Page 3, Introduction (correcting a typo) Accreditation Participation Requirements (APR)

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1 Issued 4 December 2013 Page 3, Introduction (correcting a typo) Accreditation Participation Requirements (APR) The Accreditation Participation Requirements (APR) section, new to JCI in this edition, is composed of specific requirements for participation in the accreditation process and for maintaining an accreditation award. Hospitals must be compliant with the requirements in this section at all times during the accreditation process. However, APRs are not scored like standards during the on-site survey; hospitals are considered either compliant or not compliant with the APR. When a hospital is not compliant with a specific APR, the hospital will be required to become complaiiant or risk losing accreditation.

2 Issued 7 November 2013 (Deletions in strikethrough. New text is underlined. Clarifications are blue.) Page 17, APR.10 (new text for clarity) Requirement: APR.10 Translation and interpretation services arranged by the hospital for an accreditation survey and any related activities are provided by licensed and/or qualified translation and interpretation professionals who have no relationship to the hospital. Rationale for APR.10 The integrity of the on-site evaluation process, as well as the integrity of the outcome, depend on the surveyor obtaining an unbiased, accurate understanding of his or her conversations with staff; and the hospital s staff communicating effectively in their language with the surveyor. To ensure this accurate, unbiased exchange, translation and interpretation is provided by individuals licensed and/or qualified to provide translation and interpretation services, with evidence of experience in health care translation and/or interpretation services. Individuals providing translation and interpretation services are not current or former employees of the hospital and do not have any conflicts of interest, such as immediate family members or employees of an affiliated hospital. Individuals providing translation and interpretation services have not served in any consultation capacity to the hospital in relation to accreditation or accreditation preparation, with the possible exception of assistance in translating the documents required by JCI to be in English or providing translation and interpretation services at a previous survey. Consequences of Noncompliance with APR.10 When translators are found to be unqualified due to lack of professional license and/or other qualifications, or a conflict of interest, the survey will be stopped until a suitable replacement can be found. The hospital is responsible for any additional costs related to the delay, including rescheduling of survey team members when necessary. Clarification Qualified translators and interpreters can provide to the hospital and JCI documentation of their experience in translation and interpretation that may include but is not limited to the following: Evidence of advanced education in English and the host hospital s primary language Evidence of translation and interpretation experience, preferably in the medical field Evidence of continuing education in translation and interpretation, preferably in the medical field Memberships in professional translation and interpretation associations Translation and interpretation proficiency testing results, when applicable Translation and interpretation certifications, when applicable Other relevant translation and interpretation credentials

3 Issued 17 March 2014 Page 80, AOP.6 (wording change for clarity) Intent of AOP.6 The hospital has a system for providing radiology and diagnostic imaging services required by its patient population, clinical services offered, and health care practitioner needs. Radiology and diagnostic imaging services meet all applicable local and national standards, laws, and regulations. Radiology and diagnostic imaging services, including those required for emergencies, may be provided within the hospital, by agreement with another organization, or both. Radiology and diagnostic imaging services are available after normal hours for emergencies. In addition, the hospital can identify and contact experts in specialized diagnostic areas, such as radiation physics, radiation oncology, or nuclear medicine, when necessary. The hospital maintains a roster of such experts. Outside sources are convenient for the patient to access, and reports are received in a timely way that supports continuity of care. The hospital selects outside sources based on the recommendation of the laboratory s leader or other individual responsible for radiology and diagnostic imaging services. Outside sources of radiology and diagnostic imaging services meet applicable laws and regulations and have an acceptable record of accurate, timely services. Patients are informed when an outside source of services is owned by the referring physician. Measurable Elements of AOP.6 1. Radiology and diagnostic imaging services meet applicable local and national standards, laws, and regulations. 2. Adequate, regular, and convenient radiology and diagnostic imaging 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. 3. The hospital contacts experts in specialized diagnostic areas when needed. 4. Outside sources are selected based on recommendations of the individual responsible for radiology and diagnostic imaging services laboratory leader and an acceptable record of timely performance and compliance with applicable laws and regulations. 5. Patients are informed about any relationships between the referring physician and outside sources of radiology and/or diagnostic imaging services. (Also see GLD.12.1, ME 1) 2014 Joint Commission International

4 Issued 7 November 2013 (Deletions in strikethrough. New text is underlined. Clarifications are blue.) Page 84, AOP.6.8 Clarification Standard AOP.6.8 requires the hospital to collect and review quality control results for all outside sources of diagnostic services. In this case, outside is considered to be the equivalent of contracted, meaning the hospital is required to collect quality control data from any diagnostic imaging services that are contracted by the hospital, but not within the hospital facility. When the hospital simply provides a list of diagnostic services from which a patient can freely choose or refers a patient to a diagnostic service that is not part of the hospital and for which the hospital does not contract services, the hospital is not required to obtain quality control results.

5 Issued 7 November 2013 Page 97, COP chapter, Hospitals Providing Organ and/or Tissue Transplant Services (reworded for clarity) Note: The following standards are intended to be used during those times when patients and/or families request information about organ and tissue donation and/or when organ/tissue procurement is performed. For hospitals providing organ and/or tissue transplant services, Standards COP.8 through COP.9.3 apply are intended to be used by hospitals providing organ and/or tissue transplant services. Please contact the JCI Accreditation Office with inquiries.

6 Page 109, ASC.3 Clarification of Procedural Sedation May 2014 Question: The basis for this question and answer is the JCI Standards for Hospitals, 5 th Edition. The intent of Standard ASC.3 reads: "Procedural sedation, which includes moderate and deep sedation, involves any sedation administered intravenously, regardless of the dosage." The question is: if the sedation drug is administered orally or by enema, is it still considered sedation and do the ASC.3 standards apply? The intent of the sedation administration orally or by an enema is to sedate the patient for some amnesia and not to reduce anxiety. The MEs do not specifically address this question of route of administration. Answer: The intent of ASC.3 does not provide a definition of procedural sedation, however there is a definition in the glossary which reads: The administration of medication to an individual in any setting, for any purpose, by any route to induce a partial or total loss of sensation for the purpose of conducting an operative or other procedure. The definition goes on to provide the different levels of anesthesia and sedation; minimal, moderate, and deep. The first sentence of the intent of ASC.3 was never meant to imply that the use of oral or rectal medications for the purpose of inducing partial or total loss of sensation would not be considered procedural sedation. The first sentence is meant to identify that regardless of the dosage used for intravenous administration of a sedative or anesthetic agent for the purposes of inducing partial or total loss of sensation, it is still considered sedation (for a procedure) that requires the same standardized care. Unfortunately, there is a common misperception that administering a very small dose of IV sedation does not require the same rigorous monitoring and recovery as higher doses of intravenous sedatives or anesthetic agents. The first sentence is meant to clarify that we expect the same standard of care for any intravenous sedative agent that is administered when used during procedural sedation, regardless of the dosage administered. Note: this standard refers to the administration of sedation/anesthetic agents for the purpose of partial or total loss of sensation for a procedure Intravenous sedative-type medications are also administered to patients on ventilators, to psychiatric patients whose acting out is uncontrollable, or to people with uncontrollable grief reactions. In these and other similar circumstances, standard ASC.3 does not apply Joint Commission International

7 Clarification, JCI Accreditation Standards for Hospitals, 5th Edition Issued 23 April 2014 Page 120, MMU.1 Clarification MMU.1 requires written policies for all medication-use processes within an organization. Measurable element 1 states that a written document identifies how medication use is organized and managed throughout the hospital; measurable element 2 requires all settings, services, and individuals who manage medication processes are included in the organizational structure. These measurable elements, when applied together, require all medication use processes to be directed by medication management policies Joint Commission International

8 Issued 17 March 2014 Page 180, GLD.12 and 12.1 (changing order of standards to synchronize with MEs [former GLD.12 becomes GLD.12.1; former GLD.12.1 becomes GLD.12] ; no change in requirements) Standard GLD.12 Hospital leadership establishes a framework for ethical management that promotes a culture of ethical practices and decision making to ensure that patient care is provided within business, financial, ethical, and legal norms and protects patients and their rights. The hospital s framework for ethical management addresses operational and business issues, including marketing, admissions, transfer, discharge, and disclosure of ownership and any business and professional conflicts that may not be in patients best interests. Standard GLD.12.1 The hospital s framework for ethical management addresses operational and business issues, including marketing, admissions, transfer, discharge, and disclosure of ownership and any business and professional conflicts that may not be in patients best interests. Hospital leadership establishes a framework for ethical management that promotes a culture of ethical practices and decision making to ensure that patient care is provided within business, financial, ethical, and legal norms and protects patients and their rights Joint Commission International

9 Issued 7 November 2013 Page 219, SQE.11 (changed lettered list to bulleted list to indicate advisory text [bullets] versus requirements [lettered list]) Professional Growth Medical staff members grow and mature as the organizations 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 health care and professional practice: a)patient care, including provision of patient care that is compassionate, 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.) (Also see PRF.3) b)medical/clinical knowledge, including knowledge of established and evolving biomedical, clinical, epidemiologic, and social-behavioral 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.) (Also see GLD.11.2) c)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.) d)interpersonal and communication skills, including establishment and maintenance of effective exchange of information and collaboration with patients, their families, and other members of health care teams. (Examples of potential measures include participation in teaching rounds, team consultations, team leadership, and patient and family feedback.) e)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.) f)system-based practices, including awareness of and responsiveness to the larger contexts and systems of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. (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, underuse, and misuse of systems.) g)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 health care 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.) (Also see GLD.7)

10 Issued 7 November 2013 Page 264, Glossary (text inadvertently omitted from initial publication 1 September 2013) deep sedation/analgesia A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous impaired ventilation may be inadequate. Cardiovascular function is usually maintained. anesthesia Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

11 Issued 14 October 2014 Page 272 (modifying definition to match text in QPS.7) sentinel event An unanticipated occurrence involving death or major permanent loss of function serious physical or psychological injury. See QPS.7 on page 145 for an operational definition Joint Commission International

12 Issued 4 December 2013 Page 272, Glossary (correcting a typo) specialty laboratory programs Programs that include laboratory disciplines, such as chemistry (including toxicology, therapeutic drug testing, and drugs of abuse testing), clinical cytogenetics, immunogenetics, diagnostic immunology, embryology, hematology (including coagulation testing), histocompatibility, immunohematology, microbiology (including bacteriology, mycobacteriology, mycology, virology, and parasitology), molecular biology, pathology (including surgical pathology, cytopathology, and necropsy), and radiobioassay.

Page 17, APR.10 (new text for clarity)

Page 17, APR.10 (new text for clarity) Requirement: APR.10 Translation and interpretation services arranged by the hospital for an accreditation survey and any related activities are provided by licensed