2013Hospital

Accreditation

Standards

The Joint Commission MissionThe mission of The Joint Commission is to continuously improve health care for thepublic, in collaboration with other stakeholders, by evaluating health care organizationsand inspiring them to excel in providing safe and effective care of the highest quality andvalue.

© 2013 The Joint Commission

Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The JointCommission, has been designated by The Joint Commission to publish publications andmultimedia products. JCR reproduces and distributes these materials under license fromThe Joint Commission.

JCR educational programs and publications support, but are separate from, theaccreditation activities of The Joint Commission. Attendees at JCR educationalprograms and purchasers of JCR publications receive no special consideration ortreatment in, or confidential information about, the accreditation process.

All rights reserved. No part of this publication may be reproduced in any form or by anymeans without written permission from the publisher.

Printed in the U.S.A. 5 4 3 2 1

Requests for permission to make copies of any part of this work should be mailed to thefollowing:Permissions EditorDepartment of Publications and EducationJoint Commission ResourcesOne Renaissance BoulevardOakbrook Terrace, Illinois 60181permissions@jcrinc.com

ISBN: 978-1-59940-636-7ISSN: Pending

For more information about The Joint Commission, please visithttp://www.jointcommission.org.

Contents

Introduction (INTRO) ...................................................................INTRO-1

Requirements for AccreditationAccreditation Participation Requirements (APR)..................................APR-1Environment of Care (EC) .....................................................................EC-1Emergency Management (EM) ..............................................................EM-1Human Resources (HR).........................................................................HR-1Infection Prevention and Control (IC) ....................................................IC-1Information Management (IM) ..............................................................IM-1Leadership (LD) .....................................................................................LD-1Life Safety (LS) ........................................................................................LS-1Medication Management (MM)...........................................................MM-1Medical Staff (MS).................................................................................MS-1National Patient Safety Goals (NPSG) ..............................................NPSG-1Nursing (NR) ........................................................................................NR-1Provision of Care, Treatment, and Services (PC) ....................................PC-1Performance Improvement (PI)................................................................PI-1Record of Care, Treatment, and Services (RC) .......................................RC-1Rights and Responsibilities of the Individual (RI) ....................................RI-1Transplant Safety (TS) ............................................................................TS-1Waived Testing (WT) ...........................................................................WT-1

Other InformationAppendix A: Medicare Requirements for Hospitals (AXA) ...................AXA-1Index (IX) ................................................................................................IX-1

2013 HAS, January 3

�2013 Hospital Accreditation Standards

4 2013 HAS, January

Introduction (INTRO)The 2013 Hospital Accreditation Standards (HAS) aims to keep accreditation leaders,managers, and frontline staff up to date with the requirements necessary to achieve andmaintain Joint Commission hospital accreditation. This abridged version of theComprehensive Accreditation Manual for Hospitals (CAMH) provides all hospitalstandards, elements of performance (EPs), National Patient Safety Goals (NPSGs), andAccreditation Participation Requirements (APRs) effective JanuaryJanuary 1,1, 20132013. In addition,a spring update will provide updates to accreditation standards and deemed statusrequirements in the form of replacement pages.

The CAMH and the E-dition® available on your organization’s Joint CommissionConnect™ extranet site include policies, procedures, and other information about thehospital accreditation process. These are not provided in this book.

Chapter StructureThe HAS includes the information your hospital needs for continuous performanceimprovement. Each chapter in this manual is set up as follows:� An overview explains the chapter’s purpose and the principles on which the

requirements were built.� The chapter outline shows you exactly how the chapter is laid out and provides a

frame of reference for the numbering of requirements.� Introductions at the beginning of some requirements (or cluster of requirements)

provide information about the requirement’s origin and any issues that surround it.� The standards are statements that define the performance expectations and/or

structures or processes that must be in place for your hospital to provide safe,quality care, treatment, and services.

� A rationale is additional background, justification, or information about arequirement to explain its purpose. In some cases, the rationale for a requirement isself-evident. Therefore, not every requirement has a written rationale. Rationales arenot scored.

� References (placed in parentheses following the requirement) identify relatedrequirements, whether they are in the same chapter or a different chapter. Thesereferences should help you more quickly find related requirements on a particulartopic.

2013 HAS, January INTRO – 1

�2013 Hospital Accreditation Standards

� EPs, or elements of performance, are statements that detail the specific performanceexpectations and/or structures or processes that must be in place in order for ahospital to provide quality care, treatment, and services. EPs are scored anddetermine a hospital’s overall compliance with a requirement.

� Notes provide additional or clarifying information about a specific EP. Notes are notscored.

The HAS also includes an appendix with explanatory text from the Code of FederalRegulations on Medicare certification as well as an Index.

Description of IconsThe following icons can be found in this manual:� Scoring categories are indicated by the icons A or C. Category A EPs usually relate

to structural requirements (for example, policies, programs, or plans). Such EPsaddress an issue that must be fully compliant. Category C EPs are frequency-basedrequirements and are scored based on the number of times a hospital is found not tobe compliant with a particular EP.

� The documentation icon indicates when written documentation is required todemonstrate compliance with an EP. A documentation icon is used to identify datacollection and documentation requirements that are beyond information requiredto be included in the medical record. For example, an EP that requires a writtenprocedure will have a , but the icon is not applied to an EP that contains therequired list of components of the medical record. Other examples in which thedocumentation icon is used are for EPs that require a policy, a written plan, bylaws,a license, evidence of testing, data, performance improvement reports, medicationlabels, Material Safety Data Sheets, or meeting minutes.

� Patient care impact icons ( ) indicate scoring criticality, that is, theimmediacy of risk to the quality of care and patient safety. The Joint Commissionhas identified four levels of scoring criticality:1. Immediate Threat to Health or Safety situations, identified with a , have or

may potentially have serious adverse effects on the health or safety of patients.2. EPs tagged with a icon identify issues that, when found out of compliance,

indicate a situation exists that could pose a significant threat to patient safety orquality of care. These situational decision rules will automatically trigger arecommendation for Preliminary Denial of Accreditation, Contingent Accredi-tation, or Accreditation with Follow-up Survey if the EP is found out ofcompliance.

INTRO – 2 2013 HAS, January

Introduction�

FigureFigure 1.1. Components (including icons) of a requirements chapter.

2013 HAS, January INTRO – 3

�2013 Hospital Accreditation Standards

3. Noncompliance with direct impact requirements marked by a icon indicatesituations that could directly impact patients by creating an immediate risk tosafety or quality of care, treatment, and services.

4. Indirect impact requirements pose a less immediate risk to patient care or safetythan direct impact requirements; however, noncompliance can increase risk tosafety or quality of care, treatment, or services over time. Any requirementsconsidered to have an indirect impact will not show a criticality icon in thismanual.

� The Measure of Success (MOS) icon identifies which EPs, if found to benoncompliant, would require a quantifiable measure to determine whether thecorrective action a hospital takes in response to a Requirement for Improvement(RFI) was effective and sustained.

� The risk icon identifies specific risks, as assessed by a system’s proximity topatient, probability of harm, severity of harm, and number of patients at risk. Riskcategories identified by The Joint Commission are related to NPSGs, selected directand indirect impact requirements, accreditation program–specific risk areas, andRFIs identified during current accreditation cycle survey events. This manual willshow a single icon at the EP level for the three categories related to NPSGs, selecteddirect and indirect impact requirements, and program-specific risk areas.

INTRO – 4 2013 HAS, January