JCI 7Edition

th

Hospital Accreditation
Standards Update
Patient-Centered Standards
Changes
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© 2020 Joint Commission International. All Rights Reserved.
Claudia Jorgenson, RN, MSN
Director of Standards Development,
Interpretation, and Clinical Operations
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©2020 The Joint Commission. All Rights Reserved.
Ramsey Hasan, MD
Surveyor
Joint Commission International
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©2020 The Joint Commission. All Rights Reserved.
 7th Edition Changes

Patient-Centered
Standards
International Patient
Safety Goals
(IPSG)
IPSG.1 and IPSG.2.1
▪ IPSG.1 – Patient Identification
• At least 2 identifiers
• May be different in different circumstances
• Labeling of elements related to patient
care
▪ IPSG.2.1 – Critical Results
• Clarified definition of critical vs. abnormal
results
• Provided examples
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Surveyor Tips

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Surveyor Tips
IPSG.1 and IPSG.2.1
▪ Patient ID—remember non-verbal patients--
comatose, stroke, dementia, and psychiatry
patients
▪ Ask the question the correct way; check with
patients and families, too, that it was asked the
correct way

▪ Tracking results--communication, times, and

actions
▪ Problem areas: POC testing, ECG, Echo, PFTs

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IPSG.3 through IPSG.3.2
▪ Divided goal into three separate/distinct
topics
• IPSG.3 – High-alert medications
• IPSG.3.1 – Look-alike/sound-alike
medications
• IPSG.3.2 – Concentrated electrolytes
▪ Adopted ISMP definition of High-Alert
and Look-Alike/Sound-Alike Medications
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IPSG.3 through IPSG.3.2
▪ Posed stricter requirements for
concentrated electrolytes
• Tightened definition of concentrated
electrolytes
• Specified where concentrated
electrolytes are allowed
• Identified who should be allowed to
have access

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Surveyor Tips

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Surveyor Tips
IPSG.3—3.2 High Alert Medications
▪ Ensure a current list for both HAM and LASA, with
annual review and dissemination
▪ Uniform approach to storage and labelling---all areas,
carts, cabinets; more oversight
▪ Generic vs. brand names on LASA
▪ Ways NOT to label; qualifications and training
▪ Stricter re: concentrated electrolytes on units for
dilution; Operating Theater and Obstetrics; crash carts
▪ Dispensing in concentrated form to be diluted on a
unit is NO DIFFERENT from storing it on the unit and
should not be done
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IPSG.5 and IPSG.5.1
▪ Use of evidence-based interventions to
reduce risk of hospital-associated infections
• Identify priority hospital-acquired infections
on which to focus improvements
• Implement evidence-based interventions
(such as bundles) applicable to services
provided
• Monitor for compliance and improved
outcomes
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Surveyor Tips

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Surveyor Tips
IPSG.5.1 Bundles for Infections
▪ New requirement; not new science
▪ Implement those appropriate to your patients
▪ Approach like a CPG, not a “suggestion”
▪ Line insertion checklist includes IPSG.4, 4.1
▪ Ensure documentation of key aspects, and make
this uniform in different patient care areas, for
example same daily checklists in all ICUs
▪ www.IHI.org

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Access to Care and
Continuity of Care
(ACC)
ACC.4 and ACC.4.1
▪ Combined the intents of ACC.4 and
ACC.4.1 and includes patient education
from ACC.4.3.1
▪ Addressed patient needs for education
and continuing care and information to be
provided at discharge
▪ Renumbered previous MOI.10 and its
MEs 1–4 to ACC.4.2.1

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Surveyor Tips

ACC.4 and ACC.4.1

▪ Expands core PFE issues to include at the
time of discharge; remember to address
readiness, barriers, actual teaching, and
effectiveness of teaching to patient and/or
family
▪ Include ALL meds to be taken at home,
diet, pain, equipment, follow-up

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Patient-Centered Care
(PCC)
 PFR + PFE = PCC
▪ Patients’ right to identify who can
participate in care decisions
▪ Overarching standard to provide
information in a language and manner
patient/family understands
▪ Identify specific barriers to care

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PFR + PFE = PCC
▪ Disclosure of unanticipated outcomes,
and access to medical information
▪ Added standard on patient experience
(satisfaction)

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Surveyor Tips

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Surveyor Tips

PCC.3 Patient Experience

▪ Understand, measure, and analyze
▪ Objective, not subjective satisfaction
▪ Closer to outcomes measures from
patient’s (and family’s perspective)
▪ www.ahrq.gov has tools
▪ Different patient tools available—
providers, condition-specific care,
facilities, health plans

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Surveyor Tips

PCC.3 Patient Experience

▪ Access to own medical records; perhaps
keep record in actual patient room
▪ Involvement with IPSGs—1, 4, 5, 6, 6.1—
examples
▪ Some examples also relate to Culture of
Safety
▪ Don’t just collect data, but analyze and
follow-up on a priority area for
improvement
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Assessment of Patient
(AOP)
Assessment of Patients (AOP)
▪ Combined and renumbered several
standards
▪ AOP.1.5 – Clarified requirement for
outpatient screening for pain
▪ Management of dying patient covered
entirely in COP.7

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Surveyor Tips

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Surveyor Tips

AOP.1.5 Outpatient Pain Assessment

▪ Not every outpatient needs a screening
for pain
▪ Outpatients whose condition, diagnosis,
or situation may indicate they are at risk
for pain are screened for pain
▪ When/where it makes sense, do the
screening; further assessment may be
referred elsewhere—not all will be
competent to treat (inpatient different)
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 AOP.6.2
▪ AOP.6.2 – Safety in diagnostic imaging
• Clarified requirements for radiation safety
program
• Added information to intent on safety of
Magnetic Resonance Imaging
• New ME 5 - addressing hazards related to
magnetic resonance imaging

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Surveyor Tips

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Surveyor Tips

AOP.6.2 Radiation Safety

▪ Best as a centralized function with
oversight—all areas
▪ Special attention to MRI
▪ Zones, visual warnings
▪ Fire prep, code blue prep, other drills

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Care of Patient
(COP)
New Standard
COP.3.1 – Clinical Alarms
▪ Reduce the risk of harm associated with
clinical alarms.
• Develop and implement alarm system
management program for alarm signals
that pose higher risk to patient safety.
• Identify high risk alarms based on risk to
patient safety.

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New Standard
COP.3.1 – Clinical Alarms
▪ Develop strategies for managing alarms
that consider a) through e) of the intent.
▪ Educate staff about purpose and proper
operation of alarm systems
▪ Ensure training and competence of staff
responsible for management of clinical
alarms

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Surveyor Tips

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Surveyor Tips
COP.3.1 – Clinical Alarms
▪ Ensure staff training
▪ Auditory (bedside); visual (EMR, medication
dispensing)
▪ Morbidity and mortality cases related to
alarms—overriding should trigger investigating
▪ Risk assess each type in all areas, and
document
▪ Oversee, enforce, and monitor—unit managers,
leadership walk-rounds

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New Standard
COP.3.5 – Suicide/Self-Harm
▪ Develop and implement a process to identify
patients at risk for suicide and self-harm.
▪ The process includes:
• Screening criteria
• Tools
• Risk assessment
• Protocols and procedures
• Process for monitoring effectiveness
• Staff training staff
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Surveyor Tips

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Surveyor Tips
COP.3.5 Suicide Patients
▪ Establish formal screening and training
▪ Obvious high risks: Emergency Dept,
Psychiatry, Rehabilitation, Stroke, Post-
Partum, Veterans
▪ Do you take care of these patients, or
transfer out of the ED—be CLEAR?
Ensure safety in ED and during transfer
(behind curtains, bathrooms); DO NOT
rely on family members
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Surveyor Tips
COP.3.5 Suicide Patients
▪ What type of inpatient unit?
▪ Open vs. locked unit?
▪ Ensuring safety from further self-harm
▪ Ensuring direct observation
▪ DO NOT rely on family members

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New Standard
COP.4 – Safe Use of Lasers
▪ Establish a program on safe use of lasers
and other optical radiation devices
▪ The process includes:
• Qualified individuals to oversee and supervise program
• Safety training and continuing education for staff
• Administrative and engineering controls to promote
program safety
• Appropriate use of personal protective equipment for
staff and patients
• Qualified, trained individuals to conduct inspection,
testing, and maintenance processes
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New Standard
COP.4.1 – Manage Adverse Events
Related to Lasers
▪ Report and address adverse events resulting
from lasers and other optical radiation
devices
▪ Requirements include:
• Integrate the safety program in the
hospital’s facility management and safety
structure
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New Standard
COP.4.1 – Manage Adverse Events
Related to Lasers
▪ Integrate the safety program in the
hospital’s infection prevention and control
program
▪ Report adverse events and identify and
implement action plans to prevent
recurrence

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Surveyor Tips

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Surveyor Tips
COP.4 and 4.1 – Safe Use of Lasers
▪ Stricter oversight; do not leave this to
departments
▪ Training and competencies
▪ Overall safety in treatment rooms, hazard
zone areas; signs
▪ Safety for staff and patient
▪ Equipment maintenance
▪ Manufacturer’s recommendations; strict
laws and regulations
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Surveyor Tips
COP.4 and 4.1 – Safe Use of Lasers
▪ All reflective surfaces in treatment room—
jewelry, mirrors, shiny objects (trash cans)
▪ Eye protection
▪ Risk from plumes—masks, appropriate
room ventilation
▪ Safety related to technique—skin burns,
eye injuries—reemphasize staff training
and competencies in SQE

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Anesthesia and
Surgical Case
(ASC)
ASC – Anesthesia and Surgery
▪ Minor changes related to competency of
staff providing sedation
▪ ASC.5 and ASC.5.1 – Combined
standards for anesthesia plan and post-
operative pain management
▪ Provided cross reference to COP.2.1 to
provide information on requirements of
documentation for non-surgical
procedures/treatments
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 Medication
Management and Use
(MMU)
MMU.2, MMU.3, and MMU.3.1
▪ Required availability of infusions for chronic
diseases
▪ Provided more clarity about temperature and
humidity control for stored medications
• Conduct risk assessments
▪ Clarified requirements for managing medications
and products needing special handling
• Hazardous medication
• Radioactive medications/products
• Investigational medications
▪ Clarified and expanded requirements for
emergency medications
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Surveyor Tips

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Surveyor Tips
MMU.3 Medication Storage
▪ Temp and humidity—follow manufacturer’s
recommendations
▪ How do you monitor? How do you address
variance?
▪ Where do you monitor? Where is A/C 24/7?
▪ Emergency vehicles, warehouses, others
▪ Narcotics—ensure strict uniformity
▪ Periodic inspections—frontline AND
pharmacy oversight
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Surveyor Tips

MMU.3.1 Emergency Meds

▪ Very frequent survey issue
▪ High risk for med error in emergency
▪ Standardize/oversee, especially non-ICUs
▪ Adult/Pediatrics, security, routine checks
▪ Arrange meds the same way; inventories
▪ Foster quick access
▪ Special labels—HAM, LASA
▪ No key locks; security of plastic locks
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MMU.4, MMU.5, MMU.5.1,
MMU.6.2 and MMU.6.2.1
▪ Changed requirements for medication
reconciliation
▪ Clarified requirements for preparing and
dispensing
▪ Clarified requirements for appropriateness
review
• Use of Clinical Decision Support
▪ Separated and defined process for meds
brought in by patients and sample meds 55
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Surveyor Tips

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Surveyor Tips

MMU.4 Medication Reconciliation

▪ New standard, not new concept
▪ Be more precise and aggressive at
obtaining info at time of admission—
family, other MD
▪ Don’t be willing to accept: “not obtainable”
▪ Ensure available to pharmacy and all
caring for patient
▪ Tip—ALL meds on D/C summary at time
of discharge
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Surveyor Tips
MMU.5 Preparation/Dispensing
▪ Oversight coordination—Pharmacy and Nursing
▪ Safe and clean, not necessarily sterile
▪ But……not dirty, or multi-use areas (newborns)
▪ Training, competencies; impact on staffing resource
requirements
▪ Sterile needs, air handling: chemotherapy, total
parenteral nutrition (TPN) admixtures, epidurals,
etc.
▪ Multidose vials special attention to careful and
correct use—major Hep C outbreak in Asia
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Surveyor Tips
MMU 6.2, 6.2.1 Home Meds;
Samples
▪ Enforce stricter policies: label, storage,
expirations—try harder to get the info you need—
question patient/family, get bottles, identify the
meds
▪ Self-administer (keep in room)—careful (examples)
▪ Samples—you are still responsible; know supply
chain, expirations and lot #; watch for casual
administration by physicians; many organizations
are not allowing anymore
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End of
Session
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Next up—

7th Edition Changes

Health Care
Organization
Management
Standards