JCAHO's Standards for
Organization Functions
& Structures
Organization Functions
This section provides you with an overview JCAHO Accreditation Standards for
organization functions of hospitals.
It includes role of leadership in meeting the standards of care and improving
organization performance as well as JCAHO's requirements regarding management of
human resources.
Topics include:
• Improving Organization Performance
• Leadership
• Management of the Environment of Care
• Management of Human Resources
• Management of Information
Improving Organization Performance
An Overview
Performance improvement (PI) is a continuous process. It involves measuring
the functioning of important processes and services, and, when indicated,
identifying changes that enhance performance. These changes are incorporated
into new or existing work processes, products or services, and performance is
monitored to ensure that the improvements are sustained.
Improving Organization Performance
Performance improvement focuses on outcomes of care, treatment, and services.
Leaders establish a planned, systematic, and organization wide approaches) to
performance improvement. They set priorities for performance improvement and
ensure that the disciplines representing the scope of care, treatment, and
services across the hospital work collaboratively to plan and implement
improvement activities. The leaders’ responsibilities are described in the
“Leadership” chapter (standards LD.4.10 through LD.4.70) of this manual.
An important aspect of improving organization performance is effectively
reducing factors that contribute to unanticipated adverse events and/or
outcomes. Unanticipated adverse events and/or outcomes may be caused by poorly
designed systems, system failures, or errors. Reducing unanticipated adverse
events and/or unanticipated outcomes requires an environment in which patients,
their families, and hospital staff and leaders can identify and manage actual
and potential risks to safety. Such an environment encourages the following:
●Recognizing and acknowledging risks and unanticipated adverse events
●Initiating actions to reduce these risks and unanticipated adverse events
● Reporting internally on risk reduction initiatives and their effectiveness
● Focusing on processes and systems
●Minimizing individual blame or retribution for involvement in an unanticipated
adverse event
● Investigating factors that contribute to unanticipated adverse events and
sharing that acquired knowledge both internally and with other hospitals
The leaders are responsible for fostering such an environment through their
personal example and by supporting effective responses to actual occurrences of
unanticipated adverse events; ongoing proactive reduction of safety risks to
patients; and integration of safety priorities into the design and redesign of
all relevant organization processes, functions, and services. (See standard
LD.4.50.)
This chapter focuses on the following fundamental components of performance
improvement:
● Measuring performance through data collection
● Assessing current performance
● Improving performance
Standards
• PI.1.10 The hospital collects data to monitor its performance.
Rationale for PI.1.10
Data help determine performance improvement priorities. The data collected for
high priority and required areas are used to monitor the stability of existing
processes, identify opportunities for improvement, identify changes that lead to
improvement, or sustain improvement. Data collection helps identify specific
areas that require further study. These areas are determined by considering the
information provided by the data about process stability, risks, and sentinel
events, and priorities set by the leaders. In addition, the hospital identifies
those areas needing improvement and identifies desired changes. performance
measures are used to determine whether the changes result in desired outcomes.
The hospital identifies the frequency and detail of data collection
• PI.2.10 Data are systematically aggregated and analyzed.
Rationale for PI.2.10
Aggregating and analyzing data means transforming data into information.
Aggregating data at points in time enables the hospital to judge a particular
process’s stability or a particular outcome’s predictability in relation to
performance expectations. Accumulated data are analyzed in such a way that
current performance levels, patterns, or trends can be identified.
• PI.2.20 Undesirable patterns or trends in performance are analyzed.
Elements of Performance for PI.2.20
1. Analysis is performed when data comparisons indicate that levels of
performance, patterns,
or trends vary substantially from those expected.
2. Analysis occurs for those topics chosen by leaders as performance improvement
priorities.
3. Analysis is performed when undesirable variation occurs which changes
priorities.
• PI.2.30 Processes for identifying and managing sentinel events are defined
and implemented.
Rationale for PI.2.30
Identifying, reporting, analyzing, and managing sentinel events can help the
hospital to prevent such incidents. Leaders define and implement such a program
as part of the process to measure, assess, and improve the hospital’s
performance.
• PI.3.10 Information from data analysis is used to make changes that improve
performance and patient safety and reduce the risk of sentinel events.
• PI.3.20 An ongoing, proactive program for identifying and reducing
unanticipated adverse events and safety risks to patients is defined and
implemented.
.Rationale for PI.3.20
Hospitals should proactively seek to identify and reduce risks to the safety of
patients. Such initiatives
have the obvious advantage of preventing adverse events rather than simply
reacting when they occur. This approach also avoids the barriers to
understanding created by hindsight bias and the fear of disclosure,
embarrassment, blame, and punishment that can happen after an event.
Leadership
Overview
A hospital’s leaders provide the framework for planning, directing,
coordinating, providing, and improving care, treatment, and services to respond
to community and patient needs and improve health care outcomes. Effective
leadership depends on the following processes and tools:
● Governance.
The governance of a hospital sets the framework for supporting quality patient
care, treatment, and services.
● Management.
Leaders create an environment that enables a hospital to fulfill its mission and
meet or exceed its goals. They provide for a well-managed hospital with clear
lines of responsibility and accountability.
● Planning, designing, and providing services.
Leaders develop a mission that is reflected in long-range, strategic, and
operational plans; service design; resource allocation; and organizational
policies. They provide organization, direction, and staffing for care,
treatment, and services. Leaders also communicate objectives and coordinate
efforts to integrate care, treatment, and services throughout the hospital.
● Improving safety and quality of care.
Leaders plan and implement a safety management program. They are ultimately
responsible for the safety of all patients and staff. Leaders also establish
expectations, plans, and priorities and manage the performance improvement
process. They ensure that a process is in place to measure, assess, and improve
the hospital’s governance, management, clinical, and support functions
● Use of clinical practice guidelines.
The standards do not require the leaders to use clinical practice guidelines;
however, they do provide a framework for developing and using clinical practice
guidelines if the leaders choose to do so. A guideline provides an effective way
to improve processes by reducing variance. A hospital’s success in implementing
and using clinical practice guidelines on an ongoing basis depends on the
processes for reviewing, revising, and implementing the guidelines.
● Teaching and coaching staff.
To realize the hospital’s vision and values, leaders are involved in teaching
and coaching staff; thus, staff education is an essential leadership function.
Standards
• LD.1.10 The hospital identifies how it is governed.
Rationale for LD.1.10
The hospital has governance with ultimate responsibility and legal authority for
the safety and quality of care, treatment, and services. Governance establishes
policy, promotes performance improvement, and provides for organizational
management and planning
• LD.1.20 Governance responsibilities are defined in writing, as applicable.
• LD.1.30 The hospital complies with applicable law and regulation.
• LD.2.10 An individual(s) or designee(s) is responsible for operating the
hospital according to the authority conferred by governance.
• LD.2.20 Each organizational program, service, site, or department has
effective leadership.
Rationale for LD.2.20
Effective leaders at the site or department level help to create an environment
or culture that enables a hospital to fulfill its mission and meet or exceed its
goals. They support staff and instill in them a sense of ownership of their work
processes. Although it may be appropriate for leaders to delegate work to
qualified staff, the leaders are ultimately responsible for care, treatment, or
services provided in their area.
• LD.2.50 The leaders develop and monitor an annual operating budget and, as
appropriate, a long-term capital expenditure plan.
• LD.3.10 The leaders engage in both short-term and long-term planning.
• LD.3.15 The leaders develop and implement plans to identify and mitigate
impediments to efficient patient flow throughout the hospital.
Rationale for LD.3.15
Managing the flow of patients through their care is essential to the prevention
of patient crowding, problem that can lead to lapses in patient safety and
quality of care. The emergency departments particularly vulnerable to
experiencing negative effects of inefficiency in the management of this process.
For this reason, while emergency departments have little control over the volume
and type of patient arrivals and most hospitals have lost the “surge capacity”
that existed at one time to manage the elastic nature of emergency admissions,
other opportunities for improvement do exist. Improved management of
processes can ensure the wise use of limited resources and thereby reduce the
risk to patients of negative outcomes from delays in the delivery of care,
treatment, or services.
To understand the system implications of the issues, leadership should identify
all of the processes critical to patient flow through the hospital system from
the time the patient arrives, through admitting, patient assessment and
treatment, and discharge. Supporting processes are included if identified by
leadership as impacting patient flow, for example, diagnostic, communication,
and patient
transportation procedures. Relevant measurements are selected and implemented to
enable monitoring of each process and supporting process(es) by the hospital
leaders. These critical processes should be modified for the purposes of
improving patient flow.
• LD.3.20 Patients with comparable needs receive the same standard of care,
treatment, and services throughout the hospital.
Rationale for LD.3.20
Factors such as different individuals providing care, treatment, and services;
different payment sources; or different settings of care do not intentionally
negatively influence the outcome.
• LD.3.30 A hospital demonstrates a commitment to its community by providing
essential services in a timely manner.
• LD.3.50 Services provided by consultation, contractual arrangements, or other
agreements are provided safely and effectively.
• LD.3.60 Communication is effective throughout the hospital.
• LD.3.70 The leaders define the required qualifications and competence of those
staff who provide care, treatment, and services and recommend a sufficient
number of qualified and competent staff to provide care, treatment, and
services.
Rationale for LD.3.70
The determination of competence and qualifications of staff is based on the
following:
● The hospital’s mission
● The hospital’s care, treatment, and services
● The complexity of care, treatment, and services needed by patients
● The technology used
● The health status of staff, as required by law and regulation
• LD.3.80 The leaders provide for adequate space, equipment, and other
resources.
• LD.3.90 The leaders develop and implement policies and procedures for care,
treatment, and services.
Leadership
• LD.3.110 The hospital implements policies and procedures developed with the
medical staff’s participation for procuring and donating organs and other
tissues.
• LD.3.120 The leaders plan for and support the provision and coordination of
patient education activities.
• LD.3.130 Academic education is arranged for children and youth, when
appropriate.
Rationale for LD.3.130
Educational resources are selected based on identified patient needs. The
hospital makes educational
resources available that do the following:
● Help maintain the educational and intellectual development of patients
● Address opportunities to catch up for those patients who have fallen behind in
their education because of their condition
• LD.3.140 In hospitals that do not primarily provide psychiatric or
substance abuse services, a written plan clearly defines the care, treatment,
and services or appropriate referral of patients who are emotionally ill, who
become emotionally ill while in the hospital, or who suffer the results of
alcoholism or drug abuse.
• LD.3.150 The hospital plans for the appropriate care, treatment, and services
of patients under legal or correctional restrictions.
• LD.4.10 The leaders set expectations, plan, and manage processes to measure,
assess, and improve the hospital’s governance, management, clinical, and support
activities.
• LD.4.20 New or modified services or processes are designed well.
• LD.4.40 The leaders ensure that an integrated patient safety program is
implemented throughout the hospital.
• LD.4.50 The leaders set performance improvement priorities and identify how
the hospital adjusts priorities in response to unusual or urgent events.
• LD.4.60 The leaders allocate adequate resources for measuring, assessing, and
improving the hospital’s performance and improving patient safety.
• LD.4.70 The leaders measure and assess the effectiveness of the performance
improvement and safety improvement activities.
• LD.5.10 The hospital considers clinical practice guidelines when designing or
improving processes, as appropriate.
Rationale for LD.5.10
Clinical practice guidelines can improve the quality, utilization, and value of
health care services. Clinical practice guidelines help practitioners and
patients in making decisions about preventing, diagnosing, treating, and
managing selected conditions. Clinical practice guidelines can also be used in
designing clinical processes or checking the design of existing processes. The
leaders may consider sources of clinical practice guidelines such as the Agency
for Healthcare Research and Quality, National Guideline Clearinghouse, and
professional organizations.
• LD.5.20 When clinical practice guidelines are used, the leaders identify
criteria for their selection and implementation.
Rationale for LD.5.20
Selecting and implementing clinical practice guidelines that are appropriate to
the hospital are critical. The leaders set criteria to guide the selection and
implementation of clinical practice
guidelines that are consistent with the hospital’s mission and priorities. The
leaders also consider the steps and changes or variations needed to encourage
use, dissemination, and implementation of chosen guidelines throughout the
hospital. This includes staff communication, training, implementation, feedback,
and evaluation
• LD.5.30 Appropriate leaders, practitioners, and health care professionals in
the hospital review and approve clinical practice guidelines selected for
implementation.
Rationale for LD.5.30
To be successfully implemented, clinical practice guidelines should be reviewed,
revised, or adapted by the providers using them and approved by the hospital’s
leaders.
• LD.5.40 The leaders evaluate the outcomes related to use of clinical practice
guidelines and determine steps to improve processes.
Rationale for LD.5.40
To fully benefit from the use of clinical practice guidelines, the outcomes of
patients treated using
clinical practice guidelines are evaluated, and refinements are made to how the
guidelines are used, if necessary.
Management of the Environment of Care
Overview
The goal of this function is to provide a safe, functional, supportive, and
effective environment for patients, staff members, and other individuals in the
hospital. This is crucial to providing quality patient care, achieving good
outcomes, and improving patient safety.
Achieving this goal depends on performing the following processes:
● Performing strategic and ongoing master planning by hospital leaders for the
space, clear circulation of occupants, equipment, supportive environment, and
resources needed to safely and effectively support the services provided.
Planning and designing of the environment is consistent with the hospital’s
mission and vision, and the patient’s physical condition/health, cultural
background, age, and cognitive abilities.
● Educating staff about the role of the environment in safely, sensitively, and
effectively supporting patient care. The hospital educates staff about the
physical characteristics necessary for attaining such an environment, and the
processes for monitoring, maintaining, and reporting on the hospital’s
environment of care.
● Developing standards to measure staff and hospital performance in managing and
improving the environment of care.
● Implementing plans to create and manage the hospital’s environment of care. An
Information Collection and Evaluation System (ICES) is developed and used to
continuously measure, assess, and improve the status of the environment of care.
The “environment of care” is made up of three basic components: building(s),
equipment, and people. A variety of key elements and issues can contribute in
creating the way the space feels and works for patients, families, staff, and
others experiencing the health care delivery system
Management of the Environment of Care
In addition, they can be significant in their ability to positively influence
patient outcomes, satisfaction, and improve patient safety. These elements
include the following:
● Light (both natural and artificial)
● Privacy (visual and auditory)
● Space size and configuration that are appropriate and consistent with the
clinical philosophy
● Security
● Orientation and access to nature and the outside
● Clarity of access (both exterior and interior circulation)
● Color
● Efficient layouts that support staffing and overall functional operation
When appropriately designed into and managed as part of the physical
environment, these elements create safe, welcoming, and comfortable environments
that support and maintain patient dignity and personhood, allow ease of
interaction, reduce stressors, and encourage family participation in the
delivery of care.
These key elements and issues need to be incorporated into both inpatient sites
(such as acute care hospitals, psychiatric hospitals, hospice facilities,
sub-acute care facilities, or nursing homes), as well as outpatient settings
(such as clinics, counseling centers, preadmission testing offices, infirmaries,
same-day surgery centers, dialysis centers, or imaging centers). Effective
management of the environment of care includes using processes and activities to
do the following:
● Reduce and control environmental hazards and risks
● Prevent accidents and injuries
● Maintain safe conditions for patients, staff, and others coming to the
hospital’s facilities
● Maintain an environment that is sensitive to patient needs for comfort, social
interaction, and positive distraction
● Maintain an environment that minimizes unnecessary environmental stresses for
patients, staff, and others coming to the hospital’s facilities
The standards in this chapter focus on how everyone in the hospital
participates in the processes and activities that make the care environment safe
and effective. They also address department leaders’ responsibility for
identifying and communicating the care environment needs to the hospital and
allocating appropriate space, equipment, and resources to safely and effectively
support the hospital’s services.
Some of the standards in this chapter recognize that certain settings where
care, treatment, and services are provided have more risk than others.
Therefore, some of the requirements are noted as being applicable to only
certain “occupancy* types.” The following occupancy definitions are used in this
chapter:
● Health care occupancy.
An occupancy used for purposes of medical or other treatment or care of four or
more persons who are mostly incapable of self-preservation due to age or
physical or mental disability, or because of security measures not under the
occupant’s control. Health care occupancies include hospitals, nursing homes,
and limited care facilities.
● Ambulatory health care occupancy.
An occupancy used to provide to four or more patients at the same time either
(1) outpatient services or treatment that render them incapable of taking
actions for self-preservation under emergency conditions without the assistance
of others; or (2) anesthesia that renders them incapable of taking actions for
self-preservation under emergency conditions without the assistance of others.
● Business occupancy.
An occupancy used to provide outpatient services or treatment that does not meet
the criteria in the ambulatory health care occupancy definition.
Note 1: The standards in this chapter do not prescribe any particular structure
(such as a safety committee), specific individual (such as one employee hired to
be a safety officer), or format for the required designs and planning
activities.
Note 2: The standards do not require the Statement of Conditions™ compliance
document to be completed by anyone other than an employee of the hospital. This
statement is the basis for corrective actions needed to make the environment
compliant with the requirements of the Life Safety Code® (LSC), NFPA 101®.
Note 3: The standards in this chapter require each hospital to develop a
written plan for the following:
1. Safety management (EC.1.10)
2. Security management (EC.2.10)
3. Hazardous materials and waste management (EC.3.10)
4. Emergency management (EC.4.10)
5. Fire safety (EC.5.10)
6. Medical equipment management (EC.6.10)
7. Utilities management (EC.7.10)
If a hospital has multiple sites, it may have separate management plans for
each of its locations, or it may choose to have one comprehensive set of plans.
In either case, the hospital must address specific risks and the unique
conditions at each of its sites.
Standards
Planning and Implementation Activities
• EC.1.10 The hospital manages safety risks.
Rationale for EC.1.10
Each hospital has inherent safety risks associated with providing services for
patients, the performance of daily activities by staff, and the physical
environment in which services occur. It is important that each hospital
identifies these risks and plans and implements processes to minimize the
likelihood of those risks causing incidents.
• EC.1.20 The hospital maintains a safe environment.
Rationale for EC.1.20
It is essential that the hospital conduct periodic environmental tours to
determine if its current processes for managing patient, public, and staff
safety risks are being practiced correctly and are effective. These tours can
also be used to assess staff knowledge and behaviors, identify new or altered
risks in areas where construction or changes in services have occurred, and
identify opportunities to improve the environment.
• EC.1.30 The hospital develops and implements a policy to prohibit smoking
except in specified circumstances.
Rationale for EC.1.30
This standard is intended to reduce the following risks:
● To people who smoke, including possible adverse effects on care, treatment,
and services
● Of passive smoking for others
● Of fire
The standard prohibits smoking in all areas of all building(s) under the
hospital’s control, except for patients in circumstances specified in the EPs
below.
• EC.2.10 The hospital identifies and manages its security risks.
Rationale for EC.2.10
It is essential that a hospital manages the physical and personal security of
patients, staff (including addressing the risks of violence in the workplace),
and individuals coming to the hospital’s facilities. In addition, security of
the established environment, equipment, supplies, and information is also
important.
• EC.3.10 The hospital manages its hazardous materials and waste risks.
Rationale for EC.3.10
Hospitals must identify materials they use that need special handling and
implement processes to minimize the risks of their unsafe use and improper
disposal.
• EC.4.10 The hospital addresses emergency management.
Rationale for EC.4.10
An emergency* in the hospital or its community could suddenly and significantly
affect the need for the hospital’s services or its ability to provide those
services. Therefore, a hospital needs to have an emergency management plan that
comprehensively describes its approach to emergencies in the hospital or in its
community
• EC.4.20 The hospital conducts drills regularly to test emergency
management.
• EC.5.10 The hospital manages fire safety risks.
Rationale for EC.5.10
All facilities are designed, constructed, maintained, and operated to minimize
the possibility of a fire emergency requiring the evacuation of occupants.
Because the safety of occupants cannot be ensured adequately by dependence on
evacuation of the building, their protection from fire shall be provided by
appropriate arrangement of facilities; adequate, trained staff; and development
of
operating and maintenance procedures composed of the following:
● Design, construction, and compartmentation
● Provision for detection, alarm, and extinguishment
● Fire prevention and the planning, training, and drilling programs for the
isolation of fire, transfer of occupants to areas of refuge, or evacuation of
the building
• EC.5.20 Newly constructed and existing environments of care are designed
and maintained to comply with the Life Safety Code®.
Rationale for EC.5.20
The Life Safety Code® (LSC) requires that a building is designed, constructed,
and maintained with the capability of being fire safe. When undertaking the
design of a newly-remodeled building, the hospital should also satisfy any
requirements of others (local, state, or federal) that may be more stringent
than the LSC.
• EC.5.30 The hospital conducts fire drills regularly.
Rationale for EC.5.30
The development of a fire response plan is an important part of achieving a
fire-safe environment
(see standard EC.5.10). It is important that this plan be regularly evaluated
during implementations (in drill scenarios or actual fire situations) for
performance of the fire safety equipment and staff. Implementation of the plan
should be realistic and held at varied times. An implementation held at shift
change may present an unrealistic picture as to the number of staff likely
available any time a fire occurs. Actual evacuation of patients during the
drills is not required.
• EC.5.40 The hospital maintains fire-safety equipment and building features
Management of the Environment of Care
Note 1: This standard does not require hospitals to have the types of
fire-safety equipment and building features discussed below. However, if these
types of equipment or features exist within the hospital, then the following
maintenance, testing, and inspection requirements apply.
Note 2: Hospitals that offer care, treatment, and services in leased
facilities need to communicate maintenance expectations for building equipment
not under their control to their landlord through contractual language, lease
agreements, memos, and so forth. These hospitals are not required to possess
maintenance documentation, but must only have access to such documentation as
needed and during survey. It is also important that the landlord communicate to
the hospital any building equipment problems identified that could negatively
affect the safety or health of patients, staff, and other people coming to the
hospital, as well as the landlord’s plan to resolve such issues.
• EC.5.50 The hospital develops and implements activities to protect
occupants during periods when a building does not meet the applicable provisions
of the Life Safety Code®.
Rationale for EC.5.50
When building code deficiencies are identified and cannot be immediately
corrected or during renovation or construction activities, the safety of
patients, staff, and other people coming to the hospital’s facilities is
diminished. Hospitals need to proactively identify administrative actions (for
example, additional training, additional inspections, additional fire drills,
and so on) to be taken if
these scenarios arise.
• EC.6.10 The hospital manages medical equipment risks.
Rationale for EC.6.10
Medical equipment is a significant contributor to the quality of care. It is
used in treatment, diagnostic activities and monitoring of the patient. It is
essential that the equipment is appropriate for the intended use; that staff,
including licensed independent practitioners, be trained to use the equipment
safely and effectively; and it is essential that the equipment is maintained
appropriately by qualified individuals.
• EC.6.20 Medical equipment is maintained, tested, and inspected.
• EC.7.10 The hospital manages its utility risks.
Rationale for EC.7.10
Utility systems* are essential to the proper operation of the environment of
care and significantly contribute to effective, safe, and reliable provision of
care to patients in health care organizations.
It is important that health care organizations establish and maintain a utility
systems management program to promote a safe, controlled, and comfortable
environment that does the following:
● Ensures operational reliability of utility systems
● Reduces the potential for organization-acquired illness to be transmitted
through the utility systems
● Assesses the reliability and minimizes potential risks of utility system
failures
• EC.7.20 The hospital provides a reliable emergency electrical power source.
Rationale for EC.7.20
The hospital properly installs an emergency power source that is adequately
sized, designed, and fueled, as required by the LSC occupancy requirements and
the services provided.
• EC.7.30 The hospital maintains, tests, and inspects its utility systems.
Note: Hospitals that offer care, treatment, and services in leased facilities
need to communicate maintenance expectations for building equipment not under
their control to their landlord through contractual language, lease agreements,
memos, and so forth. These hospitals are not required to possess maintenance
documentation, but must only have access to such documentation as needed and
during survey. It is also important that the landlord communicate to the
hospital any building equipment problems identified that could negatively affect
the safety or health of patients, staff, and other people coming to the
hospital, as well as the landlord’s plan to resolve such issues.
• EC.7.40 The hospital maintains, tests, and inspects its emergency power
systems.
Note: This standard does not require hospitals to have the types of emergency
power systems discussed below. However, if a hospital has these types of
systems, then the following maintenance, testing, and inspection requirements
apply.
• EC.7.50 The hospital maintains, tests, and inspects its medical gas and
vacuum systems.
• EC.8.10 The hospital establishes and maintains an appropriate environment.
Rationale for EC.8.10
It is important that the physical environment is functional and promotes healing
and caring. Certain key physical elements in the environment can be significant
in their ability to positively influence patient outcomes and satisfaction and
improve patient safety. These elements can also contribute in creating the way
the space feels and works for patients, families, visitors, and staff
experiencing the care, treatment, and service delivery system.
• EC.8.30 The hospital manages the design and building of the environment
when it is renovated, altered, or newly created (see also standard EC.5.50).
• EC.9.10 The hospital monitors conditions in the environment.
• EC.9.20 The hospital analyzes identified environment issues and develops
recommendations for resolving them.
• EC.9.30 The hospital improves the environment.
Management of Human Resources
Overview
The goal of the human resources function is to ensure that the hospital
determines the qualifications and competencies for all staff positions
(individuals such as employees, contractors, or temporary agency personnel who
provide services in the hospital) based on its mission, population(s), and care,
treatment, and services. Also see standard LD.3.40 in the “Leadership” chapter.
Hospitals must also provide the right number of competent staff to meet
patients’ needs.
To meet this goal, the hospital carries out the following processes and
activities:
● Providing an adequate number of staff.
The hospital determines the appropriate level of staffing to fulfill its mission
and meet the needs of the population(s) served. There is a sufficient number of
staff based on the hospital’s determination of the appropriate level of
staffing.
● Providing competent staff.
The hospital provides for competent staff either through traditional
employer–employee arrangements or through contractual arrangements with other
entities or persons. An initial review of credentials and qualifications is
performed. Experience, education, and abilities are confirmed during
orientation.
● Orienting, training, and educating staff.
The hospital provides ongoing in-service and other education and training to
increase staff knowledge of specific work-related issues.
● Assessing, maintaining, and improving staff competence.
Ongoing, periodic competence assessment evaluates staff members’ continuing
abilities to perform throughout their association with the hospital.
Standards
Planning
• HR.1.10 The hospital provides an adequate number and mix of staff that are
consistent with the hospital’s staffing plan.
• HR.1.20 The hospital has a process to ensure that a person’s qualifications
are consistent with his or her job responsibilities.
• HR.1.30 The hospital uses data on clinical/service screening indicators in
combination with human resource screening indicators to assess staffing
effectiveness.
Orientation, Training, and Education
• HR.2.10 Orientation provides initial job training and information.
• HR.2.20 Staff members, licensed independent practitioners, students, and
volunteers, as appropriate, can describe or demonstrate their roles and
responsibilities, based on specific job duties or responsibilities, relative to
safety.
• HR.2.30 Ongoing education, including in-services, training, and other
activities, maintains and improves competence.
Competence Assessment
• HR.3.10 Competence to perform job responsibilities is assessed, demonstrated,
and maintained.
• HR.3.20 The hospital periodically conducts performance evaluations.
Management of Information
Overview
The goal of the information management function is to support decision making to
improve patient outcomes, improve health care documentation, assure patient
safety, and improve performance in patient care, treatment, and services,
governance, management, and support processes.
While efficiency, effectiveness, patient safety, and the quality of patient care
can be improved by computerization and other technologies, the principles of
good information management apply to all methods, whether paper-based or
electronic. The standards in this chapter are designed to be equally compatible
with paper-based systems, electronic systems, or hybrid systems.
A hospital’s provision of care, treatment, and services is a complex endeavor
that is highly dependent on information. This includes information about the
science of care, treatment, and services; the individual patient; the care,
treatment, and services provided; the results of care, treatment, and services;
and the performance of the hospital itself. Furthermore, because many
individuals and areas within the hospital are involved in the provision of care,
treatment, and services, their work must be coordinated and integrated. As a
result, hospitals must treat information as an important resource to be managed
effectively and efficiently.
Managing information is an active, planned activity. The hospital’s leaders
have overall responsibility for managing information, just as they do for
managing the hospital’s human, material, and financial resources.
The quality of care, treatment, and services is affected by the many transitions
in information management that are currently in progress in health care, such as
the transition from handwriting and traditional paper-based documentation to
electronic information management, as well as the transition from free text to
structured and interactive text.
To achieve the goals of this function, the following processes are performed
well:
● Identifying information needs
● Designing the structure of the information management system
● Capturing, organizing, storing, retrieving, processing, and analyzing data and
information
● Transmitting, reporting, displaying, integrating, and using data and
information
● Safeguarding data and information
The standards in this chapter focus on hospital-wide information planning and
management processes to meet the hospital’s internal and external information
needs. They describe a vision for effectively and continuously improving
information management in health care hospitals. Achieving this vision involves
the following:
● Ensuring timely and easy access to complete information throughout the
hospital
● Assuring data accuracy
● Balancing requirements of security* and ease of access
● Producing and using aggregate data to pursue opportunities for improvement
● Ensuring data comparability within and among organizations, where possible, by
following national, state, and other recognized standards and guidelines on form
and content
● Accessing and using external knowledge bases and comparative data to pursue
opportunities for improvement
● Redesigning information-related processes to improve efficiency and
effectiveness, as well as patient safety and quality of patient care, treatment,
and services
● Increasing collaboration and information sharing to enhance patient care
Standards
Information Management Planning
• IM.1.10 The hospital plans and designs information management processes to
meet internal
• and external information needs.
Confidentiality and Security
• IM.2.10 Information privacy and confidentiality are maintained.
• IM.2.20 Information security, including data integrity, is maintained.
• IM.2.30 The hospital has a process for maintaining continuity of information.
Management of Information
Information Management Processes
• IM.3.10 The hospital has processes in place to effectively manage information,
including the capturing, reporting, processing, storing, retrieving,
disseminating, and displaying of clinical/service and non-clinical data and
information.
Information-Based Decision Making
• IM.4.10 The information management system provides information for use in
decision making.
Management of Information
Knowledge-Based Information
• IM.5.10 Knowledge-based information resources are readily available, current,
and authoritative.
Patient-Specific Information
• IM.6.10 The hospital has a complete and accurate medical record for every
individual assessed, cared for, treated or served.
• IM.6.20 Records contain patient-specific information, as appropriate, to the
care, treatment, and services provided.
• IM.6.30 The medical record thoroughly documents operative or other high risk
procedures and the use of moderate or deep sedation or anesthesia.
• IM.6.40 For patients receiving continuing ambulatory care services, the
medical record contains a summary list of all significant diagnoses, procedures,
drug allergies, and medications.
• IM.6.50 Designated qualified personnel accept and transcribe verbal orders
from authorized individuals.
• IM.6.60 The hospital can provide access to all relevant information from a
patient’s record when needed for use in patient care, treatment, and services.
Organization Structures with Functions
Medical Staff
Overview
The organized medical staff has a critical role in the process of providing
oversight of quality of care, treatment, and services. The organized medical
staff is a self-governing body that is charged with overseeing the quality of
care, treatment, and services delivered by practitioners who are credentialed
and privileged through the medical staff process. The organized medical staff
must credential and privilege all licensed independent practitioners.
Physician assistants (PAs) and advanced practiced registered nurses (APRNs) who
are not licensed independent practitioners may be privileged through the medical
staff process or a process that has been developed and approved by the hospital
that is equivalent to the process and criteria set forth in the credentialing
and privileging standards contained in this chapter. When medical staff
processes are not used, there are mechanisms to assure communication with and
input from the Medical Staff Executive Committee regarding those privileges.
The self-governing, organized medical staff must create and maintain a set of
bylaws that defines its role within the context of a hospital setting and
clearly delineates its responsibilities in the oversight of care, treatment, and
services. The medical staff bylaws, rules, and regulations create a framework
within which medical staff members can act with a reasonable degree of freedom
and confidence. The organized medical staff also provides leadership in
performance improvement activities within the organization.
The tasks of the medical staff are numerous and require a dedicated and
organized leadership to adequately perform their duties. Evaluating the
competency of privileged practitioners and delineating the scope of privileges
of privileged practitioners are key areas of responsibility for the organized
The hospital’s governing body has the ultimate authority and responsibility for
the oversight and delivery of health care rendered by licensed independent
practitioners, and other practitioners credentialed and privileged through the
medical staff process or any equivalent process.
The governing body and the medical staff define medical staff membership
criteria which, as deemed necessary by the governing body and the medical staff,
may include licensed independent practitioners and other practitioners. The
Joint Commission does not dictate who is eligible for medical staff membership
at accredited hospitals. Membership on the medical staff is not synonymous with
privileges. The medical staff may create categories of membership, as in active
member, courtesy member, and so forth. These categories may be helpful in
defining the roles and expectations for the various members of the medical
staff.
The Joint Commission does not determine if a practitioner is a licensed
independent practitioner. State law and hospital policy determine whether a
practitioner can practice independently. The Joint Commission defines a licensed
independent practitioner as “any individual permitted by law and by the
organization to provide care, treatment, and services, without direction or
supervision.” Practitioners who are responsible for the oversight of health care
delivered by all medical staff practitioners must be licensed independent
practitioners. The organized medical staff develops and uses criteria to
determine which licensed independent practitioners are eligible to participate
in the oversight process.
Standards
Organized Medical Staff Structure
• MS.1.10 The hospital has an organized, self-governing medical staff that
provides oversight of care, treatment, and services provided by practitioners
with privileges, provides for a uniform quality of patient care, treatment, and
services, and reports to and is accountable to the governing body.
• MS.1.20 Medical staff bylaws address self governance and accountability to the
governing body.
• MS.1.30 Neither the organized medical staff nor the governing body may
unilaterally amend the medical staff bylaws or rules and regulations.
• MS.1.40 There is a medical staff executive committee.
Management of Patient Care, Treatment, and Services
• MS.2.10 The organized medical staff oversees the quality of patient care,
treatment, and services provided by practitioners privileged through the medical
staff process
Medical Staff
• MS.2.20 The management and coordination of each patient’s care, treatment, and
services is the responsibility of a practitioner with appropriate privileges.
• MS.2.30 In hospitals participating in a professional graduate education
program(s), the organized medical staff has a defined process for supervision by
a licensed independent practitioner with appropriate clinical privileges of each
member in the program in carrying out his or her patient care responsibilities.
Performance Improvement
• MS.3.10 The organized medical staff has a leadership role in hospital
performance improvement activities to improve quality of care, treatment, and
services and patient safety.
• MS.3.20 The organized medical staff participates in the measurement,
assessment, and improvement of other processes.
Credentialing, Privileging, and Appointment
• MS.4.10 The organized medical staff has a credentialing process that is
defined in the medical staff bylaws.
• MS.4.20 There is a process for granting, renewing, or revising
setting-specific clinical privileges.
• MS.4.30 An organized medical staff may use an expedited process for appointing
to the medical staff and when granting privileges when criteria for that process
are met.
• MS.4.40 At the time of renewal of privileges, the organized medical staff
evaluates individuals for their continued ability to provide quality care,
treatment, and services for the privileges requested as defined in the medical
staff bylaws.
• MS.4.50 There are mechanisms including a fair hearing and appeal process for
addressing adverse decisions regarding reappointment, denial, reduction,
suspension, or revocation of privileges that may relate to quality of care,
treatment, and services issues.
• MS.4.60 The organized medical staff provides oversight for the quality of
care, treatment, and services by recommending members for appointment to the
medical staff
• MS.4.70 Peer recommendations from peers in the same professional discipline as
the applicant are used as part of the basis for the initial granting of
privileges. Peer recommendations are used to recommend individuals for the
renewal of clinical privileges when insufficient practitioner-specific data are
available.
• MS.4.80 The medical staff implements a process to identify and manage matters
of individual health for licensed independent practitioners. This identification
process is separate from actions taken for disciplinary purposes.
• MS.4.90 There is a process that defines circumstances requiring a focused
review of a practitioner’s performance and evaluation of a practitioner’s
performance by peers.
• MS.4.100 Under certain circumstances, temporary clinical privileges may be
granted for a limited period of time.
• MS.4.110 Disaster privileges may be granted when the emergency management plan
has been activated and the hospital is unable to handle the immediate patient
needs (see standard EC.4.10).
• MS.4.120 Licensed independent practitioners who are responsible for the care,
treatment, and services of the patient via telemedicine link are subject to the
credentialing and privileging processes of the originating site.
• MS.4.130 The medical staffs at both the originating and distant sites
recommend the clinical services to be provided by licensed independent
practitioners through a tele-medical link at their respective sites.
Continuing Education
• MS.5.10 All licensed independent practitioners and other practitioners
privileged through the medical staff process participate in continuing
education.
Nursing
Overview
The quality of a hospital’s nursing services is built upon the leadership of
a nurse executive and the work of a qualified staff. The nurse executive ensures
the continuous and timely availability of nursing services to patients. The
nurse executive also ensures the quality of nursing standards of patient care
and practice by incorporating current nursing research findings, nationally
recognized professional standards, and other literature into the policies and
procedures governing the provision of nursing care, treatment, and services. In
addition, the nurse executive develops, presents, and manages the nursing
services’ portion of the hospital’s budget.
A qualified staff provides patient care and nursing services on a continuous
basis, 24 hours a day, 7 days a week, to those patients requiring such care,
treatment, and services. Nursing staff monitors each patient’s status and
coordinates the provision of nursing care while assisting other professionals in
implementing plans of care. To achieve the goal of providing quality nursing
care, treatment, and services, the nurse executive participates with hospital
leaders in defining the nursing care needs of the patient population served.
The nurse executive also participates with hospital leaders in providing for a
sufficient number of appropriately qualified nursing staff members to assess
each patient’s nursing care needs, plan and provide nursing care interventions,
prevent complications, promote improvement in the patient’s comfort and
wellness, and alert other care professionals to the patient’s condition, as
appropriate.
Standards
• NR.1.10 A nurse executive directs the hospital’s nursing services.
• NR.2.10 The nurse executive is a licensed professional registered nurse
qualified by advanced education and management experience.
• NR.3.10 The nurse executive establishes nursing policies and procedures,
nursing standards of patient care, treatment, and services, standards of nursing
practice, and a nurse staffing plan(s).
Ask a question and we will answer it within the next 48 hours. If you
have no questions, please review the answer to the questions asked by others:
Question:
One of the most difficult functions in conducting performance improvement in my ambulatory organization is the availability of benchmarks in the outpatient surgery arena. What suggestion do you have for me to help in my search for information on benchmarking?
Answer:
Please contact the insturctor directly for the answer to this question.
Question:
what are the advantages of departmentalization of the medical staff over service committee organization?
Answer:
The advantages and disadvantages of departments can be found in most introductry health care management book. It provides a context for socialization and productivity and information exchange that is just not present within a committee structure.
You can
add your suggestions
or read below suggestions made by others:
Suggestion:
Together with the previous lecture on patient-focused standards, this lecture was successful in cementing our understanding of JCAHO's overall standards as well as the rationales behind them.
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