. Risks, benefits, and side effects related to
the alternatives
2. Risks related to not receiving the proposed
care, treatment, and services.
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RI.01.05.01
• The hospital has a written policy on advanced
directives in accordance with law and
regulation and implements this policy.
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118
RI.01.07.01 Review of Complaint
• The hospital establishes a complaint
resolution process.
During the survey process, the surveyor will talk
with you about patient, family or visitor
complaints.
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Transplant Safety (TS)
• Standards and EPs address the following:
• Donating and Procuring Organs and Tissue
• Transplanting Organ and Tissue
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120
TS.01.01.01 Donating Organs
• The hospital has a written agreement with an
organ procurement organization (OPO) and
follows its rules and regulations
121
121
Transplant Safety (TS)
• Development and implementation of policies
and procedures for the acquisition, receipt,
storage, and issuance of tissue.
• Retain tissue records on storage temperatures,
procedure and publication for at least 10
years.
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Waived Testing (WT)
• The hospital must obtain a Clinical Laboratory
Improvement Amendments of 1988 (CLIA)
certificate to perform waived testing.
• http:/www.fda.gov/cdrh/clia/index.html
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123
WT.02.01.01 Identify Staff
• The hospital identifies staff responsible for
performing and supervising waived testing
• The hospital provides orientation and training
and assesses the competency of staff who
perform waived testing. There is documented
satisfactory competence.
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WT.03.01.01 Staff Competency
• Competency for waived testing is assessed
using at least two methods per person per
test. (WT.03.01.01 EP5)
• Competency for waived testing is assessed at
least at the time of orientation and annually
thereafter.
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Closing Comments About JCCAP
• For the most current copy of the Candidate
Handbook and Frequently Asked Questions,
please visit www.jcrinc.com/jccap
• Continuing Education Certificates and
Instructions for obtaining your copy are found
on the left side bar. For any difficulty or
questions, please contact JCR Customer
Service at 877-223-6866 (8 am - 8 pm EST)
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Thank Module
you!!!
DOREEN FINN, RN, BSN, MBA
Senior Associate Director
Standards Interpretation Group
Division of Healthcare Improvement
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