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What Is New In

JCI 5th Edition Hospital Standards


KFSH
Dammam, KSA- Dec. 2013
PFE
Ashraf Ismail, MD, MPH, CPHQ
Managing Director, Middle East Region
Joint Commission International
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5th Edition Update Overview

Global healthcare has changed in many ways


over the last 3 years of the 4th Edition and will
continue to change

Standards ensure hospital care not only reflects


up to date practice but also help hospitals
prepare for a different future

Change means that improving quality and patient


safety will always be a work in progress with
continuous advances but no end point

Some of these changes in global healthcare


stimulated revisions to the JCI standards

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What Is New In This 5th Edition

Many changes

Continuous readiness & compliance of


JCI accredited hospitals is
emphasized by conducting
unannounced as well as announced
surveys by JCI.

All of the significant changes are listed


in a table at the beginning of each of
patient-centered and organization
management- centered chapters

Nearly, all of the 4th edition text has


been edited for clarity in the 5th edition

The total number of standards has


been reduced by more than 10% &
MEs by more than 5%
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What Is New In This 5th Edition


New standards and established standards
deemed by the field as more difficult to meet
are supported with evidence-based
references
References of various types are cited in the
text of the standard's intent and are listed at
the end of the applicable standard chapter
A new Section, Accreditation Participation
Requirements (APR) has been added.

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What Is New In This 5th Edition


Standards requiring a written policy or
procedure are indicated by a icon after the
standard text
. In previous editions, each
required policy or procedure was specified in
its own ME. In this edition, all policies and
procedures will be scored together at MOI.9
and MOI.9.1.
Examples that better illustrate compliance
are provided in most standards' intents
JCIs policies and procedures are
summarized and moved from the front of the
manual to their current location on page 253.
Starting in late 2013, JCI policies will be
published on JCIs public website.

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What Is New In This 5th Edition


The Medical Professional Education
(MPE) and Human Subjects Research
Programs (HRP) standards for
Academic Medical Center Hospitals are
now included in this manual.
The Management of Information (MOI)
chapter has been changed from
Management of Communication and
Information (MCI) in the 4th edition.

Widespread wording changes for clarity,


including frequently substituting the term

program for plan or process

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MMU

Accreditation Participation
Requirements (APR)
PFE

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APR Chapter
New Chapter
It is about how compliance will be evaluated
APRs are not scored like standards during the on-site
survey; hospitals are considered either compliant or not
compliant with the APR
Most of APR requirements have been moved from many
4th edition documents
The consequence of non-compliance
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APR Chapter Standards


APR.1 timely submission of data and information
APR.2 accurate and complete information
APR.3 reporting changes in hospital profile
APR.4- Hospital permits on site review of compliance or verification
of concerns or regulatory sanctions (at ANY TIME)
APR.5- Hospital allows JCI to request/review results and reports of
external evaluations from publicly recognized bodies
APR.6- Hospital allows observations by JCI Board members and JCI
staff

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APR Chapter Standards


APR.7- The selection and use of the Library of Measures
is integrated into the hospitals measurement priorities
APR.8 The hospital accurately represents its
accreditation status and program
APR.9 Any hospital staff member can report concerns
about safety or quality of care without retaliatory action
APR.10 translation and interpretation services are
provided by licensed translation and interpretation
professionals

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APR Chapter
APR.11 The hospital notifies the public it serves about
how to contact its hospital management and JCI to report
concerns about patient safety and quality of care
APR.12 - The hospital is required to provide patient care
in an environment that poses no risk of an immediate
threat to patient safety, public health or staff safety

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Joint Commission
International 5th
Edition Hospital
Standards

Patient Centered
Standards
MMU

IPSG, ACC,
PFR & AOP

PFE

Major Changes in the IPSG,


ACC, PFR, and AOP Chapters
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Major Changes in the IPSG, ACC,


PFR, and AOP Chapters
Focus on highlights, not all changes
Clearer and more comprehensive intent
statements, with more examples
New decision rule #5 for IPSGs

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IPSG
International Patient Safety
Goals
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IPSG Major Changes


Emphasizes the need for more
focused compliance on 3
distinct communication-related
areas
Highlights reporting of critical
results of diagnostic tests as an
important communication issue
Introduces a new requirement
for effective handovers of
patient care within the hospitalNEW STANDARD IPSG.2.2
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IPSG Major Changes


Clarify expectations for
high-alert medications &
concentrated electrolytes

Clarifies the purpose and


content of the preoperative
verification process & the
approach for the time-out
procedure

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IPSG Major Changes


Clarifies the need to address
fall risk assessment and
reassessment in both inpatients
& outpatients

Raises requirements for


addressing falls to include
locations and situations at high
risk for falls

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ACC
Access to Care and
Continuity of Care
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ACC Major Changes


Adds a new requirement for hospitals to
manage the flow of patients throughout
the hospital NEW STANDARD
ACC.2.2.1
Separates the AMA requirements
according to two conditions:
Leaving Against Medical Advice with
notification: full D/C summary is required
Leaving Against Medical Advice without
notification
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New standard to require mechanism to manage patient


flow throughout the organization including:

The available
supply of
inpatient beds

Plans for
temporary
Boarding

Staffing plans

Efficiency of
other clinical
areas

Efficiency of
the nonclinical
services

Access to
support
services

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PFR
Patient and Family Rights

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PFR Major Changes


added a new requirement for informing patients and
families of the tests & treatments that require a separate
informed consent
Informed Consent must be in a manner/language that
patient understands (NEW) & must have uniform
recording requirement (NEW)
Informed Consent to be obtained before high risk
procedures or treatments & before admission for
inpatient care

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PFR Major Changes


Further emphasized the need
to ensure patient & family
rights regarding organ & tissue
donation
Clarify requirements regarding
organ & tissue procurement

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AOP
Assessment of Patients

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AOP Major Changes


- Patient assessment and documentation
must be more patient centric
- Patient and family participation in
decisions more critical
- Patient record and outpatient
summaries are essential
communication tools
- Patient and family education at many
points in care process

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AOP Major Changes


Establishes a NEW STANDARD to
emphasize the need to reduce special
risks for laboratory staff related to
infection control & biohazards
Adds a NEW STANDARD to detail
requirements for reference (contract)
laboratories used by the hospital
Introduces a NEW STANDARD specific
to blood bank and transfusion services

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Joint Commission
International 5th
Edition Hospital
Standards

Patient Centered
Standards
MMU

COP, ASC, MMU


& PFE

PFE

Major Changes in the COP,


ASC, MMU, and PFE Chapters
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Edits by PVO, Sept 23 2013

COP
Care of Patients

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COP Major Changes


Emphasizing the need for uniform
process for prescribing patient
orders
Adds new requirement: the person
requesting, and the reason for
requesting, the procedure or
treatment are documented in the
patients record
Clearly identify expectations for the
care of high-risk patients in the
hospital

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COP Major Changes


Introduces new requirement for staff
training to recognize & respond to
changes in a patients condition NEW
STANDARD
Adds new requirement to emphasize
the need for resuscitation services to
be available & consistent throughout
the hospital NEW STANDARD
COP.3.2
Adds ME to emphasize the need for
timely distribution of food and
honoring special requests

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COP Major Changes


Adds a requirement on communication
with patients regarding potential pain from
planned treatments, procedures, or
examinations

Introduces several standards to


emphasize the need for safety & quality of
organ and tissue transplant services
NEW STANDARDS COP.8- COP.9.3

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ASC
Anesthesia and Surgical Care

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ASC Major Changes


Adds a description of sedation &
anesthesia
Emphasizes the importance of
standardization, qualification of
practitioners, and professional practice
guidelines as they relate to procedural
sedation
Adds a new requirement for discussing
the risks, benefits, and alternatives of
procedural sedation with the patient,
family, and other decision makers
NEW STANDARD ASC.3.3

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ASC Major Changes


Adds text to include documentation of the
anesthesia agent, dose, and anesthetic
technique in the patients anesthesia
record
Emphasizes the need for postoperative
analgesia education
Adds clarification that monitoring needs
to be consistent with professional
practice guidelines
Clarifies that the patients assessment
should also be used to guide the
identification of significant findings during
monitoring
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ASC Major Changes


Better detail requirements of
surgery documentation in the
patients record
Adds text to expand on what is
included in postsurgical plan of
care
Adds a new requirement regarding
the special considerations needed
in planning surgical care that
involves the implanting of medical
devices
NEW STANDARD ASC.7.4

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MMU
Medication Management and Use

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MMU Major Changes

Emphasizes the need for proper storage


of medications inside and outside of the
pharmacy

Introduces concept that hospitals should


define standards of practice for a safe
and clean dispensing environment

Required elements for prescriptions are


separated from the processes for
problematic or special types of
prescriptions

New requirements for auditing by


hospital to determine the accuracy and
completeness of prescriptions
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MMU Major Changes

Recognizes two reviews of the


prescriptions

Review 1 - Review of
appropriateness
Review 2 - Review of
medication against order

Identifies that properly trained staff


other than pharmacists may perform
the medication review for
appropriateness & specifies that the
requirement applies when the
pharmacy is open or closed

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PFE
Patient and Family Education

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PFE Major Changes


Chapter now contains standards relating
to general education principle
Specific education has been moved to
chapters where education applies
Compliance with PFE Chapter
Uniform documentation and staff
knowledge
Patient and Staff interview and Medical
records review
Compliance issues:
Staff and patient lack of knowledge
No evidence of documentation or
training

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Joint Commission
International 5th
Edition Hospital
Standards

Organization
Management
Standards
MMU

QPS, PCI, &


GLD

Major Changes in the QPS, PCI,


and GLD Chapters
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QPS
Quality Improvement and
Patient Safety
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QPS Major Changes


QPS.1 - Qualified leader of quality
program NEW STANDARD
Selection of the right individual to lead
program
Selection of the right staff for program
functions
Coordination of quality across the
organization
Implementation of a staff training program
Regular communication to hospital staff
about quality issues
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QPS Major Changes


QPS.2 Support and coordination
of quality within the hospital
NEW STANDARD
Quality program supports the
selection of measures
The program has a supportive
function for department/service and
hospital wide measure priorities
Program integrates event reporting
systems, safety culture measures
and others to facilitate an integrated
approach
Tracks progress
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QPS Major Changes


QPS.5 Impact Analysis
NEW STANDARD
At least one impact analysis
of cost efficiency per year of
an improvement project
Evaluate and re-evaluate the
use of resources for the
current and improved process
Coordination with other
departments: HR, IT, Finance
Report to leadership
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QPS Major Changes


QPS.7 Managing Sentinel Events
Sentinel event definition has been
expanded to include:
Death of a full term infant
Transmission of a chronic or
fatal disease blood, blood
products, or transplant
Rape, assault, homicide
while on site at hospital
Reporting requirement changecompletion time of Root Cause
Analysis within 45 days from date
of the event

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PCI
Prevention and Control
of Infections
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PCI Major Changes


Emphasize the need for hospitals to
track infection risks and trends in an
effort to reduce risks within the hospital
Use a risk-based approach to identify
epidemiologically important infection
prevention strategies and focus on
infection prevention.
Consider clinical practice guidelines,
and antibiotic stewardship
Annual assessment of the program

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PCI Major Changes


Clarifies further requirements for
safe handling and disposal of
sharps and needles
Increases the emphasis on
reducing the risk of infections
associated with the operations of
food services
Addresses reporting to and taking
action on reports from public
health agencies

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PCI Major Changes


Clarifies further that the infection
prevention and control program is
staffed according to hospital size,
level of risk, and the programs
complexity & scope
Emphasizes that program
strategies should cross all levels of
the hospital
Emphasizes the importance of
mechanical and engineering
controls in minimizing infection risk

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PCI Major Changes


concentrate on programs integration
of infection prevention and control
program with the hospital quality
program
A new emphasis on the measure
selection and measurement based
on the hospital wide and
department/service specific priorities
Requires reporting the data and
recommendations to the leadership
on a quarterly basis

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PCI Major Changes


A new requirement on the
environmental cleaning of
contaminated isolation rooms NEW

Focuses in the management of


sudden influx of patients with
contagious diseases and
airborne infection when negative
rooms are not available NEW

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GLD
Governance, Leadership and
Direction

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Governance, Leadership and Direction (GLD) Overview

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GLD Major Changes


Leadership role in communication
Clear and consistent
communication is a responsibility of
leadership
Process, effectiveness and content
Measure of effectiveness of
communication

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GLD Major Changes


Leadership reports to staff and governance
Develop and implement a quality program
and select leadership for the program
Quarterly report to governance
Six month review of sentinel events
Progress communicated to staff
Review minutes: governance, senior
leadership, and quality departments
Sustainability of Improvements
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GLD Major Changes


Leadership sets hospital wide improvements
Focus on measurement for system
improvement
Focus on research and education when
present
Focus on full compliance with IPSGs
Evaluate the impact of Improvement

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GLD Major Changes


NEW STANDARD to emphasize the need
to protect patients and staff from
contaminated, fake, and diverted drugs,
medical technology, and supplies

NEW STANDARD for hospital leadership


to create, implement, support, monitor, and
take action to improve a culture of safety

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GLD Major Changes


NEW STANDARDS applicable to hospitals that
conduct human subjects research but do not
meet the eligibility criteria for Academic Medical
Center Hospital accreditation

- NEW STANDARD to emphasize the need for


department/ service quality improvement
activities to be used in the ongoing professional
practice reviews of physicians and the annual
performance evaluations of nursing and other
health professionals staff

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Joint Commission
International 5th
Edition Hospital
Standards

Organization
Management
Standards
MMU

FMS, SQE, &


MOI

Major Changes in the FMS,


SQE, and MOI Chapters
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Edits by PVO, Sept 23 2013

FMS
Facility Management and Safety

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FMS Major Changes


Emphasize the distinctions for managing
all aspects of the hazardous materials and
waste program;

References the WHO list of


hazardous materials and waste categories

Program for control and disposal


Explanation of content of MSDS (Material
Safety Data Sheets)
Immediate availability of the MSDS to
manage spills
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FMS Major Changes


Medical technologys term
introduced (formerly medical
equipment)
Includes all fixed and portable
medical equipment used for
diagnosis, treatment, monitoring and
direct care of individuals
New requirement for testing of
alternative water and electricity
sources quarterly (NEW)
New requirement for determination of
on-site fuel storage needs related to
emergency power (NEW)
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FMS.9 Utility Systems


NEW STANDARD
Expanded to all utilities
A program for effective and efficient
operation
Inventory of utilities system
defined
Written inspection, maintenance
activities, inspecting and testing
intervals defined
Criteria from manufacturers
maintenance and testing
requirements
Labeling of utility system controls
introduced
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SQE
Staff Qualifications and Education

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SQE Major Changes


Total rewrite of some standards to add clarity
with terminology explained
New Measurable Elements and wording
changes, consolidation of other Measurable
Elements
Flow of standards now is more like natural
process
Identifies the need for more rigorous
vaccinations program for staff (NEW)
Acknowledges that violence in the workplace has
become an increasingly common problem in
health care organizations (NEW)

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SQE Major Changes


New, more complete explanations
for key terms:

credentials
medical staff
verification
appointment
reappointment

Revise the requirement for primary


source verification for initial surveys
(new time frame)
Clarifies requirements for
determining medical staff
membership

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SQE Major Changes


Clarify requirements regarding the
privilege delineation process for medical
staff members
Provides definition of key terms &
expectations to clarify requirements for
monitoring and evaluation of medical
staff
Emphasize the need to document and
take action on findings that affect the
appointment or privileges of medical staff
members (new)
Separates out and clarifies requirements
for reappointment and renewal of clinical
privileges of medical staff members
based on ongoing monitoring and
evaluation

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MOI
Management of Information

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MOI Major Changes


New language in the standards, intent and
MEs
Need to assess, test, evaluate health
information technology (HIT) systems
before and after implementation
Evaluate HIT systems for usability,
effectiveness and patient safety
Stakeholders participate in selection,
implementation and evaluation of HIT
system

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MOI Major Changes


Written guidelines on documents,
policies, procedures, and plans
managed to a consistent manner

Standardized formats of similar


documents

Evidence found when


documents reviewed

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MOI Major Changes


MOI.9.1 Consistency across the organization in
policy management
NEW STANDARD
Ensuring proper implementation of policies,
procedures, plans that guide clinical and
nonclinical practices

When this symbol is found a document is


expected

All are scored together at this standard one


score for the hospital - not at each location
Tracking, training, knowledge and
implementation are expected
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5th Edition JCI Hospital Standards Manual


Challenging
Achievable
Focused on the safety and quality of patient care

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