General Eligibility Requirements

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Overview General Eligibility Requirements Clinical Care Program Certification (CCPC) provides an evaluation of a clinical program that delivers care to a defined patient population. Certification is designed to evaluate the acute or chronic disease management and clinical care programs provided by hospitals, ambulatory care, home care, and long term care centers. Certification is not connected to an organization s accreditation status, although organizations, if eligible for accreditation, must first achieve accreditation by Joint Commission International (JCI) to be eligible for subsequent CCPC certification. Types of Programs Certified JCI CCPC evaluates the programs that provide clinical care directly to participants of the program and meet the eligibility requirements. Examples of programs may include but are not limited to, acute myocardial infarction, heart failure, primary stroke, asthma, chronic obstructive pulmonary disease, pain management, palliative care, low back pain, chronic depression, and HIV/AIDS. Eligibility Requirements for CCPC Survey Any clinical care program that is provided in association with a JCI accredited organization is eligible to apply for JCI certification if the following requirements are met: The program is appropriately designed and implemented for the population served A minimum of 25 patients have met the program s eligibility requirements and have been managed under the program s selected Clinical Practice Guidelines prior to (CCPC) application The program has been in operation for at least four months prior to CCPC application The program can demonstrate at least a four-month track record of consistent compliance with all of the JCI standards prior to CCPC application Clinical practice guideline(s) used are evidence based and are sponsored and supported by the auspices of medical specialty associations, relevant professional societies, public or private organizations, government agencies, or other authoritative sources. The performance measures selected for the program meet the following requirements: o Performance measures selected are appropriate and consistent with the program s intent and/or clinical practice guidelines o The program has collected four months of data for the selected performance measures at the time of submitting the application o The program has monitored at least four performance measures at the time of submitting the application Certification of Specialty Centers A specialty organization meeting specific requirements may apply for certification as a Certified Specialty Center for the specific specialty provided by that organization. For example, a specialty hospital that treats only cancer patients may apply for certification as a Certified Cancer Center. Similarly, a hospital that only performs joint replacement may apply for certification as a Certified Joint Replacement Center. Page 1 of 28

43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 Eligibility Requirements for a Specialty Center Certification Survey Any specialty hospital that is JCI accredited is eligible to apply for JCI certification as a specialty center if the following requirements are met: The specialty hospital is accredited under the JCI standards for hospitals. The hospital specializes in care for a specific patient population, such as cancer, neurology, mental health, and the like The hospital must have served a minimum number of patients at the time it submits its application to JCI Every patient must be managed under an approved Clinical Practice Guideline prior to Specialty Center Certification application To qualify as approved, the clinical practice guideline(s) used must be evidence based and sponsored and supported by the auspices of medical specialty associations, relevant professional societies, public or private organizations, government agencies, or other authoritative sources. The specialty hospital can demonstrate at least a four-month track record of consistent compliance with all of the JCI standards prior to certification application A minimum of at least four performance measures must be selected for each of the clinical practice guidelines and must meet the following requirements: o Performance measures selected are appropriate and consistent with the clinical practice guideline o The specialty hospital has collected four months of data for each of the selected performance measures o The specialty hospital has monitored at least four performance measures for each clinical practice guideline 64 65 66 67 68 69 70 71 Page 2 of 28

72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 Standards, Intents, and Measurable Elements Standard PLM.1 Program Lleadership and roles are clearly identified and leadership is collectively responsible for defining roles in the program. are clearly defined. Intent of PLM.1 Program leaders require an educational background, experience, and training or certification to develop and oversee a specialized program..leaders of the program may have formal titles or be informally recognized for their contribution to the program. It is important that all leaders be identified and brought into the process of defining the program. The clinical care, patient outcomes, and overall management of a clinical care program require clear leadership from qualified individuals in order to ensure that care is provided in a uniform manner and is consistent with the program s mission, goals, and objectives. The leaders set expectations for development of plans to manage and to improve quality in order to improve patient outcomes. Leaders are also responsible for helping to recruit and retain qualified staff. Measurable Elements of PLM.1 1. The leaders involved in program development and oversight have educational backgrounds, experience, training, and/or certification consistent with the program s mission, goals, and objectives. 2. The leaders accountability is clearly defined. 3. The leaders provide for the uniform delivery of patient care and/or services. 4. The leaders are accountable for recruitment and retention of qualified staff. The leaders ensure that practitioners practice only within their licensure, training, and current competency. (Move to DFC.1) 5. The leaders establish and implement a leadership development plan. Standard PLM.2 Program Leadership and Management (PLM) The program is designed, implemented, and evaluated collaboratively. Intent of PLM.2 Patient care services provided in the program are planned and designed to respond to the needs of the population identified. Leaders of the program identify the various clinical departments and services that are essential to implementation of the program. All relevant individuals and or disciplines represented in the program Page 3 of 28

106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 must work together to coordinate and integrate all the program s clinical services and activities. For the program to be successful in providing improvements in care and reducing risks to patients, a process to monitor and evaluate the program is essential. The leaders set expectations for development of processes to manage and to improve quality and patient safety in order to improve patient outcomes. Measurable Elements of PLM.2 1. All relevant individuals and/or disciplines represented in the program participate in designing the program. 2. All relevant individuals and/or disciplines represented in the program participate in implementing the program. 3. The leaders participate in designing, implementing, and evaluating care and/or services. 34. The leaders establish and implement processes to improve quality and patient safety. 4. All disciplines represented in the program participate in evaluating the program. 5. Program Lleaders take appropriate measures to address and resolve issues identified through the evaluation process. Standard PLM.3 The program is relevant to and meets the needs of the target population and/or health care service area. Intent of PLM.3 The services provided by the program must be planned and designed to respond to the needs of the patient population. A program s mission reflects the needs of the population to be served. It is important for all leaders of the program to define the program s mission to the targeted population. The program describes care and services that are consistent with its mission. Measurable Elements of PLM.3 1. The program s mission and scope of services are defined in writing. 2. The program s mission and scope of service are approved by the appropriate organization and program leaders. 3. 4. The program identifies its target population. The program ensures that the services available are relevant for its targeted population. 128 129 130 131 132 133 134 135 Standard PLM.4 The scope and level of care and/or services offered by the program are provided to patients and, when appropriate, families. Intent of PLM.4 Patients and their families receive sufficient information to make knowledgeable decisions. Information is provided about the proposed care, the expected outcomes, and any expected cost to the patient or family. During participation in the program, patients may require services from other departments, such as laboratory or radiology services. The patient s needs are matched with the appropriate resources. Page 4 of 28

136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 Measurable Elements of PLM.4 1. The program provides care, treatment, and services (for example, laboratory, radiology, surgical, and other services that may be applicable) to patients in a planned and timely manner. 2. The program informs patients about how to access care, treatment, and services, including after hours or in an emergency. (if applicable). 3. Adequate numbers and types of cclinical staff are always available to deliver or to facilitate the delivery of care and/or services including after hours or in an emergency. 4. The program evaluates services provided through contractual arrangement to ensure that the scope and level of care and/or services are consistently provided. 5. The program defines in writing the care, treatment, and services it provides. (Redundant to PLM3, ME1) Standard PLM.5 The scope and level of care and/or services provided are uniform and comparable for patients with the same acuity and type of disease or condition being managed, regardless of their ability to pay or the source of payment. Intent of PLM.5 A uniform level of care is provided to patients with the same health problems and care needs. To carry out the principle of a uniform level of care requires that the program leaders plan and coordinate patient care. In particular, services provided to similar patient populations are guided by policies and procedures that result in their uniform delivery. A uniform level of patient care results in the efficient use of resources and permits the evaluation of outcomes of similar care throughout the program. A uniform level of patient care is reflected in the following: a) Access to and appropriateness of care and treatment do not depend on the patient s ability to pay or the source of payment. b) Acuity of the patient s condition determines the resources allocated to meet the patient s needs. c) The level of care provided to patients is the same throughout the program. Measurable Elements of PLM.5 1. Patients have access to an adequate level of resources required to meet the health care needs for the disease(s) or condition(s) being managed. 2. Access to and appropriateness of care and treatment do not depend on the patient s ability to pay or the source of payment. 3. The level of care provided to patients is the same throughout the program. Standard PLM.6 Eligible patients have access to the care and/or services provided by the program. Intent of PLM.6 Enrolling eligible patients into the program requires the program to develop criteria for participation. Patients who meet the criteria must be informed about the program and given multiple opportunities to participate. Matching eligible patients to Page 5 of 28

174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 the care and services provided by the program depends on obtaining information about the patient s needs. Therefore, a uniform process for identifying potential patients is needed. Measurable Elements of PLM.6 1. Enrollment and/or participation requirements are well defined. 2. Criteria for participation are relevant to the program and follow recommendations from the clinical practice guidelines used. 23. The program uses a systematic method based on perceived need to identify potential patients who are not direct referrals. 34. Patients are given multiple opportunities to participate in the program. Standard PLM.7 The program operates in an ethical manner. Intent of PLM.7 The leaders of the program have an ethical and legal responsibility to their patients, patients families, healthcare providers, and the community. The leaders understand the responsibilities as they apply to the clinical activities as well as the business activities. Patients and families participate in the care process by making decisions about care, asking questions about care, and having the prerogative to refuse certain aspects of care. The program supports the patient s, andpatient s and, when appropriate, the family s rights to decline to participate in the program or request discharge from the.program. Patients have a right to voice complaints about their care and to have those complaints reviewed and, when possible, resolved. Decisions regarding care sometimes present questions, conflicts, or other dilemmas affecting decision makers. In addition, health care providers may be confronted by interprofessional disagreements regarding healthcare decisions. The program has an established process for seeking resolution of patient complaints and such ethical dilemmas. and complaints. Safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position in the hospital. Program leaders set expectations for behaviors that promote accountability and teamwork. Measurable Elements of PLM.7 1. The program protects the integrity of clinical decision making, regardless of how the program compensates or shares financial risk with its leaders, managers, and clinical staff. 2. The program respects the patient s right to decline participation in the program. 3. The program has a mechanism for receiving, managing, and resolving complaints and grievances in a timely way. 4. The program has a mechanism for managing and resolving complaints and grievances in a timely way. 45. The program has develops and implemented a code of conduct. 5. The program monitors compliance with the code of conduct. Page 6 of 28

210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 Standard PLM.8 The program complies with applicable laws and regulations. Intent of PLM.8 In order to conduct a thorough certification survey, surveyors collect information on many aspects of the program s operations. External bodies other than JCI evaluate areas related to safety and quality; for example evaluation of safety incidents or quality complaints by local authorities. The leaders are responsible for the program s overall operations. This includes compliance with applicable laws and regulations and responding to any reports from inspecting and regulatory agencies. Measurable Elements of PLM.8 1. The program complies with local and applicable national laws and regulations. 2. Those responsible for governance and leadership respond to any reports from inspecting and regulatory agencies. 3. Program leaders provide JCI with all official records, reports, and recommendations of outside agencies. Standard PLM.9 The program uses has current scientific information, reference, and resource materials to support patient care, health professional education, and clinical research.reference and resource materials readily available. Intent of PLM.9 Practitioners seek to develop clinical care processes and make clinical care decisions based on the best available scientific evidence. Evidence-based recommendations for practice are a means to ensure that the program provides safe, highquality care. Current resource and reference materials are available to support health professional education and clinical research. Measurable Elements of PLM.9 1. Clinical care processes and clinical decisions are based on the best available scientific evidence. 21. Scientific information, references, and resources support clinical education and research. The program has reference materials (hard copy or electronic) that are easily accessible to clinical staff. 3 2. The program has reference materials (hard copy or electronic) that are easily accessible to clinical staff.the resources are authoritative and current. Standard PLM.10 Facilities where patients receive care maintain and implement a program that provides a safe and secure physical environment. Intent of PLM.10 Risk prevention is essential to creating a safe and supportive patient care facility. To plan effectively, those Page 7 of 28

244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 responsible for the program must be aware of all the risks present in the facility. The goal is to prevent accidents and injuries; to maintain safe and secure conditions for patients, families, staff, and visitors; and to reduce and control hazards and risks. By understanding the risks present in the program s physical facility, those responsible for the program can develop a proactive plan to reduce those risks for patients, families, staff, and visitors Measurable Elements of PLM.10 1. The program evaluates potential risks. 2. The program implements strategies to minimize security risks. Standard PLM.11 Facilities where patients receive care maintain and implement an emergency management program. Intent of PLM.11 Community emergencies, epidemics, and disasters may directly involve the facility in which the program operates and/or the staff dedicated to providing care and services to the program s patients. To respond effectively, the program must include a plan for how to respond to such emergencies. Measurable Elements of PLM.11 1. The program develops an emergency plan. 2. The program implements strategies to minimize the risks of disruption of care due to an environmental emergency. Standard PLM.12 Facilities where patients receive care maintain and implement a program to ensure that all occupants are safe from fire and smoke. Intent of PLM.12 Fire is an ever-present risk. The program must address how it will keep its patients, families, and visitors safe in case of fire or smoke. Therefore, the program needs to evaluate the fire-safety program of the facility in which program patients receive care and incorporate those strategies into the plan. Measurable Elements of PLM.12 1. The program evaluates its fire risks and fire safety related issues. 2. The program implements strategies to minimize the risk of fire and fire safety related issues. Standard PLM.13 Facilities where patients receive care maintain and implement a program for inspecting, testing, and maintain-ing medical equipment and documenting results. Page 8 of 28

278 279 280 281 282 283 284 Intent of PLM.13 To ensure that medical equipment is available for use and functioning properly, equipment is inspected and tested when new and then on an ongoing basis as appropriate to the equipment s age and use or based on manufacturer instructions. Measurable Elements of PLM.13 1. The program develops a medical equipment management plan. 2. The program implements a medical equipment management plan. 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 Standard PLM.14 Facilities where patients receive care maintain and implement emergency processes in the event of water, power, gas, or communication failures. Intent of PLM.14 The program has different utility needs based on the mission of the program, patient needs, and resources. Regardless of the system and level of resources available, the program needs to ensure that patients, families, and staff are protected in emergencies, such as system failures, interruptions, or contaminations. Measurable Elements of PLM.14 1. The program evaluates the risk points in power, gas, water, and communication services. 2. The program implements strategies to minimize risks to power, gas, water, and communication services. Standard PLM.15 Facilities where patients receive care maintain and implement a program to ensure that all staff members receive education and training about their roles in providing a safe and effective environment. Intent of PLM.15 The program s staff are the primary source of contact with patients, families, and visitors. Thus, they need to be educated and trained to carry out their roles in identifying and reducing risks, protecting others and themselves, and creating a safe and secure facility. Periodic testing of staff knowledge on emergency procedures, including fire-safety procedures, response to emergencies, and medical equipment that poses a risk to patients and staff, is conducted. Measurable Elements of PLM.15 1. All staff members have been educated and trained about their roles in the programs for fire safety, security, and emergency plans. 2. All staff members have been trained to operate and to maintain medical equipment and utility systems. 3. There is a program to monitor all aspects of the facility/environment risk management programs. Page 9 of 28

310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 Standards, Intents, and Measurable Elements Standard DFC.1 Delivering or Facilitating Clinical Care (DFC) All clinical staff are qualified, competent, and appropriately trained. Intent of DFC.1 The program requires that there are qualified staff members to provide safe and effective care and treatment to patients enrolled in the program. Education, background, experience, training, and/or certification must be consistent with the program s mission, goals, and objectives and in accordance with applicable laws and regulations. Every effort needs to be made to verify essential information through primary source verification. Qualified staff members are hired through a process that matches the requirements of the position with the qualifications of the prospective staff member. This process ensures that the staff member s skills are initially and over time consistent with the needs of patients. Measurable Elements of DFC.1 1. All clinical staff have educational backgrounds, training, experience, training, and/or and/or certification, and experience consistent with the program s mission, goals, and objectives. 2. Core criteria for hiring clinical staff in the program include, at a minimum, relevant education, training and experience, current competence, and current licensure, relevant education, training and experience, and current competence. 3. Core criteria for evaluating clinical staff in the program include, at a minimum, current licensure and current competence. 4. Professional education, advanced training, and experience are verified from primary sources. 5. Current licensure and certifications are verified from primary sources. 339 340 341 342 Standard DFC.2 All clinical and nonclinical staff are oriented to the program and to their specific job responsibilities. Intent of DFC.2 To perform well, new staff members, no matter what their employment status, need to understand the program and the Page 10 of 28

343 344 345 346 347 348 349 350 351 352 353 354 355 organization in which the program operates. This is accomplished through a general orientation to the program and to the organization in which it operates and specific orientation to the job responsibilities of the position. The orientation includes, as appropriate, the reporting of medical errors; infection prevention and control practices; the program s policies, procedures, and guidelines; and any other necessary information and training. Ongoing educational needs are identified from monitoring data, when new technology or skills are introduced to the program, or through review of job performance. Ongoing in-service and other education and training activities reflect identified educational needs. Measurable Elements of DFC.2 1. Orientation provides information and necessary training appropriate to program responsibilities. 2. The competence of all clinical staff is assessed when new techniques or responsibilities are introduced and periodically within the time frames defined by the program. 3. Ongoing in-service and other education and training activities are relevant related to the program s needs. 356 357 358 359 360 361 362 363 364 365 366 367 368 Standard DFC.3 There are continuous, ongoing professional practice evaluations of the quality and safety of the clinical care provided by each staff member. Intent of DFC.3 There is a standardized process to, at least annually, gather relevant data on each staff member for review by appropriate leaders. Such a review allows for identification of practice trends that impact the quality of care and patient safety. When deficiencies or substandard performance are identified, corrective actions are implemented. Measurable Elements of DFC.3 1. The performance of individual staff members is reviewed when indicated by findings of quality improvement activities. 2. There is an ongoing professional practice evaluation of each staff member documented in the staff member s file that includes at least one documented evaluation each year. 3. Corrective action is taken when deficiencies or substandard performance are identified. 369 370 371 372 373 374 375 376 377 378 Standard DFC.4 The program uses a standardized process originating in clinical practice guidelines or evidence-based practice to deliver or facilitate the delivery of clinical care. Intent of DFC.4 The goals of a clinical care program include standardizing clinical care processes; reducing risks within care processes; and providing clinical care in a timely, effective manner using available resources efficiently. Page 11 of 28

379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 A variety of tools may be used to reach these goals. The program seeks to use the best available scientific evidence in developing the care process. Clinical practice guidelines are useful tools in applying the best science to a particular disease, condition, or service. Clinical practice guidelines are relevant to the program and the population being served, and are evidence-based guidelines sponsored and supported by the auspices of medical specialty associations, relevant professional societies, public or private organizations, or government agencies at the national/regional or local level; adapted when needed to the technology, drugs, or other resources of the program or to accepted national professional norms; formally approved or adopted by leaders and practitioners in the program; and periodically reviewed and updated. The clinical practice guidelines should be monitored for consistent use and effectiveness and modified as determined by analysis of outcomes. Measurable Elements of DFC.4 1. The clinical practice guidelines used are based on professional knowledge that has been evaluated as current by the clinical leaders. 2. The clinical practice guidelines used are based on professional knowledge that has been evaluated as appropriate for the target population. 3. Adapted or adopted clinical practice guidelines used in the program are reviewed annually to ensure appropriateness for the program. 4. Adapted or adopted clinical practice guidelines used in the program are reviewed annually to ensure that they are current to practice. 5. The program uses outcomes analysis to determine modifications to the clinical practice guidelines and their use. 5. Appropriate leaders and practitioners in the program review and approve clinical practice guidelines selected for implementation. Standard DFC.5 All clinical staff are knowledgeable about the adapted or adopted clinical practice guidelines and implement activities that are consistent with the clinical practice guidelines. Intent of DFC.5 Clinical practice guidelines must be implemented and monitored for consistent use and effectiveness. Clinical staff in the program must support the use of the guidelines and receive appropriate training in applying the guidelines to ensure effective integration and coordination of care. Measurable Elements of DFC.5 1. Clinical staff have been are educated about clinical practice guidelines and their use. 2. Clinical staff consistently follow the selected clinical practice guidelines. 23. Assessment activities are consistent with clinical practice guidelines. 34. Intervention activities are consistent with clinical practice guidelines. Page 12 of 28

417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 Standard DFC.6 The program tailors the standardized process to meet the patient s needs. Intent of DFC.6 The assessment process must be consistent and predictable, include the patient and family risks, and result in a complete and timely plan to deliver the needed care. Criteria are used to prioritize patient needs and identify patients who may need immediate assistance. Information gathered through triage, visual evaluation, physical examination, or previous history is used to match patient needs and conditions with the mission and resources of the program. Measurable Elements of DFC.6 1. The program defines the patient assessment process, including family risks. 2. An assessment is completed for all patients within the time frame determined by the program. 3. The assessment is used to develop a plan of care. 4. The program uses a specified method for prioritizing the needs of patients. 5. The program implements interventions based on prioritization of needs and identified patient risks. 6. The prioritization method is tailored to meet the targeted population s age and developmental needs. 7. The program continually evaluatesreassesses, revises, and implements the plan of care to meet the patient s ongoing needs. 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 Standard DFC.7 Concurrently occurring conditions and comorbidities are managed, or the information necessary for their management is communicated to the appropriate clinical staff. Intent of DFC.7 The patient care process is dynamic and may involve more than one care provider; more than one clinical care program; or multiple care settings. The integration and coordination of patient care activities are necessary for efficient care processes and the likelihood of better patient outcomes. The program uses tools and techniques to better integrate, coordinate, and communicate to appropriate clinical staff the care to be provided for their patients. When the program does not have the clinical capability to provide the needed services, the patient is assisted in identifying sources of services to meet his or her needs. The health care services and patient needs may change as the result of new information or may be evident from a sudden change in the patient s condition. The care provided involves identifying and prioritizing the treatments, procedures, and other care to meet those needs. Measurable Elements of DFC.7 1. Care is coordinated for patients with multiple diseases and/or who are managed by multiple clinical care programs. 2. When concurrently occurring conditions are identified, relevant information is communicated to the appropriate clinical staff treating or managing the condition(s). Page 13 of 28

452 453 454 455 456 3. When a concurrently occurring condition needs medical intervention, the patient is either treated by clinical staff in the program or referred to an appropriate clinical staff. 4. The program has a mechanism for managing urgent and/or emergent health needs. 5. The program has a mechanism for managing health needs after hours. 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 Standard DFC.8 The program identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk. Intent of DFC.8 The program assesses and cares for patients using many simple and complex processes, each associated with a level of infection risk to patients and staff. It is thus important to review and monitor those processes and, as appropriate, implement needed policies, procedures, education, and other strategies to reduce the risk of infection. Measurable Elements of DFC.8 1. The program identifies processes associated with infection risk. 2. The program implements strategies to reduce infection risk. 3. The program identifies which risks require policies and or procedures, staff education, practice changes, and other activities to support risk reduction. Standard PCC.6 Standard DFC.9 Medication storage, preparation, and administration follow standardized processes to ensure patient safety. Intent of DFC.9 Medication storage, preparation, and administration are standardized. The medication processes include a) the proper and safe storage and labeling of medications; b) the safety and sanitation of medication preparation and dispensing areas; c) the qualifications of those who can prescribe, dispense, and administer medications; d) medication administration and medication monitoring; e) documentation of medications prescribed and/or administered Measurable Elements of DFC.9 1. Medications used in the program are properly stored and labeled. 2. Medications preparation is safe and sanitary. 3. Only qualified individuals prescribe, dispense and administer medications. 4. Medications administered in the program are monitored. 5. Medications prescribed and/or administered are noted in the patient s record. Page 14 of 28

485 486 487 488 Supporting Self- Management (SSM) 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 Standards, Intents, and Measurable Elements Standard SSM.1 The program involves the patient and, when appropriate, the family in making decisions about managing their diseases or conditions. Intent of SSM.1 Patients and, when appropriate, families participate in the care process by making decisions about care, asking questions about care, and having the prerogative to refuse diagnostic procedures and treatment. The program supports and promotes patient and family involvement in all aspects of care by clearly explaining any pro- posed treatments or procedures to the patient and, when appropriate, the family so that they can make decisions about care. The information provided should include proposed treatments, potential benefits and draw- backs, and possible results of nontreatment. The patient and, when appropriate, the family have a responsibility to provide information to clinical staff that may facilitate treatment. Measurable Elements of SSM.1 1. Patients and, when appropriate, the family are involved in decisions about their clinical care and mutually agree upon goals. 2. Patients and, when appropriate, the family and clinical staff mutually agree upon goals. 23. Patients and, when appropriate, the family are informed of their responsibilities to provide information to facilitate treatment and to cooperate with health care clinical staff. 34. Patients and, when appropriate, the family are informed about potential consequences of not com- plying with a recommended treatment. Standard SSM.23 The program addresses the patient s and, when appropriate, the family s educational needs. Intent of SSM.23 Education focuses on the specific knowledge and skills the patient and family will need to make care decisions, to participate in their care, and to continue care at home. This is in contrast to the general flow of information between staff and the patient that is informative but not of an educational nature. The program staff inform and educate patients and, when appropriate, families at appropriate times in the care process. There is an assessment process that identifies educational needs related to lifestyle changes, health promotion, and disease prevention. In addition, patient and family education addresses information needs related to the patient s illness(es) and treatment(s). Page 15 of 28

521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 Measurable Elements of SSM.23 1. The program addresses educational needs related to lifestyle changes that support self-management regimens. 2. The program addresses educational needs related to health promotion. 3. The program addresses educational needs related to disease prevention. 4. The program addresses educational needs related to information about the patient s illness(es) and treatment(s). Standard SSM.32 The program addresses the patient s and, when appropriate, the family s readiness, willingness, and ability to learn. Intent of SSM.32 There are many patient and family variables that determine if the patient and family are willing to learn and capable of learning. For the education to be planned well and to be effective, the patient and, when appropriate, the family must be assessed for beliefs and values; literacy, level of education, and language; emotional barriers and motivations; physical and cognitive limitations; and willingness to receive information Measurable Elements of SSM.32 1. The patient s readiness, willingness, and ability to provide or to support self-management activities are assessed. 2. As appropriate, tthe family s readiness, willingness, and ability to provide or to support self-management activities are assessed. 3. The program makes initial and ongoing assessments of the patient s comprehension of program- specific information. Standard SSM.3 The program addresses the patient s and, when appropriate, the family s educational needs. Intent of SSM.3 Education focuses on the specific knowledge and skills the patient and family will need to make care decisions, to participate in their care, and to continue care at home. This is in contrast to the general flow of information between staff and the patient that is informative but not of an educational nature. The program staff inform and educate patients and, when appropriate, families at appropriate times in the care process. There is an assessment process that identifies educational needs related to lifestyle changes, health promotion, and disease prevention. In addition, patient and family education addresses information needs related to the patient s illness(es) and treatment(s). Measurable Elements of SSM.3 1. The program addresses educational needs related to lifestyle changes that support self-management regimens. 2. The program addresses educational needs related to health promotion. Page 16 of 28

557 558 559 3. The program addresses educational needs related to disease prevention. 4. The program addresses educational needs related to information about the patient s illness(es) and treatment(s). 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 Standard SSM.4 The program materials are consistent with the clinical guidelines and relevant and appropriate to the population served. Intent of SSM.4 The program uses standardized materials consistent with the clinical guidelines and scientific evidence relevant to the program. Materials related to lifestyle changes, health promotion, disease prevention, and specific treatments are uniform and appropriate to the program s target population. Measurable Elements of SSM.4 1. Program materials comply with generally recommended elements of intervention in the literature or promoted through the clinical practice guidelines. 2. Program materials are understandable and culturally sensitive. 3. Program materials are understandable and relevant to the patient s level of literacy. Standard SSM.5 The program addresses lifestyle changes that support self-management regimens. Intent of SSM.5 Education supports healing and, when possible, a return to previous function. In addition, to sustain optimal health, education supports changes to the previous lifestyle. The patient and, when appropriate and culturally acceptable, the family must be are assessed for health history, lifestyle, and physiologic data that may put them at increased risk. bbarriers to making the necessary lifestyle changes and their response to recommended changes are also assessed. Community resources that support health promotion and disease prevention are identified, and an ongoing relationship is established., when appropriate. Measurable Elements of SSM.5 1. Lifestyle changes that support self-management regimens are promoted. as necessary. 2. Family and community support structures are involved. as necessary. 3. Barriers to lifestyle change are evaluated. as necessary. 45. The effectiveness of efforts to help the patient in making lifestyle changes is assessed. 54. The patient s response to making the recommended lifestyle changes is assessed and documented. 5. The effectiveness of efforts to help the patient in making lifestyle changes is assessed. 6. When appropriate and culturally acceptable, the program communicates to the patient the results of its family risk assessment. Page 17 of 28

590 591 592 Clinical Information Management (CIM) 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 Standards, Intents, and Measurable Elements Standard CIM.1 The confidentiality, security, and retention of patient information are protected. Intent of CIM.1 The program 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 program determines and communicates to the patient and, when appropriate, the family what information and data will be used by the program. Consent for release of information is defined There is a process that indicates if patients have access to their health information and how to gain access when permitted. In addition, Tthere program has is a process for retaining patient clinical records and other data and information in accordance with applicable law and regulation. The program identifies actions to be taken in the event that confidentiality and/or security have been violated. Patient information and records are protected against loss, destruction, tampering, and unauthorized access or use. Measurable Elements of CIM.1 1. Patient The program has a written process that protects the confidentiality, security, and integrity of patient information and data is protected. 2. The program safeguards records and information against loss, destruction, tampering, and unauthorized access or use. 3. The program has determined how long health records and other data and information are retained, in accordance with applicable law and patient need. 4. Patients are made aware of how information and data related to them will be used by the program. 5. The program defines how and when consent for release of information is required requires the patient to grant permission for the release of information not covered by laws and regulations. 6. The program defines the process followed if confidentiality and/or security are violated. Standard CIM.2 The program identifies those authorized to have access to and/or to make entries in the patient clinical record. Intent of CIM.2 Page 18 of 28

622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 One aspect of maintaining the security of patient information is to determine who is authorized to make entries in the patient clinical record and who is authorized to obtain a patient clinical record. Access to information contained in the patient clinical record is based on need and defined by job title and function. An effective process defines who has access to information; the information to which an individual has access; the user s obligation to keep information confidential; and the process followed when confidentiality and security are violated. The program defines such individuals and identifies the content and format for entries in patient clinical records. There is a process to ensure that only authorized individuals make entries in patient clinical records and that each entry identifies the author of the entry and the date (and, if appropriate, the time) the entry was made. The time of the entry is also noted for items such as timed treatments or medication orders. Measurable Elements of CIM.2 1. The program defines access limitations to clinical records for individuals and/or positions. 2. The program measures compliance with clinical record access limitations. 3. There is a process to ensure that only authorized individuals make entries in the patient clinical record. 46. The program defines the process followed if confidentiality and/or security are violated. 5. The author, date, and time of each clinical entry can be identified. Standard CIM.3 The program uses standardized diagnosis codes, procedure codes, symbols, abbreviations, definitions, and methods for adding comments/addenda. Intent of CIM.3 Standardized terminology, definitions, vocabulary, and nomenclature facilitate comparison of data and information within and among health care providers. Standardization also reduces the potential for misunderstanding and misinterpretation. Uniform use of diagnosis and procedure codes supports data aggregation and analysis. Abbreviations and symbols are also standardized and include a do not use list. Such standardization is consistent with recognized local and national standards. Measurable Elements of CIM.3 1. Standardized diagnosis codes are used and the use monitored. 2. Standardized procedure codes are used and the use monitored. 3. Standardized definitions are used. 4. Standardized symbols are used, and those not to be used are identified and monitored. 5. Standardized abbreviations are used, and those not to be used are identified and monitored. 6. The program defines methods for adding comments, in the form of statements or addenda into the formal records. Standard CIM.4 Information management processes meet the program s internal and external information needs. Page 19 of 28

657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 Intent of CIM.4 The program collects and analyzes aggregate data to support patient care and program management. Aggregate data provide a profile of the program over time and allow the comparison of the program s performance with other similar programs. Thus, aggregate data are important to the performance improvement activities of the program. Aggregate data can help the program understand its current performance and identify opportunities for improvement. The format and methods of disseminating data and information are tailored to meet the user s expectations. As part of its monitoring and performance improvement activities, the program regularly assesses patient clinical record content and the completeness of patient clinical records. Patient clinical record review is based on a sample representing the practitioners involved in providing care and is conducted by each relevant clinical professionals who is authorized to make entries in the patient record. Measurable Elements of CIM.4 1. Dissemination of Ddata are easily retrieved in a timely manner without compromising security and confidentialityand information are tailored to meet the user s expectations. 2. The program uses aggregate data and information to support managerial and operational decisions. 3. The program uses aggregate data and information to support operations. 34. The program uses aggregate data and information to support performance improvement. 45. The program uses aggregate data and information to support patient care. 56. Health or clinical records are periodically reviewed by all relevant disciplines, for complete, accurate, and timely maintenance. Standard CIM.5 The program gathers information about the patient s disease or condition from clinical staff and settings has a process to provide continuity of patient care services and coordination among health care practitioners across the continuum of care. Intent of CIM.5 When a patient is admitted into the program, health care providers need to gather information from multiple sources to evaluate the patient s medical and emotional status. If care has been provided in another setting, information about that care must be included in the clinical record and integrated into the plan for care. Communicating and exchanging information between and among health care providers is essential to a smooth care process. Essential information can be communicated through verbal, written, or electronic means. The program determines what information needs to be communicated, by what means, and with what frequency. The information communicated from one health care provider to another includes patient health status; a summary of the care provided; and the patient s response to care. In addition, this information is shared directly with the patient and/or family, if appropriate. Measurable Elements of CIM.5 1. The program gathers information directly from the patient and, if appropriate, the family. 2. The program gathers information from all relevant clinical staff or health care organizations. 31. All appropriate clinical staff have access to all patient information as needed. 42. The program shares information directly with the patient and/or family, if appropriate. Page 20 of 28