Professional Documents
Culture Documents
International
Virginia Maripolsky,
Assistant CEO
Nursing Affairs
Joint Commission
International Accreditation
Evaluates the
entire health care
Philosophy
of Accreditation
organization as a complex
interaction of many clinical and
management processes
Uses published consensus
standard in conducting an
evaluation
JCI Reputation
Accredits over 17,000 organizations
worldwide
About 130 of those are acute care
hospitals in 23 countries
Joint Commission
International Standards
Focus on the patient
Designed to be interpreted/surveyed
within the local culture and legal
framework
360 Standards
1240 Measurable Elements
Section I : Patient Centered
Standards
Section II : Health Care
Organization Management
Standards
Standards Content
Each JCI Standards contains 3
components :
The Standard
Description of the intent of the
standard
Measurable element(s) to be
scored
Measurable Elements
Each standard has one or more
measurable elements that
incorporate the major principles
addressed in the intent statement
Each applicable measurable
elements is scored
Met (10)
Partially Met (5)
Not Met (0)
Mission of
Joint Commission International
To improve the safety and quality of
care in the international community
through the provision of education,
publications, consultation,
evaluation, and accreditation
services
JCI Definitions
Best practice:
Clinical, scientific, or professional
technique, method, or process that is
recognized by a majority of professionals in
a particular field as more effective at
delivering a particular outcome than any
other practice.
These practices, also sometimes referred
to as good practice or better practice,
are typically evidence based and
consensus driven.
JCI Definitions
Palliative services:
Treatments and support services intended to
alleviate pain and suffering rather than to cure
illness. Palliative therapy may include surgery or
radiotherapy undertaken to reduce or shrink
tumors compressing vital structures and thereby
improve the quality of life.
Palliative services include attending to the
patients psychological and spiritual needs and
supporting the dying patient and his or her
family.
Standard
COP.7.1 As appropriate to the care and
services provided, assessments and
reassessments of the dying patient
and their family are designed to meet
individualized needs.
Intent of COP.7.1
Assessments and reassessments need to be individualized to meet patients
and families needs when a patient is at the end of life. Assessments and
reassessments should evaluate, as appropriate
a) symptoms such as nausea and respiratory distress;
b) factors that alleviate or exacerbate physical symptoms;
c) current symptom management and the patients response;
d) patient and family spiritual orientation and, as appropriate, any involvement
in a religious group;
e) patient and family spiritual concerns or needs such as despair, suffering,
guilt, or forgiveness;
f ) patient and family psychosocial status such as family relationships, the
adequacy of the home environment if care is provided there, coping
mechanisms, and the patients and familys reactions to illness;
g) the need for support or respite services for the patient, family, or other
caregivers;
h) the need for an alternative setting or level of care; and
i) survivor risk factors such as family coping mechanisms and the potential for
pathological grief reactions.
Standard
COP.7.2 Care of the dying patient optimizes his or her comfort
and dignity.
Intent of COP.7.2
The organization ensures appropriate care of those in pain
or dying by:
taking interventions to manage pain and primary or
secondary symptoms;
preventing symptoms to the extent reasonably possible;
taking interventions that address patient and family
psychosocial, emotional, and spiritual needs regarding
dying and grieving;
taking interventions that address patient and family
religious and cultural concerns; and
involving the patient and family in care decisions.
Intent of COP.7.2
The organization ensures appropriate care of
those in pain or dying by:
taking interventions to manage pain and primary
or secondary symptoms;
preventing symptoms to the extent reasonably
possible;
taking interventions that address patient and
family psychosocial, emotional, and spiritual
needs regarding dying and grieving;
taking interventions that address patient and
family religious and cultural concerns; and
involving the patient and family in care decisions.
Standard
AOP.1.8 The initial assessment includes
determining the need for additional specialized
assessments.
Intent of AOP.1.8
The initial assessment process may identify a need for
other assessments such as dental, hearing and
language, and so on. The organization refers the patient
for such assessments when available within the
organization or the community.
Measurable Elements of AOP.1.8
1. When the need for additional specialized
assessments is identified, patients are referred within the
organization or outside the organization.
2. Specialized assessments conducted within the
organization are completed and documented in the
patients record.
Standard
AOP.1.8.2 All patients are screened for pain and
assessed when pain is present.
During the initial assessment and reassessments, the
organization identifies patients with pain. When pain is
identified, the patient can be treated in the organization
or referred for treatment. The scope of treatment is
based on the care setting and services provided.
When the patient is treated in the organization, a more
comprehensive assessment is performed. This
assessment is appropriate to the patients age and
measures pain intensity and quality such as pain
character, frequency, location, and duration. This
assessment is recorded in a way that facilitates regular
reassessment and follow-up according to criteria
developed by the organization and the patients needs.
Standards
PFR.1.1 Care is considerate and respectful of the
patients personal values and beliefs.
PFR.1.1.1 The organization has a process to respond to
patient and family requests for pastoral services
or similar requests related to the patients spiritual and
religious beliefs.
Intent of PFE.4
The organization routinely provides education in areas that
carry high risk to patients. Education supports the return to
previous functional levels and maintenance of optimal
health.
The organization uses standardized materials and processes
in educating patients on at least the following topics:
Safe and effective use of all medications taken by the
patient (not just discharge medications), including potential
medication side effects
Safe and effective use of medical equipment
Potential interactions between prescribed medications and
other medications (including over-the-counter
preparations) and food;
Diet and nutrition;
Pain management; and
Rehabilitation techniques.
Standard PFE.4
1.
2.
3.
4.
5.
6.
http://www.capc.org/search?SearchableText=pain
Pathways
http://www.guideline.gov/
National Guideline Clearing House
Palliative care. Institute for Clinical Systems
Improvement - Private Nonprofit Organization.
2007 Jan (revised 2008 May). 58 pages. [NGC
Update Pending] NGC:006526
Pathways
http://www.guideline.gov/
National Guideline Clearing House
Clinical practice guidelines for quality palliative
care. National Consensus Project - Disease
Specific Society. 2004 May (revised 2009 Jan).
80 pages. NGC:007218
Centers of
Excellence