Joint Commission International (JCI

)
Requirements Related to Safe Surgery
The following chart shows JCI requirements related to safe surgery, including
handling of tissue specimens. Requirements are listed alphabetically by three-letter
standards code (for example, ACC for standards covering Access to Care and
Continuity of Care).
Note: This list is not all-inclusive. For a complete list of requirements, consult the current JCI
accreditation manual for your program. All JCI requirements are in effect at the time of publication of the Safe
Surgery Guide (October 2010), except the hospital requirements, which are in effect as of January 1, 2011.

Joint Commission International (JCI) Requirements
Standard

Requirement

Applicable to

Access to Care and Continuity of Care (ACC)
ACC.1.1.1

ACC.3
ACC.3.3

ACC.3.4
ACC.3.5

ACC.5.2

Patients with emergent, urgent, or immediate
needs are given priority for assessment and
treatment.
There is a policy guiding the referral or discharge
of patients.
The clinical records of outpatients receiving
continuing care contain a summary of all known
significant diagnoses, drug allergies, current
medications, and any past surgical procedures
and hospitalizations.
Patients and, as appropriate, their families are
given understandable follow-up instructions.
The organization has a process for the
management and follow-up of patients who leave
against medical advice.
The receiving organization, during inter-facility
transfer, is given a written summary of the
patient’s clinical condition and the interventions
provided by the referring organization.

Hospital

Hospital
Hospital

Hospital
Hospital

Medical Transport

Assessment of Needs (AON)
AON.1

AON.2

AON.2.3

1

All individuals provided with care and services by
the organization have their needs identified
through an established assessment process.
Each individual’s medical, nursing, and general
physical, activity, socialization, functional, and
cognitive needs are assessed.
Initial assessments for special populations are
appropriate to the population.

Care Continuum

Care Continuum

Care Continuum

Care Continuum Care Continuum Care Continuum Care Continuum Assessment of Patients (AOP) AOP.2. Patients are screened for nutritional status and functional needs and are referred for further assessment and treatment when necessary. and all such services meet applicable local and national standards.1.Joint Commission International (JCI) Requirements Related to Safe Surgery AON. and economic factors.1.1 AOP. Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital .1. the individual’s need and desire for services.3 AOP.1. reassessments. or the setting.6 AOP.1. based on applicable laws and regulations and professional standards.4 AON.3.1.1. social. Assessment findings are documented in the patient’s record and readily available to those responsible for the patient’s care.1.5 AOP. Laboratory services are available within a time frame to meet individual needs. The patient’s medical and nursing needs are identified from the initial assessments and recorded in the clinical record.1 AOP.1. psychological. and regulations. All individuals are reassessed at appropriate intervals to determine their response to care and services and to plan for continued care and services or discharge. The initial medical assessment is documented before anesthesia or surgical treatment.4.1 AOP.5.1. Policies and procedures address specific testingrelated processes.5 AON.1 AOP.3 Individuals are referred for any additional assessments when the need is identified through findings from the initial assessment. laws. the individual’s response to previous services.3 AON. The organization has determined the scope and content of assessments. Assessments are completed in the time frame prescribed by the organization. Each patient’s initial assessment(s) includes an evaluation of physical.7 AOP.2 AOP. All inpatients and outpatients are screened for pain and assessed when pain is present.11 2 All patients cared for by the organization have their health care needs identified through an established assessment process. The initial medical and nursing assessments of emergency patients are based on their needs and conditions. The initial assessment includes determining the need for discharge planning.4 AOP. and as required by law and regulation. including a physical examination and health history.

laws. laws.6 3 Anesthesia services (including moderate and deep sedation) are available to meet patient needs. AOP. AOP. A qualified individual(s) is responsible for managing the anesthesia services (including moderate and deep sedation). The anesthesia used and anesthetic technique are written in the patient record. A qualified individual conducts a preanesthesia assessment and preinduction assessment. Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital . Anesthesia and Surgical Care (ASC) Hospital ASC. his or her family. AOP. AOP.1 There is a process for reporting critical results of diagnostic tests.Joint Commission International (JCI) Requirements Related to Safe Surgery All patients are reassessed at intervals based on their condition and treatment to determine their response to treatment and to plan for continued treatment or discharge.1 Hospital AOP. and alternatives are discussed with the patient.5.4 Physicians. and the patient is discharged from the recovery area by a qualified individual or by using established criteria.5.5 Laboratory services are available to meet patient needs. and regulations. AOP. and disposing of specimens are followed. identifying.5.5.2 ASC.6 Procedures for collecting. and all such services meet applicable local and national standards. and regulations and professional standards. The risks. and all such services meet applicable local and national standards. and regulations. Each patient’s postanesthesia status is monitored and documented. AOP. handling.4 ASC.2 ASC.2 ASC.3 ASC.1 ASC. laws. safely transporting.6 Radiology and diagnostic imaging services are available to meet patient needs.3. and other individuals and services responsible for patient care collaborate to analyze and to integrate patient assessments. benefits. or those who make decisions for the patient. Each patient’s anesthesia care is planned and documented in the patient’s record. Policies and procedures guide the care of patients undergoing moderate and deep sedation.5 ASC. nurses.3 Qualified individuals conduct the assessments and reassessments. and all such services meet applicable local and national standards.

and use of stocked hazardous materials and the control and disposal of selfgenerated hazardous materials and waste. definitions. benefits. Hospital Hospital Hospital Hospital Hospital Exposure to and Transmission of Biologic and Chemical Agents (BCA) BCA.7. and dispensed in a safe and clean environment. and disinfectants are available and used correctly when required. storage. prepared. the control of medication samples. Medications are stored.1 ASC.4 BCA.7. procedure codes. Services and Support (CAS) CAS. masks.3 ASC. Gloves.3 Policies and procedures govern an individual’s self-administration of medications. The risks. the use of any medications brought into the organization by the individual or his or her family.7. Patient care after surgery is planned and documented. and alternatives are discussed with the patient and his or her family or those who make decisions for the patient.4 Each patient’s surgical care is planned and documented based on the results of the assessment. symbols.2.2 ASC.2 CAS.Joint Commission International (JCI) Requirements Related to Safe Surgery ASC. handling. Care Continuum Care Continuum Clinical Information Management (CIM) CIM.8. soap. and methods for adding comments/addenda. Each patient’s physiological status is continuously monitored during and immediately after surgery and written in the patient’s record.5 The organization establishes the focus of the infection prevention and reduction program.7. Medical Transport Medical Transport Medical Transport Medical Transport Care. abbreviations. Clinical Care Certification .2 BCA.3 4 The program uses standardized diagnosis codes. and the dispensing of medications at discharge. The medical transport organization identifies the policies and processes associated with the risk of infection and implements strategies to reduce infection risk. The organization has a plan for the inventory.7 ASC.8.3 BCA. protective clothing. There is a surgical report or a brief operative note in the patient’s record to facilitate continuing care.

Policies and procedures are developed to guide how specimens are accessioned and processed in the laboratory.3 EMS. families. Each patient’s sedation is documented. and visitors are safe from fire.6 COP. The laboratory develops policies. Each patient’s physiological status is monitored during and following administration of sedation.8 Policies and procedures identify and guide the care of high-risk patients and the provision of high-risk services.2 DCP. procedures. to meet individuals’ care and services needs in the organization’s environment.5 5 The organization plans and implements a program to ensure that all individuals. slides.5 COP.4 DCP. Invasive procedures are based on the results of a patient’s assessment.Joint Commission International (JCI) Requirements Related to Safe Surgery Care of Patients(COP) COP. Clinical Laboratory Environmental Management and Safety (EMS) EMS. staff.2. to meet essential care and services needs in the organization’s environment. Policies and procedures identify and guide the care of high-risk patients and the provision of high-risk services. Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Ambulatory Care.4 COP.2.7 COP. and controls for the postexamination processes.3 COP.3 EMS. tissues.4. A written protocol defines the storage and maintenance requirements for records. staff. The organization has emergency processes to protect individuals served.5 Procedures for ordering tests are defined in writing.4 EMS. smoke. families.6 COP.2 DCP. Potable water is available 24 hours a day. including retained specimens.1 DCP.4. 7 days per week. Patients are supported in managing pain effectively. Sedation is provided by qualified individuals. and visitors in the event of water or electrical system disruption within the organization’s environment. Care Continuum Care Continuum Care Continuum Care Continuum . Hospital Medical Transport Medical Transport Hospital Medical Transport Medical Transport Medical Transport Development and Control of Policies and Procedures (DCP) DCP. 7 days a week. and blocks. Electrical power is available 24 hours per day. or other emergencies. Policies and procedures are developed to provide step-by-step specimen collection protocols for each type of specimen submitted to the laboratory. through regular or alternate sources.4. through regular or alternate sources.

families.6. and use of hazardous materials and the control and disposal of hazardous materials and waste. water. medical gas. The organization plans and implements a program to manage the physical environment. discharge. including any devices related to early detection and suppression. and other key systems are regularly inspected. waste. Equipment is received and stored appropriately at organization sites.1 The organization’s framework for ethical management includes marketing. handling. Leadership. Hospital Medical Transport Medical Transport Hospital Hospital Hospital Hospital Hospital Governance.2 6 All staff/practitioners/students/volunteers/contract workers understand and can demonstrate their role relative to safety.6 EMS. The organization regularly tests its fire and smoke safety plan. and. staff. when appropriate.7 FMS.2. families. improved.5 FMS.7. admissions. visitors. abatement. The organization inspects for safety and has a plan to reduce evident risks and provide a safe physical facility for patients.2 FMS. maintained. early detection. and staff. transfer. storage.1 FMS. suppression. Electrical. or other emergencies in the facility. ventilation.Joint Commission International (JCI) Requirements Related to Safe Surgery EMS.10 The organization develops and maintains a written plan(s) describing the processes to manage risks to patients. handling. The organization plans and implements a program to ensure that all occupants are safe from fire.2 FMS. smoke. Hospital Human Resource Management (HRM) HRM. Care Continuum Care Continuum Facility Management and Safety (FMS) FMS. and Direction (GLD) GLD.2 FMS. The plan includes prevention. and use of hazardous materials and the control and disposal of hazardous materials and waste. and disclosure of ownership and any business and professional conflicts that may not be in patients’ best interests. Ambulatory Care .7. storage. and visitors. and safe exit from the facility in response to fires and nonfire emergencies. The organization has a plan for the inventory.2.8 The organization has a plan for the inventory. and documents the results.1 FMS.

Education methods consider the individual’s and family’s values and preferences and allow sufficient interaction among the individual. family. Individual and family education includes the identification. Care Continuum Care Continuum Care Continuum Infection Control and Facility Safety (IFS) IFS.Joint Commission International (JCI) Requirements Related to Safe Surgery Individual and Family Education (IFE) IFE. Individual and family education includes the following topics.4.3.4 IFS.3 IFE. and applicable law and regulation. as appropriate to the individual’s care and services: the safe use of medications. The ambulatory care organization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk. and staff for learning to occur.3.3. Ambulatory Care Ambulatory Care . the safe use of medical equipment. Informed consent is obtained before use of blood and blood products and other high-risk treatments and procedures. The organization informs individuals and families about how to choose to donate organs and other tissues. Individual and family education includes managing pain as part of treatment. handling.6 IFE. and access to medical gases and related supplies when applicable. potential interactions between medications and food. accepted practice guidelines.2. and rehabilitation techniques.4 Individuals participate in decisions about transfer or discharge.3 IFR. nutritional guidance.1 IFE.5 IFE. handling. and disposal of hazardous materials and wastes in a safe and sanitary manner.3 IFE.8. Care Continuum Care Continuum Care Continuum Care Continuum Care Continuum Care Continuum Care Continuum Care Continuum Individual and Family Rights (IFR) IFR. Individual and family education includes storage.3. The individual and family are taught in a format and language that they understand.5 7 The infection prevention and control program is based on current scientific knowledge.4 IFE. Individual and family education includes precautions to prevent and control infections.4 IFR.1 Education supports individual and family participation in care and services decisions and care and services processes.2 IFE.

and safe clinical care in a secure and supportive environment. Ambulatory Care Ambulatory Care Ambulatory Care International Patient Safety Goals (IPSG) ISPG. Hospital. contamination. Clinical Care Program (Certification) Hospital. correct-procedure. Ambulatory Care. and follow-up care instructions. Clinical Laboratory.12 The ambulatory care organization’s facility is designed to provide accessible.1.8 IFS.5 The organization develops an approach to reduce the risk of health care–associated infections. or failure. The ambulatory care organization plans and implements a program to ensure that all occupants are safe from fire.3 The organization develops an approach to improve the safety of high-alert medications. Clinical Care Program (Certification) Hospital. Clinical Laboratory. and definitions. and correct-patient surgery. ISPG. Clinical Laboratory. The clinical record of every patient receiving emergency care includes the time of arrival. Hospital Hospital .6 The organization develops an approach to reduce the risk of patient harm resulting from falls. Primary Care. ISPG. procedure codes. Ambulatory Care. smoke. Ambulatory Care. symbols.13 MCI. Ambulatory Care Management of Communication and Information (MCI) MCI. ISPG. Primary Care Hospital. the patient’s condition at discharge. Clinical Laboratory. Ambulatory Care.4 The organization develops an approach to ensuring correct-site. or other emergencies. Primary Care.7 IFS. abbreviations. The ambulatory care organization has emergency processes to protect facility occupants in the event of water or electrical system disruption.19.Joint Commission International (JCI) Requirements Related to Safe Surgery IFS.1 8 The organization uses standardized diagnosis codes. the conclusions at termination of treatment. efficient. Clinical Care Program (Certification) Improvement in Quality and Patient Safety (IQS) IQS. Primary Care.3 Quality monitoring includes both clinical and managerial processes and outcomes as selected by the ambulatory care organization’s leaders.

Improvement in quality and safety is sustained.1.1 MGT.4.Joint Commission International (JCI) Requirements Related to Safe Surgery Management and Leadership (MGT) MGT.4 MGT. d) Postanalytic processes.5 MMU. including • patient preparation.1.4.3 MMU. Medications prescribed and administered are written in the patient’s record. Medications are prepared and dispensed in a safe and clean environment.5.4. The leaders define performance and quality control activities used to monitor the laboratory’s processes and the systems used to ensure proper operation and control of these processes.3 MGT.1 MGT. The frequency of data analysis is appropriate to the process being studied and meets laboratory requirements. and • accuracy of reports. labeling. Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Medication Management and Use (MMU) MMU. The leaders are responsible for providing adequate resources for the provision of planned laboratory services. • timeliness of reporting test results.1.2 MGT. • adequacy of documentation. Medication prescriptions or orders are reviewed for appropriateness. • specimen quality processes (collection.2.1.3 MMU.4. The leaders assign adequate resources to quality management and improvement activities. The laboratory director is responsible for assuring the consistent performance of reference laboratory services.4 MGT.4.2. and rejection).7 The laboratory director is responsible for assuring the consistent performance of contract laboratory services. Hospital Hospital Hospital Hospital .1.1.3 MGT. Leaders communicate the key elements of the quality management and improvement program to employees. and • completeness of requisitions. transportation. Quality measurement includes those aspects of the following that are selected by leaders: a) The laboratory’s safety and infection control programs b) The laboratory’s quality control programs c) Preanalytic processes.4.2 MGT. including • efficient transfer of information.1 9 Medications are properly and safely stored.2. preservation.4.

smoke. The ambulatory care organization seeks to reduce physical.8 10 Patients have access to services based on their identified health care needs and the ambulatory care organization’s mission.16 ODS.24. The primary care center facility is designed to provide accessible. symbols.4 PAA. procedure codes. Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care . language.2 PAA. Medical Transport Organization and Delivery of Services (ODS) ODS.3 PAA.1. Case findings and identification of demographically important infections provide surveillance data and data for reporting.3 ODS. The primary care center plans and implements a program to ensure that all occupants are safe from fire. and definitions are used in the organization.28 The primary care center uses standardized diagnosis codes. efficient.11 ODS. abbreviations. There is an established reassessment process for patients requiring additional services or ongoing care. symbols. Care Continuum. cultural.27.1 PAA.Joint Commission International (JCI) Requirements Related to Safe Surgery Management of Information (MOI) MOI. within the primary care center and to public health agencies. and definitions. procedure codes.17 ODS. The primary care center identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risks. Primary Care Primary Care Primary Care Primary Care Primary Care Primary Care Patient Access and Assessment (PAA) PAA. An initial assessment process is used to identify the health care needs of all patients. or other emergencies in all its facilities. and other barriers to access and delivery of services. All staff/practitioners/students/volunteers/contract workers understand and can demonstrate their role relative to safety. and safe clinical care in a secure and supportive environment. and scope of services. Pathology and clinical laboratory services and consultation are readily available to meet patient needs.8 Standardized diagnosis codes. when appropriate. resources.1 ODS.

8.1 PAS. • specimen preservation. laws.6 PAS.8. Each patient’s postanesthesia status is monitored and documented. and have a quality control program.2 Laboratory services provided within the ambulatory care organization meet applicable local and national standards. Current written policies and procedures are readily available and address.7. and regulations. The anesthesia used and the anesthetic technique are documented in the patient’s record. at a minimum • specimen collection. and a qualified individual discharges the patient using established criteria. Each patient’s physiological status during anesthesia administration is continuously monitored and documented in the patient’s record. when appropriate. are directed and staffed by qualified individuals. and • test performance. or other high-risk procedures/interventions.3 11 Anesthesia services (which includes general and major regional anesthesia and moderate and deep sedation). Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care . anesthesia. laws.1 PAS. are organized with adequate supplies. Each patient’s anesthesia care is planned and documented. • instrument calibration.2 PAS. Policies and procedures guide the care of patients undergoing moderate and deep sedation. if provided by the organization. and regulations.4 PAS.3 PAS. benefits. potential complications. Informed consent is obtained before procedural sedation. A qualified individual conducts a presedation/anesthesia assessment.7 PAS. The risks.7. surgery. A qualified individual(s) is responsible for managing the anesthesia services and maintains policies and procedures that guide the care of patients undergoing anesthesia or sedation.2 PAS.5 PAS.1 PAA. • quality control and remedial action. meet professional standards and applicable local and national standards. • equipment performance evaluation.7. use of blood products. Ambulatory Care Ambulatory Care Patient Anesthesia and Surgery (PAS) PAS.Joint Commission International (JCI) Requirements Related to Safe Surgery PAA. the family or those who make decisions for the patient. and options of sedation/anesthesia are discussed with the patient and.

2 PCI. Gloves. The surgery performed is written in the patient record. soap/gel/rubs. eye protection. The organization uses a risk-based approach in establishing the focus of the health care– associated infection prevention and reduction program. Each patient’s surgical care is planned and documented based on the results of the assessment.9.5 Policies and procedures guide the care of highrisk patients and the provision of high-risk services. Gloves.3 PCI.4 PCI. Each patient’s physiological status is continuously monitored during and immediately after surgery and written in the patient’s record.7.7. and options of surgery/interventions are discussed with the patient and.2 PAS. The organization reduces the risk of infections by ensuring adequate equipment cleaning and sterilization and the proper management of laundry and linen. when appropriate.9 12 The organization establishes the focus of the infection prevention and reduction program.7.1 PCI.9. The organization has a policy and procedure on the disposal of sharps and needles. other protective equipment. Ambulatory Care Ambulatory Care Prevention and Control of Infections (PCI) PCI. Medications available within the ambulatory care organization for dispensing to patients or for practitioner administration are organized efficiently and effectively. and use is guided by policies and procedures.3 PCC.9 PAS.1 PAS.2 PCI. and disinfectants are available and used correctly when required.3 The risks. Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care Ambulatory Care Patient Care and Continuity of Care (PCC) PCC. The organization reduces the risk of infections through proper disposal of waste.5 PCI. masks. and disinfectants are available and used correctly when required.6 PCI. Primary Care Hospital Hospital Hospital . Care Continuum Care Continuum Care Continuum Care Continuum Hospital Hospital.Joint Commission International (JCI) Requirements Related to Safe Surgery PAS.3 PCI. Patient care after surgery is planned and documented. soap.8 PAS. benefits. Cultures are obtained from designated sites associated with recurrent infections. potential complications.9. masks. The organization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk. the family or those who make decisions for the patient.

nutritional guidance.14. Primary Care Primary Care Primary Care Primary Care Primary Care Primary Care Primary Care Primary Care Patient and Family Education (PFE) PFE. Medications available within the primary care center for dispensing to patients or for practitioner administration are organized efficiently and effectively. Hospital Ambulatory Care Medical Transport Medical Transport .1 13 The organization provides education that supports patient and family participation in care decisions and care processes. pain. appropriate for each patient and consistent with his or her condition. Patient and family education include the following topics. treatment. and nutritional and functional needs. Food. family participation in care decisions and care processes. Patients are screened for behavioral health needs. and their use is guided by policies and procedures. and follow-up when indicated. The primary care center lists those categories or types of treatments and procedures that require informed consent.1 PFE.17.9.4 PCS. is made available for patients who require an extended stay in the primary care center.2 The primary care center is responsible for providing processes that support patient and family rights during care. the safe use of medications. potential interactions between medications and food.17. as appropriate to the patient’s care: health promotion and disease prevention.8 PCS. including ways to reduce falls and other injuries at home. Education supports patient and family participation in care decisions and care processes.10. The medical transport provider educates patients when they refuse treatment or transport or the medical transport provider declines to treat or transport them.1 PCS.15 PCS.1 PCS. Education supports patient and family participation in care decisions and care processes. and the patient’s and family’s ability to learn and willingness to learn are assessed. Patient education is focused on patient and. the safe use of medical equipment. when appropriate. and rehabilitation techniques.1 PFE.1 PCS. and they are referred for full assessment.1 PFE.17 PCS.Joint Commission International (JCI) Requirements Related to Safe Surgery Patient-Centered Services (PCS) PCS. Education related to a patient’s immediate and long-term health needs is recorded in the patient’s record.1.

Informed consent is obtained before surgery.2. Ambulatory Care Ambulatory Care Hospital Hospital Hospital Patient and Family Rights (PFR) PFR. and the patient’s right to participate in these processes.3 PFE.6 The ambulatory care organization provides patient and family education related to treatment and services provided by the organization as well as the patient’s immediate and ongoing health needs.6. The organization informs patients and families about its process to receive and act on complaints. Education methods incorporate the patient’s and family's values and preferences and allow sufficient interaction among the patient. family. use of blood and blood products. and other high-risk treatments and procedures.4 PFE. potential interactions between medications and food.Joint Commission International (JCI) Requirements Related to Safe Surgery PFE. Facilities where patients receive care maintain and implement a program to ensure that all staff members receive education and training about their roles in providing a safe and effective environment. Health professionals caring for the patient collaborate to provide education. Education methods include the patient’s and family’s values and preferences and allow sufficient interaction among the patient. and staff for learning to occur.3 PFR.2 PFE.5 PFE. and rehabilitation techniques.15 14 Facilities where patients receive care maintain and implement a program to ensure that all occupants are safe from fire and smoke.12 PLM. and staff for learning to occur. The organization provides oversight of the harvesting and transplantation of organs and tissues. Patient and family education includes the following topics. and differences of opinion about patient care. The organization informs patients and families about how to choose to donate organs and other tissues.4 PFR. pain management. the safe use of medical equipment. family. anesthesia. related to the patient’s care: the safe use of medications. Clinical Care Program (Certification) Clinical Care Program (Certification) .11 The organization supports the patient’s right to appropriate assessment and management of pain. Hospital Medical Transport Hospital Hospital Hospital Program Leadership and Management (PLM) PLM.4 PFR. nutritional guidance.10 PFR. conflicts.

Ambulatory Care Patient Rights and Responsibilities (PRR) PRR. definitions.11. procedure codes. the elderly. A detailed history of a donor is performed prior to selection for blood donation.11. Before transplantation is performed.1 QCP.12 QCP. disabled individuals. Storage of records and specimens is addressed. as appropriate to the study or individual procedure performed.1 Care.12.2 QCP.12. treatment. The organization lists those categories or types of treatments and procedures that require specific informed consent. the laboratory uses appropriate screening techniques for donors and recipients.1.Joint Commission International (JCI) Requirements Related to Safe Surgery Pain Management (PME) PME.1 QCP.12. Ambulatory Care Ambulatory Care Patient Service Contracts (PSC) PSC. and abbreviations.10 QCP.7 The ambulatory care organization uses standardized diagnosis codes. The laboratory performs HLA serologic typing of both donor and recipient as appropriate to the study or individual procedure performed.3 PRR.6 15 The laboratory uses written quality control procedures that provide diagnostic reliability and patient and staff safety when it uses in vitro radioisotopes.3 QCP.4.5. Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory . and limits the number of abbreviations allowed. Care Continuum Patient Record and Information Flow (PRI) PRI.4 Pain assessment and management in the organization is designed to meet individual needs and to support the care and services provided. symbols. When performing histocompatibility testing. the laboratory crossmatches potential recipients and donors using the most reactive and recent sera. Storage areas used for blood and components are appropriate for the volume and variety of components stored.1. and other populations at risk receive appropriate protection. or services provided through contractual agreement are provided safely and effectively.2 Children. Ambulatory Care Quality Control Processes (QCP) QCP.

The laboratory uses a coordinated process to reduce the risks of infection as a result of exposure to biohazardous materials and waste.1 RSM. The organization’s leaders identify key measures for each of the organization’s clinical structures. the family’s educational needs.6.2 Maintenance and inspection ensure that equipment is safe. care.3. and services provided.2 The organization’s leaders identify key measures (indicators) to monitor the organization’s clinical.2 QMI.4 QMI. processes. and managerial structures.7.2. Adequate safety devices and equipment are provided.3 The organization’s leaders identify key measures in the organization’s structures.7. processes. processes. Monitoring includes the effectiveness of the pain management program.4. The laboratory conducts fire drills regularly. and outcomes to be used in the organizationwide quality improvement and patient safety plan.3 RSM. Monitoring includes the use of antibiotics and other medications and medication errors. Care Continuum Care Continuum Care Continuum Medical Transport Quality Improvement and Patient Safety (QPS) QPS. The laboratory has a plan for inventory.6 RSM. and use of hazardous materials and the control and disposal of hazardous waste.2 QMR.7.Joint Commission International (JCI) Requirements Related to Safe Surgery Quality Management and Improvement (QMI) QMI. and outcomes as appropriate to the mission. when appropriate. The organization’s leaders identify key measures for each of the International Patient Safety Goals. Laboratory leaders address fire safety.2 QPS.1.3 16 The program addresses the patient’s and.6. Hospital Hospital Hospital Hospital Resource Management and Laboratory Environment (RSM) RSM.3.1 RSM. The organization’s leaders identify key measures for each of the organization’s managerial structures. and outcomes. Monitoring includes invasive procedures. and outcomes.3. processes. handling. nonclinical. storage. there are processes for safe handling and monitoring of them.1 RSM.2 RSM.3.1 QPS.2.3 QPS. Clinical Care . Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Clinical Laboratory Supporting Self-Management (SSM) SSM. If radioactive materials are used in the laboratory.