Professional Documents
Culture Documents
INTERNATIONAL ACCREDITATION
STANDARDS
INTERPRETATIONS
Hospital Accreditation Program
1 June 2004
STANDARD: AOP.1.1 The organization has determined the scope and content of
assessments, based on applicable laws and regulations.
ISSUE: AOP.1.1 is included in the list of required policies, procedures, written
documents or bylaws in the Survey Process Guide. Thus, does the scope and content of
assessments need to be contained in a policy, or can various assessment forms identify,
for different settings (e.g., ambulatory or in-patient) or different patients (e.g., adult,
pediatric), the required scope and content of the assessment?
INTERPRETATION: The list in the Survey Process Guide covers all types of written
documents, including forms. The most important issue is that, as the measurable elements
require, the scope and content of each type of assessment is defined in writing. To
satisfy this requirement, a form would need to be clear as to;
the health professional(s) responsible for completing the form or each section, and
the minimal content for the form to be considered complete in terms of the
required assessment scope and content.
Thus, a form will usually require guidelines for completion. Such guidelines can be on
the form, or in a separate policy. The form, with guidelines, is needed to fully meet the
standards.
Date: June 2004
Modified:
findings and conclusions are no longer justified. The 30-day threshold is thus set
aside until supported by clinical evidence as to the appropriateness of this
threshold.
c) An initial medical assessment of less than 6 months must have the two questions
related to continued clinical indication and candidate risk updated at the time of
admission with a confirmatory note. Professional judgment and good clinical
practice determines when all or a part of the assessment must be repeated.
Medical staff or hospital policy may set any associated criteria or conditions.
Date: June 2004
Modified:
physician can then decide the frequency of reassessment based on this range, and
consistent with the condition of his or her patient.
Date: August 2003
Modified:
STANDARD: AOP.5.11 The organization regularly reviews quality control results for
all outside sources of laboratory services.
ISSUES: If the outside source of the laboratory service (or radiology or other service) is
a JCI accredited facility, must quality control results be collected and reviewed? Also,
under proficiency testing (AOP.10.1) which uses outside sources by design, must quality
control data be collected and reviewed?
INTERPRETATION: Quality control results must always be collected and reviewed,
even when the outside source is a JCI accredited facility. The JCI accredited facility can
share all or part of its internal quality control review with the contracting organization, or
if significant services are under contract, someone from the laboratory service at the
contracting organization can be included in the quality control group at the other facility.
Proficiency testing is a quality control process by design and the process always results in
a report and analysis.
Two other considerations are relevant: the use of the results from the outside source in
the patient care process (e.g., laboratory results in patient assessment) or a process
directly related to patient safety (e.g., biomedical equipment maintenance), and secondly,
what is the volume of use of the outside source. Thus, quality control results from the
contractor for grounds maintenance are not very critical, nor are quality control results
from a clinical laboratory used every several months for a rare test that the hospital does
not perform.
Date: August 2003
Modified:
STANDARDS: COP.5.9 Policies and procedures guide the care of patients undergoing
moderate and deep sedation.
COP.6 A qualified individual conducts a pre-anesthesia assessment.
ISSUE: Pre-anesthesia assessment for patients undergoing moderate and deep sedation.
INTERPRETATION: Patients undergoing moderate and deep sedation do not need a
pre-anesthesia assessment and anesthesia plan unless required by hospital policy. The
pre-anesthesia assessment and plan are intended to support the use of general anesthesia
as described in COP.7-COP.9.
Date: August 2003
Modified:
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Both of these types of employee satisfaction surveys would satisfy the standard.
Date: December 1999
Modified:
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document the retraining. Whatever method is used should be simple and practical and
thus permit more frequent testing.
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