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. Interpretation 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 Page 1 of 5
Page 84, AOP.6.8 Interpretation 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. Page 2 of 5
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. Page 3 of 5
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) Page 4 of 5
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. Page 5 of 5
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. Page 1 of 2
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 2 of 2