Joint Commission International Laboratory Standards

Joint Commission International in an independent, not for profit international organization that accredits and certifies health care organizations and programs around the globe.

Although the accreditation is voluntary, their list of standards ensures patient safety and delivers quality healthcare that is acceptable universally.

There are different chapters in the accreditation standard and below are the one which is applicable to a clinical laboratory. 

JCI Requirements are described in these categories:

1.     Standards

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

2.     Intents

A standard’s intent helps explain the full meaning of the standard. The intent describes the purpose and rationale of the standard, provides an explanation of how the standard fits into the overall program, sets parameters for the requirement(s), and otherwise “paints a picture” of the requirements and goals. The bulleted lists in the intent statement are considered advisory and serve as a helpful explanation of practices that might meet the standard. Numbered or lettered lists in the intent statement include required elements that must be in place to meet the standard.

3.     Measurable Elements (MEs)

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

The score will either be “met” or “partially met” or “not met” based on the compliance of the laboratory.

If a standard is “not met” or only “partially met” a Strategic Improvement Plan (SIP) will be required especially if it has an impact on patient safety and quality. The written SIP is expected to do the following:

·       Establish the strategies/approach that the hospital will implement to address each identified finding.

·       Describe specific actions the hospital will use to achieve compliance with the standards/MEs cited

·       Describe specific steps the hospital will use to communicate and educate its staff, physicians and other in implementing actions to achieve compliance with the MEs cited.

·       Describe methodology to prevent reoccurrence and to sustain improvement over time.

·       Identify the measures that will be used to evaluate the effectiveness of the improvement plan.

The SIP must demonstrate that the hospital’s actions lead to full compliance with the standards and MEs. The SIP is reviewed and approved and accepted by the JCI Accreditation Office staff after the Accreditation or Certification Letter and Gold Seal have been awarded.

An organization that fails to submit an acceptable Strategic Improvement Plan (SIP) within 120 days of the organization’s survey is placed at risk of accreditation denial and a follow–up survey is required to verify evidence of compliance. When this occurs, the client organization is notified and the follow–up survey protocol is implemented.

 

ASSESSMENT OF PATIENT (AOP) STANDARD 

Standard AOP.5

Laboratory services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations.

Intent of AOP.5

The hospital has a system for providing laboratory services, including clinical pathology services, required by its patient population, clinical services offered, and health care practitioner needs. The laboratory services are organized and provided in a manner that meets applicable local and national standards, laws, and regulations.

Laboratory services, including those required for emergencies, may be provided within the hospital, by agreement with another organization, or both. Laboratory services are available after normal hours for emergencies. In addition, the hospital can identify and to contact experts in specialized diagnostic areas, such as parasitology, virology, or toxicology, when needed.

Outside sources are convenient for the patient to access. The hospital selects outside resources based on the recommendation of the laboratory’s leader or other individual responsible for laboratory services. Outside sources of laboratory services meet applicable laws and regulations and have an acceptable record of accurate, timely services. Patients are informed when an outside source of laboratory services is owned by the referring Physician.

Measurable Elements of AOP.5

þ Laboratory services meet applicable local and national standards, laws, and regulations 

þ Laboratory services are available to meet the needs related to the hospital’s mission and patient population, the community’s health care needs, and emergency needs, including after normal hours 

þ Experts in specialized diagnostic areas are contacted when needed.

þ Outside sources are selected based on an acceptable record and compliance with laws and regulations.

þ Patient are informed about any relationships between the referring Physician and outside sources of laboratory services.

Standard AOP.5.1

A qualified individual(s) is responsible for managing the clinical laboratory or pathology services.

Intent of AOP.5.1

Clinical laboratory services are under the direction of an individual who is qualified by virtue or documented training, expertise, and experience, consistent with applicable laws and regulations. This individual assumes professional responsibility for the laboratory facility and the services provided in the laboratory as well as tests performed outside the laboratory, such as testing performed at bedside (point–of– care testing). The oversight of services outside the laboratory includes ensuring consistent hospital wide policies and practices, such as training and supply management, among others. It does not include daily supervision of those activities. Daily supervision remains the responsibility of the leaders of the department or unit in which the testing is conducted.

When this individual provides clinical consultation or medical opinion, he or she is a Physician, preferably a Pathologist. Specialty and subspecialty laboratory services are under the direction of appropriately qualified individuals. Responsibilities of the laboratory leader include:

·       Developing, implementing, and maintaining policies and procedures 

·       Administrative oversight;

·       Maintaining any necessary quality control program;

·       Recommending outside sources of laboratory services; and

·       Monitoring and reviewing all laboratory services.

Measurable elements of AOP.5.1

þ The clinical laboratory and other laboratory services throughout the hospital, are under the direction and oversight of one or more qualified individuals.

þ Responsibilities for developing, implementing, and maintaining policies and procedures are defined and carried out.

þ Responsibilities for administrative oversight are defined and carried out.

þ Responsibilities for maintaining quality control programs are defined and carried out.

þ Responsibilities for recommending reference/contract laboratory services are defined and carried out.

þ Responsibilities for monitoring and reviewing all laboratory services within and outside the laboratory are defined and carried out.

Standard AOP.5.1.1

A qualified individual is responsible for the oversight and supervision of the point– of–care testing program.

Intent of AOP.5.1.1

Point–of–care testing (POCT) is defined by the College of American Pathologist as “test designed to be used at or near the site where the patient is located, that do not require permanent, dedicated space and that are performed outside the physical facilities of the clinical laboratories.”

When POCT is included in the hospital services, oversight, and supervision for the services, regardless of where the services are performed, are provided by the individual responsible for managing the laboratory services or a designee. The hospital must have a clearly defined and well–structured approach to POCT to ensure that it is performed safely and correctly and that the results generated are accurate and reliable.

A POCT program includes thorough planning with leaders electing to implement POCT in their department/ward. Planning includes selection of tests to be performed, identification of staff who will be performing the test(s), and a protocol for reporting abnormal test results, including the process for reporting critical results. Staff performing POCT require training for each test being performed, along with a competency evaluation to ensure that results are accurate.

Quality control performance, documentation, and evaluation are required to be performed within defined specifications, generally recommended by the manufacturer, daily as well as between new batches of test kits. The quality control sample may be included with the test kit or may need to be purchased from the manufacturer or authorized representative. All staff performing POCT adhere to defined quality control procedures and understand what actions to take when the quality control samples is out of specification.

A POCT program should be monitored and evaluated to ensure that the program is meeting the needs of its customers (health practitioners, testing staff, and patients). This may be accomplished by developing and monitoring quality improvement measures, through patient surveys and/or reviews of quality control and Proficiency Testing results, and utilization reports.

Measurable Elements of AOP.5.1.1

þ The person responsible for managing the laboratory services, or a designee, provides oversight and supervision of the POCT program.

þ Staff performing point–of–care testing have the required qualifications and training and are competent to perform POCT.

þ The POCT program includes a defined process for reporting abnormal test results, including reporting of critical results.

þ The POCT program includes quality control performance, documentation, and evaluation.

þ The POCT program is monitored and evaluated and included in quality improvement activities.

Standard AOP.5.2

All laboratory staff have the required education, training, qualifications, and experience to administer and perform the tests and interpret the results.

Intent of AOP.5.2

The hospital identifies the education, training, qualifications, and experience of laboratory staff members performing and interpreting laboratory tests, those who are approved to perform point–of–care screening tests at the bedside, and those who direct or supervise staff who perform testing. Supervisory staff and technical staff are oriented to their work. Technical staff are given work assignments consistent with their training and experience. In addition, the laboratory implements a staffing program that allows staff to perform tests promptly and to ensure laboratory staffing during all hours of operation and for emergencies.

Measurable Elements of AOP.5.2

þ All laboratory staff have the required credential to administer, perform and interpret tests.

þ A staffing program is implemented that allows staff to perform tests promptly and to provide staffing during all hours of operation and during emergencies.

þ Laboratory supervisory staff are identified and have the proper qualifications and experience.

Standard AOP.5.3

A laboratory safety program is in place, followed, and documented, and compliance with the facility management and infection control programs is maintained.

Intent of AOP.5.3

The laboratory has an active safety program to the degree required by the risks and hazards encountered in the laboratory. The program addresses safety practices and prevention measures (for example, eye–wash stations, spill kits and the like) for laboratory staff, other staff, and patients when present. The laboratory program is coordinated with the hospital’s facility management and infection control program.

The laboratory safety management program includes:

·       Compliance with standards addressing facility management and infection control programs;

·       Compliance with local and regional laws and regulations;

·       Availability of safety devices appropriate to the laboratory’s practices and hazards encountered;

·       The orientation of all laboratory staff to safety procedures and practices;

·       In–service education for new procedures and newly acquired or recognized hazardous materials.

Measurable Elements of AOP.5.3

þ A laboratory safety program addresses potential safety risks in the laboratory and other areas outside the laboratory where laboratory services are provided.

þ The program is part of the hospital’s facility management and infection control programs and reports to the hospital safety structure at least annually and when any safety events occur.

þ Identified safety risks are addressed by specific processes and/or devices to reduce the safety risks.

þ Laboratory staff are oriented to safety procedures and practices and receive ongoing education and training for new practices and procedures.

Standard AOP.5.3.1

The laboratory uses a coordinated process to reduce the risks of infection because of exposure to infectious diseases and biohazardous materials and waste.

Intent of AOP.5.3.1

There are policies, procedures, and practices implemented to reduce the hazards of exposure to biohazardous materials. Infections acquired in the laboratory are reported internally and, when appropriate, to public health agencies. The following biosafety hazards and practices are addressed in written procedures, and the requirements of the procedures are followed:

a.     Exposures to aerosols and droplets are controlled (for example, when mixing, sonicating, centrifuging, and flaming inoculating loops).

b.     Laboratory coats, gowns, or uniforms are worn to protect street clothes and prevent contamination.

c.      Biosafety cabinets are used when required.

d.     Rules govern how to handle laboratory exposure to infectious agents, accidental cuts, needlestick injuries, accidental ingestion, and contact of potentially infectious agents with mucus membranes. These rules include decontamination procedures, whom to contact for emergency treatment, and the location and use of safety equipment.

e.     There are written procedures defining safe collection, transport, and handling of all specimens. The procedure includes prohibiting anyone in laboratory technical areas from eating, drinking, smoking, applying cosmetics, manipulating contact lenses, and mouth pipetting.

f.      When relevant to their jobs, staff have received training about precautionary measures, modes of transmission and prevention of blood–borne pathogens.

g.     The laboratory also has a procedure to control exposure to infectious diseases, such as Ebola, MERS, tuberculosis, Zika, and others.

When problems with practice are identified, or accidents occur, corrective actions are taken, documented, and reviewed.

Measurable Elements of AOP.5.3.1

þ The laboratory has a defined process for reducing the risks of infection.

þ Infections acquired in the laboratory are reported, as defined in the policy, and in compliance with applicable laws and regulations.

þ The laboratory follows biosafety rules for relevant practice address in elements (a) through (g) in the intent.

þ When problems with practice are identified, or accidents occur, corrective actions are taken, documented, and reviewed.

Standard AOP.5.4

Laboratory results are available in a timely way as defined by the hospital.

Intent of AOP.5.4

The hospital defines the time period for reporting laboratory test results. Results are reported within a time frame on patient needs, services offered, and clinical staff needs. Emergency tests and after–hours and weekend testing needs are included. Results from urgent tests, such as those from the emergency department, operating theatres, and intensive care units are, are given special attention in the quality measurement process. In addition, when laboratory services are by contract with an outside organization, the reports are also timely, as set forth by hospital policy or the contract.

Measurable Elements of AOP.5.4

þ The hospital has established the expected report time for results.

þ The timeliness of reporting of urgent/emergency tests is measured.

þ Laboratory results are reported within a time frame to meet patient needs.

Standard AOP.5.5

All equipment used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities.

Intent of AOP.5.5

Laboratory staff work to ensure that all equipment, including medical devices used for point–of–care testing, function at acceptable levels and in a manner that is safe to the operator(s). The laboratory develops and implements a program to manage equipment and medical equipment that provides for:

·       Selecting and acquiring laboratory equipment and medical equipment;

·       Identifying and taking inventory of laboratory equipment and medical equipment;

·       Assessing laboratory equipment use through inspection, testing, calibration, and maintenance;

·       Monitoring and acting on laboratory equipment hazard notices, recalls, reportable incidents, problems, and failures; and

·       Documenting the management program.

Testing, maintenance, and calibration frequency are related to the laboratory’s use of its equipment and its documented history of service.

Measurable Elements of AOP.5.5

þ The laboratory develops, implements, and documents a program to manage laboratory equipment.

þ The program identifies how laboratory equipment is selected and acquired.

þ There is a documented inventory of all equipment.

þ Laboratory equipment is inspected and tested when new and according to age, use, and manufacturer’s recommendations thereafter and the inspections are documented.

þ Laboratory equipment is calibrated and maintained according to manufacturer’s recommendations, and the calibration and maintenance are documented.

þ The hospital has a system in place for monitoring and acting on laboratory equipment hazard notices, recalls, reportable incidents, problems, and failures.

Standard AOP.5.6

Essential reagents and supplies are available, and all reagents are evaluated to ensure accuracy and precision of results.

Intent of AOP.5.6

The hospital has identified those reagents and supplies necessary to provide laboratory services to its patients. There is a process to order or secure those essential reagents and supplies.

All reagents are stored and dispensed according to manufacturers’ directives or packaging instructions. All reagents are evaluated according to written guidelines. Written guidelines ensure the complete and accurate labelling of reagents and solutions.

Measurable Elements of AOP.5.6

þ Essential reagents and supplies are identified.

þ Essential reagents and supplies are available, and there is a process to address when essential reagents are not available.

þ All reagents are stored and dispensed according to manufacturers’ directives or packaging instructions.

þ The laboratory establishes and follows written guidelines for the evaluation of all reagents to ensure accuracy and precision of results.

þ All reagents and solutions are completely and accurately labelled.

Standard AOP.5.7

Procedures for collection, identifying, handling, safely transporting, and disposing of specimen are established and implemented.

Intent of AOP.5.7

Procedures are established and implemented for:

·       Ordering tests;

·       Collecting, storing, and preserving specimens; and

·       Receiving, logging, and tracking specimens.

These procedures are observed for specimens sent to reference/contract laboratory services for testing.

Measurable Elements of AOP.5.7

þ Procedures are established and implemented for the ordering of tests.

þ Procedures are established and implemented for the collection and identification of specimens.

þ Procedures are established and implemented for the transport, storage, and preservation of specimens.

þ Procedures are established and implemented for the receipt and tracking of specimens.

þ Procedures are established and implemented for the disposal of specimens.

þ The procedures are followed when reference/contract laboratory services are used.

Standard AOP.5.8

Established norms and ranges are used to interpret and to report clinical laboratory results.

Intent AOP.5.8

The laboratory establishes reference intervals or “normal” ranges for each test performed. The range is included in the medical record, either as part of the report or by including a current listing such values approved by the laboratory leader. Ranges are furnished when reference/contract laboratory service performs the test. The reference ranges are appropriate to the hospital’s geography and demographics are reviewed and updated when methods change.

Measurable Elements of AOP.5.8

þ The laboratory has established reference ranges for each test performed.

þ The range is included in the medical record at the time test results are reported.

þ Ranges are furnished when tests are performed by reference/contract laboratory services.

þ Ranges are appropriate to the hospital’s geography and demographics.

þ Ranges are reviewed and updated as needed.

Standard AOP.5.9

Quality control procedures for laboratory services are in place, followed, and documented.

Standard AOP.5.9.1

There is a process for Proficiency Testing of laboratory services.

Intent of AOP.5.9 and AOP.5.9.1

Well–designed quality control systems are essential to providing excellent pathology and clinical laboratory services.

·       Validation of the test methods used for accuracy, precision, and reportable range;

·       Daily surveillance of results by qualified laboratory staff;

·       Testing of reagents;

·       Rapid corrective action when a deficiency is identified; and

·       Documentation of results and corrective actions.

Proficiency testing determines how well an individual laboratory’s results compare with other laboratories that use the same methodologies. Such testing can identify performance not recognized by internal mechanisms. Thus, the laboratory participates in an approved Proficiency Testing program when available.

Alternatively, when approved programs are not available, the laboratory exchanges samples with a laboratory in another organization for purposes of peer comparison testing. The laboratory maintains a cumulative record of participation in a Proficiency Testing, or an alternative, is carried out for all specialty laboratory programs when available.

Measurable Elements of AOP.5.9

þ The hospital establishes and implements a quality control program for the clinical laboratory.

þ The program includes the validation of test methods.

þ The program includes the daily surveillance and documentation of test results.

þ The program includes testing of reagents.

þ The program includes rapid correction and documentation of deficiencies.

Measurable Elements of AOP.5.9.1

þ The Laboratory participates in a Proficiency Testing Program, or an alternative for all specialty laboratory services and tests.

þ For each specialty, subspecialty, analyte, or test, the laboratory’s Proficiency Testing results meet satisfactory performance criteria in accordance with laws and regulations.

þ The laboratory maintains records of its participation in a Proficiency Testing program.

Standard AOP.5.10

Reference/contract laboratories used by the hospital are licensed and accredited or certified by a recognized authority.

Standard AOP.5.10.1

The hospital identifies measures for monitoring the quality of the services to be provided by the reference/contract laboratory.

Intent of AOP.5.10 and AOP.5.10.1

When the hospital uses the services of a reference/contract laboratory – whether for select tests or to provide all laboratory services – the following information is required:

a.     A copy of a license from a recognized licensing authority

b.     A copy of the certificate or letter of accreditation or certification from a recognized laboratory accreditation or certification program*

c.      Documentation that the reference (contract) laboratory participates in an outside Proficiency Testing program

*A recognized laboratory accreditation or certification program is one that has been reviewed and endorsed by a laboratory professional society or governmental or private agency.

In addition, the hospital identifies measures for monitoring the quality of the services provided by all reference/contract laboratories – for example, turnaround times for tests, critical results reporting, and problems with specimens such as missing identifiers or specimen rejections. Qualified individuals review and act on the results of the quality monitoring.

Measurable Elements of AOP.5.10

þ The hospital maintains a copy of the license, from a recognized authority, for all reference/contract laboratories used by the hospital.

þ The hospital maintains a copy of the certificate or Letter of Accreditation or certification, from a recognized laboratory accreditation or certification program, for all reference/contract laboratories used by the hospital.

þ The hospital maintains documentation that any reference/contract laboratory used by the hospital participates in an outside Proficiency Testing program.

Measurable Elements of AOP.5.10.1

þ The frequency and type of performance expectation data from reference/contract laboratories are determined by the hospital.

þ The qualified individual responsible for the laboratory or a qualified designee reviews the performance expectation data from reference/contract laboratories.

þ The responsible individual or qualified designee acts based on the results.

þ An annual report of the data from reference/contract laboratories is provided to hospital leadership to facilitate management of contracts and contract renewals.

Standard AOP.5.11

A qualified individual is responsible for blood bank and/or transfusion services and ensures that services adhere to laws and regulations and recognized standards of practice.

Intent of AOP.5.11

Blood bank and/or transfusion services, when provided by the hospital, are under the direction of an individual who is qualified by virtue of documented training, expertise, and experience, consistent with applicable laws and regulations. This individual assumes professional responsibility for all aspects of blood bank services provided in the hospital. The oversight of services includes establishment, implementation, and documentation of the processes for:

a.     Blood donor selectio 

b.     Blood screening for disease

c.      Blood collection

d.     Blood storage

e.     Compatibility testing

f.      Blood distribution

Quality control processes for all blood bank services are established, implemented, and documented to ensure the safety of blood bank and transfusion services. Blood donor and transfusion services are guided by laws and regulations and recognized standards of practice.

Measurable Elements of AOP.5.11

þ A qualified individual is responsible for blood bank and/or transfusion services.

þ The blood bank has established, implemented, and documented processes for (a) through (f) of the intent.

þ Quality control measures are in place for all blood bank and transfusion services and are established, implemented, and documented.

þ The blood bank and transfusion services comply with applicable laws and regulations and recognized standard of practice.

 

INTERNATIONAL PATIENT SAFETY GOALS (IPSG) STANDARDS

Standard IPSG.1

The hospital develops and implements a process to improve accuracy of patient identification.

Intent of IPSG.1

Wrong–patient errors occur in virtually all aspects of diagnosis and treatment. Patients may be sedated, disoriented, not full alert, or comatose; may change beds, rooms, or locations within the hospital; may have sensory disabilities; may not remember their identity; or may be subject to other situations that may lead to errors in correct identification. The intent of this goal is twofold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual.

The identification process used throughout the hospital requires at least two ways in which to identify a patient, such as the patient’s name, identification number, birth date, a bar–coded wrist band, or other ways. The patient’s room number or location in the hospital cannot be used for identification. The process for using two different patient identifiers is uniform throughout the hospital. However, the two identifiers used in the inpatient department may be different from the two identifiers in the outpatient department. For example, the patient’s name and identification number or medical record number may be used in all inpatient areas, and the patient’s name and birth date may be used in all outpatient departments, such as the emergency department, ambulatory care department, or other outpatient location.

There are special circumstances in which the hospital may need to develop a specific process for patient identification; for example, when a comatose or confused/disoriented patient arrives with no identification, in the case of a new-born when the parents have not immediately chosen a name, and other examples. The process considers the unique needs of the patients, and staff use the process for patient identification in these special circumstances to prevent error.

Two different patient identifiers are required in any circumstances involving patient interventions. For example, patient is identified before providing treatments (such as administering medications, blood, or blood products; serving a restricted diet tray; or providing radiation therapy); performing procedures (such as insertion of an intravenous line or hemodialysis); and before any diagnostic procedures (such as taking blood or other specimen for clinical testing, or performing a cardiac catheterization or diagnostic radiology procedure).

Measurable Elements of IPSG.1

þ Patient are identified using two patient identifiers, not including the use of the patient’s room number and location in the hospital.

þ Patients are identified before performing diagnostic procedures, providing treatments, and performing other procedures (e.g. phlebotomy).

þ The hospital ensures the correct identification of patients in special circumstances, such as the comatose patient or new-born who is not immediately named.

Standard IPSG.2

The hospital develops and implements a process to improve the effectiveness of verbal and/or telephone communication among caregivers.

Standard IPSG.2.1

The hospital develops and implements a process for reporting critical results of diagnostic tests.

Standard IPSG 2.2

The hospital develops and implements a process for handover communication.

Intent of IPSG.2 through IPSG2.2

Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and results in improved patient safety. Communication can be electronic, verbal, or written. Patient care circumstances that can be critically impacted by poor communication include verbal and telephone patient care orders, verbal and telephone communication of critical test results, and handover communications.

Patient care orders given verbally in–person and over the telephone, if permitted under local laws and regulations, are some of the most error–prone communications. Different accents, dialects, and pronunciations can make it difficult for the receiver to understand the order being given. For example, drug names and numbers that sound alike, such as erythromycin and azithromycin or fifteen or fifty, can affect the accuracy of the order. Background noise, interruptions, and unfamiliar drug names and terminology often compound the problem. Once, received, a verbal order must be transcribed as a written order, which adds complexity and risk to the ordering process.

The reporting of critical results of diagnostic tests is also a patient safety issue. Diagnostic tests include but are not limited to laboratory tests, radiology exams, nuclear medicine exams, ultrasound procedures, magnetic resonance imaging, and cardiac diagnostics. This includes critical results from any diagnostics tests performed at the bedside, such as point–of–care testing, portable radiographs, bedside ultrasounds, or transesophageal echocardiograms. Results that are significantly outside the normal range may indicate a high–risk or life–threatening condition. A formal reporting system that clearly identifies how critical results of diagnostic tests are communicated to health care practitioners and how the information is documented reduces patient risks.

Handover communications can also be referred to as handoff communications. Handovers of patient care within a hospital occur:

·       Between health care practitioners (for example, physician to physician, physician to nurse, nurse to nurse, and so on);

·       Between different levels of care in the same hospital (for example, when the patient is moved from an intensive care unit to a medical unit or from an emergency department to the operating theatre);

·       From inpatient unit to diagnostic or other treatment departments, such as radiology or physical therapy; and

·       Between staff and patients/families, such as at discharge.

Breakdowns in communication can occur during any handover of patient care and can result in adverse events. Interruptions and other distractions from unit activities can inhibit clear communication of important patient information. Standardized, critical content for communication between the patient, family, caregiver, and health care practitioners can significantly improve the outcomes related to handovers of patient care.

Standardized forms, tools, or methods support a consistent and complete handover process. The content of the handover communication and the form, tool, or method used is standardized for the type of handover. The handover process may be different for different types of handovers within the hospital. For example, handovers of patient care for the emergency department to a medical ward may require a different process or different content than handovers for the operating theatre to the intensive care unit; however, the handovers are standardized for the type of handover occurring. Handover forms or tools, if used by the hospital, are not required to be part of the medical record. In addition, the detailed information communicated during the handover is not required to be documented in the medical record; however, the hospital may want to have documentation that the handover occurred. For example, the health care practitioner would record that he or she completed the handover and to whom he or she endorsed care, and then sign, date, and time the entry.

Safe practices for effective communication include the following:

·       Limiting verbal communication of prescription or medication orders to urgent situations in which immediate written or electronic communication is not feasible. For example, verbal orders can be disallowed when the prescriber is present, and the patient’s chart is available. Verbal orders can be restricted to situations in which it is difficult or impossible for hard–copy or electronic order transmission, such as during a sterile procedure.

·       The development of guidelines for requesting and receiving test results on an emergency or STAT basis, the identification and definitions of critical tests and critical values, to whom and by who critical test results are reported and monitoring compliance.

·       Writing down, or entering to a computer, the complete order or test result by the receiver of the information; the receiver reading back the order or test result; and the sender confirming that what has been written down and read back is accurate. Permissible alternatives for when the read–back process may not always be possible may be identified, such as in the operating theatre and in emergent situations in the emergency department or intensive care unit.

·       Use of standardized, critical content for communication between the patient, family, health care practitioner, and others involved in the patient’s care during handovers of patient care.

·       Use of standardized methods, forms, or tools to facilitate consistent and complete handovers of patient care.

Measurable Elements of IPSG.2

þ The complete verbal order is documented and read back by the receiver and confirmed by the individual giving the order.

þ The complete telephone order is documented and read back by the receiver and confirmed by the individual giving the order.

þ The complete test result is documented and read back by the receiver and confirmed by the individual giving the result.

Measurable Elements of IPSG.2.1

þ The hospital has defined critical values for each type of diagnostic test.

þ The hospital has identified by whom and to whom critical results of diagnostic tests are reported.

þ The hospital has identified what information is documented in the medical record.

Measurable Elements of IPSG.2.2

þ Standardized critical content is communicated between health care practitioners during handover of patient care.

þ Standardized forms, tools, or methods support a consistent and complete handover process.

þ Data from adverse events resulting from handover communications are tracked and used to identify ways in which handover can be improved, and improvements are implemented.

Standard IPSG.5

The hospital adopts and implements evidence–based hand–hygiene guidelines to reduce the risks of healthcare–associated infections.

Intent of IPSG.5

Infection prevention and control are challenging in most healthcare settings, and rising rates of healthcare–associated infections are a major concern for patient and healthcare practitioners. Infections common to all healthcare settings include catheter–associated urinary tract infections, bloodstream infections, and pneumonia (often associated with mechanical ventilation).

Central to the elimination of these and other infections is proper hand hygiene. Evidence–based hand–hygiene guidelines are available from the World Health Organization (WHO), the United States Center for Disease Control and Prevention (US CDC), and various other national and international organizations.

The hospital adopts and implements current evidence–based hand–hygiene guidelines. Hand–hygiene guidelines are posted in appropriate areas, and staff are educated in proper hand–washing and hand–disinfection procedures. Soap, disinfectants, and towels or other means of drying are in those areas where hand–washing and hand–disinfecting procedures are required.

Measurable Elements of IPSG.5

þ The hospital has adopted current evidence–based hand–hygiene guidelines.

þ The hospital implements a hand–hygiene program throughout the hospital.

þ Hand–washing and hand–disinfection procedures are used in accordance with hand–hygiene guidelines throughout the hospital.

 

PATIENT AND FAMILY RIGHTS (PFR) STANDARDS

Standard PFR.1

The hospital is responsible for providing processes that support patients’ and families’ right during care.

Intent of PFR.1

The hospital leadership is primarily responsible for how a hospital will treat its patients. Thus, leadership needs to know and to understand patient and family rights and the hospital’s responsibilities as identified in laws and regulations. Leadership then provides direction to department/service leaders who ensure that staff throughout the hospital assume responsibility for protecting these rights. To effectively protect and to advance patient rights, leadership works and seeks to understand their responsibilities in relation to the community served by the hospital.

The hospital respects the right of patient, and in some circumstances the right of the patient’s family, to have the prerogative to determine what information regarding their care would be provided to family or others, and under what circumstances. For example, the patient may not wish to have a diagnosis or laboratory result shared with family, or the family may not want the patient to know his or her diagnosis.

Patient and family rights are a fundamental element of all contacts among hospital, its staff, and patients and families. Thus, policies and procedures are developed and implemented to ensure that all staff members are aware of and respond to patient and family rights issues when they interact with and care for patients throughout the hospital. The hospital uses a collaborative and inclusive process to develop the policies and procedures and includes patients and families in the process.

Measurable Elements of PFR.1

þ Hospital leadership works to protect and to advance patient and family rights.

þ Hospital leadership understands patient and family rights as identified in laws and regulations and in relation to the cultural practices of the community or individual patients served.

þ The hospital respects the rights of patients, and in some circumstances the right of the patient’s family, to have the prerogative to determine what information regarding their care would be provided to family or others, and under what circumstances.

þ All staff are knowledgeable about patient rights and can explain their responsibilities in protecting patient rights.

Standard PFR.1.2

The hospital provides care that supports patient dignity, is respectful of the patient’s personal values and beliefs, and responds to requests for spiritual and religious observance.

Intent of PFR.1.2

One of the most important human needs is the desire for respect and dignity. Often, patients experience feelings of loss due to increased dependency in situations such as the need for assistance with feeding, movement, and personal hygiene. The patient has the right to care that is always respectful and considerate, in all circumstances, and recognizes the patient’s personal worth and self–dignity.

Each patient brings his or her own set of values and beliefs to the care process. Some values and beliefs are commonly held by all patients and are frequently cultural and religious in origin. Other values and beliefs are those of the patient alone. All patients are encouraged to express their beliefs in ways that respect the beliefs of others.

Strongly held values and beliefs can shape the care process and how patients respond to care. Thus, all staff seek to understand the care and services they provide within the context of the patient’s values and beliefs.

When a patient or family wishes to speak with someone related to religious or spiritual needs or observe a spiritual or religious custom, the hospital has a process to respond to the request. The process may be carried out through on–site religious staff, local sources, or family–referred sources. The process to respond is more complex; for example, when the hospital or country does not officially “recognize” and/or have sources related to a religion or belief for which there may be a request.

Measurable Elements of PFR.1.2

þ Staff provide care that is respectful and considerate of the patient’s dignity and self-worth.

þ Patients’ values and beliefs are identified.

þ Staff provide care that is respectful of the patient’s values and beliefs.

þ The hospital responds to routine as well as complex requests related to religious or spiritual support.

Standard PFR.1.3

The patient’s rights to privacy and confidentiality of care and information are respected.

Intent of PFR.1.3

Patient privacy, particularly during clinical interviews, examinations, procedures/treatments, and transport, is important. Patient may desire privacy from other staff, from other patients, and even from family members. Also, patients may not wish to be photographed, to be recorded, or to participate in accreditation survey interviews. Although there are some common approaches to providing privacy for all patients, individual patients may have different or additional privacy expectations and needs according to the situation, and these expectations and needs may change over time. Thus, as staff members provide care and services to patients, they inquire about the patient’s privacy needs and expectations related to the care or service. This communication between a staff member and his or her patient builds trust and open communication and does not need to be documented.

Medical and other health information, when documented and collected, is important for understanding the patient and his or her needs and for providing care and services over time. This information may be in paper or electronic form or a combination of the two. The hospital respects such information as confidential and has implemented policies and procedures that protect such information from loss or misuse. The policies and procedures reflect information that is released as required by laws and regulations.

Staff respects patient privacy and confidentiality by not posting confidential information on the patient’s door or at the nursing station and by not holding patient –related discussion in public places. Staff are aware of laws and regulations governing the confidentiality of information and inform patients about how the hospital respects their privacy and the confidentiality of information. Patients are also informed about when and under what circumstances information may be released and how their permission will be obtained.

The hospital has a policy that indicates if patients have access to their health information and the process to gain access when permitted.

Measurable Elements of PFR.1.3

þ Staff members identify patient expectations and needs for privacy during care and treatment.

þ A patient’s expressed need for privacy is respected for all clinical interviews, examinations, procedures/treatments, and transport.

þ Confidentiality of patient information is maintained according to laws and regulations.

þ Patients are requested to grant permission for the release of information not covered by laws and regulations.

Standard PFR.3

The hospital informs patients and families about is processed to receive and to act on complaints, conflicts, and difference of opinion about patient care and the patient’s right to participate in these processes.

Intent of PFR.3

Patients have a right to voice complaints about their care and to have those complaints reviewed and, when possible, resolved. Also, decisions regarding care sometimes present questions, conflicts, or other dilemmas for the hospital and the patient, family, or other decision makers. These dilemmas may arise from issues of access, treatment, or discharge. They can be particularly difficult to resolve when the issues involve, for example, withholding resuscitative services or foregoing or withdrawing life–sustaining treatment.

The hospital has established process for seeking resolution of such dilemmas and complaints. The hospital identifies in policies and procedures those who need to be involved in the processes and how the patient and family participate.

Measurable Elements of PFR.3

þ Patients are informed about the process for voicing complaints, conflicts, and differences of opinion.

þ Complaints, conflicts, and differences of opinion are investigated by the hospital.

þ Complaints, conflicts, and differences of opinion that arise during the care process are resolved.

þ Patients and families participate in the resolution process.

Standard PFR.5.2

Informed consent is obtained before surgery, anesthesia, procedural sedation, use of blood and blood products, and other high–risk treatments and procedures.

Intent of PFR.5.2

When the planned care includes surgical or invasive procedures, anesthesia, procedural sedation, use of blood and blood products, or other high–risk treatments or procedures, a separate consent is obtained. This consent process provides the information identified in PFR.5.3 and documents the identity of the individual providing the information.

Not all treatments and procedures require a specific, separate consent. Each hospital identifies those high–risk procedures and treatments for which consent must be obtained. The hospital lists these procedures and treatments and educates staff to ensure that the process to obtain consent is consistent. The list is developed collaboratively by those physicians and others who provide the treatments or perform the procedures. The list includes procedures and treatments provided on an outpatient basis and inpatient basis.

Measurable Elements of PFR.5.2

þ Consent is obtained before surgical or invasive procedures.

þ Consent is obtained before anesthesia or procedural sedation.

þ Consent is obtained before the use of blood and blood products.

þ The hospital has listed those additional procedures and treatments that require separate consent.

Consent is obtained before the additional and/or other high–risk procedures and treatments.

Standard PFR.6

The hospital informs patients and families about how to choose to donate organs and other tissues.

Standard PFR.6.1

The hospital provides oversight for the process of organ and tissue procurement.

Intent of PFR.6 and PFR.6.1

The shortage of available organs for transplant has encouraged may countries to develop procedures and systems to increase that supply. In some countries, laws determine that everyone is a donor unless specified otherwise (which is considered presumed consent). In other countries, explicit consent for organ donation is required. The hospital is responsible for defining the process of obtaining and recording consent for cell, tissue, and organ donation in relation to international ethical standards, and the way organ procurement is organized in their country. The hospital has a responsibility to ensure that adequate controls are in place to prevent patients from feeling pressured to donate.

The hospital supports the choice of patients and families to donate organs and other tissues for research or transplantation. Information is provided to patients and families on the donation process and the way organ procurement is organized for the community, region or nation (such as national or regional organ procurement agency or network).

The shortage of organs for transplant has resulted in questionable practices in the procurement and transplantation of organs. The practice of inducing vulnerable individuals or groups (such as illiterate and impoverished persons, undocumented immigrants, prisoners and political or economic refugees) to become living donors, organ trafficking (the buying and selling of organs over black market trade), the harvesting of organs without consent from executed prisoners or dead patients, and transplant tourism are inconsistent with ensuring organ donor and recipient safety.

Oversight for the process of organ and tissue procurement includes defining the donation process that is consistent with laws and regulations, respecting the community’s religious and cultural values, ensuring ethical practices, and identifying requirements for consent. Hospital staff are trained on the donation process that supports patient and family choices. Staff are also trained in the contemporary concerns and issues related to organ donation and availability of transplants. The hospital cooperates with other hospitals and agencies in the community responsible for all or a portion of the procurement, banking, transportation, or transplantation process.

Measurable Elements of PFR.6

þ The hospital supports patient and family choices to donate organs other tissues.

þ The hospital provides information to patients and families on the donation process.

þ The hospital provides information to the patient and family on the way organ procurement is organized.

þ The hospital ensure that adequate controls are in place to prevent patients from feeling pressured to donate.

Measurable Elements of PFR.6.1

þ The hospital defines the organ– and tissue–donation processes and ensure that the process is consistent with the region’s laws and regulations and its religious and cultural values.

þ The hospital identifies consent requirements and develops a consent process consistent with those requirements.

þ Staff are trained in the contemporary issues and concerns related to organ donation and the availability of transplants.

þ The hospital cooperates with relevant hospitals and agencies in the community to respect and to implement choices to donate.

 

CARE OF PATIENT (COP) STANDARDS

Standard COP.2.2

The hospital develops and implements a uniform process for prescribing orders.

Intent of COP.2.2

Many patient care activities require a qualified individual to prescribe an order for that activity that must be documented in the patient medical record. Such activities may include, for example, orders for laboratory testing, administration of medications, specific nursing care, nutrition therapy, rehabilitative therapy, and the like. Patient care activities requiring orders are ordered by individuals qualified to do so. Such orders must be easily accessible if they are to be acted on in a timely manner. Locating orders on a common sheet or in a uniform location in the patient’s medical record facilitates the carrying out of orders. Documented orders help staff understand the specifics of an order, when the order is to be carried out, and who is to carry out the order. Orders can be written on an order sheet that is transferred to the patient’s medical record periodically or at discharge, or a computerized order entry system may be used in hospitals that are using electronic patient medical records.

Each hospital decides

·       Which orders must be written/documented and not by telephone, verbal, or test messaging (if verbal, telephone, or text orders are allowed). For example, telephone orders may be limited to emergency situations when a Physician is not present, verbal orders may be limited to situations in which the ordering physician is performing a sterile procedure, and texting orders may be limited to diagnostic tests only;

·       Which diagnostic imaging and clinical laboratory test orders must provide a clinical indication/rationale;

·       Any exceptions in specialized settings, such as emergency departments and intensive care units;

·       Who is permitted to prescribe orders;

·       Where orders are to be in the patient medical record, including those that may be received via text.

As technology has evolved, many licensed independent practitioners have begun to use their personal mobile devices to text orders to the hospital for patient care, treatment, or services. Current text messaging platforms may offer the functionality to address previous concerns related to accuracy, timeliness, documentation, confidentiality, security of information and patient safety.

If a hospital chooses to allow orders to be transmitted through text messaging, the hospital ensures a secure text messaging platform is implemented and includes the following:

a.     Securing sign–on process(es)

b.     Encrypted messaging

c.      Prohibited use of unsecured test messaging (for example, short message service (SMS) text messaging)

d.     Delivery and read receipts.

e.     Date and time stamp

f.      Customized message retention time frames

g.     A process for authentication by the ordering physician

Measurable Elements of COP.2.2

þ The hospital develops and implements a uniform process for prescribing written/documented patient orders that includes identifying orders that may be received verbally, via telephone, and via text.

þ Diagnostic imaging and clinical laboratory test orders include a clinical indication/rationale when required for interpretation.

þ Orders are prescribed only by those qualified to do so.

þ Orders are found in a uniform location in medical records.

þ When hospitals allow orders to be transmitted through text messaging, the hospital ensures that process is through a secure text messaging platform and complies with (a) through (g) in the intent.

þ When hospitals allow orders to be transmitted through text messaging, the hospital collects data to monitor the process of communication for clarification when questions arise.

Standard COP.3.3

Clinical guidelines and procedures are established and implemented for the handling, use, and administration of blood and blood products.

Intent of COP.3.3

Blood must be administered in accordance with standards of practice and in a consistent manner in order to ensure the safety of the recipient. Therefore, clinical guidelines and procedures describe the process for:

a.     Patient consent for administration

b.     Procurement of blood from the blood bank or blood storage area;

c.      Patient identification;

d.     Blood administration;

e.     Monitoring of the patient; and

f.      Identification and response to signs of potential transfusion reactions

An individual with the education, knowledge, and expertise to oversee the blood and blood products administration ensures that processes, procedures, and clinical guidelines for transfusion are defined and implemented.

Measurable Elements of COP.3.3

þ An individual with education, knowledge and expertise oversees the administration of blood and blood products.

þ Clinical guidelines and procedures are established and implemented for the handling, use, and administration of blood and blood products.

þ Clinical guidelines and procedures address the process for (a) through (f) in the intent.

 

PREVENTION AND CONTROL OF INFECTION (PCI) STANDARDS

Standard PCI.7.2

The hospital reduces the risk of infections through proper disposal of waste.

Intent of PCI.7.2

Hospitals produce considerable waste each day. Frequently that waste is or could be infectious. Thus, the proper disposal of wate contributes to the reduction of infection risk in the hospital. This is true for the disposal of body fluids and materials contaminated with body fluids, the disposal of blood and blood components, and the disposal of waste from the mortuary and post mortem area, when present.

Measurable Elements of PCI.7.2

þ Disposal of infectious waste and body fluids is managed to minimize infection transmission risk.

þ The handling and disposal of blood and blood components are managed to minimize infection transmission risk.

þ Operation of the mortuary and post-mortem area is managed to minimize infection transmission risk.

Standard PCI.7.3

The hospital implements practices for safe handling and disposal of sharps and needles.

Intent of PCI.7.3

One of the dangers of needlestick injuries is the possible transmission of blood– borne diseases. Incorrect handling and improper disposal of sharps and needles present a major staff safety challenge. Work practices influence the risk of injury and potential exposure to disease. Identifying and implementing evidence–based practices to reduce the risk of injury from sharps ensures that exposure to such injuries is minimal. Hospitals need to provide staff with education related to safe handling and management of sharps and needles.

Proper disposal of needles and sharps also reduces the risk of injury and exposure. Proper disposal includes the use of containers that are closable, puncture–proof, and leakproof on the sides and the bottom. Containers should be easily accessible to staff and should not be overfilled.

Disposal of discarded needles, scalpels and other sharps, when not done properly, can pose a health risk to the general public and to those who work in waste management. Disposing of sharps container in the ocean, for example, can pose risks to the public if the containers break open. Hospitals must dispose of sharps and needles safely or contract with organizations that ensures the proper disposal of medical waste containers and that do so in accordance with laws and regulations.

The hospital implements a policy that adequately addresses all steps in the process, including identifying the proper type and use of containers, the disposal of the containers, and the surveillance of the process of disposal.

Measurable Elements of PCI.7.3

þ The hospital identifies and implements practices to reduce the risk of injury and infection from the handling and management of sharps and needles 

þ Sharps and needles are collected in dedicated, closable, puncture–proof, leakproof containers that are not reused.

þ The hospital disposes of sharps and needles safely or contracts with sources that ensure the proper disposal of sharps containers in dedicated hazardous waste sites or as determined by national laws and regulations.

 

FACILITIES MANAGEMENT AND SAFETY (FMS) STANDARDS

Standard FMS.8

The hospital establishes and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results.

Intent of FMS.8

To ensure that medical equipment is available for use and functioning properly, the hospital performs and documents:

·       An inventory of medical equipment;

·       Regular inspections of medical equipments;

·       Testing of medical equipment according to its use and manufacturers’ requirements; and

·       Performance of preventive maintenance.

Qualified individuals provide these services. Medical equipment is inspected when new and then on an ongoing basis, according to the equipment, age, use, and manufacturers’ instructions. Inspections, testing results, and any maintenance are documented. This helps ensure the continuity of the maintenance process and helps when doing capital planning for replacements, upgrades and other changes.

Measurable Elements of FMS.8

þ The hospital establishes and implements a medical equipment program throughout the hospital.

þ There is an inventory of all medical equipment.

þ Medical equipment is inspected and tested when new and according to age, use, and manufacturers’ recommendation thereafter.

þ The medical equipment program includes preventive maintenance.

þ Staff providing these services are qualified and trained for the services being provided.

 

STAFF QUALIFICATION AND EDUCATION (SQE) STANDARDS

Standard SQE.1.1

Each staff member’s responsibilities are defined in a current job description.

Intent of SQE.1.1

Individual staff members who are not licensed to practice independently have their responsibilities defined in current job descriptions. The job descriptions are the basis for their assignments, orientation to their work, and evaluation of how well they fulfil job responsibilities.

Job descriptions are also needed for health care practitioners when:

a.     The individual serves in primarily a managerial role, such as department manager, or in dual clinical and managerial roles, with the managerial responsibilities identified in a job description.

b.     The individual has some clinical responsibilities for which he or she has not been authorized to practice independently, such as an independent practitioner learning a new role or new skills;

c.      The individual is in educational program and under supervision, and the academic program identifies, for each stage or level of training, what can be done independently and what must be under supervision. The program description can serve as the job description in such cases; and

d.     The individual is permitted to temporarily provide services in the hospital, for example, a nurse for a temporary staffing agency.

When a hospital uses national or generic job descriptions (for example, a job description for a “nurse”), it is necessary to augment this type of job description with specific job responsibilities for the types of nurses (for example, intensive care nurse, pediatric nurse, or operating theatre nurse, among others). For those permitted by law and the hospital to practice independently, there is a process to identify and to authorize the individual to practice based on education, training, and experience. The requirements of this standard apply to all types of “staff” who require job description (for example, full time, part–time, employed, voluntary, or temporary).

Measurable Elements of SQE.1.1

þ Each staff member not permitted to practice independently has a job description.

þ Those individuals identified in (a) through (d) in the intent, when present in the hospital, have job descriptions appropriate to their activities and responsibilities or have been privileged if noted as an alternative.

þ Job descriptions are current according to hospital policy 

Standard SQE.2

Leaders of hospital departments and services develop and implement processes for recruiting, evaluating, and appointing staff as well as other related procedures identified by the hospital.

Intent of SQE.2

The hospital provides an efficient, coordinated, or centralized process for:

·       Recruiting individuals for available positions 

·       Evaluating the training, skills, and knowledge of candidates; and

·       Appointing individuals to the hospital’s staff.

If the process is not centralized, similar criteria, processes, and forms result in a uniform process across the hospital for similar types of staff, for example, for nurses or physical therapists. Departments/services leaders participate by recommending the number and qualifications of staff needed to provide clinical services to patients, as well as nonclinical support functions, and to fulfil any teaching, research, or other departmental responsibilities. Department and service leaders also help make decisions about individuals to be appointed to the staff. Thus, the standards in this chapter complement the Governance, Leadership, and Direction standards that describe/service leader’s responsibilities.

Measurable Elements of SQE.2

þ The hospital establishes and implements a process to recruit staff.

þ The hospital establishes and implements a process to evaluate the qualification of new staff.

þ The hospital establishes and implements a process to appoint individuals to the staff.

þ The hospital establishes and implements a process that is uniform across the hospital for similar types of staff.

Standard SQE.3

The hospital uses a defined process to ensure that clinical staff knowledge and skills are consistent with patient needs.

Intent of SQE.3

Qualified staff members are hired by the hospital through a process that matches the requirements of the position with the qualification of the prospective staff member. This process also ensures that the staff member’s skill is initially and over time consistent with the needs of patients.

For the hospital’s health care practitioner who are independent practitioners (that is, they do not practice under job description), the process is identified in SQE.9 through SQE.12.

For clinical staff under job description, the process includes the following:

·       An initial evaluation to ensure that he or she can assume those responsibilities in the job description. This evaluation is carried out before or at the time of starting to perform work responsibilities. The hospital may have a “probationary” or other period during which the clinical staff member is closely supervised and evaluated, or the process may be less formal. Whatever the process, the hospital ensures that staff providing high–risk services or providing care to high–risk patients are evaluated at the time they begin providing care, before the probationary or orientation period is completed. This evaluation of necessary skills, and knowledge and desired work behaviours, is carried out by the department or service to which the staff member is assigned.

·       The hospital then defines the process for and the frequency of the ongoing evaluation of staff abilities.

Ongoing evaluation ensures that training occurs when needed and that the staff member can assume new or changed responsibilities. Although such evaluation is best carried out in an ongoing manner, there is at least one documented evaluation of each clinical staff member working under a job description each year.

Measurable Elements of SQE.3

þ The hospital uses a defined process to match the clinical staff knowledge, skills and competency with patient needs. 

þ New clinical staff members are evaluated before or at the time they begin their work responsibilities.

þ The department or service to which the individual is assigned conducts the evaluation.

þ The hospital defines the frequency of ongoing clinical staff evaluation.

þ There is at least one documented evaluation of each clinical staff member working under a job description each year or more frequently as defined by the hospital.

Standard SQE.4

The hospital uses a defined process to ensure that nonclinical staff knowledge and skills are consistent with hospital needs and the requirements of the position.

Intent of SQE.4

The hospital seeks staff that can completely fill the requirements of nonclinical positions. The supervisor of the nonclinical staff member provides an orientation to the position and ensures that the worker can fulfil the responsibilities of the job description. The staff member receives the required level of supervision and on a periodic basis is evaluated to ensure continuing competence in the position.

Measurable Elements of SQE.4

þ The hospital uses a defined process to match nonclinical staff knowledge and skills with the requirements of the position.

þ New nonclinical staff are evaluated before or at the time they begin their work responsibilities.

þ The department or service to which the individual is assigned conducts the evaluation.

þ The hospital defines the frequency of ongoing nonclinical staff evaluation.

þ There is at least one documented evaluation of nonclinical staff members each year or more frequently as defined by the hospital.

Standard SQE.5

There is documented personnel information for each staff member.

Intent of SQE.5

An accurate personnel file provides documentation of staff knowledge, skill, competency, and training required for carrying out job responsibilities. In addition, the record shows evidence of staff performance and whether they are meeting job expectations. Personnel files may contain sensitive information and thus must be kept confidential.

Each staff member in the hospital, including those permitted by law and the hospital to work independently, has a record(s) with information about his or her qualifications; required health information, such as immunization and evidence of immunity; evidence of participation in orientation as well as ongoing in–service and continuing education; results of evaluations, including individual performance of job responsibilities and competencies; and work history. The records are standardized and kept current according to hospital policy.

Measurable Elements of SQE.5

þ Personnel files for each staff member are standardized and current and maintained and kept confidential according to hospital policy.

þ Personnel files contain the qualification and the work history of the staff member.

þ Personnel files contain the job description of the staff member when applicable.

þ Personnel files contain a record of orientation to the hospital and the staff member’s specific role and in–service education needed by the staff member.

þ Personnel files contain the results of performance reviews.

þ Personnel files contain required health information.

Standard SQE.6

A staffing strategy for the hospital, developed by the leaders of hospital departments and services, identifies the number, types, and desired qualifications of staff.

Standard SQE.6.1

The staffing strategy is reviewed on an ongoing basis and updated as necessary.

Intent of SQE.6 and SQE.6.1

Appropriate and adequate staffing is critical to patient care as well as to all teaching and research activities in which the hospital may be engaged. Staff planning is carried out by department/service leaders. The planning process uses recognized methods for determining levels of staffing. For example, a patient acuity system is used to determine the number of licensed nurses with pediatric intensive care experience to staff a 10–bed pediatric intensive care unit.

The strategy is written and identifies the number and types of required staff and the skills, knowledge, and other requirements needed in each department and service. The strategy addresses:

·       The reassignment of staff from one department or service to another in response to changing patient needs or staff shortages;

·       The consideration of staff requests for reassignment based on cultural values or religious beliefs; and

·       Compliance with local laws and regulations

Planned and actual staffing is monitored on an ongoing basis, and the strategy is updated as necessary. There is a coordinated process for the department/service leaders to update the overall strategy.

Measurable Elements of SQE.6

þ The hospital’s department/service leaders develop a written strategy for staffing the hospital in a manner the complies with local laws and regulations.

þ The number, types, and desired qualifications of staff are identified in the strategy using a recognized staffing method.

þ The strategy addresses the assignment and reassignment of staff.

Measurable Elements of SQE.6.1

þ The effectiveness of the staffing strategy is monitored on an ongoing basis.

þ The strategy is revised and updated when necessary.

þ The strategy is coordinated through a process that involves the department/service leaders.

Standard SQE.7

All clinical and nonclinical staff members are oriented to the hospital, the department or unit to which they are assigned, and to their specific job responsibilities at appointment to the staff.

Intent of SQE.7

The decision to appoint an individual to the staff of a hospital sets several processes in motion. To perform well, a new staff member, no matter what his or her employment status, needs to understand the entire hospital and how his or her specific clinical and nonclinical responsibilities contribute to the hospital’s mission. This is accomplished through a general orientation to the hospital and his or her role in the hospital and a specific orientation to the job responsibilities of his or her position. The orientation includes the reporting of medical errors, infection prevention and control practices, the hospital’s policies on telephone medication orders, and so on. Contract workers, volunteers, and students and trainees are also oriented to the hospital and their specific assignments or responsibilities, such as patient safety and infection prevention and control.

Measurable Elements of SQE.7

þ New clinical and nonclinical staff members are oriented to the hospital, to the department or unit to which they are assigned, and to their job responsibilities and any specific assignments.

þ Contract workers are oriented to the hospital, to the department or unit to which they are assigned, and to their job responsibilities and any specific assignments.

þ Volunteers are oriented to the hospital and assigned responsibilities.

þ Students and trainees are oriented to the hospital and assigned responsibilities.

Standard SQE.8

Each staff member receives ongoing in–service and other education and training to maintain or to advance his or her skills and knowledge.

Intent of SQE.8

The hospital collects data from several sources to understand its staff’s ongoing education needs. The results of quality and safety measurement activities are one source of information to identify staff education needs. Also, monitoring data from the facility management program, the introduction of new medical equipment, skill and knowledge areas identified through the review of job performance, new clinical procedures, and plans to provide new services represent such sources of data. Also, the hospital determines which staff, such as health care practitioners, are required to obtain continuing education to maintain their credentials and how the education of these staff will be monitored and documented.

To maintain acceptable staff performance, to teach new skills, and to provide training on new medical equipment and procedures, the hospital provides or arranges for facilities, educators, and time for ongoing in–service and other education. This education is relevant to each staff member as well as to the continuing advancement of the hospital in meeting patient needs. For example, medical staff members may receive education on infection prevention and control, advances in medical practice, culture of safety, or new medical equipment. Each staff member’s educational achievements are documented in his or her personnel record.

Hospital leadership supports the commitment to ongoing staff in–service education by making available space, equipment, and time for education and training programs. The availability of current scientific information supports the education and training. The education and training can take place in a centralized location or in several smaller learning and skill development locations throughout the facility. The education can be offered once to all or repeated for staff on a shift–by–shift basis to minimize the impact on patient care activities.

Measurable Elements of SQE.8.1

þ Staff members who provide patient care and other staff identified by the hospital are trained and can demonstrate appropriate competence in resuscitative techniques.

Intent of SQE.8.1

Each hospital identifies those staff to be trained in resuscitative techniques and the level of training (basic or advanced) appropriate to their roles in the hospital. The appropriate level of training for those identified is repeated based on the requirements and/or time frames identified by a recognized training program, or every two years if a recognized training program is not used. There is evidence to show if each staff member attending the training achieved the desired competency level.

Measurable Elements of SQE.8.1

þ Staff members who provide patient care and other staff identified by the hospital to be trained in cardiac life support are identified.

þ The appropriate level of training is provided with sufficient frequency to meet staff needs.

þ There is evidence to show if a staff member passed the training.

þ The desired level of training for everyone is repeated based on the requirements and/or time frames established by a recognized training program, or every two years if a recognized training program is not used.

Standard SQE.8.2

The hospital provides a staff health and safety program that addresses staff physical and mental health and safe working conditions.

Standard SQE.8.2.1

The hospital identifies staff who are at risk for exposure to and possible transmission of vaccine–preventable diseases and implements a staff vaccination and immunization program.

Intent of SQE.8.2 and SQE.8.2.1

A hospital’s health and safety program are important to maintain staff physical and mental health, satisfaction, productivity, and safe condition for work.

How a hospital orients and trains staff, provides a safe workplace, maintains equipment and medical equipment, prevents or controls health–care associated infections, and many other factors determine the health and well–being of staff. A staff health and safety program can be located within the hospital or be integrated into external programs. The program provides for the following:

a.     Initial employment health screening 

b.     Measures to control harmful occupational exposures, such as exposure to toxic drugs and harmful noise levels.

c.      Periodic preventive immunization and examinations

d.     Education, training, and interventions on safe patient handling

e.     Education, training and interventions on managing workplace violence.

f.      Education, training and interventions for staff who may be second victims of adverse or sentinel events.

g.     Treatment for common work–related conditions, such as back injuries or more urgent injuries

Whatever the staffing and structure of the program, staff understand how to report, be treated for, and receive counselling and follow–up for common work–related injuries such as those that may result from needlesticks, exposure to infectious diseases, encounters with workplace violence, handling of patients, hazardous conditions in the facility, and other health safety matters. The design of the program includes staff input and draws upon the hospital’s clinical resources as well as those in the community.

Nursing and other staff who assist with moving patients are at increased risk of back injuries and other musculoskeletal injuries due to the physical demands of patient handling. Improper patient handling techniques can also have a negative impact on patient safety and quality of care. Patient movement and handling tasks are being done in many different types of clinical settings. Thus, there is not any one specific solution that is appropriate for all areas in which patient movement and handling occurs. Examples of safe handling interventions may include the use of gate belts, lateral transfer aids, training on body mechanics, implementation of a transfer team and the like.

Violence in the workplace has become an increasingly common problem in health care organizations. Staff shortages, increased patient acuity, and the misconception that violence does not occur in health care organizations – or if violence does occur, it is part of the job – are just few of the barriers to acknowledging that workplace violence exists and to developing violence prevention programs.

The caregiving environment often presents emotional challenges that can be mentally and physically stressful. Health care practitioners are often the second victims of errors and sentinel events. When patients and their family members are compromised by clinical errors, the remorse and anxiety felt by caregivers and their feelings of moral distress are frequently not acknowledged or addressed. Hospitals need to acknowledge that the emotional health and performance of health care practitioners involved in adverse and sentinel events can have an impact on the quality and safety of patient care.

Because of their contact with patients and patients’ infectious material, many health care practitioners are at risk of exposure to and possible transmission of vaccine– preventable diseases. Identifying epidemiologically important infections, determining staff at high risk for these infections, and implementing screening and prevention programs (such as immunizations, vaccinations, and prophylaxis) can significantly reduce the incident of infectious disease transmission.

Asymptomatic infections are common, and individuals can be infectious prior to having any symptoms, including influenza. In addition, studies show that health care practitioners often report to work even when ill.

Hospitalized patients are at significant risk of injury or death from healthcare– associated infectious disease transmissions. Infectious disease outbreaks in hospitalized patients have been traced to unvaccinated healthcare practitioners, particularly in the case of influenza. Hospitals must consider taking steps toward reducing the risks associated with the transmission of infectious diseases by unvaccinated healthcare practitioners. Healthcare practitioners have an ethical and professional obligation to protect themselves, their co-workers, and patients/families. Vaccination is a duty or all healthcare practitioners.

Strategies for reducing patients’ risk of exposure to infectious diseases may include efforts to promote flu vaccination, encouraging staff to get the flu vaccine, and requiring unvaccinated staff to wear masks during flu season. Unvaccinated staff providing care to patients who are vulnerable to infection, such as the immunocompromised, the elderly, and infants, increases the risks to those patients already at high risk for infection. Therefore, staff immunization status needs to be considered when making staff assignments.

Measurable Elements of SQE.8.2

þ The hospital provides a staff health and safety program that is responsive to urgent and nonurgent staff needs through direct treatment and referral. 

þ The staff health and safety program include (a) through (g) in the intent.

þ The hospital identifies areas/situations for potential workplace violence and implements interventions to reduce the risk.

þ The hospital provides evaluation, counselling, and follow–up treatment for staff who are injured because of workplace violence.

þ The hospital provides education, evaluation, counselling, and follow–up for staff who are second victims of adverse or sentinel events.

Measurable Elements of SQE.8.2.1

þ The hospital identifies epidemiologically significant infections, as well as staff that are at high risk for exposure to and transmission of infections and implements a staff vaccination and immunization program.

þ The hospital evaluates the risks associated with unvaccinated staff and identifies strategies for reducing the patient’s risk of exposure to infectious diseases from unvaccinated staff.

þ The infection prevention and control program guide the evaluation, counselling, and follow–up of staff exposed to infectious diseases.

Standard SQE.9

The hospital has a uniform process for gathering the credential of those medical staff members permitted to provide patient care without supervision.

Standard SQE.9.1

Medical staff members’ education, licensure/registration, and other credentials required by law or regulations and the hospital are verified and kept current.

Standard SQE.9.2

There is a uniform, transparent decision process for the initial appointment of medical staff members.

Intent of SQE.9 through SQE.9.2

Explanations of terms and expectations found in these standards are as follows:

a.    Credentials 

Credentials are documents that are issued by a recognized entity to indicate completion of requirements or the meeting of eligibility requirements, such as a diploma from a medical school, specialty training (residency) completion letter or certificate, completion of the requirements of a medical professional organization, a license to practice, or recognition of registration with a medical or dental council. These documents, some of which are required by law or regulation, but some by hospital policy, must be verified form the original source that issued the document. 

Credentials can also be documents from individuals and entities that address some aspect of the applicant’s professional history or competency, such as letters of recommendation, a history of all previous hospital medical staff appointments, records of previous clinical care, health history, picture, or police background check, for example. These documents may be required by hospital policy as part of the credential–gathering process but are not verified from the source that issued the document unless required by hospital policy. This requirement for verification of the credential will vary by the position the applicant is seeking. For example, for an applicant for leader of a department/clinical service, the hospital may want to verify information regarding the individual’s previous administrative positions and experience. Also, for clinical positions, the hospital may require a certain number of years of experience and thus would verify this level of experience.

b.    Medical Staff

Medical staff are all Physicians, Dentists, and other professionals who are licensed to practice independently (without supervision) and who provide preventive, curative, restorative, surgical, rehabilitative, or other medical or dental services to patients; or who provide interpretative services for patients, such as pathology, radiology, or laboratory services. All classification of appointments, all types, and levels of staff (employed, honorary, contract, visiting, and private community staff members), are included. Visiting staff include those who are locum tenens, or invited experts, “master class” teachers, and others allowed to provide patient care services temporarily.  A hospital must define those other practitioners, such as “house officers,” “hospitalists,” and “junior doctors,” that are no longer in training, but may or may not be permitted by the hospital to practice independently. The term medical staff is thus inclusive of all physicians and other professionals permitted to treat patients with partial or full independence, regardless of their relationship to the hospital (for example, employed staff or independent consultants). Note that in some cultures traditional medicine practitioners, such as acupuncturists, chiropractors, and others, may be permitted by law and the hospital to practice independently thus, they are considered medical staff members, and these standards apply in full.

c.     Verification

Verification is the process of checking the validity and completeness of a credential from the source that issued the credential. This process can be accomplished by an inquiry to a secure online database of, for example, those individuals licensed in the hospital’s city or country. The process can also be accomplished by documenting a telephone conversation with the issuing source, or by sending an e–mail or conventional postal letter inquiry with the source. Verification of credentials from outside the country may be more complex and, in some cases, not possible. There should, however, be evidence of a credible effort to verify the credential. A credible effort is characterized by multiple (at least within 60 days) attempts by various methods (for example, phone, email, and letter) with documentation of the attempts and result(s).

The three following situations are acceptable substitutes for hospital performing primary source verification of credentials:

1.     Applicable to hospitals overseen directly by governmental bodies, the government’s verification process, supported by the availability of published governmental regulations about primary source verification; plus, government licensure, or equivalent such as registration; and the granting of specific status (for example, consultant, specialist, and others) are acceptable. As with all third–party verification processes, it is important to verify that the third party (for example, a government agency) implements the verification process as described in policy or regulations and that the process meets the expectations described in these standards.

2.     Applicable to all hospitals, an affiliated hospital that has already conducted primary source verification of the medical staff applicant, is acceptable as along as the affiliated hospital has current Joint Commission International (JCI) accreditation with “full compliance” on its verification process found in SQE.9.1, MEs 1 and 2. Full compliance means the hospital’s Official Survey Findings Report indicates that all measurable elements are fully met, or any not met or partially met measurable element required to be addressed by Strategic Improvement Plan (SIP) actions have been addressed and are now in full compliance.

3.     Applicable to all hospitals, the credentials have been verified by an independent third party, such as a designated, official, governmental, or nongovernmental agency, as long as the following conditions apply: Any hospital that bases its decisions in part on information from a designated, official, governmental, or nongovernmental agency should have confidence in the completeness, accuracy, and timeliness of that information. To achieve this level of confidence in the information, the hospital should evaluate the agency providing the information initially and then periodically thereafter to ensure that JCI standards continue to be met.

It is important to understand the process for issuing some credentials. For example, does the government agency that issues the license to practice base its decision on any or all the following: verification of education, an examination of competence, training by a medical specialty association, or membership and payment of fees? Also, if admission to a specialty education program is based on verification of education and experience to date, the hospital does not need to verify education again. The process used by the government agency is documented by the hospital. If the hospital does not have direct knowledge of the process used by the agency to verify education, or the hospital has never had an opportunity to verify that the agency carries out the process as described, then the hospital need to perform its own verification.

d.    Appointment

Appointment is the process of reviewing an initial applicant’s credentials to decide if the individual is qualified to provide patient care services that the hospital’s patients’ needs, and the hospital can support with qualified staff and technical capabilities. For initial applicants, the information reviewed is primarily from outside sources. Hospital policy identifies the individuals or mechanism accountable for this review, any criteria used to make decisions, and how decisions will be documented. Hospital policy identifies the process of appointment of independent practitioners for emergency needs or a temporary period. For such individuals, the appointment and identification of privileges are not made until at minimum licensure has been verified.

e.    Reappointment

Reappointment is the process of reviewing the medical staff member’s file to verify:

o   Continued Licensure

o   That the medical staff member is not compromised by disciplinary actions of licensing and certification agencies;

o   That the file contains sufficient documentation for seeking new or expanded privileges or duties in the hospital; and

o   That the medical staff member is physically and mentally able to provide patient care and treatment without supervision.

The information for this review is from both internal and external sources. When a clinical departments/service (for example, a subspecialty service) does not have a leader, there is a hospital policy that identifies who will do the review of the professionals in that department/service. The credential file of a medical staff member should be a dynamic source of information and under constant review. For example, when a medical staff member presents a certificate of achievement related to an advanced degree or advanced specialty training, the new credential should be immediately verified from the issuing source. Similarly, when an outside agency investigates a sentinel event related to a medical staff member and issues sanctions, this information should be used promptly to re-evaluate the clinical privileges of the medical staff member. To ensure that medical staff files are complete and accurate, the files are reviewed at least every three years, and a note in the file indicates any actions taken or that no action is necessary and the appointment to the medical staff continues.

Medical staff membership may not be guaranteed if the hospital does not have the special medical equipment or staff to support the professional practice of the individual. For example, a nephrologist seeking to provide dialysis services at the hospital, may not be granted medical staff membership if the hospital does not provide such services.

Finally, when an applicant’s licensure/registration has been verified from the issuing source, but other documents – such as education and training – have yet to be verified, the individual may be granted medical staff membership, and privileges may be identified for the applicant for a period not to exceed 90 days. Under such circumstances, these individuals may not practice independently and require supervision until all credentials have been verified. Supervision is clearly defined in hospital policy as to level and condition, and is not to exceed 90 days.

Measurable Elements of SQE.9

þ The hospital has an ongoing, uniform process to manage the credentials of medical staff members.

þ Medical staff members permitted by laws, regulations, and the hospital to provide patient care without supervision are identified.

þ Education, licensure/registration, and other credentials required by law or regulations are copied by the hospital and maintained for each medical staff member in their personnel file or in separate credential file.

þ All credentials required by hospital policy are copied by the hospital and maintained for each medical staff member in his or her personnel file or in a separate credential file.

Measurable Elements of SQE.9.1

þ Education, licensure/registration, and other credentials required by law or regulation or issued by recognized education or professional entities as the basis for clinical privileges are verified from the original source that issued the credential. 

þ Additional credentials required by hospital policy are verified from the source that issued the credential when required by hospital policy.

þ When third–party verification is used, the hospital verified that the third party (for example, a government agency) implements the verification process as described in policy or regulations and that the process meets the expectations described in the intent.

Measurable Elements of SQE.9.2

þ Medical staff appointments are made according to hospital policy and are consistent with the hospital’s population, mission, and services provided to meet patient needs.

þ Appointments are not made until at least licensure/registration has been verified from the primary source, and the medical staff member then provides patient care services under supervision until all credentials required by laws and regulations have been verified from the original source, up to a maximum of 90 days.

þ The method of supervision, frequency of supervision, and accountable supervisors are documented in the credential file of the individual.

Standard SQE.11

The hospital uses an ongoing standardized process to evaluate the quality and safety of the patient care provided by each medical staff member.

Intent of SQE.11

Explanations of terms and expectations found in these standards are as follows:

1.    Ongoing Monitoring and Evaluation

Ongoing monitoring and evaluation compose the process of continuously accumulating and analyzing data and information on the behaviors, professional growth, and clinical results of medical staff members. The department/service leader is responsible for the integration of the data and information on medical staff and taking appropriate actions. Immediate actions may be to counsel the staff member, place him or her under supervision, limit privileges, other measures intended to limit risks to patients and improve quality of care and patient safety. Long–term actions include synthesizing the data and information into a recommendation for continued medical staff membership and clinical privileges. Other actions may be to note to other medical staff members the benchmark behaviours and clinical results evident in the data and information of the medical staff member.

The ongoing monitoring and evaluation of medical staff members provides critical information to the process of maintaining medical staff membership and to the process of granting clinical privileges. Although three–year cycles are required for renewing medical staff membership and clinical privileges, the process is intended to be ongoing and dynamic. Critical quality and patient safety incidents can arise if a medical staff member’s clinical performance issues are not communicated and acted on when they arise.

The process of ongoing monitoring and evaluation is intended to:

o   Improve individual practices to high–quality, safe patient care.

o   Provide the basis for reducing variation within a department/service through comparisons among colleague and the development of practice guidelines and clinical protocols; and

o   Provide the basis for improving the results of the entire department/service through comparisons with external benchmark practices and published research and clinical results.

The ongoing monitoring and evaluation of medical staff members encompasses three general areas – behaviors, professional growth, and clinical results.

2.    Behaviors

Medical staff members are models and mentors in creating a safe culture in a hospital. A safe culture is characterized by full participation by all staff, without fear of reprisal or marginalization. Safe cultures also include high respect between professional groups in which disruptive and other behaviours do not occur. Staff feedback through surveys and other mechanisms can shape desired behaviours and can support medical staff role models.

An evaluation of behaviors can include:

o   Evaluation of whether a medical staff member understands and supports the hospital’s code of behavior and the identification of acceptable and unacceptable behavior.

o   Gathering, analysis, and use of information and data from staff surveys and other sources regarding the culture of safety in the hospital.

The ongoing monitoring and evaluation process should indicate, as part of the review process, the relevant achievements, and challenges of the medical staff member in efforts to be a full participant in a safe and just culture.

3.    Professional Growth

Medical staff members grown and mature as the organization in which they practice evolve, introducing new patient groups, technologies, and clinical science. Each medical staff member, to varying degrees, will reflect growth and improvement in the following important dimensions of healthcare and professional practice:

o   Patient care, including provisions of patient care that is compassionate, appropriate, appropriate, and effective for health promotion, disease prevention, treatment of disease, and care at the end of life. (Potential measures include frequency of preventive services and reports from patients and families.)

o   Medical/clinical knowledge, including knowledge of established and evolving biomedical, clinical, epidemiologic, and social–behavioural sciences, as well as the application of knowledge to patient care and the education of others. (Potential measures include application of clinical practice guidelines, including the adaptation and revision of guidelines, participation in professional conferences, and publications.)

o   Practice–based learning and improvement, including use of scientific evidence and methods to investigate, evaluate, and continuously improve patient care based on self–evaluation and lifelong learning. (Examples of potential measures include self–motivated clinical inquiry/research, acquiring new clinical privileges based on study and acquiring new skills, and full participation in meeting requirements of professional specialty requirements or continuing education requirements of licensure.)

o   Interpersonal and communication skills, including establishment and maintenance of effective exchange of information and collaboration with patients, their families, and other members of healthcare teams. (Examples of potential measures include participation in teaching rounds, team consultations, team leadership, and patient and family feedback.)

o   Professionalism, including commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward patients, their profession, and society. (Examples of potential measures include an opinion leader within the medical staff on clinical and professional issues, service on an ethics panel or discussions of ethical issues, keeping appointed schedules, and community participation.)

o   System–based practices, including awareness of and responsiveness to the larger contexts and systems of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. (Examples of potential measures include understanding the meaning of frequently used, hospitalwide systems, such as the medication system; and awareness of the implications of the overuse and underuse, and misuse of systems).

o   Stewardship of resources, including understanding of the need for stewardship of resources and practicing cost–conscious care, including avoiding the overuse and misuse of diagnostic tests and therapies that do not benefit patient care but add to healthcare costs. (Examples of potential measures include participation in key purchasing decisions within their practice area, participating in efforts to understand appropriate use of resources, and being aware of the cost to patients and payers of the services they provide.)

The ongoing monitoring and evaluation process should recognize, as part of the review process, the relevant areas of achievement and potential improvement of the medical staff member in these professional growth areas.

4.    Clinical Results

The ongoing monitoring and evaluation process for a medical staff member reviews information common to all medical staff members as well as specific information related to the clinical privileges of the member and the services provided by his or her specialty.

a.     Hospitalwide Data Sources

Hospital collects a variety of data for use in management; for example, reporting to health authorities to support allocation of resources or payment of services. To be useful in the ongoing evaluation of an individual medical staff member, such as hospitalwide data:

o   Need to be collected in such a manner that individual practitioners can readily be identified;

o   Must relate to the clinical practice of the individual medical staff member; and

o   Can be benchmarked internally and/or externally to understand individual practitioner patterns.

Examples of such potential sources of data include length of stay, frequency of diagnostic testing, blood usage, and usage of certain drugs, among others.

b.     Department–specific Data Sources

Data are collected at the level of each department/service. The department/service leader set the priorities for measurement in the department for purposes of monitoring as well as improvement. The measures are specific to the services provided and the clinical privileges of the individual medical staff members within the department. As with hospitalwide data, to be useful in the ongoing evaluation of an individual department/service member, the data:

o   Need to be collected in a manner such that individual practitioners can readily be identified;

o   Must relate to the clinical practice of the individual medical staff member; and

o   Can be benchmarked within the department/service and/or externally to understand individual practitioner patterns.

Examples of such potential department/service data include frequency of clinical procedures performed, complications, outcomes, and use of resources such as consultants, among others.

Also, it is important to note that it is not anticipated that any department/service will have the capacity or need to monitor all the listed privileges of every practitioner. It is more feasible to collect data on key services or some aspect of key services on the department level for which all or most department/service staff members have privileges.

Thus, there is no one set of data that will suffice to monitor and evaluate all medical staff members. The choice of data, the frequency of monitoring and analysis, and the actual use of the data and documentation in the record of the medical staff member are very specific to the department/service, to the relevant profession, and to the privileges of the practitioner. The monitoring and evaluation of medical staff members is supported by a variety of data sources, including electronic and paper records, observations, and peer interactions.

An important final step is to ask question: “How is this practitioner doing compared to other colleagues within his or her department and in comparison to professional colleagues in other hospitals, regions or countries?” The internal comparison is primarily to reduce variation in practice and outcomes within the department and learn from the best practices within the department. The external comparison is to ensure that the hospital achieves best practices within the respective profession. Each department will have knowledge of those professional databases, clinical practice guidelines, and scientific literature sources that describe those desirable benchmark practices. For example, oncology registries can be helpful, or data from practitioners using the same science (clinical practice guidelines). Similarly, a national or international surgical society may collect outcome or complication data.

In summary, the ongoing medical staff monitoring and evaluation process:

o   Is standardized by type of medical staff member and/or department or clinical services unit;

o   Uses the monitoring data and information for internal comparisons to reduce variation in behaviors, professional growth, and clinical results;

o   Uses the monitoring data and information for external comparisons with available, objective, evidence–based best practice or benchmark sources of clinical result data and information;

o   Is conducted by the individual’s department or service head, senior medical manager, or a medical staff review body;

o   Includes the monitoring and evaluation of senior medical staff and department heads by an appropriate professional; and

o   Provides information that will be documented in the medical staff member’s file, including the results of reviews, action taken, and the impact of those actions on privileges (if any).

Finally, while the process of monitoring and evaluation of medical staff members is intended to be ongoing, and data and information may be accumulated on an ongoing basis, hospital policy requires a review at least once during a 12–month period. The review is conducted by the individual’s department or service head, as senior medical manager, or a medical staff review body. Findings, conclusions, and any actions taken or recommended are recorded in the medical staff member’s file. When the findings affect the appointment or privileges of the medical staff member, there is a process to take action on the findings. Such immediate “for cause” actions are documented in the practitioner’s file and are reflected in the list of clinical privileges. Notification is sent to those in which the practitioner provides services.

Measurable Elements of SQE.11

þ All medical staff members are included in an ongoing professional practice monitoring and evaluation process as defined by hospital policy and standardized at the department/service level.

þ The monitoring and evaluation process identifies areas of achievement and potential improvement related to the behaviors, professional growth, and clinical results of the medical staff member compared to other department/service medical staff members.

þ The clinical results of data and information available on medical staff members are reviewed with objective and evidence–based information, as available, for external benchmarking.

þ The data and information from the monitoring are reviewed at least every 12 months by the individual’s department or service head, senior medical manager, or medical staff body, and the results, conclusions, and any actions taken are documented in the medical staff member’s credentials file and other relevant files.

þ When the findings affect the appointment or privileges of the medical staff member, there is a process to act on the findings, and such “for cause” actions are documented in the practitioner’s file and are reflected in the list of clinical privileges. Notification is sent to those sites in which the practitioner provides services.

Standard SQE.15

The hospital has a uniform process to gather, to verify, and to evaluate other healthcare practitioners’ credentials (license, education, training, and experience).

Intent SQE.15

Hospitals employ or may permit a variety of other healthcare practitioners to provide care and services to their patients or to participate in patient care processes. For example, these professionals include nurse practitioners, nurse midwives, surgical assistants, emergency medical care specialists, pharmacists, and pharmacy technicians. In some countries or cultures, this group also includes traditional healers or those who provide alternative services or services that complement traditional medical practice (for example, acupuncture, herbal medicine). Often, these individuals do not actually practice in the hospital; instead, they refer to the hospital or provide continuing or follow–up care for patients in the community. Many of these professionals complete formal training programs and receive licenses or certificates or are registered with local or national authorities. Others may complete less formal apprentice programs or other supervised experiences.

For those other healthcare practitioners permitted to work or to practice in the hospital, the hospital is responsible for gathering and verifying their credentials. The hospital must ensure that other healthcare practitioners are qualified to provide care and treatments and must specify the types of care and treatment they are permitted to provide if not identified in laws or regulations. The hospital ensure that other healthcare practitioners are qualified to provide safe and effective care and treatment to patients by:

·       Understanding the applicable laws and regulations that apply to such practitioners; 

·       Gathering all available credentials on everyone, including at least evidence of education and training, evidence of current licensure or certification when required; and

·       Verification of the essential information, such as current registry, licensure, or certification

The hospital needs to make every effort to verify essential information relevant to the individual’s intended responsibilities, even when the education took place in another country and a significant time ago. Secure websites, documented phone confirmation form the source, written confirmation, and third parties, such as a designated, official governmental or nongovernmental agency, can be used.

The situations described for medical staff in the intent of SQE.9 are acceptable substitutes for a hospital performing primary source verification for the credentials or other healthcare practitioners staff.

Standard compliance requires that primary source verification is carried out for:

·       New applicants beginning four months prior to initial accreditation survey; and

·       Currently employed health practitioners during a period of three years postsurvey.

When there is no required formal education process, licensure, or registry process or other credential or evidence of competency, this is documented in the individual’s record. When verification is not possible, such as with the loss of records in disaster, this is documented in the individual’s record. The hospital gathers and maintains a file of each healthcare practitioner’s credentials. The files contain current licenses or registry when regulations require periodic renewal.

Measurable Elements of SQE.15

þ The hospital has a standardized process to gather and document the education, certifications, and experience of each healthcare practitioner.

þ Education, training, and certification are verified from the original source according to the parameters found in the intent of SQE.9 and are documented.

þ Licensure is verified from the original source according to the parameters found in the intent of SQE.9 and is documented.

þ There is a record maintained on other healthcare practitioners that contains copies of any required license, certification, or registration.

þ The hospital has a process to ensure that other staff who are not employees of the hospital but accompany private physicians and provide services to the hospital’s patients have valid credentials that are comparable to the hospital’s requirement for credentials.

Standard SQE.16

The hospital has a uniform process to identify job responsibilities and to make clinical work assignments based on other healthcare practitioners’ credentials and any regulatory requirements.

Standard SQE.16.1

The hospital has a uniform process for healthcare practitioners’ participation in the hospital’s quality improvement activities.

Intent of SQE.16 and SQE.16.1

The hospital is responsible for identifying the types of activities or range of services these individuals will provide in the hospital. This can be accomplished through agreements, job assignments, job descriptions or other methods. In addition, the hospital defines the level of supervision (consistent with existing laws and regulations), if any, for these professionals. Other healthcare practitioners are included in the hospital’s quality management and improvement program.

Measurable Elements of SQE.16

þ Licensure, education, training, and experience of other healthcare practitioners are used to make clinical work assignments.

þ The process considers relevant laws and regulations.

þ The process supports the staffing process for other healthcare practitioners.

Measurable Elements of SQE.16.1

þ Other healthcare practitioners participate in the hospital’s quality improvement activities.

þ The performance of other healthcare practitioners is reviewed when indicated by the findings of the quality improvement activities.

þ Appropriate information from the review process is documented in the health care practitioner’s file.

 

MANAGEMENT OF INFORMATION (MOI) STANDARD 

Standard MOI.1

The hospital plans and designs information management process to meet internal and external information needs.

Intent of MOI.1

Information is generated and used during patient care and for managing a safe and effective hospital. The ability to capture and to provide information requires effective planning. Planning incorporates input from a variety of sources, including the following:

·       The healthcare practitioners

·       The hospital’s managers and department/service leaders

·       Those outside the hospital who need or require data or information about the hospital’s operation and care processes

The planning also includes the hospital’s mission, services provided, resources, access to affordable technology, and support for effective communication among caregivers. The priority information needs of these sources influence the hospital’s information management strategies and ability to implement those strategies. The strategies meet the needs of the hospital based on the hospital’s size, complexity of services, availability of trained staff, and other human and technical resources. The information processes are comprehensive and include all the departments and services of the hospital. Planning for the management of information does not require a formal written information program but does not require evidence of a planned approach that identifies the hospital’s information needs.

Measurable Elements of MOI.1

þ The information needs of those who provide clinical services are considered in the planning process.

þ The information needs of those who manage the hospital are considered in the planning process.

þ The information needs and requirements of individuals and agencies outside the hospital are considered in the planning process.

þ The planning is based on the hospital’s size and complexity.

Standard MOI.2

Information privacy, confidentiality, and security – including data integrity – are maintained.

Intent of MOI.2

The hospital maintains the privacy and confidentiality of data and information and is particularly careful about preserving the confidentiality of sensitive data and information. The balance between data sharing and data confidentiality is addressed. The hospital determines the level of privacy and confidentiality maintained for different categories of information (for example, patient information research data, and quality data).

Maintaining data integrity is an important aspect of information management. The information contained in a database must be accurate to ensure that the interpretation of results from data analysis is meaningful. In addition, data integrity is maintained during planned and unplanned downtown of data systems. This is accomplished through implementation of downtime recovery tactics and ongoing data backup processes.

Policies and procedures address security procedures that allow only authorized staff to gain access to data and information. Access to different categories of information is based on need and defined by job title and function, including students in academic settings. An effective process defines:

·       Who has access to data and information.

·       The information to which an individual has access.

·       The user’s obligation to keep information confidential.

·       The process for maintaining data integrity; and

·       The process followed when confidentiality, security, or data integrity are violated.

Measurable Elements of MOI.2

þ The hospital has written process that protects the confidentiality, security and integrity of data and information.

þ The process is based on and consistent with laws and regulations.

þ The process identifies the level of confidentiality maintained for different categories of data and information.

þ Those persons who need or have a job position permitting access to each category of data and information are identified.

þ Compliance with the process is monitored, and actions are taken when confidentiality, security or data integrity are violated.

Standard MOI.3

The hospital determines the retention time of records, data, and information.

Intent of MOI.3

The hospital determines the retention time of medical records and other data and information. Medical records and other data and information are retained for sufficient periods to comply with laws and regulations and to support patient care, management, legal documentation, research, and education. The retention of records, data, and information is consistent with the confidentiality and security of such information. When the retention period is complete, medical records and other records, data, and information are destroyed in a manner that does not compromise confidentiality and security.

Measurable Elements of MOI.3

þ The hospital determines the retention time of patient medical records and other data and information.

þ The retention process provides expected confidentiality and security.

þ Records, data, and information are destroyed in a manner that does not compromise confidentiality and security.

Standard MOI.5

The data and information need of those in and outside the hospital are met on a timely basis in a format that meets user expectations and with the desired frequency.

Intent of MOI.5

The format and methods of disseminating data and information to the intended user are tailored to meet the user’s expectations. Dissemination strategies include:

·       Providing only the data and information the user requests or needs.

·       Formatting the report to aid use in the decision process.

·       Providing reports with the frequency needed by the user.

·       Linking sources of data and information; and

·       Providing interpretation or clarification of data.

Measurable Elements of MOI.5

þ Data and information dissemination meet user needs.

þ Users receive data and information on a timely basis.

þ Users receive data and information in a format that aids its intended use.

þ Staff have access to the data and information needed to carry out their job responsibilities.

Standard MOI.6

Records and information are protected from loss, destruction, tampering and unauthorized access or use.

Intent of MOI.6

Medical records and other data and information are secure and always protected. For example, active medical records are kept in areas where only authorized healthcare practitioners have access, and records are stored in locations where heat, water, fire, or other damage is not likely to occur. The hospital implements processes to prevent unauthorized access to electronically stored information.

Measurable Elements of MOI.6

þ Records and information are protected from loss.

þ Records and information are protected from damage or destruction.

þ Records and information are protected from tampering and unauthorized access or use.

Standard MOI.7

Decision makers and other staff members are educated and trained in the principles of information use and management.

Intent of MOI.7

Individuals in the hospital who generate, collect, analyze, and use data and information are educated and trained to effectively participate in using and managing information. This education and training enable these individuals to:

·       Understand security and confidentiality of data and information.

·       Use measurement instruments, statistical tools, and data analysis methods.

·       Assist in interpreting data.

·       Use data and information to help in decision making;

·       Educate and support the participation of patients and families in care processes; and

·       Use measures to assess and to improve care and work processes.

Individuals are educated and trained according to their responsibilities, job descriptions, and data and information needs.

The information management process makes it possible to combine information from various sources and generate reports to support decision making. In particular, the combination of clinical and managerial information helps department/service leaders to plan collaboratively. The information management process supports department/service leaders with integrated longitudinal data and comparative data.

Measurable Elements of MOI.7

þ Decision makers and others are provided education on the principles of information use and management.

þ The education is related to the data and information needs of the individual and job responsibilities.

þ Clinical and managerial data and information are integrated as needed to support decision making.

Standard MOI.8

Written documents, including policies, procedures, and programs, are managed in a consistent and uniform manner.

Intent of MOI.8

Policies and procedures are intended to provide uniform knowledge on organizational clinical and nonclinical functions. A written document guides how all policies, procedures and programs in the hospital will be developed and controlled. This guidance document includes the following key components:

a.     Review and approval of all documents by an authorized person before issue.

b.     The process and frequency of review and continued approval of documents.

c.      The control for ensuring that only current, relevant versions of documents are available.

d.     How changes in a document can be identified.

e.     The maintenance of document identity and legibility.

f.      A process for managing documents that originated outside the hospital.

g.     Retention of obsolete documents for at least the time required by law and regulations, while ensuring that they will not be mistakenly used.

A tracking system allows each document to be identified by title, date of issue, edition and/or current revision date, number of pages, who authorized issue and/or reviewed the document, and database identification (if applicable). The tracking system helps staff quickly locate a policy relevant to their assignment or a particular situation. For example, staff in the emergency department can quickly locate the policy on informed consent when an unaccompanied minor requires a surgical procedure.

These processes for developing and maintaining policies, procedures, and programs are implemented.

Measurable Elements of MOI.8

þ There is a written guidance document that defines the requirements for developing and maintaining policies, procedures, and programs, including at least items (a) through (g) in the intent.

þ There are standardized formats for all similar documents, for example, all policies.

þ All policies, procedures, and other written documents in circulation are identified and tracked.

þ The requirements of the guidance document are implemented and evident in the policies, procedures, and programs found throughout the hospital.

Standard MOI.8.1

The policies, procedures, plans, and other documents that guide consistent and uniform clinical and nonclinical processes and practices are fully implemented.

Intent of MOI.8.1

Throughout the accreditation standards found in this manual, policies, procedures, plans and other written documents are required. These documents are required, as they reduce process variation and reduce the risk inherent in processes. This is particularly important in clinical processes to improve quality and patient safety.

There is a process to ensure that staff members have read and are familiar with policies, procedures, and plans relevant to their work. This process may be part of the orientation of staff members to their department and their responsibilities, or may be part of groupwide or hospitalwide special training sessions. Most importantly, when a policy, procedure, or plan is relevant to the assignment of an individual, the intended actions described in the document are evident in the actions of the individual.

Measurable Elements of MOI.8.1

þ Required policies, procedures, and plans are available, and staff understand how to access those documents relevant to their responsibilities.

þ Staff are trained and understand those documents relevant to their responsibilities.

þ The requirements of the policies and procedures, and plants are fully implemented and evident in the actions of individual staff members.

þ The implementation of policies, procedures, and plans is monitored, and the information supports full implementation.

 

MEDICAL PROFESSIONAL EDUCATION (MPE) STANDARDS

Standard MPE.1

The hospital’s governing body and leadership of the hospital approve and monitor the participation of the hospital in providing medical education.

Intent of MPE.1

Integrating education of medical students and trainees into a hospital’s operations requires a significant commitment of time, energy, and resources. Trainees include interns, residents, house officers, and fellows. Decisions on the integration of education and operations are best made at the highest decision–making level of the hospital. When the decision to provide medical education involves a network or consortia of organization, the governing entity is fully informed as to all the relationships and accountabilities. As the governing entity level also is responsible for decisions related to the hospital’s mission, strategic plans, resource allocation, and quality program, it is necessary to make this an integrated decision. For example, is the commitment to educate medical students and trainees consistent with the hospital’s mission, and how will this commitment be portrayed to the public and the hospital’s patients?

The governing entity and leadership of the hospital are also responsible for obtaining, reviewing, and agreeing to the education program parameters of the sponsoring academic program.

A set of metrics, relevant to the education programs within the hospital, is selected and reported to the governing entity and hospital leadership on an annual basis for a review of the scope and activities of the program, achievement of program goals, any relevant regulatory compliance issues, and the satisfaction of patients and staff with the program.

Measurable Elements of MPE.1

þ The decision to provide medical education is made by the governing entity and leadership of the hospital, is consistent with the hospital’s mission, and is documented.

þ The hospital’s governing entity and leadership obtain, review, and accept the parameters of the participating medical school, and this action is documented.

þ The hospital’s governing entity and leadership endorse a set of metrics to monitor and evaluate the ongoing operation of medical education programs, and there is documented review of the monitoring data.

þ The hospital’s governing entity and leadership review, at least annually, the medical education programs within the hospital, and the review is documented.

þ The review includes the satisfaction of patients and staff with the clinical care provided under the program.

Standard MPE.2

The hospital’s clinical staff, patient population, technology, and facility are consistent with the goals and objectives of the education program.

Intent of MPE.2

Providing a rich and meaningful learning experience for medical students and trainees requires many factors, in addition to the governing entity and hospital leadership commitment. The clinical staff of the hospital must be adequate in number and in expertise to advance medical student and trainee education. For example, nursing staff numbers support the educational program, and nursing staff understand their relationship to the educational program.

The hospital’s patient population is sufficient in number and needs to support the education and clinical learning experience. There must be adequate classroom space, off–duty study and rest facilities, and print and online resources to support an effective learning environment. In addition, adequate opportunities and time for learning and interactions with clinical staff must be provided. Contemporary technology needs to be available so that evidence–based health care practices can be taught.

Measurable Elements of MPE.2

þ There is evidence that the clinical staff of the hospital are in adequate number and have the education, training, and competence to support and advance the education of medical students and trainees.

þ There is evidence that the hospital’s patient population is adequate in number and clinical needs to support the education of medical students and trainees.

þ There is evidence that the hospital’s facilities, technology, and other resources support the education of medical students and trainees.

Standard MPE.3

Clinical teaching staff are identified, and each staff member’s role and relationship to the academic institution is defined.

Intent of MPE. 3

Those clinical staff who have responsibility for medical student and trainee education and supervision are clearly identified so that the medical students and trainees and other hospital staff understand educational accountabilities and authority. For example, when any hospital staff member has a comment, concern, or other matter related to the educational program or medical students and trainees, he or she will understand who is accountable for receiving and acting on that information.

The relationship of the clinical teaching staff of the hospital to the sponsoring academic institution(s) needs to be clear. For example, when academic titles are conferred on clinical staff members, it is clear if titles are earned or honorary, how those titles are to be used, and what the titles mean to the public. The hospital has a complete listing of clinical teaching staff with their medical and academic titles. Any requirements for the renewal or redesignation of academic titles are monitored for compliance.

Measurable Elements of MPE.3

þ Clinical teaching staff are identified to hospital staff, and there is a complete list of clinical teaching staff, including both professional and academic titles.

þ Staff are educated about these individuals, their accountabilities, and their authority.

þ The hospital has a process in place to monitor academic titles and requirements for renewal or redesignation and to keep such titles up to date.

Standard MPE.4

The hospital understands and provides the required frequency and intensity of medical supervision for each type and level of medical student and trainee.

Intent of MPE.4

Supervision is required to ensure safe patient care and ensure that the training program is a learning experience for the medical student and trainee. The required level of supervision is consistent with the level of training within the specialty and level of competence of the medical student and trainee. The hospital understands that medical student and trainee competence cannot be assumed and must be demonstrated early in the training program.

Each medical student and trainee understand the clinical supervision process, including who is to provide the supervision and the frequency of the supervision. For example, a medical student understands whether supervision is provided by a resident or by the patient’s primary physician or by a medical school faculty member. Medical students and trainees also understand whether the supervision includes daily signing of all notes and orders, signing of the care plan and progress notes every other day, or making a separate entry in the patient’s medical record. Likewise, it is clear as to how the evidence of that supervision is documented, including the frequency and location of the documentation. Finally, to ensure a uniform learning experience, the hospital has identified and monitors the uniform expectations for the mentoring/supervision process.

Measurable Elements of MPE.4

þ Hospital policy identifies and provides the required level of supervision within the specialty for each level of medical student and trainee.

þ The level to be provided is based on the demonstrated competency of the medical student and trainee.

þ Each medical student and trainee understand the level, frequency, and documentation of his or her supervision.

þ There is a uniform process for documenting the required supervision that is consistent with hospital policy, program goals, and the quality and safety of patient care.

þ The hospital has established uniform expectations for all staff providing supervision to ensure that the process results in uniform medical student and trainee experiences.

þ Medical records are reviewed for compliance with the documentation requirements and frequency.

Standard MPE.5

Medical education provided in the hospital is coordinated and managed through a defined operational mechanism and management structure.

Intent of MPE.5

Medical education programs in hospitals require an effective management structure and a commitment of staff time for their coordination and daily operation. The agreements between the hospital and the medical school need to be established and then monitored. There is an accurate list of all medical students and trainees in the hospital. For each medical student and trainee, there is a documentation of:

a.     Enrolment status.

b.     Academic classification.

c.      Any required licensure or certification.

d.     Reports of medical student and trainee achievements.

e.     Identification of medical student and trainee competencies.

f.      Any known factors that will require accommodation; and

g.     Any known factors that may influence the level of supervision required.

The documentation of (a) through (g) for a medical student may be limited depending on their enrolment status and current level of training. When an academic program is sponsored by the hospital, it is determined how and where these activities are conducted.

Measurable Elements of MPE.5

þ The operational structure for medical education in the hospital has been determined and is in operation as required.

þ The management structure for medical education in the hospital has been determined and is in operation as required.

þ There is a complete and current list of all medical students and trainees in the hospital.

þ For each medical student and trainee, there is documentation of at least (a) through (g) of the intent.

Standard MPE.6

Medical students and trainees comply with all hospital policies and procedures, and all care is provided within the quality and patient safety parameters of the hospital.

Intent of MPE.6

Training program and their students are a critical factor in overall quality of care and patient safety. Although it would be desirable for each medical student and trainee to have basic education on quality and patient safety in his or her respective academic program, this rarely happens. Thus, the hospital must have a planned and deliberate program to introduce such concepts, support the medical students and trainees in complying with relevant policies and guidelines, and include medical students and trainees in all quality and safety monitoring programs. For example, medical students and trainees would be educated to comply with the International Patient Safety Goals.

Also, required clinical practice guidelines, surgical time–out procedures, medication –ordering policies, and other mechanism to reduce variation in care processes – and thus reduce the risk in those processes – are part of all medical students’ and trainees’ initial orientation and ongoing training and monitoring. The orientation for the medical student and trainee includes at least:

a.     Hospital quality and patient safety program

b.     Infection control program

c.      Medication safety program

d.     International Patient Safety Goals

e.     All other required hospital orientation, including at the department and unit level and

f.      Any ongoing required education 

Those persons providing medical student and trainee supervision ensure that all medical students and trainees are knowledgeable about these quality and safety programs and are included in the monitoring process.

Measurable Elements of MPE.6

þ All medical students and trainees are provided an orientation that includes at least (a) through (f) of the intent.

þ Medical students and trainees are included in the data collection for the hospital’s quality monitoring programs.

þ Those supervising medical students and trainees ensure that the medical students and trainees are knowledgeable of the programs and participate in the programs.

þ Medical students and trainees can demonstrate knowledge of these programs.

þ Those supervising medical students and trainees consider compliance with these programs in their evaluation of medical student and trainee performance.