Errata and Interpretations, JCI Accreditation Standards for Hospitals, 5th Edition

Issued 4 December 2013

(Deletions in strikethrough. New text is underlined.)

Page 3, Introduction
(correcting a typo)

Accreditation Participation Requirements (APR)

The Accreditation Participation Requirements (APR) section, new to JCI in this edition, is composed of specific
requirements for participation in the accreditation process and for maintaining an accreditation award. Hospitals
must be compliant with the requirements in this section at all times during the accreditation process. However,
APRs are not scored like standards during the on-site survey; hospitals are considered either compliant or not
compliant with the APR. When a hospital is not compliant with a specific APR, the hospital will be required to
become complaiiant or risk losing accreditation.

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©2013 Joint Commission International
Errata and Interpretations, JCI Accreditation Standards for Hospitals, 5th Edition
Issued 7 November 2013
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Page 17, APR.10

(new text for clarity)

Requirement: APR.10
Translation and interpretation services arranged by the hospital for an accreditation survey and any related
activities are provided by licensed and/or qualified translation and interpretation professionals who have no
relationship to the hospital.

Rationale for APR.10

The integrity of the on-site evaluation process, as well as the integrity of the outcome, depend on the surveyor
obtaining an unbiased, accurate understanding of his or her conversations with staff; and the hospital’s staff
communicating effectively in their language with the surveyor. To ensure this accurate, unbiased exchange,
translation and interpretation is provided by individuals licensed and/or qualified to provide translation and
interpretation services, with evidence of experience in health care translation and/or interpretation services.
Individuals providing translation and interpretation services are not current or former employees of the hospital
and do not have any conflicts of interest, such as immediate family members or employees of an affiliated
hospital.

Individuals providing translation and interpretation services have not served in any consultation capacity to the
hospital in relation to accreditation or accreditation preparation, with the possible exception of assistance in
translating the documents required by JCI to be in English or providing translation and interpretation services at
a previous survey.

Consequences of Noncompliance with APR.10

When translators are found to be unqualified due to lack of professional license and/or other qualifications, or a
conflict of interest, the survey will be stopped until a suitable replacement can be found. The hospital is
responsible for any additional costs related to the delay, including rescheduling of survey team members when
necessary.

Clarification
Qualified translators and interpreters can provide to the hospital and JCI documentation of their
experience in translation and interpretation that may include but is not limited to the following:
 Evidence of advanced education in English and the host hospital’s primary language
 Evidence of translation and interpretation experience, preferably in the medical field
 Evidence of continuing education in translation and interpretation, preferably in the medical field
 Memberships in professional translation and interpretation associations
 Translation and interpretation proficiency testing results, when applicable
 Translation and interpretation certifications, when applicable
 Other relevant translation and interpretation credentials

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©2013 Joint Commission International
Errata and Interpretations, JCI Accreditation Standards for Hospitals, 5th Edition
Issued 17 March 2014
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Page 80, AOP.6

(wording change for clarity)
Intent of AOP.6
The hospital has a system for providing radiology and diagnostic imaging services required by its patient
population, clinical services offered, and health care practitioner needs. Radiology and diagnostic imaging
services meet all applicable local and national standards, laws, and regulations.
Radiology and diagnostic imaging services, including those required for emergencies, may be provided within the
hospital, by agreement with another organization, or both. Radiology and diagnostic imaging services are
available after normal hours for emergencies. In addition, the hospital can identify and contact experts in
specialized diagnostic areas, such as radiation physics, radiation oncology, or nuclear medicine, when necessary.
The hospital maintains a roster of such experts.
Outside sources are convenient for the patient to access, and reports are received in a timely way that supports
continuity of care. The hospital selects outside sources based on the recommendation of the laboratory’s leader
or other individual responsible for radiology and diagnostic imaging services. Outside sources of radiology and
diagnostic imaging services meet applicable laws and regulations and have an acceptable record of accurate,
timely services. Patients are informed when an outside source of services is owned by the referring physician.

Measurable Elements of AOP.6

 1. Radiology and diagnostic imaging services meet applicable local and national standards, laws, and
regulations.
 2. Adequate, regular, and convenient radiology and diagnostic imaging services are available to meet the
needs related to the hospital’s mission and patient population, the community’s health care needs, and
emergency needs, including after normal hours.
 3. The hospital contacts experts in specialized diagnostic areas when needed.
 4. Outside sources are selected based on recommendations of the individual responsible for radiology and
diagnostic imaging services laboratory leader and an acceptable record of timely performance and
compliance with applicable laws and regulations.
 5. Patients are informed about any relationships between the referring physician and outside sources of
radiology and/or diagnostic imaging services. (Also see GLD.12.1, ME 1)

© 2014 Joint Commission International

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Errata and Interpretations, JCI Accreditation Standards for Hospitals, 5th Edition
Issued 7 November 2013
(Deletions in strikethrough. New text is underlined. Clarifications are blue.)

Page 84, AOP.6.8

Clarification
Standard AOP.6.8 requires the hospital to collect and review quality control results for all “outside” sources
of diagnostic services. In this case, “outside” is considered to be the equivalent of “contracted,” meaning
the hospital is required to collect quality control data from any diagnostic imaging services that are
contracted by the hospital, but not within the hospital facility. When the hospital simply provides a list of
diagnostic services from which a patient can freely choose or refers a patient to a diagnostic service that is
not part of the hospital and for which the hospital does not contract services, the hospital is not required to
obtain quality control results.

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©2013 Joint Commission International
Errata and Interpretations, JCI Accreditation Standards for Hospitals, 5th Edition
Issued 7 November 2013
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Page 97, COP chapter, Hospitals Providing Organ and/or Tissue Transplant
Services
(reworded for clarity)

Note: The following standards are intended to be used during those times when patients and/or families request
information about organ and tissue donation and/or when organ/tissue procurement is performed. For
hospitals providing organ and/or tissue transplant services, Standards COP.8 through COP.9.3 apply are
intended to be used by hospitals providing organ and/or tissue transplant services. Please contact the JCI
Accreditation Office with inquiries.

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©2013 Joint Commission International
Clarification, JCI Accreditation Standards for Hospitals, 5th Edition
Issued 23 April 2014

Page 120, MMU.1

Clarification
MMU.1 requires written policies for all medication-use processes within an organization. Measurable
element 1 states that a written document identifies how medication use is organized and managed
throughout the hospital; measurable element 2 requires all settings, services, and individuals who manage
medication processes are included in the organizational structure. These measurable elements, when
applied together, require all medication use processes to be directed by medication management policies.

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©2014 Joint Commission International
Errata and Interpretations, JCI Accreditation Standards for Hospitals, 5th Edition
Issued 17 March 2014
(Deletions in strikethrough. New text is underlined.)

Page 180, GLD.12 and 12.1

(changing order of standards to synchronize with MEs [former GLD.12 becomes
GLD.12.1; former GLD.12.1 becomes GLD.12] ; no change in requirements)

Standard GLD.12
Hospital leadership establishes a framework for ethical management that promotes a culture of ethical practices
and decision making to ensure that patient care is provided within business, financial, ethical, and legal norms and
protects patients and their rights. The hospital’s framework for ethical management addresses operational and
business issues, including marketing, admissions, transfer, discharge, and disclosure of ownership and any business
and professional conflicts that may not be in patients’ best interests.

Standard GLD.12.1
The hospital’s framework for ethical management addresses operational and business issues, including marketing,
admissions, transfer, discharge, and disclosure of ownership and any business and professional conflicts that may
not be in patients’ best interests. Hospital leadership establishes a framework for ethical management that
promotes a culture of ethical practices and decision making to ensure that patient care is provided within business,
financial, ethical, and legal norms and protects patients and their rights.

©2014 Joint Commission International

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Errata and Interpretations, JCI Accreditation Standards for Hospitals, 5th Edition
Issued 7 November 2013
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Page 219, SQE.11

(changed lettered list to bulleted list to indicate advisory text [bullets] versus
requirements [lettered list])
Professional Growth
Medical staff members grow and mature as the organizations in which they practice evolve, introducing new
patient groups, technologies, and clinical science. Each medical staff member, to varying degrees, will reflect
growth and improvement in the following important dimensions of health care and professional practice:
 a)Patient care, including provision of patient care that is compassionate, appropriate, and effective for
health promotion, disease prevention, treatment of disease, and care at the end of life. (Potential
measures include frequency of preventive services and reports from patients and families.) (Also see
PRF.3)
 b)Medical/clinical knowledge, including knowledge of established and evolving biomedical, clinical,
epidemiologic, and social-behavioral sciences, as well as the application of knowledge to patient care
and the education of others. (Potential measures include application of clinical practice guidelines,
including the adaptation and revision of guidelines, participation in professional conferences, and
publications.) (Also see GLD.11.2)
 c)Practice-based learning and improvement, including use of scientific evidence and methods to
investigate, evaluate, and continuously improve patient care based on self-evaluation and lifelong
learning. (Examples of potential measures include self-motivated clinical inquiry/research, acquiring
new clinical privileges based on study and acquiring new skills, and full participation in meeting
requirements of professional specialty requirements or continuing education requirements of licensure.)
 d)Interpersonal and communication skills, including establishment and maintenance of effective
exchange of information and collaboration with patients, their families, and other members of health
care teams. (Examples of potential measures include participation in teaching rounds, team
consultations, team leadership, and patient and family feedback.)
 e)Professionalism, including commitment to continuous professional development, ethical practice, an
understanding and sensitivity to diversity, and a responsible attitude toward patients, their profession,
and society. (Examples of potential measures include an opinion leader within the medical staff on
clinical and professional issues, service on an ethics panel or discussions of ethical issues, keeping
appointed schedules, and community participation.)
 f)System-based practices, including awareness of and responsiveness to the larger contexts and systems
of health care, as well as the ability to call effectively on other resources in the system to provide
optimal health care. (Examples of potential measures include understanding the meaning of frequently
used, hospitalwide systems, such as the medication system; and awareness of the implications of the
overuse, underuse, and misuse of systems.)
 g)Stewardship of resources, including understanding of the need for stewardship of resources and
practicing cost-conscious care, including avoiding the overuse and misuse of diagnostic tests and
therapies that do not benefit patient care but add to health care costs. (Examples of potential measures
include participation in key purchasing decisions within their practice area, participating in efforts to
understand appropriate use of resources, and being aware of the cost to patients and payers of the
services they provide.) (Also see GLD.7)

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©2013 Joint Commission International
Errata and Interpretations, JCI Accreditation Standards for Hospitals, 5th Edition
Issued 7 November 2013
(Deletions in strikethrough. New text is underlined.)

Page 264, Glossary

(text inadvertently omitted from initial publication 1 September 2013)

deep sedation/analgesia A drug-induced depression of consciousness during which patients

cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to
independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a
patent airway, and spontaneous impaired ventilation may be inadequate. Cardiovascular function is usually
maintained.

anesthesia Consists of general anesthesia and spinal or major regional anesthesia. It does not include
local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not
arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often
impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may
be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular
function. Cardiovascular function may be impaired.

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©2013 Joint Commission International
Errata and Interpretations, JCI Accreditation Standards for Hospitals, 5th Edition
Issued 4 December 2013
(Deletions in strikethrough. New text is underlined.)

Page 272, Glossary

(correcting a typo)

specialty laboratory programs Programs that include laboratory disciplines, such as chemistry (including
toxicology, therapeutic drug testing, and drugs of abuse testing), clinical cytogenetics, immunogenetics,
diagnostic immunology, embryology, hematology (including coagulation testing), histocompatibility,
immunohematology, microbiology (including bacteriology, mycobacteriology, mycology, virology, and
parasitology), molecular biology, pathology (including surgical pathology, cytopathology, and necropsy), and
radiobioassay.

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©2013 Joint Commission International