Corrections to first printing of Joint Commission International

Accreditation Standards for Hospitals, 4th Edition

Updated 20 June 2011
(Deletions in strikethrough. New text is underlined.)
Page 5, Introduction
ACC.1.1.1, Patients with emergent, urgent, or immediate
needs are given priority for assessment and treatment.
A new Measurable Element 54 was added to emphasize the need to
stabilize emergency patients prior to transfer to another organization using
an evidence-based triage process.
Page 27, Joint Commission International Policies and Procedures
At a minimum, an organization must include those events that are subject
to review listed below:
Unanticipated death unrelated to the natural course of the patients illness
or underlying condition
Major permanent loss of function unrelated to the natural course of the
patients illness or underlying condition
Wrong-site, wrong-procedure, wrong-patient surgery
Infant abduction or infant who was sent home with the wrong parents
Page 42, Access to Care and Continuity of Care chapter, ACC.1.2
(standards-only section)
ACC.1.2 At admission as an inpatient, patients and families receive
information on the proposed care, the expected outcomes of that care, and
any expected cost to the patient for the care.
Page 50, Access to Care and Continuity of Care chapter, ACC.3.2,
Measurable Elements
1. A discharge summary is prepared at discharge by a qualified individual.
2. The summary contains follow-up instructions.
32. A copy of the discharge summary is placed in the patient record.
43. Unless contrary to organization policy, laws, or culture, the patient is
given a copy of the discharge summary.
54. A copy of the discharge summary is provided to the practitioner
responsible for the patients continuing
or follow-up care.
65. Policy and procedure define when the discharge summary must be
completed and in the record.

Page 65, Patient and Family Rights chapter, PFR.2.3, Measurable

Elements
1. The organization has identified its position on withholding
resuscitative services and forgoing or withdrawing life-sustaining
treatments.
2. The organizations position conforms to its communitys religious and
cultural norms and any legal or regulatory requirements.
3. The organization guides health professionals on the ethical and legal
considerations in carrying out such patient wishes.
4. Patient/family decisions about resuscitative services are documented
in the clinical record.
5. Policies and procedures support consistent practice.
Page 75, Assessment of Patients chapter, AOP.1.1 and AOP.1.3.1
(standards-only section)
AOP.1.1 The organization has determined the scope and minimum
content of assessments, based on applicable laws and regulations and
professional standards.
AOP.1.3.1 The initial medical and nursing assessments of emergency
patients is are based on their needs and conditions.
Page 76, Assessment of Patients chapter, AOP.4 (standards-only
section)
AOP.4 Medical, nursing, Physicians, nurses, and other individuals and
services responsible for patient care collaborate to analyze and to integrate
patient assessments.
Page 79, Assessment of Patients chapter, AOP.1.3.1
AOP.1.3.1 The initial medical and nursing assessments of emergency
patients is are based on their needs and conditions.
Page 110, Care of Patients chapter, COP.6, Measurable Elements
1. Based on the scope of services provided, the organization has
processes to identify patients in pain. (Also see AOP.1.7, ME 1, and
AOP.1.8.2, ME 1)

Page 148, Quality Improvement and Patient Safety chapter, QPS.1,

Intent Statement
The governing body holds ultimate accountability for quality and patient
safety in the organization, and, thus, it approves the quality and patient
safety plan (also see GLD.1.56); on a regular basis, it receives and acts
on reports related to the organizations program to improve quality and
patient safety (also see GLD.1.56).
Page 152, Quality Improvement and Patient Safety chapter, QPS.2.1,
Measurable Element 3
3. The organization implements a clinical guidelines, and a clinical
pathway, or clinical protocol for each identified priority area.
Page 160, Quality Improvement and Patient Safety chapter, QPS.9,
Measurable Elements
1. The organization plans and implements improvements in quality and
safety.
2. The organization uses a consistent process for identifying priority
improvements that are selected by the leaders.
23. The organization documents the improvements achieved and
sustained.
Page 178, Governance, Leadership, and Direction (GLD) chapter,
GLD.3.3
GLD.3.3 The leaders are accountable for provide oversight of contracts
for clinical or management services.
Page 181, Governance, Leadership, and Direction (GLD) chapter,
GLD.1.4, Measurable Element 3
3. The evaluation of the senior managerment is performed at least
annually.
Page 199, Facility Management and Safety chapter, FMS.4.2,
Measurable Elements
2. The organization plans and budgets for upgrading or replacing
systems, buildings, or components needed for the continued operation of a
safe and effective facility. (Also see ACC.6.1, ME 5)
Page 200, Facility Management and Safety chapter, FMS.5,
Measurable Elements
2. The plan for safe handling, storage, and use of hazardous materials and
waste is established and implemented. (Also see AOP.5.1, intent statement,
and ME 3; AOP.5.5, ME 3; AOP.6.2, ME 4; and AOP.6.6, ME 3)

Page 209, Staff Qualifications and Education chapter, SQE.1.1

(standards-only section)
SQE.1.1 Each staff members responsibilities are defined in a current job
description.