JCI HospitalStandards 7thedition FAQ July 2022

Standards Interpretation FAQs
Standards Subject Interpretation Question Response

International Patient Safety Goal (IPSG)
1 IPSG.1 Patient Identification One of our measures to These are extraordinary times, and it is understood that the service you are referencing
During Telephone combat COVID 19 is solely dedicated to assisting the public in determining whether to seek medical care
Consultation transmission in the OPD is via a phone conference in order to avoid having patients physically come into the
telephonic consultation. hospital if not needed.
What is the minimum
documentation required The standards do not specifically address these circumstances; however, there are several
regarding the telephonic standards that may be referenced in ensuring the quality and safety of patient care
consultation? services. Standard ACC.3 identifies the need to design and carry out processes to provide
continuity of patient care services. While this does not specifically address phone
consultations, the principles of this standard apply. When telephone advice is provided it is
important to ensure the continuity of care. For example, if a patient calls for advice, basic
information about this consultation needs to be documented.
As identified, the documentation can be very simple such as a one page form that includes
patient identifying information (Name and Birthdate or Name and ID number) as required in
IPSG.1; the information the patient provides during the phone consultation, including any
response to questions asked by the physician; and the outcome of the phone conference,
such as patient referred to outpatient clinic for further assessment and treatment, or patient
instructed to remain at home and come into the hospital if symptoms worsen. If possible,
the information may be communicated to the service to which the patient is being referred
or made available to the referral service, if requested.
2 IPSG.2 Corona Virus Tests as Is the COVID-19 (PCR and The intent of Standards IPSG.2 through IPSG.2.2 states that “Safe practices for effective
Critical Result antibody test) test communication includes the development of guidelines for requesting and receiving test
considered a critical test? results on an emergency or STAT basis, the identification and definitions of critical tests
and critical values, to whom and by whom critical test results are reported, and monitoring
compliance.”
The standards do not specify which diagnostic tests should be identified as a critical test,
however; a critical result is defined as a variance from normal range that represents a
pathophysiologic state that is high-risk or life-threatening, is considered urgent or emergent
in nature, and in which immediate medical action is likely necessary to preserve life or
prevent a catastrophic occurrence.
As explained in the intent, the organization should identify and define their own critical
tests and critical values. Because the list of critical tests for an organization change based
on the patient population need and organization’s changing priorities, it is up to the
organization to identify which diagnostic tests should be defined as critical to the patient
population they serve. Standard IPSG.2.1 is focused on the development and
implementation of a process for reporting critical results of diagnostic tests. While there
are currently no measurable elements that are tied to the development of a critical test
JCI Accreditation Standards for Hospitals, 7th Edition Page 1 of 63
Last Update: July 2022
list, Standard IPSG.2.1, ME 1 requires the hospital to develop a formal reporting process
that identifies how critical results of diagnostic tests are reported/communicated to health
care practitioners.
3 IPSG.2 Critical Results If a test result is considered The standard does not specify a mandatory requirement for reporting repeated critical
Reporting critical, the treating results from a series of the same laboratory tests that were ordered to monitor critical ICU
physician is immediately patients. The intent of IPSG.2 through IPSG.2.2 defines a critical result as a variance from
notified. If the test is normal range that represents a pathophysiologic state that is high-risk or life-threatening, is
repeated routinely (maybe considered urgent or emergent in nature, and in which immediate medical action is
every 4 hours) and the necessary to preserve life or prevent a catastrophic occurrence. The intent also defines
result is still critical, the abnormal result as a result that is outside of the expected range for the test but is not an
treating physician is not urgent or emergent life threat.
notified immediately with
the new critical result, and In the case of repeated critical results, subsequent critical results may or may not require
it's handled as an abnormal an immediate medical action and it is up to the organization to identify which repeated
result, not a critical result. laboratory test results would be considered “critical” and would require continuous provider
Is it mandatory to report notification based on the immediate action that may be required by the treating physician.
repeated critical results IPSG.2, ME 1 states that “The hospital defines critical results that may represent urgent or
separately even if it was emergent life-threatening values for diagnostic tests.” In defining critical results, the
already reported as critical organization should address repeated laboratory tests results that may be within the
within the last 4 hours? laboratory’s critical range and work with the laboratory department in defining scenarios
when these subsequent critical results would not require continuous notification to the
ordering physician.
4 IPSG.2.1 Reporting Abnormal Is read-back necessary Standard AOP.5.2, ME 3 states that “The POCT program includes a defined process for
and Critical Test when the process in place reporting abnormal test results, including reporting critical results.” The intent of the
Results is for a nurse to report the standard refers to IPSG.2.1 when establishing a protocol for reporting abnormal test
patient details and result to results, including the process for reporting critical results. The measurable elements of
the physician and IPSG.2.1 outline specific requirements on defining critical results, communicating critical
document the result and results to healthcare practitioners, and identifying what information should be reported
responding actions in the along with the results. IPSG.2 specifies the requirements for read-back policy which are
EMR? focused on the hospital’s process for improving the effectiveness of verbal and/or
telephone communication among caregivers.
5 IPSG.2.1 Critical Results for The understanding is that Cardiotocography (CTGs) is used to monitor fetal heart rate during pregnancy as a method
CTG the application of critical of assessing fetal well‐being, predominantly in pregnancies with increased risk of
results for CTGs applies to complications. During this continuous monitoring activity, certain CTG result and
urgent / emergent situations interpretations may require urgent and immediate medical action to prevent a catastrophic
when a diagnosis occurrence such as any CTG reading that indicates fetal distress and may require
("diagnostic test") is sought. emergency C-section. For example, inaudible fetal heart beating and/or rare sinusoidal
Additionally, most pattern that usually indicates severe fetal hypoxia, severe fetal anemia, or fetal/maternal
organizations have hemorrhage. (Reference: https://www.aafp.org/afp/1999/0501/p2487.html).
established critical results In these specific cases, the results of monitoring (not in a continuous way) is considered a
parameters (beyond the critical result because they represent an urgent or emergent life-threatening value. In this
variance of highs and lows) context, requirements of IPSG.2.1 on critical results would apply and the hospital must
for the CTGs in which define what would be considered a “critical result” for CTGs being performed that would
immediate medical require notification to the healthcare provider per IPSG.2.1, MEs 1 and 2. To meet the
intervention is required requirements of IPSG.2.1 in this scenario, the organization may define or at minimum, list
during the continuous CTG results that may require immediate intervention. For example, the organization policy
monitoring process. Should may state that “any inaudible fetal heart rate requires immediate notification and
the organization address consultation with the obstetrician.”
CTG as having critical
results in both standards Standard COP.3.1 focuses on clinical alarm management and must be used when scoring
IPSG 2.1 (related to critical noncompliance on the use of clinical alarms. While CTGs are often done at bedside,
results) and COP 3.1 Standard AOP.5.2 focuses on Point-of-Care “laboratory” testing.
(related to alarm settings),
in addition, to the AOP 5.2
standard on POCT?
6 IPSG.2.1 Critical Results for Clarification regarding the The intent of IPSG.2.1 defines a critical result as "a variance from normal range that
CTG IPSG. 2.1 for reporting represents a pathophysiologic state that is high-risk or life-threatening, is considered urgent
critical results of diagnostic or emergent in nature, and in which immediate medical action is likely necessary to
tests: preserve life or prevent a catastrophic occurrence." Further, in the intent it is stated that
It is understood that the "Diagnostic tests that produce defined test results that may indicate a threat to life are
intent of the standard which different from continuous electronic monitoring, such as cardiac telemetry, continuous EEG
states that continuous (electroencephalogram) monitoring, or fetal monitoring.
electronic monitoring such
as fetal monitoring Continuous electronic monitoring is a clinical assessment tool used to detect changes in
(cardiotocography fetal) is the patient’s condition that may identify a threat to life but is not designed to produce a
not considered a critical defined critical result." Fetal heart monitoring used as a form of continuous electronic
result. In situations where monitoring for laboring patients on an L&D ward would not fall under the requirements of
patients are admitted to the IPSG.2.1. However, as described in the question, fetal heart monitoring placed on a patient
emergency room in an presenting to the emergency department in an emergent condition is used as a point of
emergent condition when care, diagnostic test to determine if further actions are needed to prevent harm to the fetus.
the physician monitors fetal In this context, critical results would be defined by the hospital so that staff utilizing fetal
activity, not in a continuous heart monitoring in this context would understand when to contact the physician and care
way, in order to detect fetal team to initiate further care.
distress, such as inaudible
fetal heart beating FHB,
these limit values are taken
into account during the
monitoring to refer the
patient to an emergency C-
section because of the
imminent threat of fetal
death.
In situations such as this,

could the result of the CTG
monitoring (no continuous
way) be considered a
critical result because it is
representing an urgent or
emergent life-threatening
value?
7 IPSG.2.2 Handover Between For physicians, is it required Standard IPSG.2.2 states that “The hospital develops and implements a process for
Physicians by End of that handover is handover communication.” This standard outlines the requirements for safe communication
Shift documented for every and handover, noting that breakdown in communication during different types of patient
patient by the end of each handover can result in adverse events. The hospital must determine the method and
shift? process for handover communication, including the development and implementation of
standardized forms or tools that are used to ensure that the appropriate information is
communicated. It is stated in the intent of IPSG.2.2 that “The handover process may be
different for different types of handovers within the hospital. For example, handovers of
patient care for the emergency department to a medical ward may require a different
process or different content than handovers for the operating theatre to the intensive care
unit; however, the handovers are standardized for the type of handover occurring.”
JCI does not specify that the handover is documented in the medical record, but rather it is
recommended as a best practice that there is some form of documentation that the
handover took place. Further, it is mentioned in the intent that “Handover forms or tools, if
used by the hospital, are not required to be part of the medical record. The detailed
information communicated during the handover is not required to be documented in the
medical record; however, the hospital may want to have documentation that the handover
occurred.” An example of this would be the practitioner documenting in the medical record
that the handover was completed and the identity of whom he or she transferred the
responsibility of care to.
8 IPSG.2.2 Handover Between Is it acceptable that the The hospital must determine the method and process for handover communication,
Specialties handover mechanism and including the development and implementation of standardized forms or tools that are used
tool is different between to ensure that the appropriate information is communicated.
specialties? Do we have to
document the handover? It is stated in the intent of IPSG.2.2 that “The handover process may be different for
different types of handovers within the hospital. This applies to handover between
disciplines (i.e., physician-to-physician will be different than nurse-to-physical therapist)
and between units (i.e., ED-to-ICU will be different than X-ray-to-inpatient ward).
JCI does not specify that the handover is documented in the medical record, but rather it is
recommended in the intent as a best practice that there is some form of documentation that
the handover took place. Further, it is mentioned in the intent that “Handover forms or
tools, if used by the hospital, are not required to be part of the medical record. In addition,
the detailed information communicated during the handover is not required to be
documented in the medical record; however, the hospital may want to have documentation
that the handover occurred.” An example of this would be the practitioner documenting in
the medical record that the handover was completed and the identity of whom he or she
transferred the responsibility of care to.
9 IPSG.2.2 Pre-Procedure and Is it necessary to conduct a When the pre-procedure, the procedure, and the post-procedure (all three) involve the
Post-Procedure preprocedural and post- same staff who are responsible for the patient and providing direct care to the patient, a
Handover procedure hand off if the handoff communication may not be necessary. Handoff/handover communication practices
same staff remains with the are referenced in Standard IPSG.2.2 which states “The hospital develops and implements
patient in all three areas a process for handover communication.” Handoff (also known as handover) is required
(pre-procedure, procedure, when there is a transfer of responsibility for a patient and the patient’s care such as:
and post-procedure)? • Between health care practitioners (for example, physician to physician, physician to
nurse, nurse to nurse, and so on)
• Between different levels of care in the same hospital (for example, when the
patient is moved from an intensive care unit to a medical unit or from an emergency
department to the operating theatre)
• From inpatient units to diagnostic or other treatment departments, such as
radiology or physical therapy; and between staff and patients/families, such as at
discharge.
10 IPSG.3.1 High-Alert Medications How do we distinguish IPSG.3.1 was updated to focus solely on how the hospital manages look-alike sound-alike
which LASA medications (LASA) medications. In the intent of IPSG.3.1 it is described that not all LASA medications
should be included in meet the definition of high-alert medications, therefore it is required in IPSG.3.1 ME 1 that
high-alert medication list? the hospital must define in writing a list of LASA medications that is separate from the list
of high-alert medications. Some medications may actually be on both lists, but many will
only be on one or the other. An example of medications that may be on both the look-
alike/sound-alike list as well as the high-alert list is glyburide and glipizide – both of which
are oral hypoglycemic medications.
Hospitals should be looking at their medication utilization patterns as well as data related
to near misses, medication errors, and sentinel events to create their own lists of high-
alert and look-alike/sound-alike medications.
11 IPSG.3.1 Look-alike Medications How can organizations Standard IPSG.3.1 states “The hospital develops and implements a process to improve
for Medications from decrease risk with LASA the safety of look-alike/sound-alike medications.” The intent for this standard applies to
the Same (look-alike/sound-alike) look-alike medicine packaging, such as medicine containers or primary packaging that look
Pharmaceutical medications when the like that of other medications, which may lead to potentially harmful medication errors. In
Company packaging of medications addition to the risk for error due to look-alike medicine packaging, the intent also mentions
from the same that there are many medication names that sound or look like other medication names; for
pharmaceutical company all example, dopamine and dobutamine. This is included because confusing names is a
look the same? common cause of medication errors throughout the world. The intent further clarifies that
hospitals need to institute risk management strategies to minimize adverse events with
LASA medications and enhance patient safety. This is supported by IPSG.3.1, ME 2 which
requires that the hospital develops and implements a process for managing look-
alike/sound-alike medications that is uniform throughout the hospital.
Standard MMU.6.1 provides further guidance by requiring that medication administration

includes a process to verify the medication is correct based on the medication prescription
or order. MMU.6.1 ME 1-3 specifies what must be included in the verification process:
ME.1 Medications are verified with the prescription or order. ME. 2 The dosage amount of
the medication is verified with the prescription or order. ME. 3 The route of administration
is verified with the prescription or order. Additionally, if bulk packaging from a single
pharmaceutical company is similar for all medications, it is recommended that the following
requirements are used as guidance: 1) MMU.6.1, MEs 1-3, and 2) , MMU.5.2, ME 1
“Medications are dispensed in the most ready-to-administer form available.”
12 IPSG.3.1 Medication List In addition to having a IPSG.3.1 was updated to focus solely on how the hospital manages look-alike/sound-alike
LASA (look-alike/sound- (LASA) medications. In the intent of IPSG.3.1 it is described that not all LASA medications
alike) medication list, meet the definition of high-alert medications, therefore it is required in IPSG.3.1 ME 1 that
should LASA medications the hospital must define in writing a list of LASA medications. The requirements in the
be included in the high-alert IPSG.3 through IPSG.3.2 standards thus require that the hospital maintain two separate
medications list as well? lists, one for LASA medications and one for high-alert medications.
13 IPSG.3.1 Different Dosages of Are different dosages of the The intent of IPSG.3.1 defines look-alike/sound-alike medications as “Look-alike/sound-
the Same Medication same medication alike (LASA) names are medicine names that look or sound the same as other medicine
considered as look- names when written or spoken. Look-alike medicine packaging refers to medicine
alike/sound-alike (LASA) containers or primary packaging that looks like that of another medicine.” Different
medications? concentrations/dosages of the same medication are not considered LASA medications.
MMU.6.1, ME 2 states that “The dosage amount of the medication is verified with the
prescription or order.” This process should take place prior to medication being
administered and will prompt staff to ensure that the correct dosage of the correct
medication is being delivered.
14 IPSG.3.2 Concentrated Can you explain the phrase The intent of IPSG.3 though IPSG.3.3 explains that vials of concentrated electrolytes that
Electrolytes in Patient “as much as is possible require dilution before administration are not to be stored as floor stock in any patient care
Care Areas given the pharmacy areas of the hospital except in situations specifically identified in the intent. The intent also
capabilities” from the intent identifies the specific exceptions and includes concentrated potassium that may be kept in
a cardiac surgery box in the operating theatre when open heart surgeries are performed,
of IPSG.3 through magnesium sulfate that is expected to be kept on emergency carts as well as in labor and
IPSG.3.3? delivery.
For example, CCU is one of The exception identified for the ICU is for concentrated sodium for the treatment of
the areas where increased intracranial pressure. The ICU is not identified as an exception for concentrated
concentrated electrolytes potassium chloride. As such, the CCU would also not qualify as an exception for storing
are heavily used and the vials of concentrated electrolytes. The intent does provide for situations in which storing all
areas with an extreme concentrated electrolytes within the pharmacy may not be always possible. Some
emergency. ICU is organizations do not have 24-hour pharmacy support because pharmacists are not as
identified as an exception readily available in some countries. In situations such as those, the organization may
where concentrated identify other methods for storing and preparing concentrated electrolytes. However, the
electrolytes in patient care expectation is that the organization performs a risk assessment identifying potential risks to
areas are stored. Is it patients while also identifying methods for mitigating those risks. In addition, IPSG.3.3. ME
possible to regard CCU as 1 states: "Only qualified and trained individuals have access to concentrated electrolytes,
one of the exceptions to the and they are clearly labeled with appropriate warnings and segregated from other
JCI recommendation as the medications." The expectation of this ME is that anyone handling and preparing
area beyond the concentrated electrolytes must be qualified and trained.
pharmacy’s maximum
capabilities?
15 IPSG.3.2 Concentrated In our hospital we have 3% 3% and 5% sodium chloride solutions that are already prepared as infusions are not
Electrolytes sodium chloride that comes considered concentrated electrolytes. However, they may be labeled as high-alert
in this formulation from the medications in your organization depending on how it is used in your organization and
manufacturer thus no your own data related to adverse events or near misses. These solutions can cause fluid
further dilution needed. overload in patients that already have peripheral or pulmonary edema. Other conditions or
Is this considered a high- certain medications can also make patients sensitive to the use of these solutions. You are
alert medication? encouraged to look at your data and use information and identify it as a high-alert solution
if your data indicates this.
One thing to consider about labeling high-alert medications is that if you label many
medications as high-alert without thinking about your own data, staff can become
desensitized to the label and can lead to staff not really paying as much attention to these
labels.

16 IPSG.3.2 Storage of High-Alert The intent states that vials The intent of IPSG.3, 3.1, and 3.2 requires that hospitals develop and implement a process
Medications, LASA, contained in a cardiac to improve the safety of high-alert medications, LASA medications, and concentrated
and Concentrated surgery kit, or a cardiac electrolytes. The intent of these standards explains the use of a risk management process
Electrolytes surgery locked storage area to prevent the risks related to these medications.
are exceptions to the
recommendation to remove Part of the risk management process is the completion of a risk assessment. In reference
concentrated electrolytes to the examples given of housing concentrated electrolytes in a cardiac surgery locked
from patient care areas. storage area, the hospital can complete a risk assessment to understand what the types of
staff are who have access to the area and what is the workflow of the area. For instance, if
There is a storage area in the concentrated electrolytes are stored in an unlocked medication room that is located
the surgery area. Is it within the locked cardiac surgery area and environmental services staff have access to the
necessary to lock the area after hours or in an unsupervised manner, this can pose a risk of unauthorized staff
storage room/area in the accessing the concentrated electrolytes. The hospital can then use the information
surgery area with high gathered from the risk assessment to determine how to best ensure that only trained and
security? qualified staff members have access to concentrated electrolytes.
17 IPSG.3.2 Preparation and Is it required that all The intent of IPSG.3 through IPSG.3.3 identifies the incorrect or unintentional
Dilution of concentrated electrolytes administration of concentrated electrolytes (for example, potassium chloride, potassium
Concentrated be mixed and prepared phosphate, sodium chloride, magnesium sulfate) as a frequently cited medication safety
Electrolytes at the pharmacy before issue.
sending to the patient
care units? The literature has identified several instances of death as a result of the inadvertent
administration of a concentrated electrolyte in its concentrated form. The intent further
states: Vials of concentrated electrolytes should not be dispensed in their concentrated
form to patient care units for individual patients. When vials of concentrated electrolytes are
stored on the ward, or a vial is sent from the pharmacy to the ward to be prepared by staff
on the ward, there is a significant risk of the medication inadvertently being administered in
its concentrated form which could result in death or permanent harm to the patient.
The literature recommends, as does the Institute of Safe Medication Practices (ISMP) that
concentrated electrolytes should be prepared in the pharmacy by qualified, trained
individuals. IPSG.3.2. ME 1 states: "Only qualified and trained individuals have access to
concentrated electrolytes, and they are clearly labeled with appropriate warnings and
segregated from other medications." The expectation of this ME is that anyone handling
and preparing concentrated electrolytes must be qualified and trained.
The intent states “magnesium sulfate contained in emergency carts or in areas in which
patients with preeclampsia may be treated (labor and delivery, emergency department, or
intensive care unit)”. With the use of “or,” Magnesium Sulfate can be stored in all
emergency carts as well as the other areas that could treat pre-eclampsia.

18 IPSG.3 High-Alert Medications One of the examples of IPSG.3 through IPSG.3.2 address the requirements for improving the safety of high-
IPSG.3.1 strategies listed in the alert medications, which are defined as “drugs that bear a heightened risk of causing
IPSG.3.2 intent is "Applying significant patient harm when they are used in error. Although mistakes may or may not
redundancies." Could you be more common with these drugs, the consequences of an error are clearly more
elaborate on what it devastating to patients.”
means to apply
redundancies? Many examples of strategies are given in the intent to improve safety with high-alert
medications, such as applying redundancies. While JCI does not require specific strategies
to improve the safety of administering high-alert medications, redundancy is a suggested
policy. An example of a redundancy would be before a nurse could administer a high-alert
medication, they would need to have a second nurse complete the medication verification
against the order and then document this double check; therefore, the verification process
would be completed twice by two separate individuals permitted to do so.
19 IPSG.3 Safety of High-Alert Is there a mandate The intent of IPSG.3, 3.1, and 3.2 requires that hospitals develop and implement a process
IPSG.3.1 Medications requiring specific to improve the safety of high-alert medications, LASA medications, and concentrated
IPSG.3.2 medications to be included electrolytes. The intent of these standards explains the use of a risk management process
in the list of High-Alert to prevent the risk related to these medications.
Medications or is the
hospital to determine all The intent emphasizes that the hospital needs to develop its own list(s) based on its unique
High-Alert Medications? utilization patterns of medications and its own internal data about near misses (or close
calls), medication errors, and sentinel events, as well as safety issues published in
professional literature. For example, published lists of high-alert medications are available
from organizations such as ISMP and WHO.
The intent of these standards further explains that the list includes medications identified as
high risk for adverse outcomes and that information from the literature and/or Ministry of
Health may also be used in helping to identify which medications should be included.
20 IPSG.3.2 Non-24-Hour Please provide guidance When vials of concentrated electrolytes are stored on the ward, or a vial is sent from the
Pharmacy Hours and regarding compliance with pharmacy to the ward to be prepared by staff on the ward, there is a significant risk of the
Concentrated storing concentrated medication being inadvertently administered in its concentrated form. The literature has
Electrolyte Storage electrolytes on wards due to identified several instances of death because of accidentally administering the
limited pharmacy service concentrated form of an electrolyte. The literature recommends, as does the Institute for
hours. Safe Medication Practices (ISMP), that concentrated electrolytes should be prepared in the
pharmacy by qualified, trained individuals. The intent explains situations in which storing,
mixing, and preparing of all concentrated electrolytes within the pharmacy may not be
always possible. For example, some organizations do not have 24-hour pharmacy support
because pharmacists are not as readily available in some countries. In situations like this,
the organization may develop an alternative process for preparing and storing
concentrated electrolytes. However, storing concentrated electrolytes on a ward with other
medications, particularly the neonatal intensive care unit, is not recommended. Also
identified in the intent, several pediatric deaths have occurred as a result of administering
concentrated potassium in its concentrated form.
When an organization determines the need to store concentrated electrolytes outside of

the pharmacy for preparation by individuals other than pharmacists, the following is
expected:
1. The organization is expected to conduct a proactive risk assessment. A proactive
risk assessment is a process for identifying and systematically analyzing the risks
and hazards embedded in the process and structure of care to prevent adverse
events from occurring. Knowing where the risks and hazards are helps to inform the
design, planning, and development of appropriate interventions that will eliminate or
minimize risks and hazards before patient injuries occur.
2. The organization is expected to show evidence that those who prepare concentrated
electrolytes are trained and competent to do so.
3. Concentrated electrolytes prepared outside of the pharmacy are expected to be
segregated from other medications and clearly labeled with appropriate warning
signs. Measurable Element #1 from IPSG.3.2 states: "Only qualified and trained
individuals have access to concentrated electrolytes, and they are clearly labeled
with appropriate warnings and segregated from other medications."
21 IPSG.3.2 Standard Protocols Could you provide more Patient safety literature has identified several instances of patient death resulting from the
for Concentrated information on what is inappropriate administration of concentrated electrolytes. Effective ways to reduce this risk
Electrolytes meant by "standard are listed in the intent of Standard IPSG.3.2, such as removing concentrated electrolytes
protocols" for IPSG.3.2, ME from the patient care units and storing them in the pharmacy and using standardized
3? protocols for managing patients requiring electrolyte replacement. It is for this reason that
the use of standard protocols is required in IPSG.3.2 ME 3. Standard protocols are chosen
and developed by the clinical experts for each population, are evidence-based, and are
standardized for much of a specific patient population. For example, the pediatric
department would develop a protocol for potassium replacement based on evidence from
literature. Standardization decreases variation and thus lowers the risk of patient harm.
22 IPSG.4 Surgical Site When a site marking There are instances where alternative site markings are necessary. For example, site
Marking cannot be placed on the marking for removal of an ovary is done on a body drawing or on a digital image rather than
part of the body such as the the body itself, or with tooth extractions which are often done on diagrams or digital
face during Ophthalmologic images. It may be necessary to use alternative measures for site marking in selected
or Dermatologic surgical Ophthalmologic or Dermatologic surgical procedures as well. When alternative measures
procedures, can a for site marking are required, the organization is expected to specify in their policy how the
pictogram be used instead site will be marked for these procedures. The organization should also identify these
of marking directly on the differences (that is, how they choose to mark the site--body diagram or digital image, etc.)
face? in their policy.

While the standard does not specify how alternative site markings must be done, an “X” is
not recommended as the mark because it may be interpreted as “not here” or “wrong side”
and could potentially lead to errors in patient care. The hospital must use an instantly
recognizable and unambiguous mark for identifying the surgical/invasive site.
Additional information on site markings are further outlined in the intent of IPSG.4-
IPSG.4.1.
23 IPSG.4 Time-Out Are IPSG4 & 4.1 applicable The intent statement of IPSG.4 and IPSG.4.1 states that “organizations need to identify all
IPSG.4.1 to invasive procedures areas within the hospital where surgical and invasive procedures take place; for example,
performed outside of the cardiac catheterization lab, interventional radiology department, gastrointestinal lab,
operation theater? and the like. The approach the hospital takes to ensuring safe surgery applies to all areas
of the hospital in which surgical and invasive procedures occur.”
IPSG.4 and IPSG.4.1 relates to surgical and invasive procedures and, defines invasive
procedures as “all procedures involving an incision or puncture, including, but not limited
to, open surgical procedures, percutaneous aspiration, selected injections, biopsy,
percutaneous cardiac and vascular diagnostic or interventional procedures, laparoscopies,
and endoscopies”; these procedures can take place in other areas of the hospital as well
such as the emergency department, ICU, or procedure room located on a ward. The
hospital must determine all areas where surgical and invasive procedures can be
completed, and the requirements of IPSG.4 and IPSG.4.1 apply to all the identified areas
as determined by the hospital.
24 IPSG.4 Time-out and Sign-out Do the time-out and sign- As identified in the intent of IPSG.4 and IPSG.4.1, The time-out process is held
IPSG.4.1 Processes out processes require immediately before the start of the procedure with all team members present. Signatures
signatures by the surgical of the team members are not required. The requirements for ISPG.4 and IPSG.4.1 along
team, or is it okay to just with the intent provide further details of the required elements.
document the components
with tick boxes and the time IPSG.4.1, ME2 requires that the sign-out process is expected to be performed in the area
when it was done? At where the procedure was done, and before the patient leaves. This provides evidence that
present we are taking the appropriate components of the sign-out were done, and the time it was done would
signatures of the surgical verify that the sign-out was performed. The intent identifies that the four components (as
team for time-out process applicable to the procedure performed) are verbally confirmed by a member of the team,
only. typically a nurse. The standard does not specify what type of documentation is needed for
the sign-out; but a verbal confirmation of the sign-out must be completed and, at a
minimum, included) through g) of the intent. Signatures of the team members present for
the sign-out are not required.
25 IPSG.4 Preoperative Checklist For procedures done According to the intent of IPSG.4, preoperative verification is an ongoing process of
for Procedures outside the OR setting, we information gathering and confirmation. Some of the information gathered during the
do the time-out and sign- preoperative verification process is similar and purposely duplicative to what is gathered
Performed Outside the out only and the time-out during the time-out, such as the correct patient identity, procedure, and site. There are
OR Setting elements contain all other elements of the preoperative verification process that are not captured during the
elements of the time-out and should be verified prior to the procedure, such as ensuring that relevant
preoperative checklist. Do images, documents, and studies are available, and verifying that all required blood
we still need to do a products or medical equipment are available.
preoperative checklist for
procedures done outside JCI does not specify how the preoperative verification process or time-out is documented,
the OR setting? a checklist is an example of how this can be accomplished. If the hospital determines that
a single checklist or document can be used for specific procedures outside of the OR, the
document should identify the specific components of each process since they are two
separate processes.
26 IPSG.4 Surgery/ Procedural 1. If two surgeries/ 1. Per the JCI requirements, a time-out must be performed before all surgical and
IPSG.4.1 Time-Out Process procedures are invasive procedures as defined in the intent statement of IPSG.4 and IPSG.4.1 and
scheduled back-to-back, any other procedures as defined by the hospital in policy and procedure. Additionally,
are two separate time- the time-out must include all staff that will assist in the procedure and address that the
outs (sign-ins) required correct patient is receiving the correct procedure at the correct site (i.e., right versus
for the two procedures, left leg). Two separate time-outs are required for two separate procedures when
and if so, when should different surgeons are responsible for the separate procedures. For instance, if a
they occur (at the surgical procedure is begun by a thoracic surgeon and completed by a general
beginning of each stage surgeon, then when the general surgeon enters to complete the second procedure a
of the procedure, or second time-out would be required prior to beginning the second procedure. If two
collectively at the procedures will be completed in the same surgery by one surgeon, then one time-out
beginning of the first can be completed prior to the surgery and must involve all the required time-out
procedure)? Which staff elements for each procedure being completed.
should be present at
each of the time-outs? 2. If the two procedures are being completed by two different surgeons, then a time-out
What are the required would be required prior to each procedure and if one surgeon is completing both
elements for each of the procedures during the surgery, the time-out should take place immediately before the
time-outs? surgery and address both procedures to be performed. Per JCI requirements in
IPSG.4.1, the time-out must include all the staff members that will be present during
2. If the two timeouts can the procedure. The required elements that the team must address during a time-out
be combined, which are: (a) Correct patient identity (b) Correct procedure to be done, and (c) Correct
staff must be present? If surgical/invasive procedure site.
the two time-outs can
be combined, what
elements of the second
surgery must be
reviewed separately at
the first sign-in?

27 IPSG.4 Dental Surgery Site Please provide examples There are special circumstances in which making an external mark on the surgical site
Marking for marking a may not be feasible. Examples of this may be tooth extraction, oral surgery, or removal of
surgical/invasive site with an ovary. In these cases, the hospital must define how the site marking will take place, for
an instantly recognizable example, a digital mark may be placed on the X-ray or other digital imagery and then
and unambiguous mark for confirmed with the patient prior to the procedure. It is stated in the intent of IPSG.4 that the
dental surgery. site marking process must be uniform throughout the hospital.
28 IPSG.4 Site Marking in Cath Is site marking for Cath Site marking for certain interventional procedures that do not involve laterality, multiple
Lab Procedures lab procedures such as structures, or multiple levels is not required. Examples include cardiac interventions
angiography required? performed in the cardiac cath lab or interventional radiology where the insertion site may
be the "surgical site. For example, balloon angioplasty or embolization of an AVM.
However, if the procedure involves a left or right organ, such as a left or right kidney or left
or right ovary, a diagnostic image should be available to identify the specific organ
involved.
29 IPSG.4 Surgical Site Markings Can medical students IPSG.4, ME 3, requires that the site marking is done by the person performing the
perform the actual site procedure. The intent further explains specific scenarios on who can do the site marking
marking on a patient by stating the following:
while the surgeon who is • Responsible surgeon – The surgical/invasive procedure site marking is done by the
performing the procedure person who will perform the procedure. This person will do the entire
is doing direct surgical/invasive procedure and remain with the patient throughout the entire
observation of the student procedure. In cases of surgical procedures, the surgeon responsible typically
(student is acting as an performs the surgery and therefore would mark the site. There are different titles
extension of the hand of used for the responsible surgeon, such as attending or consultant surgeon.
the surgeon)? • Trainee who performs the “entire” procedure with minimal supervision – when the
trainee performs the entire procedure, requiring minimal or no supervision from the
responsible surgeon or physician. In these circumstances, the trainee marks the
surgical site. For a trainee to require minimal or no supervision, a trainee would need
to be in his or her advanced surgical training program. A trainee who is still in a
medical school and often referred to as a “medical student” would not be allowed to
mark the site. Medical students performing the procedure who requires a direct
observation by the surgeon do not qualify to mark the site.
In this circumstance, the surgeon who is observing the medical student is considered the
“responsible surgeon.” When a trainee is in the role of assisting the surgeon or physician
responsible, only the responsible surgeon or physician may perform the site marking. An
assistant surgeon may also be considered a trainee. As stated in the intent, a trainee who
performs the entire procedure with minimal supervision is allowed to mark the site.
However, when the trainee or assistant surgeon requires a higher level of supervision, the
responsible surgeon or physician is required to perform the site marking even if the trainee
performs the entire procedure.

30 IPSG.5.1 Use of Bundles Are organizations IPSG.5.1 sets forth the requirement that hospitals use evidence-based interventions to
required to use bundles? decrease the most common hospital-associated infections (HAI), such as catheter-
associated urinary tract infections (CAUTI) and ventilator-associated pneumonia (VAP).
The intent of IPSG.5.1 uses the Institute for Healthcare Improvement (IHI) definition of
bundles as “A small set of evidence-based interventions for a defined patient
segment/population and care setting that, when implemented together, will result in
significantly better outcomes than when implemented individually.”
While JCI does not require that the hospital use a specific bundle, it is required that the
hospital uses evidence-based interventions to address the priority HAIs. Based on the IHI
definition of a bundle that is utilized for this standard, the combination of certain evidence-
based interventions can be referred to as bundles. The wording in IPSG.5.1 ME 2
addresses this when it states that bundles are an example of evidence-based interventions
that can be used to prevent HAIs.
31 IPSG.6 Fall Assessment Is there any minimum policy The policy for consultation is addressed in the Standard GLD.6.2, ME 1 which states
we can implement for our that…” All diagnostic, consultative, and treatment services provided by independent
Telephone Consultations? practitioners outside the hospital, such as telemedicine, teleradiology, and interpretations
of other diagnostics, such as electrocardiogram (ECG), electroencephalogram (EEG),
Can education and fall risk pathology, and the like, are credentialed and privileged by the hospital to provide such
be included in this? services.”
Regarding the assessment of fall risk for inpatient and outpatient, the hospital determines
the process for fall risk assessment and screening. There are different components of the
fall risk assessment process that will be very challenging to perform through telephone
consultation.
Fall risk screening often involves a tool, which may include a minimal number of questions
and/or observations. If the results of screening indicate patient populations that are at risk
for falls, interventions and/or measures are implemented to reduce risk. In the outpatient
setting, screening generally provides the information needed to identify appropriate fall-risk
interventions/measures.
The organization may wish to perform an in-depth assessment following screening for
specific outpatients or situations; however, it is up to the organization to make this
determination.
Unlike fall-risk screening that can be performed by trained administrative staff, fall-
risk assessments must be performed by competent and trained clinicians.
There are examples of fall-risk screening tools as well as fall-risk assessment tools for
different patient populations that can be found in the literature. Keep in mind, as required
by IPSG.6.1, ME 1 (outpatients), the screening/assessment tools need to be appropriate
to the patients being served—for example, the tool used for screening pediatric patients
would not be the same as that used with geriatric patients.
32 IPSG.6.1 Fall Assessment My question is about IPSG.6.1 requires that outpatients are screened for fall risk. However, not all
international patient safety outpatients have to be screened given the general nature of outpatient visits. The intent
goal 6.1: regarding identifies that,
preventing harm from falls “Only those patients whose condition, diagnosis, situation, and/or location identifies them
in the outpatient unit. as at risk for falls are screened.” It is up to the hospital to identify the types of outpatients
who are screened, and this will be based on various factors, including patient population,
I would like to ask about fall the services that are provided, environmental factors, individual patients' physiological
assessment, factors, and other issues.
documentation, and
measure such as put The hospital determines the process for fall risk screening of outpatients, including the
bracelet for the patient with staff who will perform screening. If a hospital chooses to have staff at the registration desk
high risk for fall in some screen patients for fall risk when the patient arrives, the staff must be trained to screen
situations such as a patient outpatients accurately, educated in the falls management program, and understand their
who comes to submit the role and responsibilities.
pathology sample or to
blood withdraw, for a patient Fall risk screening often involves a tool, which may include a minimal number of questions
who comes to perform and/or observations. If the results of screening indicate the outpatient is at risk for falls,
some imagining such as XR interventions and/or measures are implemented to reduce risk. In the outpatient setting,
knowing that there are no screening generally provides the information needed to identify appropriate fall-risk
nurses in the unit interventions/measures.
The organization may wish to perform an in-depth assessment following screening for
specific outpatients or situations; however, it is up to the organization to make this
determination.
Unlike fall-risk screening that can be performed by trained administrative staff, fall-
risk assessments must be performed by competent and trained clinicians.
There are examples of fall-risk screening tools as well as fall-risk assessment tools for
different patient populations that can be found in the literature. Keep in mind, as required
by IPSG.6.1, ME 1 (outpatients), the screening/assessment tools need to be appropriate to
the patients being served—for example, the tool used for screening pediatric patients
would not be the same as that used with geriatric patients.
Access to Care (ACC)

1 ACC.4.1 Discharge Summary Do outpatients and ER ACC.4.2 states that a complete discharge summary is prepared for all inpatients, including
ACC.4.2 patients receive discharge content such as admission diagnosis, significant physical and other findings, diagnostic or
summaries? therapeutic procedures performed, medications administered and prescribed, status at time
of discharge, and follow up instructions.
Patients cared for and discharged from the Emergency Department, or an outpatient clinic
of the hospital are not considered inpatients, however; ACC.4 and ACC.4.1 require that
the hospital has a discharge planning and referral process that addresses the patient and
family education related to the patient’s ongoing need for continuing care and services. In
the intent of ACC.4 and ACC.4.1, discharge planning is defined as a process that helps
determine what types of continuing care and services a patient may need after leaving the
hospital.
Based on this definition and the continuity of care that is covered between inpatients,
those cared for in the ED, and outpatient clinics, the hospital should have a process to
determine what instructions the patient and family needs after discharge from the ED and
outpatient encounters. The hospital must then have a process for communicating this
information with patients and families in order to ensure that they understand how to
continue caring for themselves and maintain their necessary follow up care.
Patient-Centered Care (PCC)

1 PCC.3 Patient Experience For the PCC standard on PCC.3, ME 2 states that ”Data from the patient experience are aggregated, analyzed, and
patient experience transformed into information to identify strategies for improving the patient experience.” Net
measurement, is it Promoter Scores can be used with additional free text although the standard does not
sufficient to use a Net specify how organizations measure, aggregate, and analyze patient experience data.
Promoter Score (NPS) as
the framework for us to However, it is important that the organization identifies the patient's experience that needs
measure patient to be measured and analyzed based on the organizational needs and settings. The intent
experience as we of PCC.3 further explains that “Measuring patient satisfaction is one way to capture patient
complement the NPS experience information”. However, hospital leaders need to be aware that patient
survey with free text satisfaction is a subjective measure, while patient experience is an objective measure. For
comments? example, asking patients if they were pleased with the room layout would be a patient
satisfaction measure because preference on a room layout is subjective. Asking patients if
they have access to their health care records is a measure of patient experience because
patient data access is an objective measure. As an integral component of health care
quality, patient experience includes several aspects of health care delivery that patients
value highly when they seek and receive care, such as timely appointments, easy access
to information, and good communication with health care providers.”
2 PCC.4.1 Uniform Recording of The organization has a The intent of PCC.4.1 states that informed consent may be obtained at several points in
Informed Consent process for recording the the care process, such as upon admission or immediately prior to an invasive procedure.
informed consent for For example, informed consent can be obtained when the patient is admitted for inpatient
elective surgeries by signing care in the hospital and before certain procedures or treatments for which the risk is high.
a consent and scanning it
into the patient medical The standard does not specify the point in the patient care process when informed consent
record. However, this must be obtained as long as the consent process is obtained before the start of the
process is not followed procedure or treatment and is clearly defined in the hospital’s policies and procedures.
during emergency cases When there are different informed consent processes for different circumstances, such as
and verbal consent is in an emergency when the usual consent process cannot be followed, these process
obtained from the patient differences must also be defined in the policies and procedures. Relevant laws and
and noted in the patient regulations should also be incorporated into the policies and procedures.
record. Can this
compromise the uniform
recording of patient
consent?
3 PCC.4.3 Informed Consent The intent lists different Informed consent is a process. The process needs to include a discussion with the
Process elements in the informed patient. The elements of informed consent listed in PCC.4.3 do not need to be listed on
consent process that must the consent forms unless required by hospital policy. However, the requirement is that
be explained to the patient these elements are explained to the patient when informed consent(s) is required for the
prior to obtaining consent. treatment and procedure.
Are these elements
required to be documented When the patient consents to a surgical procedure, the patient must be informed of all the
in the patient consent elements identified in the intent of PCC.4.3, that is: patient condition, proposed treatment,
forms? potential benefits and drawbacks, possible alternatives, the likelihood of success, possible
problems related to recovery, and possible results of non-treatment. This information
needs to come from the surgeon performing the procedure. The standard does not
specifically require that this information is provided through written documentation.
Measurable element #1 states: “Patients are informed of elements a) through h) in the
intent as part of the informed consent process…” The standard and MEs do not specify
how the information must be presented to the patient. It could be provided through a
pamphlet that the patient reviews followed by a discussion with the physician, it could be
provided via an audio/visual presentation (such as on CCTV), or through a one-on-one
discussion by the physician. The hospital may choose the format in which the information
is presented. The hospital may choose to document this by making a note in the chart of
what information was provided to the patient and how it was presented. The consent can
then say that information presented to the patient has been documented in the clinical
record.
The patient also has the right to be informed about the anesthesia being used. The
anesthesiologist is responsible for informing the patient about the risks, benefits, and
alternatives of the anesthesia selected. Again, this information can be documented in the
patient record.
The process must follow the requirements identified in obtaining informed consent,
however it is up to the organization to decide whether it is in one consent form or separate
forms. If the organization chooses to use one form, the form needs to clearly identify who
informed the patient about each of those areas (i.e., surgery, anesthesia, administration of
blood products), what information the patient was given, and that the patient understood
the information.
4 PCC.5.2 Patient Education Are written educational The intent of PCC.5.2 states that the hospital decides when and how verbal education is
materials for patient reinforced with written materials to enhance understanding and to provide a future
education reinforcement educational reference.
required for theater
procedures, anesthesia and Best practices in education show that for learning to take place, the content being taught
sedation? must be reinforced multiple times, both in verbal and non-verbal interactions. In addition to
this, many factors that relate to the patient experience in the hospital such as medication
use, chronic medical conditions, and stress further increase the need for reinforcing
education with written materials. It is recommended that verbal education be reinforced for
surgical procedures and other procedures that require the use of anesthesia or sedation.
For instance, patients admitted as an inpatient post-surgery can be provided written
materials upon discharge to reinforce education about topics such as wound care, follow up
appointments, and when to call for signs of infection.
For patients undergoing an outpatient procedure, the hospital can provide written
materials that reinforce education about the procedure, follow up appointments, and the
possible side effects that may be experienced after anesthesia or sedation.
Assessment of Patients (AOP)

1 AOP.1 Minimum Content of The standards require The intent of Standard AOP.1 states that “the hospital defines, in policies, the minimum
Assessments for Each hospitals to define minimum content of assessments to be performed by physicians, nurses, and other clinical
Clinical Discipline content of assessment for disciplines”
each clinical discipline. Is it
also required to define the With regard to defining the minimum content of assessments performed at each clinical
minimum content of department, the hospital must consider situations where the content varies from other
assessments to be departments. For example, the minimum content for patient assessments in the
performed in each clinical dermatology clinic may be very different from the minimum content of assessments in the
department? cardiology clinic. In these instances, the hospital’s policies must define how these
variations are addressed.
Additionally, the intent of Standard AOP.4 states that “a patient may undergo many kinds
of assessments outside and inside the hospital by many different departments and
services.” As such, Standard AOP.4, ME 1 requires that patient assessment data and
information be analyzed and integrated.
2 AOP.1.5 Pain Assessment Could you please explain The intent of AOP.1.5 states that “When pain is identified in the outpatient setting, the
the required process for patient may be more thoroughly assessed and treated in the hospital or provided with a
providing a referral for a referral for further assessment and treatment.”
patient in pain who is seen

in an outpatient The intent also provides examples of questions that may be used in screening patients for
department? pain. These include asking if the patient is currently experiencing pain, if the level of pain is
keeping the patient from sleeping at night and from participating in any activities, and if the
patient is experiencing pain daily. In an outpatient setting, it is important to establish a pain
screening process to determine the need for patient referral. An outpatient who provided
positive answers to the organization’s pain assessment questions could indicate the need
for a more in-depth assessment of the patient’s pain. This in-depth follow-up assessment
may lead to providing the patient additional guidance to manage his or her pain, or it may
also lead to the patient being treated in the hospital. For example, an outpatient at a
Physical Therapy clinic whose pain assessment results indicated the need for further
assessment may be referred to the hospital’s pain clinic for treatment. AOP.1.5, ME.4 also
states that “The assessment is recorded in a way that facilitates regular reassessment and
follow-up according to criteria developed by the hospital and the patient’s needs.” As such,
the organization must establish specific criteria that will determine the appropriate follow up
procedures based on the initial pain assessment results.
3 AOP.1.5 Pain Assessment If pain assessment is done AOP.1.5, ME 2 states that “Outpatients whose condition, diagnosis, or situation may
for all patients as part of indicate they are at risk for pain are screened for pain.” Based on this, the hospital must
checking vital signs, do we determine which outpatient populations will require screening for pain. As defined in the
still need to perform pain intent of AOP.1.5, a screening is a very high-level process that can be performed by
screening for OPD clinicians, support staff (such as a registration clerk), or even the patient. A screening for
patients? pain may consist of one or more simple questions that can be asked during the registration
process, on an intake form completed by the patient, or may be asked and documented by
the physician referring the patient to the hospital or outpatient setting. Additionally,
AOP.1.5, ME 5 states that “when the need for additional specialized assessments is
identified, patients are referred within the hospital or outside the hospital.”
4 AOP.6.2 Maximum Radiation Is the meaning of AOP.6.2, ME 4 states that “Radiation safety includes education about dosing and
Dose "maximum dose of a study" implementation of protocols that identify the maximum dose of radiation for each type of
that radiation exposure study.” JCI does not specify the maximum doses for each type of study; Instead,
cannot exceed that limit, organizations must follow applicable professional standards, laws, and regulations which
and does it apply to patient often identify the recommended maximum doses of radiation for healthcare settings. If
dose monitoring, X-ray regional or local laws and regulations do not provide guidance, organizations may refer
machine QC and to industry standards and other published resources. Regarding the application of
calibration, and Diagnostic maximum doses for real patient monitoring, QC, and calibration, and the use of
Reference Level (DRL)? Diagnostic Reference Level, organizations must follow manufacturer requirements of the
corresponding diagnostic imaging instruments.
5 AOP.6.5 Use of PACS (Picture Is the use of Picture While JCI does not endorse or recommend a specific practice to manage the
Archive and Archive and organization’s PACS system, AOP.6.5 does require that the hospital uses a quality
Communication Communication System control process to manage the radiology and diagnostic imaging service. AOP.6.5 ME 3
System) (PACS) required to prevent
critical patient information states that “quality control includes regular surveillance and documentation of imaging
from being swapped in the results.”
archive system?
In relation to the question about imaging results or patient information being easily swapped
in the system, putting together a process where qualified staff complete regular surveillance
of imaging results can potentially identify this possible swapping of patient information.
While JCI does not endorse any specific practice to manage a PACS system, the following
is a link to an executive summary and guidance document on the technical and quality
management requirements for PACS systems:
https://www.nccoe.nist.gov/sites/default/files/library/sp1800/hit-pacs-nist-sp1800-24-
draft.pdf.
6 AOP.6.5 Quality Control • ME 1 - are "quality AOP.6.5, ME 1 – The intent of Standard AOP.6.5 contains a bullet point list that
Procedures control procedures" describes what should be included in the hospital’s quality control procedures for
limited to equipment diagnostic imaging. Examples given in this list include validation of the test method,
only, or are they regular surveillance of imaging results, and testing of any reagents or solutions when
dedicated to quality of used. Based upon the items in this list, the quality control procedures listed in AOP.6.5,
services/imaging ME 1 relate to both equipment and the quality of services/imaging results.
results?
• Does ME.3 require AOP.6.5, ME 3 – JCI does not specify how the regular surveillance of imaging results
conducting a must be completed. It is described in the intent of AOP.6.5 that qualified radiology staff
surveillance of image should complete this regular surveillance, for example, specific radiologists qualified to
interpretation /findings read radiology results may randomly review a representative sample of both low
reported by radiologist frequency, high-risk imaging results/reports and high-frequency, low risk imaging results
in the form of a Known and reports to ensure consistency in the reported results and imaging modality. The
Performance Indicator hospital does not necessarily need to make this data into a KPI to the hospital leadership
(KPI), for example, a but may choose to make it a Known Performance Indicator (KPI) for the radiology
KPI for monitoring department.
incidents where there's
a difference between AOP.6.5, ME 5 – JCI does not specify whether the correction and documentation of
the preliminary and final deficiencies needs to be made a KPI. The hospital may choose to develop a KPI
report? regarding this if review of the documentation shows that a specific exam is repeatedly
• Does ME.5 require being corrected or re-run, for example, repeat head CT angiography (CTA) exams.
maintaining a KPI for Making this into a KPI can help the radiology department to understand what is leading
monitoring identified to the need for repeat CTA such as the issue being due to improper contrast
deficiency of the quality administration technique.
of the image (i.e., a KPI
for monitoring incidents
where a radiologist asks
to repeat a CT scan test

to obtain a better
image)?
Care of Patients (COP)

1 COP.3.1 Clinical Alarm What is the expectation of The amount of data required and the timeframe for the data will depend on the
Management the data from medical specific medical devices that are being reviewed.
devices on which alarms
are causing false alarms? The intent of COP.3.1 states that the hospital coordinates with the medical leadership of
each area to understand which alarms pose risks if ignored. The hospital can then gather
data from those devices to determine which alarms happen most often. For instance,
medical devices more commonly used, such as cardiac monitoring will have much more
data related to alarms than something less frequently used; therefore, the hospital wouldn’t
have to gather as long a timeframe worth of data to have enough information to guide the
team.
2 COP.3.1 Clinical Alarm For clinical alarms, is the For units that utilize centralized monitoring, for example, monitoring patient’s heart rate in
Management presence of a central an ICU and then having a centralized set of monitors in the nursing station, JCI does not
monitor technician require that a central monitoring technician be hired. COP.3.1, MEs 4 and 5 state that
mandatory for units with staff utilizing monitoring technologies are trained and competent to do so; therefore, if
both central monitoring centralized monitoring is used, the staff on the unit must be trained to operate and
and decentralized respond to the presence of clinical alarms.
monitoring?
3 COP.3.1 Clinical Alarm Is an alarm management JCI does not require that hospitals hire a specific person to act as an alarm management
Management technician mandatory for technician to be compliant with the measurable elements of COP.3.1. It is recommended
hospitals that have both that staff working in the decentralized monitoring area (such as central telemetry
centralized and technicians) be included in the team that manages the clinical alarms management
decentralized alarm program because they are responsible for responding to many clinical alarms throughout
management systems? the hospital.
4 COP.3.1 Clinical Alarm Does this include the Nurse call bells could be included in the alarm management program. While nurse call
Management Nurse call bells? bells are not alarms for physiologic monitoring, they are a way for patients to call for help;
thus, alarm fatigue in relation to nurse call bells may also lead to patient harm.
5 COP.3.1 Data for Clinical Alarm What types of data needs to The intent of COP.3.1 outlines considerations that can be helpful in determining alarm
Management be collected in establishing signals that may pose a risk to patient safety. These considerations include input from the
our clinical alarm medical staff and clinical departments, data from medical devices on which alarms are
management program? causing false or nonactionable alarms, and potential for patient harm based on internal
incident history. For example, when medical devices cause a high incidence of false or
nonactionable alarms, staff may assume that the alarms are unlikely to represent any
actionable clinical event and potentially silence the alarms or modify the parameters
inappropriately.

This data and information would be important for an organization to understand to identify
strategies to reduce the risk of harm. Incident reports related to clinical alarms and data
from alarm manufacturers should provide useful starting points in gathering data for
establishing an alarm system management program. In establishing the program, the
organization may identify additional data that would be helpful in specific clinical units. This
additional data may be discussed during the survey even if they are still under progress for
integration in the organization’s clinical alarm system management program.
6 COP.3.1 Clinical Alarm Do the standards cover Standard COP.3.1 focuses on managing clinical alarm systems used for patient care.
Management equipment with alarms in These clinical alarms include all patient physiologic monitoring and patient care
the laboratory, or only equipment alarms such as cardiac monitor alarms, fetal monitors, apnea alarms, cell-
medical salvaging devices, elopement alarms, infusion pump alarms, ventilator alarms, pulse
equipment/devices used oximeters and emergency assistance alarms. Most alarms used in the laboratory are used
for direct patient care? for laboratory equipment and performing laboratory procedures. These alarms may be
considered part of the laboratory equipment and should be maintained according to
manufacturer’s instruction and laboratory policies. In maintaining alarms used in the
laboratory, standard AOP.5.5 states that “All equipment used for laboratory testing is
regularly inspected, maintained, and calibrated, and appropriate records are maintained
for these activities.”
7 COP.3.5 Self-Harm Risk Please elaborate on JCI does not specify which areas of the hospital require patients to be screened for
Assessment what areas other than suicide risk; the Psychiatric ward, the Emergency Department, and the Labor
Psych unit, ED and Ob- &Delivery/Post-Partum units are given as an example in the intent. The hospital
gyn would need attention determines, based on its patient population and services offered, which areas should use
for suicidal or self- harm screening for suicide risk.
risk assessment
8 COP.3.5 Suicide Risk Do you have any COP.3.5, ME 2 states that “The hospital uses evidence-based tools to assess patients for
Assessment recommendation for suicidal ideation based on established criteria. Patients who screen positive, are identified
screening tools to assess as “at risk” for suicide and/or self-harm based on the established criteria.” JCI does not
suicide risk in patients? endorse a specific tool. The hospital must determine which tool best suits the patient
population that it intends on screening. Examples of evidence-based, validated screening
tools include, the Ask Suicide-Screening Questions (ASQ) toolkit developed by the
National Institute of Mental Health, and the Columbia Suicide Risk Scare C-SSRS
assessment tool.
9 COP.4 Use of Protective In our hospital a laser is Standard COP.4, ME 5 states that “Personal protective equipment appropriate to the type
Equipment for used for vascular surgery. of lasers and optical radiation devices and type of procedures is available for staff and
Lasers The laser is switched on in patients, and staff use it correctly and ensure that patients are protected during procedures.”
the vein and switched off The standard does not specify the type of laser procedures that would make the use of
before leaving the vein. Are goggles necessary. However, best practices and literature always recommend the use of
personal protective equipment (including goggles) when lasers are being used. For
goggles necessary in this example, using personal protective equipment at all times when using lasers could prevent
situation? potential harm in situations where lasers were accidentally switched on while not in use, or
left on after completion of the procedure.
10 COP.4 Management of In the case of Laser The intent of COP.4 provides examples of administrative and engineering controls that
Lasers Soldering Machine, which promote safety and prevent injury with the use of laser technologies. The standards do not
runs a laser in a controlled specify these engineering controls and room requirements because of various laser
environment inside the technologies that are available and use in different organizational settings. It is up to the
machine, with built-in organization to identify these safety measures to ensure that the hospital’s program for the
coolant controls, do we still safe use of lasers and optical radiation devices is based on manufacturers’
need to meet the general recommendations, industry standards and professional guidelines, and complies with
room and interlocking applicable laws and regulations per COP.4, ME 1.
requirements of laser
standards?
11 COP.4 Management of Which equipment and Standard COP.4 states that “The hospital establishes and implements a program for the
Lasers technologies are safe use of lasers and other optical radiation devices used for performing procedures and
included in the scope of treatments.”
the laser management
programs? The intent of the COP.4 standard also states that “The use of lasers is becoming more
common in health care as laser technology evolves and the clinical applications broaden.”
The intent describes For this reason, the standard does not specify which equipment and technologies should
lasers as a source of be part of the program. While the intent of COP.4 provides examples of procedures and
optical radiation, which treatments that may use laser technology and optical radiation, it is up to the organization
includes ultraviolet to identify their own equipment and technologies where standard COP.4 would apply.
radiation, high-intensity
visible light, and infrared For other radiation equipment and technologies where COP.4 may not be applicable, such
radiation. as for ionizing radiation used in brachytherapy, Magnetic Resonance Imaging, and nuclear
Are Ionizing Radiation, medicine scans for example, standard AOP.6.2 states that “A radiation and/or diagnostic
commonly used in imaging safety program for patients, staff, and visitors is in place, is followed, and is
Brachytherapy, included compliant with applicable professional standards, laws, and regulations.”
in the program’s scope
and are Healthcare organizations should always determine potential risks to patients, staff, and
biophotomodulation visitors when developing programs, policies, and procedures to meet the standard. As
equipment (LEDS) such, the intent of AOP.6.2 also states that “The safety program reflects the risks and
considered as optical hazards encountered and addresses safety practices and prevention measures for
radiation? radiology and diagnostic imaging staff, patients, and visitors.”
12 COP.8.5 Informed Consent Please clarify the informed Standard COP.8.5, ME 1 requires that the transplant program follows the hospital's policy
from Transplant consent process for when obtaining informed consent from transplant candidates. The requirements for
Candidates transplant candidates, and informed consent for the hospital are found in PCC.4.1. Standard PCC.4.1 states that the
the intent for MEs 2-6. hospital must develop a uniform process for obtaining informed consent that is carried out
Additionally, does this by staff who are trained to do it in a manner and language that the patient understands. The
information need to be standard does not require a written process; however, the standard does require that there
documented in the medical is uniform documentation of the process for obtaining informed consent in the patient
record, or just be verbalized medical record. Many hospitals choose to use a written process which clearly demonstrates
to the patient? the information provided to patients, the patient's permission as evidenced by a signature,
and a uniform recording of the process.
MEs 2- 6 of Standard COP.8.5 are the required additional processes and information that
are specific to the transplant program. For example, COP.8.5, ME 3 requires additional
information to be provided that is specifically related to the transplant factors which are
identified in the intent. Like the hospital's requirements for informed consent, there is
nothing in the standard that requires this information to be written into a formal document.
However, the surveyors will look for evidence that this process occurs. For example, they
may interview patients and/or families to determine what information they received; they
may question staff about the process, including what information is provided; and/or they
may review the medical record to determine how the informed consent process was
recorded.
13 COP.8 Bone Marrow If a hospital only performs The Organ and Tissue Transplant standards are meant to address both solid organ as well
COP.9 Transplant bone marrow transplants, as relevant tissue transplants. Some tissue transplants present very little risk to the patient.
how would COP.8 and For example, a corneal transplant does not involve living donors, and is at very low risk of
COP.9 standards apply? rejection and has a very high success rate. On the other hand, bone marrow transplant
involves living donors and presents potential risks to the donor as well as the recipient. As
an example, the literature identifies that the one-year survival rate is an important factor
because the first year is the period when complications of a stem cell transplant are most
likely to happen. Therefore, as identified in COP.8.5, ME 4, it would be important to include
the expected one-year survival rate in the informed consent. The literature also identifies
that a complication of bone marrow transplant is "graft-versus-host disease."
As identified in COP.8.5, ME 5, providing the potential transplant recipient with potential

rejection rates, along with other relevant information is an important aspect of the informed
consent process. While stem cells are not considered "organs", there are expectations
related to the suitability of the donor and the match to the recipient. The literature identifies
criteria for being a donor and excludes, for example, people with diseases defined as
autoimmune disorders, such as multiple sclerosis, systemic lupus, chronic fatigue
syndrome and fibromyalgia. Therefore, there are some general requirements from standard
COP.8.6, that would apply - such as ME 1 that requires CPGs related to donor data and
recipient data to ensure compatibility before retrieval of stem cells; ME 2 that requires
ensuring the medical suitability of the donor; and ME 4 that requires confirming the donor
was tested and is free from infectious diseases and malignancies.

There are potential risks to the stem cell/bone marrow donor. When bone marrow is
harvested via a surgical procedure – generally aspiration of marrow from the donor’s hip –
there are risks to the donor. Risks are related to undergoing a surgical procedure such as,
the risk of anesthesia, the risk of surgical site infection, etc. In addition, the donor may
experience pain for days following the procedure and may have interruptions in their daily
activities. The donor has a right to understand all these risks, as well as have an advocate
that supports them, should they decide not to donate. In addition, as mentioned above, the
literature identifies criteria for accepting bone marrow from a donor, therefore standard
COP.9.2 applies. Finally, a bone marrow donor who has undergone a surgical procedure
for collection of bone marrow should have a care plan that guides their care and treatment
following their procedure requirements. With respect to stem cell donation (which is a form
of bone marrow donation) – generally, the stem cells are collected via a process that is
similar to donating blood. In this type of donation, the rigor of the COP.9 standards may not
be necessary; however, the donor should still be provided with information about the
process and provide consent. These are examples only and are not all-inclusive of the
standards and MEs that would pertain to bone marrow donor and transplantation.
Anesthesia and Surgical Care (ASC)

1 ASC.3 Definition of Procedural Are minimal There are multiple references in the ASC chapter that discuss the continuum of sedation
Sedation sedation/anxiolysis included that begin with mild sedation. The overview of the ASC chapter states: "Anesthesia and
in the definition of procedural sedation are commonly viewed as a continuum from minimal sedation to full
procedural sedation and anesthesia along which the patient gradually loses their reflexes to protect their airway,
therefore subject to the such as coughing and gagging." The overview goes on to state: "This chapter does not
same standards as address the use of sedation for the purposes of anxiolysis or sedation required in the ICU
moderate sedation? for ventilator tolerance."
In addition, the intent of ASC.1 states that "Sedation and anesthesia are commonly viewed
as a continuum from minimal sedation to full anesthesia. A patient’s response may move
along that continuum during which the patient’s protective airway reflexes are at risk." The
intent of ASC.3.2 supports this by stating again: "The degrees of sedation occur on a
continuum from mild to deep sedation, and a patient may progress from one to another."
Lastly, ASC.3 goes on to say, after the definition, that "Regardless of the medication, dose,
or route of administration, when a medication is used for the purposes of altering the
patient's cognitive state in order to facilitate a specific procedure, it is considered
procedural sedation." The requirements identified in the ASC standards related to
procedural sedation are expected to be applied to what health care practitioners identify as
"mild sedation" when used for the purposes of allowing a patient to tolerate a painful or
unpleasant procedure.
Small doses of Chloral Hydrate intended for use as an anxiolytic prior to anesthesia and
surgery do not fall under procedural sedation. However, when Chloral Hydrate is
administered, particularly in children, with the intent to allow the patient to tolerate an
unpleasant procedure (commonly used to sedate the child for a CT or MRI), it is
considered procedural sedation and all standards/expectations for procedural sedation
apply.
2 ASC.3 Administration of Can minimal monitoring for The intent of ASC.3 states that the administration of procedural sedation must be uniform
Procedural Sedation sedation requirements be throughout the hospital and those hospitals must develop specific guidelines for how and
different in a section of the where procedural sedation may be used. Hospital policies and procedures must describe
hospital if it is supported by the standardization of procedural sedation. Regarding monitoring for sedation, ASC.3.2
a credible internationally requires that “procedural sedation is administered and monitored according to
accepted guideline? professional practice guidelines.”
Policies and procedures must describe the monitoring process for wherever procedural
sedation is provided throughout the hospital based on the professional practice guidelines.
In addition, the individual responsible for providing the monitoring must be competent in
monitoring requirements, response to complications, use of reversal agents, and recovery
criteria per ASC.3.2, ME 2. 2.
3 ASC.3 Immediate Availability When a sedated patient is The intent of ASC.3 states that “standardization of procedural sedation is supported by
of Medical Equipment being transported to policies and procedures that are understood by all practitioners permitted to administer
During Procedural another service, the procedural sedation and identifies the immediate availability and use of specialized
Sedation “immediately available medical equipment, appropriate to the age and history of the patient.” In addition, ASC.3
equipment” during the ME 3 states that “emergency medical equipment and supplies are immediately available
transport may not be and customized to the type of sedation being performed and the age and medical
immediately available. Can condition of the patient.”
it be considered “available”
within the reach of code Patients who have recently undergone procedural sedation are at a heightened risk for
team (below 5 minutes)? respiratory compromise, even during transport, and therefore the emergency medical
equipment needed to resuscitate the patient must be immediately present. For instance,
the team transporting the patient should have a staff member trained in advanced
resuscitation and have a bag or other means of bringing this emergency equipment with
them during transport.
4 ASC.3 Advanced Life Support Is the Pediatric Emergency ASC.3, ME 4 states that “an individual with advanced life-support training appropriate for
Training for Assessment, Recognition the age and history of the patient, is immediately available when procedural sedation is
Administration of and Stabilization (PEARS) being performed.”
Procedural Sedation course offered by AHA
acceptable as advanced The intent of ASC.3 requires that those staff members permitted to administer procedural
life support training? sedation must have special qualifications and skills; therefore, they must have sufficient
experience with the patient population that they care for, such as pediatric patients. In
relation to the PEARS course provided by the American Heart Association, the course is
intended for physicians and nurses that do not specialize in the care of pediatric patients.
PEARS training ensures an individual understands how to recognize and manage pediatric
emergencies. A PEARS class teaches the trainee how to provide support during the
treatment of sick or injured pediatric patients. However, PEARS training does not prepare
an individual to lead advanced life-support resuscitation as a course such as PALS would
provide and as is required by ASC.3, ME 4.
There are many courses in pediatric life support provided through the American Heart
Association and other professional associations that are designed for physicians and
nurses who specialize in the care of pediatric patients and provide the required advanced-
life support training.
5 ASC.3 Procedural Sedation Procedural sedation is defined as “A technique of administering sedatives or dissociative
Is the administration of IV agents with or without analgesics to induce a state that allows the patient to tolerate
valium for “anxiolysis” by unpleasant procedures while maintaining cardiorespiratory function.”
non- anesthesiologists in
an outpatient setting The situation described is considered procedural sedation and all related standards to
considered “minimal procedural sedation apply. As stated in the Intent of Standard ASC.3, “Regardless of the
sedation”? If so, do the medication, dose, or route of administration, when a medication is used for the purposes of
standards of “procedural altering the patient’s cognitive state in order to facilitate a specific procedure, it is
sedation” not apply? considered procedural sedation.”
Standard ASC.3.2 also describes the levels of sedations not in terms of the medications
used but in terms of the patient’s ability to protect and maintain a patent airway. The Intent
of Standard ASC.3.2 also states that “Patients undergoing procedural sedation require
monitoring of their level of consciousness, ventilator and oxygenation status, and
hemodynamic variables at a frequency based on the type and amount of medication
administered, the length of the procedure, and the type and condition of the patient.
Important considerations during the sedation procedure include the patient/s ability to
maintain protective reflexes; an independent, continuous patent airway; and the capability
to respond to physical stimulation or verbal commands.”
6 ASC.7.2 Operative Report For ASC.7.2, ME 3 ,3, what ASC.7.2, ME 3 states that “The surgical report, template, or operative progress note is
is considered the “next level available immediately after surgery before the patient is transferred to the next level of
of care” in relation to “The care.” When discussing the next level of care in the intent, it is stated that “To support a
surgical report, template, or continuum of postsurgical supportive care, the information about the surgery is recorded in
operative progress note is the patient’s medical record immediately after surgery, prior to the patient being transferred
available immediately after from the surgical or the post-anesthesia recovery area.” The use of the word “or” denotes
surgery before the patient is that for the purposes of this standard and ME, the PACU is considered an extension of the
transferred to the next level OR.
of care.”
Medication Management and Use (MMU)

1 MMU.1 Uniform Medication Please explain The hospital must have a process for distributing medication from the main pharmacy to
Dispensing expectations for “uniform the wards and other patient care areas that is uniform. Using a uniform process for all
medication dispensing areas will help to reduce errors and ensure that the correct medication is delivered to the
and distribution correct area for the correct patient.
systems”?
Likewise, there should be a uniform or standardized process for dispensing medications on
each ward or unit to patients. Using a standardized process can help to reduce error and
ensure that the correct dose of the correct medication is given to the correct patient
through the correct route and the correct time. For example, the hospital may choose to
use an automated medication dispensing system on the wards and units that interfaces
with the electronic medical record in order to decrease medication error. Or, if using a
manual system, a standardized process should be followed to ensure that staff trained to
administer medications complete the appropriate checks prior to administration. To support
this, the use of pre-packaged and pre-labeled medications has been shown to reduce the
risk of medication administration errors. For instances where medications are prepared
and not immediately used (such as preparing medications from multi-use vials into
syringes and sterile basins in the operating theater or procedural areas) these medications
must be labeled with the required elements defined in the hospital policy and MMU.4.2.
2 MMU.3 Medication Labeling in Do we need to place the MMU.3 provides guidance for organizations on how medications should be stored. As
Pharmacy label of "Name of the mentioned in the intent of MMU.3, medications must be stored in places determined by
Medication" in the bottom the organization that are suitable to product stability and labeled in such a manner that
or beside for each facilitate the staff’s ability to ensure that the correct medication, dose, and route, are
medication cupboard in given to the correct patient at the correct time as required in MMU.4.1 ME 4. It is not
the pharmacy? required that medication drawers be labeled in any specific manner; therefore, the
organization must determine how to best label medication drawers in the areas where
medications are stored. MMU.4.1 ME 3 requires that the organization has a uniform
process for dispensing and distributing medications in the most ready-to-administer form
as possible. It is important that all individual vials, packages, and other dosages of
medications are labeled in such a way that the staff administering medications can easily
identify the medication, dose, route, and any other special considerations such as
whether the medication is a high-alert or look-alike sound-alike medication.
3 MMU.3.1 Access to Emergency How can organizations Standard MMU.3.1 requires that hospitals provide quick access to appropriate emergency
Medication Cart properly secure medications based upon the location and services provided.
emergency medications
and be available for quick MMU.3.1 ME 3 further states that “access to emergency medications does not require a
access during specific individual or keys to unlock the emergency cart.” In the case of an emergency, if
emergencies? the specific individual or the keys to unlock the cart are not immediately available, there
may be a significant delay in accessing the necessary resuscitation medications that could
result in a poor outcome. An example of how the hospital might store the medications in a

ready to access manner would be in a designated drawer in the unit’s emergency cart or in
an emergency box with a breakaway lock rather than a key lock.
4 MMU.3.1 Emergency Medication What do you mean by Standard MMU.3.1 addresses the accessibility of emergency medications, including
for Pediatric Patient Emergency medication emergency pediatric medications. While common emergency medications used in
for pediatric patients? pediatric resuscitation are not different than those used in adult resuscitation, the dosage
is often different, and weight based. Pediatric medications may also require a different
concentration whereas adult medications are generally given by dose.
JCI does not require that hospitals have a designated pediatric emergency cart; however,
if the hospital does care for pediatric patients, emergency medications for pediatric
patients should be readily available. If the hospital does not have specific pediatric
emergency carts, the intent of MMU.3.1 gives the example of designating a specific drawer
in the adult emergency cart. This designated drawer allows for the storage of medications
and other emergency equipment needed for care and dosing in a standardized manner to
prevent errors in emergency situations.
5 MMU.3 Disposal of Narcotics What are the recommended JCI does not specify how hospitals must dispose of narcotics. Standard MMU.3, ME 2
methods for proper disposal addresses the security, storage, and accountability of controlled substances and identifies
of narcotics? that an organization must follow the country’s applicable laws and regulations. The intent
of standards FMS.7 through FMS.7.2 identifies pharmaceuticals as a category of
hazardous materials and addresses the requirement for the organization to have a
process for the proper disposal of hazardous waste in a safe and legal manner. The
organization may consider including narcotics and controlled substances as part of the
hazardous waste plan.
The most common and least costly method cited in the literature is to flush or expel partial
excess narcotic doses down a drain (sewerage). Some organizations have wasted the
excess into a needle box; however, this method is not considered to be tamper-proof.
Professional organizations such as Institute for Safe Medication Practice (ISMP), the
WHO, and other regional professional organizations may identify acceptable practices for
disposal of narcotics.
6 MMU.4 Medication List Should we provide a list of Standard MMU.4, ME.2 states that “the patient’s medical record contains a list of current
medications that includes medications taken prior to admission or registration as an outpatient, and this
new medications and information is made available to the patient’s health care practitioners and the pharmacy
previously prescribed as needed.”
medications a patient
should continue to take, or Standard MMU.4, ME 3 also states that “Initial medication orders are compared to the list
is it sufficient to keep this of medications taken prior to admission, according to the hospital’s established process.”
information only in the
patient’s electronic medical When patients are taking medications prior to admission, proposed new medication orders
record where medical should be compared against the list of medications the patient is currently taking. After this
providers can check them process of medication reconciliation, the patient’s medical record should be updated to list
easily? all medications taken prior to admission and the list of all medications that the patient
should continue to take including those that were newly prescribed while inpatient. The
goal of this review process is to improve the quality and safety of adding a new medication
to the patient’s treatment plan and reduce the risk of an adverse medication event.
A listing of all current medications is recorded and should be made available to the
pharmacy, nurses, and physicians. While a patient is an inpatient, they should also be
informed of the medications that are being administered to them but there is not a
requirement to provide a written list to the patient while they are in the hospital. However,
as identified in ACC.4.1, MEs 2 and 3, upon discharge from the hospital, patients are
provided with a complete list of medications to be taken at home and they are educated
about the safe and effective use of all medications.
7 MMU.4 Medication please clarify Medication samples are prescription medications packaged as one or more dosage units
Reconciliation definition of sample by a manufacturer or distributor in accordance with local laws and regulations. A
medications. medication sample is not intended to be sold and is intended to promote the eventual sale
of the medication.
8 MMU.4 Medication We have CPOE in our Standard MMU.4, ME.2 states that “the patient’s medical record contains a list of current
Reconciliation institution but only for medications taken prior to admission or registration as an outpatient, and this information
inpatient units and some is made available to the patient’s health care practitioners and the pharmacy as needed.”
daycare units, but
outpatient areas are Standard MMU.4, ME 3 also states that “Initial medication orders are compared to the list
manual prescription. What of medications taken prior to admission, according to the hospital’s established process.”
is the best way in a busy
outpatient clinic to perform Inpatient and outpatient settings that use manual prescription processes may pose an
medication reconciliation? added challenge for medication reconciliation. As such, it is critical that the organization
establish a process to keep patient profiles updated.
Proposed new medication orders should be immediately compared against the list of
medications the patient is currently taking. After this process of medication reconciliation,
the patient’s medical record should be updated to list all newly prescribed medications and
the list of all medications that the patient should continue to take. The goal of this review
process is to improve the quality and safety of adding a new medication to the patient’s
treatment plan and reduce the risk of an adverse medication event.
As described in the intent, Joint Commission International recognizes that it can be difficult
to obtain a complete medication list from every patient in an encounter, and accuracy is
dependent on the patient’s ability and willingness to provide this information. The intent
further explains that a credible effort to collect this information is recognized as meeting the
intent of the requirement. Examples of a credible effort may include contacting the patient’s
pharmacy and/or family members or consulting with the patient’s primary physician.
9 MMU.4 Medication Currently we have manual The intent of Standard MMU.4 highlights medication reconciliation as a critical safe
Reconciliation prescriptions, can you give medication management process for reducing risks for adverse events. The standard does
some examples for how to not specify areas where medication reconciliation between physicians and other
achieve medication healthcare providers are required. However, medications are prescribed in many areas of
reconciliation in outpatient/ the hospital. As such, medication reconciliation between physicians and other healthcare
ambulatory care setting? providers should be conducted in all areas where medication prescription occurs which
Home meds recorded by includes outpatient clinics and the emergency department. There are specific situations in
physician are not in the which a targeted medication review can be completed. For example, when contrast media
information of pharmacist is being administered in a diagnostic imaging organization, there is the potential for
interactions with drugs the patient may be taking, such as drugs that may enhance the
renal effects of contrast media, drugs that may enhance allergic-type reactions to contrast
media, or drugs that may interfere with the hematological effects of contrast media. The
pharmacist is not specifically identified as the person that needs to complete all medication
reconciliation. In the example listed of the outpatient/ambulatory setting, the reconciliation
process can be completed by a physician, nurse, or other trained staff member. Standard
MMU.5.1 describes the appropriateness review process, which is more detailed and is
completed by the pharmacist. MMU.5.1, ME 4 states that the full appropriateness review
process must be completed within 24 hours when a designated professional is not
immediately available to complete the review.
Additionally, Standard ACC.4.3 describes the information that is required to be in the

outpatient profile, part of this information is documentation of the medication
reconciliation process.
10 MMU.4 Medication On MMU, what As described in the intent of MMU.4, Joint Commission International recognizes that it can
Reconciliation information/ details should be difficult to obtain a complete medication list from every patient in an encounter, and
be documented to prove accuracy
that a "credible" effort was is dependent on the patient’s ability and willingness to provide this information. The intent
done? further explains that a credible effort to collect this information is recognized as meeting the
intent of the requirement. Examples of a credible effort may include contacting the patient’s
pharmacy and/or family members or consulting with the patient’s primary physician.
The hospital can document this credible effort in situations where all the required
information cannot be gathered. The hospital can then decide about the safety of
administering the medications based on the information that has been obtained.
11 MMU.4 Medication Does the medication The intent of Standard MMU.4 highlights medication reconciliation as a critical, safe
Reconciliation in reconciliation between medication management process for reducing risks for adverse events. The standard
Physician and other does not specify areas where medication reconciliation between physicians and other
Outpatient healthcare provider only healthcare providers are required. However, medications are prescribed in many areas of
Departments apply to Inpatient the hospital. As such, medication reconciliation between physicians and other healthcare
Admission or does it also providers should be conducted in all areas where medication prescription occurs which
apply to the emergency include outpatient clinics and the emergency department.
departments and outpatient
clinics?
12 MMU.4 Medication When physician and The standard does not require an additional medication reconciliation by nurses prior to
Reconciliation Prior to pharmacist are reconciling administration. However, standard MMU.6.1 includes specific measurable elements that
Administration medications upon initial require the hospital to establish a medication administration process to verify that the
orders, is it required for medication is correct based on the medication prescription or order. The intent of MMU.6.1
nurses to also reconcile also outlines items to verify for safe administration of medications.
before administration?
These include verifying the medication with the prescription or order, time and frequency
of administration with the prescription or order, dosage amount with the prescription or
order, route of administration with the prescription or order, and identity of the patient.
13 MMU.4 Information Needed to The intent of the MMU 4 Standard MMU.4, ME 1 state that “The hospital identifies the information needed to
Reconcile Current and states that “The types of reconcile current and newly ordered medications.” The intent of Standard MMU.4 also
Newly Ordered information that clinicians states that “The types of information that clinicians use to reconcile medications include,
Medications use to reconcile but are not limited to, medication name, dose, frequency, route, and purpose.”
medications include, but
are not limited to, The term “purpose” is actually meant as the “indication” for the medication. For example,
medication name, dose, when ordering paracetamol, it would be important to identify if the intent is to reduce fever
frequency, route, and or to control pain. This also becomes important during the appropriateness review when an
purpose.” What does additional medication is ordered that may have the same indication. For example, ordering
purpose mean? morphine sulfate for pain when the patient currently has an order for paracetamol. The
intent further states that “Organizations should identify the information that needs to be
collected to reconcile current and newly ordered medications and to safely prescribe
medications in the future.”
Identifying the purpose (or indication) against each current medication is not required.
Instead, it is up to the organization to identify all information to be collected to ensure a
safe and accurate medication reconciliation process as per Standard MMU.4, ME 1. The
organization’s process should include a review of a proposed new medication against the
list of medications the patient is currently taking in a manner that will identify and reduce
the risk of an adverse medication event.
14 MMU.4 Electronic and Manual Can we use a manual Standard MMU.4 outlines requirements for medication reconciliation as an important
Reconciliation Forms document attached to the process of safe medication management. The measurable elements of MMU.4 address
electronic medical records, specific required steps in which organizations must comply for a safe medication
or must there be one reconciliation process. The process can be utilized with electronic or non-electronic
standardized electronic systems or both. Often, as organizations begin their conversion from paper records to
process for medication electronic records, they may need to use a combination of both. The JCI standards do not
reconciliation? limit organizations to using only one or the other if the documentation provides a safe
patient care process for meeting the requirements of the standards.
15 MMU.4 Medication The intent of MMU.4 MMU.4 focuses on the medication reconciliation process for initial orders prior to
Reconciliation suggests that this standard admission as an inpatient or registration as an outpatient. The standard does not
is to be applied during specifically require a full medication reconciliation during transfers of care within the
"initial" encounters hospital. Medication reconciliation can be addressed in standard ACC.3 MEs 1,3, & 5.
(admission, outpatient Specifically, ACC.3, ME 5, mentions that a summary of information transferred with the
visits). Since managing patient should contain items f) through l) of the intent. Item j) in the intent is medications.
medication during inpatient This concept can also be addressed via IPSG.2.2, which describes handover
transitions and discharge communications being:
are addressed in other 1. Between health care practitioners
standards, can medications 2. Between different levels of care within the hospital (such as ICU to med surg, OT to
during transition be recovery, emergency department to ward, etc.)
addressed in ACC 3, ME 1 3. From wards to diagnostic or treatment areas within the hospital
and ME 3, and discharge 4. Between staff and patients/families
meds in ACC 4.1?
16 MMU.4.2 Required Elements of a Are “indication” and There is a difference between letter c) of the intent of MMU.4.2, which requires additional
Complete Order or “maximum dose” required information for use to be included in orders for PRN medications that is different from
Prescription in every prescription? Measurable Element 2 of MMU.4.2 which states that the maximum dose is required in all
medication orders. Additionally, the wording in the intent statement “all orders and
prescriptions contain the name of the drug, the dose, and the frequency and route of
administration” does not match the requirements in MMU.4.2 ME 2.
The expectation for PRN medications represents a special set of medication orders and
therefore, adding the additional information about maximum dose is necessary to help staff
safely administer these medications. For example, if the patient has multiple PRN
medications for pain such as acetaminophen and Norco (or other narcotic/acetaminophen
combinations) listing the maximum dose of acetaminophen is important.
Joint Commission International has issued an errata and updated the 7th Edition of the
Accreditation Standards for Hospitals to address this clarification. The errata are available
on The Joint Commission website and can also be accessed through the following link:
Errata to JCI Accreditation Standards for Hospitals, 7th Edition
17 MMU.4.2 Complete Medication We have some medicines JCI states in the intent of MMU.4.2 that errors in medication orders account for
Order that include tablets, and approximately 50% of medication errors.
the concentration of the
tablet is 200 mg, and the
doctor wants a dose of 600 In response to the example listed in your question, the order should be written in a way that
mg. What is the safest way clearly defines the dose, which is one of the key medication order elements that are listed
to write the medicine? in MMU.4.2 ME 2. For instance, with orders that are written referencing pills or vials, the
specific dose of the pills or vials should be listed as well in order to prevent an error. There
Is it to write 3 pills (200 X3) could be a situation where a specific medication is stocked in both 200 mg and 400 mg pills
or just write the dose 600 and if the total dose ordered is 600 mg, the order should be written in such a way as to
mg and the nursing gives 3 indicate that 3 of the 200 mg pills are needed to deliver the full dose of 600 mg.
pills?
It should be noted however, that the standard and ME do not require that an order specify
the number of pills or vials, only that it specifically state the dose of the medication.
Organizations are encouraged to develop policies/procedures that specify the safest way
in which to write medication orders.
18 MMU.4.2 IV Medication Order Should all IV medication The intent for Standard MMU.4.2 identifies the elements of a complete order or
orders include rates? prescription and letter f) of the intent states that when intravenous infusions are ordered,
the rate of administration needs to be specified. How the rate of administration is stated in
an order can vary depending on the route or type of medication, and the writing style of the
prescriber. Examples of how the rate of administration can be stated in an order:
• IV push medication, in place of a rate for administration, the order might indicate
that the medication be given over a certain amount of time, such as "Labetalol, 50
mg, IV push over 2 minutes."
• IV bolus medications - the physician specifies the amount of the bolus and over a
specific period of time, such as “500ml 0.9% normal saline bolus to be
administered over one hour."
• Certain medications, such as Vancomycin, where the rate of administration is
determined when calculating dosages during preparation according to patient
information such as lab values and patient weight, as stated in letters d and e.
The intent further explains that standard MMU.4.2 “sets hospitalwide expectations for
medication orders. The processes are reflected in complete orders entered in the medical
record, the pharmacy or dispensing unit receiving the information needed for dispensing,
and the administration of the medication based on a complete order.” Therefore, missing
elements of a medication order, such as the IV medication rate, will not meet the
requirements for standard MMU.4.2, and MMU.4.2, ME 3.
19 MMU.5.1 Appropriateness If the procedure requires The intent of MMU.5.1 states that “there may be circumstances in which the full
Review procedural sedation and the appropriateness review is not practical, such as in an emergency or when the ordering
physician ordering sedation physician is present for ordering, administering, and monitoring of the patient (for example,
medication is available in the operating theatre or the emergency department), or with oral, rectal, or injectable
during ordering, contrast in interventional radiology or diagnostic imaging where the medication is part of
administration, and the procedure.”
monitoring, does the
sedation medication need Another example of a situation analogous to those listed above in which the physician is
to go through continually present is during procedural sedation. However, the requirements identified in
appropriateness review? the ASC standards related to procedural sedation are expected to be applied. For
example, Standards ASC.3 and ASC.3.3 on Sedation Care outline very specific
requirements on standardized practice, practitioner’s responsibility and patient monitoring,
use of professional guidelines, and risk-benefit analysis.
20 MMU.5.2 Medication Labeling For the MMU it says label MMU.5.2 states that “a system is used to safely dispense medications in the right dose to
the container upon the right patient at the right time.”
transferring from original
container. If we are using The intent of MMU.5.2 further explains that “when a medication is removed from its
Ziplock, are we going to original packaging or prepared and dispensed in a different form/container—and not
label the Ziplock or the immediately administered—the medication must be labeled with the name of the
medication cup? medication, the dosage/concentration of the medication, the date of preparation, the
date of expiration, and two patient identifiers.”
Based on these statements, when medications are being transferred to a Ziplock or

medication cup and are not meant to be immediately administered to the patient, these
medications must be labeled. Additionally, organizations must recognize that multiple
medications in a Ziplock bag or medication cup may be misidentified due to the color or
size of specific pills looking similar and therefore present an increased risk for medication
administration error.
21 MMU.6.2 Patients Own It is often difficult to obtain Standard MMU.6.2 states that “policies and procedures govern medications brought into
Medications the information on the hospital by the patient or family and medication prescribed for patient self-
“resource” of medications administration.”
from the patients. How can
a hospital perform risk In developing these policies and procedures, the intent of MMU.6.2 explains that
assessment for the hospital is required to perform a risk assessment on all medications that the
medications brought in by patient or patient’s family brings to the hospital. As stated in the intent, elements
the patient/family? of the risk assessment are listed as: “where the patient obtained the medication,
when the medication was obtained, and how the medication was stored at home.”
The intent of MMU.6.2 also states that based on the results of the risk
assessment, the hospital determines whether the medications are safe for
administration to the patient.
JCI recognizes that given certain situations, it may be difficult to gather all the necessary
information about medication from patients and their family. MMU.4 describes the overall
process for medication reconciliation and requires that hospitals put forth a credible effort
to obtain this information. For example, a credible effort may include contacting the
patient’s pharmacy and/or family members or consulting with the patient’s primary
physician. The hospital can document this credible effort in situations where all the
required information cannot be gathered and then make a decision about the safety of
administering the medications based on the information that has been obtained.
Quality Improvement and Patient Safety (QPS)

1 QPS.6 Data Validation What is the expectation for The JCI standards don’t specifically address data validation for data that is collected from
data validation and data IT systems; however, the same concepts related to data validation can be applied to data
collected from IT systems? that is collected both electronically and manually.
Can you share examples of
data validation For data that is gathered electronically, the hospital must perform data validation when any
methodologies that will be of the items a) through f) in the intent of QPS.6 are met. In addition to this, it is
acceptable during the recommended that manual data validation be performed upon the adoption of any new data
survey? system and on a periodic basis. While the use of electronic systems to gather data may
help improve workflow and resource use, a system that is incorrectly gathering data that is
not validated could lead to a large amount of incorrect data and can therefore lead to an
overall decrease in quality.
2 QPS.6 Evidence-Based Data Could you share examples Standard QPS.6 states that “The hospital uses an internal process to validate data.” JCI
Validation Methodology of Evidence-based data does not specify which evidence-based process for data validation should be used to
validation methodologies? meet the requirements of this standard. One example of a data validation process is
described as follows:
1. Re-collecting the data by a second person not involved in the original data
collection
2. Using a statistically valid sample of records, cases, and other data. A 100% sample
would only be needed when the number of records, cases, or other data is very
small.
3. Comparing the original data with the re-collected data
4. Calculating the accuracy by dividing the number of data elements found to be the
same by the total number of data elements and multiplying that total by 100. A 90%
accuracy level is a good benchmark.
5. When data elements are found not to be the same, noting the reasons (for
example, unclear data definitions) and taking corrective actions
6. Collecting a new sample after all corrective actions have been implemented to
ensure the actions resulted in the desired accuracy level.
7. Other areas for data validation include ensuring the accuracy of data entry and
data extraction, particularly when using information technology and software
programs for data collection and analysis.
3 QPS.6 Data Validation Regarding the internal data Standard QPS.6 describes the requirements for data validation and describes six specific
Process validation process: when situations in the lettered list of the intent when data validation would be required. An
considering a sample important part of completing an unbiased and valid data validation process would be to
analysis methodology by a ensure interrater reliability. JCI does not require that the individuals completing the data
second individual to seek validation and assessing for interrater reliability be from different departments, but rather
95% accuracy, are there that two different individuals take part in the process. Additionally, the individuals
expectations for the participating in data aggregation and validation should be trained to do so, as is stated in
individuals participating in QPS.3, ME 2 “Individuals with appropriate clinical or managerial experience, knowledge,
data aggregation and and skills participate in the process.”
validation to ensure
interrater reliability?
4 QPS.7 Definition of Sentinel The standard requires the The Scope of the Survey is explained in The Summary of Key Accreditation Policies where
Event hospital to include the it states that “All standards contained in the current edition of the Joint Commission
definition of sentinel event in International Accreditation Standards for Hospitals are applicable unless the hospital does
its policy that includes the not provide that service (for example, does not provide laboratory services on-site).”
elements a) through r) in the
intent. Are we required to The intent of Standards QPS.7 and QPS.7.1 carefully outline different patient safety events
include all these elements in that healthcare organizations should include in their definition of a sentinel event. The
our sentinel event definition hospital must define in their policy which events outlined in the Intent of Standards QPS.7
even if the event may not be and QPS.7.1 would not be encountered due to the hospital not offering a specific service.
encountered due to the For example, organizations that do not provide blood transfusion services may state in their
service not being offered in policy that “Hemolytic transfusion reaction involving administration of blood or blood
our facility? For example, products having major blood group incompatibilities (ABO, Rh, other blood groups) is not
severe neonatal applicable.”
hyperbilirubinemia for those
who do not have maternity Following the indication of such an event being “not applicable,” the policy should clearly
and newborn services. state the rationale as services not being offered. However, the organization must be aware
that the service not being offered may not be the sole reason for a patient safety event to
not occur.
The expectation is that organizations carefully review all system issues that can lead to
patient, staff, or visitor harm and that the hospital must have a process for identifying and
managing all patient safety events that are applicable to their situation by starting with the
events outlined in the intent.
5 QPS.7 Sentinel Event – We would like to Bilirubin test results may be expressed as direct, indirect, or total bilirubin. While total
Severe Neonatal understand whether we bilirubin is a combination of direct and indirect bilirubin, laboratory results for bilirubin in
Hyperbilirubinemia should consider the total some countries only include direct and total bilirubin. As with most laboratory tests,
bilirubin value or indirect reporting may vary based on applicable local and national standards, laws, and
bilirubin value to identify regulations.
sentinel events in item
n) severe neonatal Additionally, results reporting may vary from laboratory to laboratory. In determining
hyperbilirubinemia bilirubin value for severe neonatal hyperbilirubinemia, the hospital should consult the
(bilirubin> 30 milligrams / laboratory on how they report test results for bilirubin. The hospital’s definition of severe
deciliter)? neonatal hyperbilirubinemia should be based on the laboratory’s test reporting for bilirubin.
The hospital should also refer to Standard AOP.5.8 which states that “Established norms
and ranges are used to interpret and to report clinical laboratory results.” The measurable
elements of Standard AOP.5.8 further outline requirements on reference ranges for each
test performed and establishing ranges based on the hospital’s geography and
demographics.
6 QPS.7 Sentinel Event Question about no harm The definition of no harm events and near miss events are included in the intent of
incidents: is the process of Standard QPS.7.1 and are as follows:
investigation for a no harm
incident similar to near • A no-harm event is a patient safety event that reaches the patient but does not
miss? Also, what shall we cause harm.
call incidents that do not • A near miss (or close call) is a patient safety event that did not reach the patient.
include patients? Do we
call non-patient events an QPS.7.1, ME 4 states that “Hospital leadership defines a process for managing near miss
incident? For example, events and no-harm events that includes an analysis of the events to identify corrective
facility maintenance, actions.” After the hospital defines the process, it should be uniformly applied to both no-
smoking, cleaning issues. harm and near miss events.
etc.
In the intent of QPS.7, the definition of sentinel event is centered around events that may
affect the patient; however, letter k) in the list on page 181 relates to rape or assault of
staff, independent practitioners, visitors, or vendors while on site at the hospital. The FMS
chapter contains standards to stipulate how the hospital is required to manage the facility
to promote safety and security for staff and patients, many of the examples such as facility
maintenance, smoking, cleaning issues (hazardous materials), are addressed in this
chapter.
7 QPS.7.1 Data for Adverse What is the difference QPS.7.1 relates to how the hospital manages adverse, no-harm, and near miss events.
QPS.8 Events between QPS.7.1 and Based upon the definition of these events, they can happen anywhere in the hospital and
QPS.8 and how are these the
two standards handled? response that is outlined in QPS.7.1 is a reactive response. For example, a patient can
have a fall with injury while waiting in a registration area for the outpatient diagnostic
imaging area, but this may be rare. While the specific events in the lettered list a) through
h) in the intent of QPS.8 can meet the definition of adverse, no-harm, or near miss events
in QPS.7.1, the requirements of this standard are more focused on proactive monitoring.
These are high-risk events that can happen in specific areas of the patient care process
and the hospital is expected to proactively monitor for and respond to these events.
8 QPS.8 Preop/Postop What is expected for the Standard QPS.8 is a standard that requires organizations to monitor patient care outcomes
Discrepancies data gathering of all major in order to identify the quality of the services and determine if quality improvement
discrepancies between initiatives are needed. Letters a) through h) of the intent identify the minimum services that
preoperative and are to be monitored. Letter d) requires organizations to monitor undesirable trends that
postoperative diagnoses? occur in surgical procedures.

One of the undesirable trends in surgery is associated with a post-operative diagnosis
being very different from the pre-operative diagnosis. Choosing the surgical procedure is
dependent on the surgeon having a pre-operative diagnosis, for example, appendicitis,
abdominal aortic aneurysm, intestinal tumor, ovarian growths, etc. Obtaining the correct
informed consent, preparing the patient for the correct surgery, preparing the operating
theatre, setting out the correct instruments/equipment, and having a properly trained
surgical team are all dependent on the patient’s pre-op diagnosis. When the pre-op
diagnosis is significantly different from the post-op diagnosis, there is the potential for
increased risk of poor outcomes as there may be changes in the surgical procedure
required because of a different diagnosis. Changes in the procedure may result in changes
to the team, the equipment, the instruments, and the like. For example, the surgical
equipment, instruments, and team needed to perform a colon resection for an intestinal
obstruction is likely very different from the instruments, equipment, and surgical team
needed for repair of an abdominal aortic aneurysm. It is also possible that the surgery
cannot be completed, resulting in the added risk of the patient having to have a second
surgery. Reviewing and analyzing all the major discrepancies can help identify areas for
improvement, thereby reducing the incidence of risks to patients and ultimately improving
patient outcomes.
Prevention and Control of Infections (PCI)

1 PCI.6.1 Expired Supplies In the 7th edition, what Standard PCI.6.1 and its intent both address having a process and policy for managing
measurable element is expired supplies. Therefore, the expectation remains that the organization have a process
applicable for the for managing expired supplies. The requirement for managing expired supplies was
management of expired inadvertently left out of the measurable elements of PCI.6.1.
supplies?
Accreditation Standards for Hospitals to address this clarification. The following has been
added to PCI.6.1, ME 1:
The hospital identifies single-use devices and materials that may be reused in accordance
with local and national laws and regulations and implements a process for managing
expired supplies
The errata are available on The Joint Commission website and can also be accessed
through the following link:
Errata to JCI Accreditation Standards for Hospitals, 7th Edition
2 PCI.9 Food Service and How should the The intent of PCI.9 states that “The hospital conducts a risk assessment when food is
Storage refrigerator used by stored or prepared outside of central kitchen areas, including patient refrigerators, and
patients and their families implements protocols to mitigate risk related to this practice.”
be managed? Do I need
to open the refrigerator Part of conducting the risk assessment may include regular inspection although the
for inspection? standard does not specify how to conduct risk assessments for refrigerators used by
patients. The expectation is that the hospital stores food and nutrition products in a manner
that reduces the risk of infection as per PCI.9, ME1.
3 PCI.9 Food Storage Would validation of a Standard PCI.9 states that "The hospital reduces the risk of infections associated with the
process meet the operations of food services." Regarding the validation process, this would depend on what
requirements of PCI.9, to is included in the validation process. An example of one method for ensuring food safety
ensure food is safe during during transportation and distribution may be for the organization to randomly check the
transportation and temperature during transportation to ensure the temperature is within the correct range.
distribution.
The measurable elements of PCI.9 have specific requirements on food storage,
temperature checks, and following professional guidelines to ensure food safety. All
requirements of the measurable elements of PCI.9 must be met to ensure food safety
during transportation and distribution.
Governance, Leadership, and Direction (GLD)

1 GLD.4.1 Hospital Leadership What does “regular In the context of the JCI standards, “regular basis” means a structured or systematic
Communication basis” mean? occurrence of an event. For example, GLD.4.1 states that “Hospital leadership
communicates quality improvement and patient safety information to the governing entity
and hospital staff on a regular basis.” Because it is not always possible to specify time
intervals to comply to all JCI standards (i.e., monthly, annually), the term “regular basis” is
used so that organizations can determine how to establish their process of review at an
interval that is most optimal to the organization.
2 GLD.5 Reporting IPSG Do you require reporting Standard GLD.5 ME 3 states: “The chief executive and hospital leadership set priorities for
Compliance to IPSG compliance to compliance with the International Patient Safety Goals.” Standard GLD.4.1, ME 1 states:
Leadership governance? “Hospital leadership reports on the quality and patient safety program at least quarterly to
the governing entity.”
While there is no standard that specifically states that IPSGs must be reported to
leadership, the requirement for leadership to set priorities for compliance with IPSGs as
part of the QPS program and the requirement to report on the QPS program indicates that
the reporting includes the IPSGs.
3 GLD.6 Contracted Services GLD.6 requires monitoring GLD.6 outlines requirements on hospital leadership’s responsibilities for management of
the quality of clinical and contract services. It is stated in the intent of Standard GLD.6 that “Hospital leadership
nonclinical contracts. How describes, in writing, the nature and scope of services provided through contractual
do we draw the line for the agreements.” Thus, the hospital must determine the scope of each contract. GLD.6
“scope” of contractors? addresses all contracts for any services provided to the hospital by an external party. In
monitoring these contracts, GLD.6, ME3 states that “Department/service leaders share
accountability for the review, selection, and monitoring of clinical and nonclinical contracts.”
Therefore, contract monitoring also includes contractors for services that have always been
provided by contractors. For example, if a hospital has always contracted maintenance of
certain medical equipment since its purchase, these contracts with equipment maintenance
service providers must be monitored to ensure that medical equipment continue to function
correctly and appropriately. JCI recognizes that an organization may have several clinical
and nonclinical contract services to meet patient and management needs of the hospital.
However, leadership oversight of these contract services are critical to ensure that all
aspects of patient care remains optimal and safe.
4 GLD.6.2 Credentialing, Please clarify what is meant Standard GLD.6.2 describes the responsibilities of hospital leadership in ensuring the
Privileging, and by GLD.6.2, ME 2 being credentials and competence of both contracted services that utilize practitioners, such as
Evaluation of applicable to “independent teleradiology, and independent practitioners that provide direct or indirect care within the
Contracted Medical practitioners outside the hospital. Throughout the intent and the following MEs the standard delineates the
Staff hospital,” and GLD.6.2, ME difference between how the hospital interacts with contracted services that utilize health
3 being applicable to care practitioners and independent practitioners that practice within the hospital. GLD.6.2,
“independent practitioners ME 2 refers to how the hospital interacts with contract services that utilize health
providing services on the practitioners, such as teleradiology. In this example, the hospital must ensure that the
premises of the hospital.” individuals working in the teleradiology service are credentialed and privileged to provide
their services; however, the hospital does not have the authority to evaluate the
practitioners, that is the responsibility of the service itself. The hospital can put quality
metrics for the service into its contract and complete quality assurance on its services but
cannot evaluate the practitioners individually.
GLD.6.2, ME 3 relates to independent practitioners contracted to provide services on the

premises of the hospital; therefore, the hospital has more authority over these individuals
and in addition to credentialing and privileging, are also evaluated in the same manner as
other practitioners in accordance with SQE.9 through SQE.12.
5 GLD.7.1 Supply Chain We have identified supplies The standard does not require any specific number of supply chain analyses to be done
at most risk, such as annually. The requirement is for organizations to identify the supplies that are at most risk
medications, medical and determine what, if any, risks points there are in the chain. It is not expected that
equipment, medical organizations would have the resources to analyze the supply chain for all supplies at risk
consumables, implants, at once, but it is expected that organizations begin by analyzing the supplies that have
blood and blood products, been prioritized as having the highest risk. The priority may be based on different factors.
and nutritional products. For example, a supply that is suddenly not performing in the manner that has been
expected, may be a criterion to identify this supply as a high priority. A sudden change in
Do we have to perform an the performance of a supply, such as a medication that is no longer as effective as it once
annual supply chain was; or a change in the packaging of a supply or medication may also trigger an
analysis on each of these organization to analyze the chain or contact the manufacturer.
supplies or 1 analysis on 1
supply per year? Each organization may identify different supplies at risk and may prioritize the at-risk
supplies differently depending on their own data and experiences.

6 GLD.10 Department Planning GLD.10 talks about The intent of GLD.10 states that…” Department policies and procedures reflect the
department planning department’s goals and services as well as the knowledge, skills, and availability of staff
documents, does this mean required to assess and to meet patient care needs.” Each department will have a different
a department manual for scope of services, staffing requirements, and processes. As such, a manual for each
each department outlining department may be necessary depending on the size of the hospital. However, it is also
scope of services, staffing critical to coordinate and/or integrate services within and with other departments and
requirements, qualifications, services as per GLD.10, ME 5. Integration and coordination avoid unnecessary duplication
competencies, department of services and help conserve resources.
processes, etc.?
For smaller healthcare organizations who chose to develop one manual for all
department services, the integrated manual must also be coordinated to ensure that the
manual clearly describe the current and planned services provided by each department
or service.
7 GLD.11.2 Clinical Practice In regard to the five CPG/ GLD.11.2, ME 4 states that “Department/service leaders demonstrate how the use of
Guidelines protocols/ pathways clinical practice guidelines, clinical pathways, and/or clinical protocols has reduced
annually: variation in processes and outcomes.”
1. How actively do we
need to monitor it? 1. JCI does not specify how active the hospital must be in monitoring the implementation
and outcomes of the CPGs that were chosen.
2. Of all CPGs • It is recommended that when a new process, such as the implementation of a
established; can the new CPG is implemented, it is frequently monitored to help educate staff and
hospital decide what intervene while the CPG is new in practice.
subset to monitor? • Once the staff responsible for monitoring the newly implemented CPGs
determine that compliance with the CPG is sufficient and being followed
3. Can a hospital carry appropriately, they may decide to monitor the CPG less actively, for example,
forward/continue some completing chart audits monthly as opposed to weekly. Before determining this,
of the previous year's the staff involved in the monitoring must determine what the goals are, such as
clinical practice percent compliance, how to monitor, such as random chart audits, and then
guidelines/pathways to what level of non-compliance or deviation would indicate the need to increased
the next year to monitoring.
complete the annual 2. The intent of Standard GLD.11.2 describes the process that leadership must take to
requirement of at least determine which Clinical Practice Guidelines (CPG) or protocols are evidence-based
five, if the process and and appropriate for the services that the hospital provides.
outcome measures still • GLD.11.2, ME 1 state that the hospital determines at least five CPGs to focus
show need for on
improvement, or is it • The hospital may utilize many CPGs depending on the scope of services
expected that hospital provided; however, data may show that they do not need to monitor all as
has to select five new intensely
guidelines/pathways o i.e., monitoring for maintenance vs. active monitoring that is covered in
irrespective of the fact GLD.11.2, ME 4

where the previous 3. GLD.11.2, ME 1, states that “On an annual basis, department/service leaders
ones stand? collectively determine at least five hospital-wide priority areas on which to focus the
use of clinical practice guidelines.” In meeting the required five CPG/pathways that are
identified annually, organizations may carry forward a CPGs from the previous year if
the outcome measures continue to show the need for improvement. In addition, an
organization may choose to select the same CPGs if the organization still wants to
increase the goal for compliance. Please also note that GLD.11.2, ME 2 require that
CPGs, pathways, and protocols are selected, evaluated, implemented, and monitored
following the items a) through h) of the intent.
8 GLD.14 Eligibility for Academic If research is not allowed JCI states in the Introduction of the Accreditation Standards for Hospitals that “JCI will
Medical Centers and not available in our consider an applicant hospital an eligible academic medical center if it meets the following
institution but our hospital three criteria:
is the principal training site
for an integrated medical 1. It is integrated (by organization or administration) with a medical school.
school, will we be surveyed
as an academic medical 2. It is the principal site for the education of both (a) medical students (that is,
center and should follow undergraduates) and (b) postgraduate medical specialty trainees (for example,
MPE and HRP chapters or residents or interns) from such medical schools.
will we only be surveyed
with GLD.14 for oversight 3. At the time of application, it conducts medical research with approval and oversight by
of our medical education an Institutional Review Board (IRB) or research ethics committee.
program?
Hospitals that do not conduct medical research as outlined in numbered 3 above will not be
surveyed against the MPE and HRP chapters. The requirements of GLD.14 will be
considered when reviewing the oversight of medical education.
Facilities Management and Safety (FMS)

1 FMS.2 Qualified Individual for What are the qualifications/ The intent of FMS.2 states that “training and experience may include, but is not limited to,
Facility Management certifications needed for a risk management, facility management, and hospital operations.”
and Safety Program Safety Officer?
The hospital determines what additional experience or education may be required to
manage the overall Facility Management and Safety (FMS) Program based upon the size,
services, and needs of the hospital. For example, the individual may have previous
experience leading an FMS program at a smaller organization or have experience leading
or co-leading a program that covers risk or facility management. Additionally, the intent
states that the individual chosen to lead the FMS program may be a member of the
hospital leadership team or a leader of one of the FMS programs mentioned in the FMS
chapter.
2 FMS.2 Annual Review of FMS FMS.2, letter “f” of the FMS.2, ME 2 directs the organization to letter “f” in the intent which requires programs to
Plans and Programs intent states that “the be reviewed and revised annually, or more frequently if needed. If a review finds that a
programs are reviewed and revision is not needed at that time, the review still needs to happen and proof of the review
revised at least annually, or is expected. For example, most program policies have a space to document the date of the
more frequently as review, and the name and signature of the individual who completed the review. If no
needed.” If the programs revisions are needed, the document would just require a date change and a signature
are reviewed annually, but reflecting that it was reviewed. This would be an acceptable form of proof that the review
the policies only reflect was completed. Verbal confirmation of a review is not acceptable because it is not
when they are revised, providing a “record” of the review. Review and revision of programs every two years does
would that meet the not meet the requirement.
requirement?
Additionally, FMS.2, ME 2 (element f) also states that the facility management and safety
structure must be managed effectively and in a consistent and continuous manner. The
individual who oversees the facility management and safety structure is responsible for
elements a) through f) of the intent, such as ensuring the programs are reviewed and
revised at least annually, or more frequently if needed (for example, when there are
changes to requirements in the country’s laws and regulations; changes to the hospital’s
facilities, systems, or equipment; and so on).
3 FMS.3 Risk Assessment I would like to ask about The Joint Commission International's SAFER Matrix is designed to help organizations
the risk assessment prioritize the findings from their accreditation survey - SAFER is an acronym for the
process. following: "Survey Analysis for Evaluating Risk™". The SAFER Matrix is JCI’s
When we are evaluating transformative approach for identifying and communicating risk levels of findings cited
the risks in the hospital, a during surveys. It provides one, comprehensive visual representation of survey findings to
“5x5 matrix” is used by help organizations prioritize and focus corrective actions by measuring the likelihood to
scoring the likelihood harm and scope for each measurable element cited.
(probability of the hazard
causing harm) and impact Organizations are not expected to adopt JCI's SAFER Matrix as their framework for
(a consequence of the conducting risk assessments. Generally, organizations choose from well-established and
harm occurring) of the published proactive risk assessments, such as a Hazard Vulnerability Analysis (HVA) or a
risk. Failure Modes and Effects Analysis (FMEA).
The likelihood is scored The SAFER Matrix is more of a reactive analysis to non-compliance issues found by
from 1 to 5 (Rare, Unlikely, surveyors during the survey process. QPS.10 is asking organizations to use a proactive
Possible, Likely, and approach to identifying risks in their organization.
Extreme). The impact is
scored from 1 to 5
(Insignificant, Minor,
Moderate, Major, and
Extreme).
But, according to the

SAFER Matrix, the
likelihood and scope of
the risks are assessed by
three levels.
Therefore, how can we
adapt the risk evaluation
process in the Hospital
Risk Evaluation System?
Do we need to change the
scoring of the risk
evaluation /or risk
evaluation levels according
to the SAFER Matrix?
4 FMS.3.1 Risk Assessment Plan I understand that for each A risk assessment is a thorough look at your workplace to identify those things, situations,
of the FMS plans we need processes, and the like, that may cause harm. After identification is made, the hospital
a separate risk assessment analyzes and evaluates how likely and severe the risks are. When this determination is
which is very specific to made, the hospital can next decide what measures should be in place to effectively
each plan. However, for the eliminate or control the harm from happening.
integrated risk assessment
plan required for FMS.3, do Standard FMS.3, ME 1 state that "The risk assessments from all eight FMS programs are
we combine all the areas integrated to develop and document a comprehensive, facility-wide risk assessment at
for improvement identified least annually." The rationale for integrating the risk assessments is to determine which
in each plan’s risk risks from each program are most serious and need to be addressed/controlled first. It is
assessment along with likely that the risk assessments can identify multiple risks for each program, but the
corrective actions and seriousness of each risk may be very different. For example, it may be that the risks from
monitor its progress, or are the security program risk assessment identify 4 risks, but the probability and severity of
we expected to identify key each risk has been identified as low.
or critical processes from
each of the plans and put On the other hand, the risk assessment for the fire safety program has identified three
them together to conduct a risks, but the probability and severity of each risk has been identified as moderate to high.
risk assessment for Through integration of the eight risk assessment programs, the hospital can create a
FMS.3? ranking or an action list that allows leadership to determine the risks that need to be
addressed first. JCI does not specify any particular method for identifying, combining, and
ranking risks; however, leadership needs to be able to review the integrated risk
assessment plan and determine which risks from the overall combined risk assessments
have the greatest priority.
5 FMS.4 FMS Monitoring Data Are the monitoring data FMS.4, ME 1 state’s that “Monitoring data are collected and analyzed for each of the
collected and analyzed facility management and safety programs and used to reduce risks in the environment
under FMS.4, ME 1, and and support planning for replacing or upgrading facilities, systems, and equipment.” The
the monitoring data monitoring data addressed in this ME is the same as the monitoring data for each
collected under FMS.5, program that are referenced in the following MEs: FMS.5, ME 4; FMS.6, ME 5; FMS.7,
ME 4, FMS.6, ME 5, ME 3; FMS.8, ME 4; FMS.9, ME 3; FMS.10, ME 3.
FMS.7, ME 3, FMS.8, ME
4, FMS.9, ME 3, FMS.10, Each of the above MEs applies to the specific monitoring data for each program and
ME 3. all the same, or ae FMS.4 applies to how the FMS program utilizes the monitoring data, including
they different? What is the aggregation, analysis, incorporation into the QPS program, and reporting to leadership.
expectation?
6 FMS.8 Goals for Reducing Please provide details on FMS.8, ME 4 states that “The hospital identifies goals, implements improvements, and
Fire Safety Risk how the hospital can monitors data to ensure that fire safety risks are reduced or eliminated.” The goals that
identify goals, implement are discussed in this ME are related to the data that is generated from the completion of
improvements, and the fire safety risk assessment that is discussed in the intent of Standard FMS.8. The
monitor data to ensure that intent provides a list of items a) through k) that must be a part of this risk assessment.
fire safety risks are Depending on the condition of the hospital facility, the services provided, and other factors
reduced or eliminated? incorporated into the assessment, the hospital will need to decide what goals are to be
tracked, for example, the hospital may determine that the medical gas system in the
operating theatre is damaged and thus must be repaired. A goal derived from this may be
to utilize interim safety measures, repair the system as soon as possible to protect patient
safety, and then to proactively assess the function of the system to ensure that it remains
free from damage.
JCI does not specify a certain document that must be used to assess or track the goals
identified, but an example of a tool that can be used to complete the risk assessment
addressed in the intent of FMS.8 is the Failure Mode & Effects Analysis (FMEA) tool that
is referenced throughout the standards manual and the Survey Process Guide.
7 FMS.8.1 Containment of Fire FMS.8.1, ME 3 states that FMS.8.1, ME 3 would depend on local laws and regulations. However, organizations must
and Smoke “When required by local still meet the requirements on FMS.8.1, ME 1 and ME 2:
laws and regulations, the
fire safety program ME 1: The fire safety program includes equipment/systems for the early detection and
includes containment of alarm notification of fire and smoke.
fire and smoke, and these
features are maintained to ME 2: The fire safety program includes equipment/systems for the suppression of fire.
ensure effectiveness and
safety.” FMS.8.1, ME 3 is an example of when the organization is responsible for adhering to our
standards OR following local laws and regs, whichever is “more stringent.” Making this
Is this required only mandatory without including the local laws and regs clause could be very costly for
when “required by local organizations. As such, ME 1 and ME 2 are those we require while ME 3 would depend on
laws and regulations”? the local laws and regulation requirement. During the survey/engagement, it would be
helpful for JCI field staff to ask the organization to provide a copy of the local laws related
to this requirement and/or ask them to explain the local regulations.
8 FMS.8.4 Fire Safety Education If an organization’s doctors Fire safety education is part of the facility management and safety programs. FMS.13, ME
are not staff members, 2 states “Training on the facility management and safety programs includes vendors,
would you expect them to contract workers, volunteers, students, trainees, and others, as applicable to the
also participate in fire safety individuals’ roles and responsibilities, and as determined by the hospital.”
education?
Some independent practitioners may only work for the organization at very limited time
frames based on their contract agreement. In these cases, the organization must determine
and specify in their policy the appropriate safety education and training required to ensure
that these vendors, contract workers, and others are knowledgeable of the fire safety
program and can describe how to bring patients to safety per FMS.8.4, ME 2
.
9 FMS.8.4 Staff Evaluation for Fire Does the hospital need to The standard does not specify how the organization establishes the evaluation of
Safety Measures literally “evaluate” (meaning exercises. While the intent provides several examples of exercises that organizations may
an “exam” or a “test”) the use, it is up to the organization to establish their own evaluation process. A computer-
staff? If not, then what does based teaching and a written exam are some of these examples that the organization may
“staff who do not pass are use. Some exercises may also depend on what their national, local, or regional laws and
reeducated” mean? regulations require.
The critical component of this standard is to make sure that whatever the exercise chosen
to evaluate the fire safety program, staff should be knowledgeable of the program and be
able to describe how to bring patients to safety. When a staff member does not
demonstrate the ability to bring patients to safety or follow established protocols based on
the organization’s evaluation, staff must be re-educated and retested. Reeducation and
retesting do not necessarily mean a written exam; however, the organization should
establish this reeducation and retesting in their policy. For example, if the staff is not able to
point to the safety exits or demonstrate the proper use of fire extinguishers during an
exercise, those staff will require reeducation and training and the organization’s policy must
include the requirement for follow up training and reeducation of these staff members.
10 FMS.8.4 Fire Safety Evaluation Do “all” staff need to take FMS.8.4, ME 1 state “staff from all shifts including the night shift and weekends, annually
of Staff from All Shifts part in the fire safety participate in an exercise to evaluate the fire safety program.” As such, participation of all
evaluation and testing? staff members in at least one fire safety exercise per year is required. The 7 edition
th
clarifies that staff includes those working on different shifts and on weekends. As the
intent of the standard explains, organizations can choose how to evaluate their staff in
their fire safety programs. Some examples of these exercises are also provided in the
intent. Whatever the exercise chosen to evaluate the fire safety program, staff should be
knowledgeable of the program and be able to describe how to bring patients to safety.
Another related standard is FMS.13, ME 2which states that… “Training on the facility
management and safety programs includes vendors, contract workers, volunteers,
students, trainees, and others, as applicable to the individuals’ roles and responsibilities,
and as determined by the hospital.” Because some independent practitioners may only
work for the organization at very limited time frames based on their contract agreement,
organizations must determine and specify in their policy the appropriate safety education
and training required to ensure that these vendors, contract workers, and others are
knowledgeable of the fire safety program and can describe how to bring patients to safety
per FMS.8.4, ME 2.
11 FMS.9.1 Frequency of According to the FMS.9.1, ME 3 requires the organization to inspect and test new medical equipment and
Inspection/Testing of manufacturer's according to age, use, and manufacturers’ recommendations thereafter. JCI recognizes
Medical Equipment recommendations, periodic that following manufacturer’s recommendations may not always be optimal depending on
inspections are the frequency, and the numbers of equipment in an organization.
recommended once every
six months for some When the hospital deviates from manufacturer recommendations, it is critical to a conduct
equipment. With the risk assessment and ensure that the equipment functions appropriately and that the
number of units requiring deviation does not negatively impact patient care. Any deviations from manufacturer
inspection, it is not always recommendations must be justified based on the results of the organization’s risk
possible to inspect all the assessment. Accordingly, FMS.9, ME 2 states that “A medical equipment risk assessment
equipment as is conducted and documented annually throughout the hospital, and medical equipment
recommended. Is it risks are identified and prioritized from the risk assessment.”
necessary to inspect all the
equipment during the
recommended period?
12 FMS.9.1 Medical Equipment What is the standard JCI does not specify the minimum percent of periodic preventative maintenance per month,
monthly percentage, or goal but states in the intent of FMS.9.1 that: “As part of the medical equipment program, the
for the periodic preventive hospital conducts and documents a risk assessment, at least annually, to identify areas in
maintenance (PPM) for which medical equipment risks exist.” Based upon the results of the risk assessment and
medical equipment? For the equipment’s age, use, and manufacturer’s instructions, the hospital determines how
example, if the hospital has often periodic preventive maintenance (PPM) should be completed for different types of
100 pieces of medical equipment and develops a program to accomplish this as defined in FMS.9.1, ME 1.
equipment due for periodic
preventive maintenance for FMS.9.1, ME 3 states that “The hospital identifies goals, implements improvements, and
the month of August, what monitors data to ensure that medical equipment risks are reduced or eliminated.” One of
is the minimum percentage the goals of JCI and accreditation compliance is to improve quality and patient safety, and
of medical equipment that progress to a high reliability environment; therefore, it is not recommended that if a specific
should be maintained as standard is being met (such as a goal of 95% compliance) the hospital would decrease the
per JCI standards? rigor of the goal.
13 FMS.10.3 Potable Water Testing Can an organization carry The intent of FMS.10.3 and FMS.10.3.1 states that testing of potable water can be carried
out water testing in house out by individuals designated by the hospital, such as staff from the clinical laboratory, or
such as the hospital's by public health or water control authorities outside the hospital, or others judged
laboratory or must the tests competent to perform such tests.
be outsourced? Should the
laboratory doing the testing When testing is done in-house, the hospital must follow industry standards and
be accredited? professional guidelines for maintaining water quality and comply with local laws and
regulations for ensuring safe drinking water. The standard does not require that water
testing laboratories be accredited. However, it is the responsibility of the hospital to ensure
that the testing laboratory is reputable and follows applicable laws and regulations for
water testing.
14 FMS.10.3.1 Water Testing in Renal Why is JCI prescriptive Patients undergoing hemodialysis are directly and internally exposed to water, primarily in
Dialysis about renal dialysis and the form of dialysate. Patient adverse events have resulted from water and dialysis solutions
not in other areas where that contain contaminants and chemicals because patients are directly exposed to the water
water is being used such used in this process; therefore, the quality of the water used for dialysis is critical.
as blood bank, lab, CSSD,
etc.? The literature identifies standards and recommended practices that address limits on
specific contaminants within water used for dialysis, dialysate, and substitution fluids.
Because the quality of the water is so critical in the safety of hemodialysis, the JCI 7th
edition standard FMS.10.3.1 includes the specific, evidence-based requirements for
testing the water used in the hemodialysis process.
Standard FMS.10.3 addresses the testing requirements for potable water which
includes water that is used in processes in the dental clinic, laboratory, blood bank, and
CSSD. In addition, standard PCI.6, MEs 1 and 2 require that the hospital follow
professional practice guidelines for sterilization techniques and for low- and high-level
disinfection.
15 FMS.10.3.1 Sensitivity Testing of If the available Water testing can be carried out by available testing options in the country, by public
Dialysis Water laboratories in a country health, by water control authorities outside the hospital, or by others judged competent to
do not provide testing of perform such tests. The standard does not specify limitations on the sensitivity for testing
dialysis water as per the and concentration of chemicals. However, FMS.10.3.1, ME 1 requires the hospital to
JCI suggested standards, identify and follow industry standards and professional guidelines for maintaining water
and as there are quality and implementing infection prevention and control measures.
limitations with regards to
sensitivity for testing very The standard also does not specify which chemical contaminants must be tested because
low concentration of this may vary per local regulations and updated industry standards that hospitals follow.
certain chemicals, can an However, the organization must ensure that water used in hemodialysis is tested monthly
organization go with the for bacterial growth and endotoxins and tested annually for chemical contaminants per
available testing options in FMS.10.3.1, ME 2.
the country for chemical
analysis of dialysis water,
such as testing for
Mercury, Beryllium &
Thallium?
16 FMS.10.3 Water Testing Regarding water testing: FMS.10.3, ME 1, states “Quality of potable water is tested at least quarterly or more
FMS.10 requires that frequently based on local laws and regulations, conditions of the sources for water, and
potable water be tested at previous experience with water quality problems. The testing results are documented.”
least quarterly. For This ME applies to potable water that enters the facility through the local utility systems or
organizations that do not water that may be stored in large containers at the facility.
have centralized potable
water supply, but use For water that is prepackaged in water drums and delivered in a sealed manner from a
water drums mounted on contracted company, the organization should understand what testing process is used by
portable water dispensers, the company which fills and supplies the prepackaged water drums. This testing and
how is this standard quality management completed by the company would fall under GLD.6 and should be
applied? written into the contract with the water company. For the cooler that the drums are placed
onto, the maintenance and cleaning of these would need to be in accordance with
manufacturer recommendations and would fall under the purview of the FMS program and
applicable PCI standards such as PCI.7.
17 FMS.11 Testing Disaster Due to COVID-19, we are FMS.11, ME 4 requires hospitals to test their disaster preparedness program annually and
Preparedness Plan not states that this can be done with the community or internally, JCI recognizes that given the
able to conduct disaster current situation with COVID-19, completing annual testing with the larger community may
preparedness training. not be feasible or safe. An alternative temporary measure could include participation in a
Are there alternative tabletop drill, or simulating a disaster with trained professionals, during which staff discuss
measures to meet the their response to both these events, and documentation of a plan
requirements for testing
the entire emergency The organization may also review Standard PCI.12.2 on the evaluation of an emergency
management program preparedness program for global communicable diseases. The intent of PCI.12.2 states
and all critical elements in that “If the hospital experiences an actual event, activates its program, and debriefs
the intent? properly afterward, this represents the equivalent to an annual evaluation. Debriefing
following an annual evaluation, or an actual event can identify vulnerable processes that
may need to be reevaluated.”
Staff Qualifications and Education (SQE)

1 SQE.6 Weekly Day Off and What is the JCI requirement JCI Hospital Standards do not specify or require that an organization define the number of
Working Hours for number of days off per hours staff work or the number of patients each health care professional cares for at one
week and weekly total time. However, there are requirements in the Hospital Standards that address human
working hours? resources as well as identifying safety risks in the organization. The issue of long work
hours and risks to patient safety may be linked, and there are examples in the literature
related to working excessively long hours and the impact this may have on patient safety.
The Staff Qualifications and Education (SQE) chapter addresses human resource issues.
Standard SQE.6 requires organizations to use a recognized staffing plan and to assign
and reassign staff according to the plan. SQE.6.1 requires organizations to evaluate the
effectiveness of the staffing plan. It is here that the risk of tired staff and number of staff in
relation to patient safety might be identified. Standard SQE.8.2 addresses the requirement
for a staff health and safety program, and ME 6 requires: "The hospital promotes staff well-
being by creating a culture of wellness that supports physical well-being and emotional
health." The Governance, Leadership, and Direction (GLD) chapter also has relevance to
this inquiry.
Standard GLD.1.2, ME 2 requires that the hospital’s governing entity receive and act on
reports from the quality and patient safety program. If long working hours have resulted in
incidents such as adverse events or near miss events related to patient safety, they should
be reported to the quality and patient safety structure. In turn, these should be reported to
the governing entity for consideration and action. GLD.2 requires organizations to operate
within applicable laws and regulations. Some countries have laws and regulations that
address the length of a working day and/or number of patients per physician, and
organizations are expected to be compliant with those laws and regulations.
2 SQE.8.1 Resuscitative SQE 8.1, ME1 requires Per the wording of SQE.8.1, ME 1, all staff that care for patients are required to be trained
Technique for that all staff members that in at least BLS and per SQE.8.1, ME 2 the hospital must then identify staff whose role
Anesthesiologists and provide patient care are necessitates additional training such as ACLS. Based on these requirements, the
Other Staff trained in at least BLS. anesthesiologists in question would need to be trained in both BLS and ACLS. Additionally,
SQE 8.1, ME 2 while the American Heart Association (AHA) does not require BLS as a prerequisite for
requires that the hospital taking ACLS, many training centers require BLS prior to taking an ACLS course and strong
identifies the appropriate BLS skills are the foundation of effective ACLS implementation.
level of training (advanced
or basic) appropriate to
their role. We have required
that all anesthesiologists
are trained in ACLS. Is
ACLS sufficient to meet
SQE 8.1, ME1?
3 SQE.8.1.1 Resuscitation Training Do "the other staff specified Standard SQE.8.1 identifies the requirements regarding resuscitation training for staff who
for Non- Clinical Staff by a hospital" include the provide patient care. These staff include, for example, doctors, nurses, nursing assistants,
cleaning staff, supplier staff, physician assistants, and others who care for patients. This standard requires that these
and others who may not be staff have at minimum, training in basic life-support.
involved with patient care?
The standard also requires the organization to identify the staff who need to have
advanced life-support. Staff requiring advanced life-support include for example, staff
who are responsible for providing procedural sedation and staff who are part of a
resuscitation team. The hospital may also identify that staff who work in intensive care
units, the emergency department, or the operating theatre may also need advanced life-
support.
Standard SQE.8.1.1 addresses the requirements if a hospital should choose to train other
staff in resuscitation. However, it is not required for a hospital to train other staff. Other staff
would be those who do not provide patient care and examples of other staff could include
registration clerks, housekeeping staff, and some that you also identified, such as IT staff,
telephone staff, suppliers, and the like. Just to reinforce, staff who do not provide patient
care are NOT required to be trained in resuscitation, however if hospitals choose to train
other staff, they must meet the requirements of SQE.8.1.1. Standard SQE.8.1.1 could be
considered not applicable if hospitals choose not to train other staff.
4 SQE.9 Primary Source It is stated in the intent that The intent of Standard SQE.9 through SQE.9.2 states that “an affiliated hospital that has
SQE.9.1 Verification (PSV) a hospital is not required to already conducted primary source verification of the medical staff applicant is acceptable
SQE.9.2 conduct PSV if another JCI as long as the affiliated hospital has current Joint Commission International accreditation
accredited hospital has with full compliance on its verification process found in SQE.9.1, MEs 1 and 2.”
already conducted it for the
concerned physician. For Full compliance means the hospital’s Official Survey Findings Report indicates that all
this to apply, do we have to measurable elements are fully met, or any not met or partially met measurable element
be affiliated with this required to be addressed by Strategic Improvement Plan (SIP) actions have been
hospital or can it apply addressed and are now in full compliance. As such, hospitals who are not affiliated with
without affiliation? another JCI- accredited organization must conduct their own verification process per
measurable elements of SQE.9.1. If a hospital is affiliated with another JCI-accredited
healthcare organization that has conducted primary source verification, it is important to
remember that the affiliated hospital must provide a copy of the Official Survey Findings
Report indicating that all measurable elements of SQE.9.1 are fully met from its most
recent survey.
5 SQE.9 Primary Source In some countries, SQE.9.1, ME 1, SQE.13, ME 2 and SQE.15, ME 2 state that "Education, training, and
SQE.13 Verification primary source certifications are verified from the original source according to parameters found in the
SQE.15 verification is completed intent of SQE.9 and are documented." Also, SQE.9, ME 1, SQE.13, and SQE.15 require
by state boards, an ongoing, uniform process to manage and verify credentials, with documentation.
councils, or other
government entities. If the hospital is following their established process, and documentation is provided
Because of this, according to said process, and in compliance with the JCI requirements, the practice is
hospitals are not acceptable. Standards SQE.9-SQE.9.2 describe the process for assessing the
conducting their own credentials of staff and completing primary source verification. Additionally, the intent
primary source outlines the process by which a governmental or nongovernmental third party can
verifications for their complete the PSV and if the hospital has confidence in this agency, and can provide
nurses and allied health evidence that PSV was completed, this is acceptable.
professionals, excluding
physicians. Is this an
acceptable practice, and
if so, what evidence is
expected?
6 SQE.9 Primary Source For countries that offer The requirements for primary source verification in SQE.13 and SQE.15 are described in
SQE.13 Verification online verification of the intent of SQE.9. The intent of SQE.9 states that “Verification is the process of
SQE.15 licensure for nurses and checking the validity and completeness of a credential from the source that issued the
other licensed allied credential. This process can be accomplished by an inquiry to a secure online database
health professionals, is it of, for example, those individuals licensed in the hospital’s city or country.” Per this
acceptable practice for explanation, the hospital can verify the licensure of nurses and other license allied health
the nurses and others professionals via the secure online database of the appropriate board. To satisfy
licensed allied health SQE.13, ME 13 and SQE. 15 ME 3, the hospital will need a uniform process for
professionals to submit a documentation of verification.
copy of the verification to
the hospital and then HR
staff can use this to
verify the license online
indicating the verification
was completed.
7 SQE.9 Contracted and Are all providers required There are two main sets of standards that relate to the hospital’s responsibilities with
SQE.10 Hospital Employed to be contracted or medical staff and health care providers. For providers that are employed by the hospital,
SQE.11 Providers employed by the Standards SQE.9-12 describe the initial credentialing and primary source verification
SQE.12 organization? process, privileging, ongoing professional practice evaluation, and reappointment and
renewal of clinical privileges. For licensed health care professionals and independent
health care practitioners not employed by the hospital, Standard GLD.6.2 describes the
requirements that the hospital must follow.
8 SQE.11 Ongoing Professional Is there guidance related The standards do not specify the number of hours that doctors are allowed to work
Practice Evaluation to physician weekly work consecutively or weekly. If there are specific governmental regulations on doctor’s hours or
(OPPE) hours, and physician-to- regulations from the Ministry of Health, then those would be considered more rigorous than
patient ratios? the JCI Standards in this regard and the expectation would be that the hospital follows and
complies with these regulations.
The SQE chapter lists several standards that relate to how the hospital must determine
what privileges doctors hold and how the hospital monitors the safety and quality of care
delivered by doctors. Specifically, SQE.11 states that the hospital must have a
standardized and ongoing process to evaluate the quality and safety of care provided by
each medical staff member. It is further discussed in the intent of this standard that the
person responsible for evaluating the quality and safety of care uses a standardized and
evidence-based process to gather data that is necessary to evaluate quality and safety and
compare against other medical staff members in the same department. The hospital
determines what data is gathered to evaluate safety and quality of care delivered.
Additionally, SQE.8.2 addresses the concept of staff burnout, stating in the intent that
“Best-practice research related to compassion fatigue and staff burnout recommends that
hospitals create programs to support staff involved in sentinel and adverse events and to
proactively develop skills to promote staff resiliency and promote staff health and well-
being.” As mentioned in this statement and SQE.8.2, ME 6, the hospital should have a
program to address staff well-being, part of this would include determining an appropriate
amount of work hours and patient ratios that are safe for both patients and staff.
9 SQE.11 Ongoing Professional Requesting additional SQE.11, ME 2 states that “The ongoing professional practice evaluation process
Practice Evaluation of guidance regarding the identifies areas of achievement and potential improvement related to the behaviors,
Medical Staff Members ongoing professional professional growth, and clinical results of the medical staff member, and the results are
practice evaluation of reviewed with objective and evidence-based information as available. These results are
medical staff members compared to other department/service medical staff members.” Identification of areas of
requirement that states, achievements and improvement opportunities related to medical staff behaviors vary in
“physician behaviors and each organization and each medical staff.
professional growth
comparison to other The intent of SQE.11 provides examples of evaluating behaviors which can include the
departments/service following: (1) evaluation of whether a medical staff member understands and supports
medical staff member.” the hospital’s code of behavior and the identification of acceptable and unacceptable
behaviors; (2) an absence of reported behaviors by the medical staff member that are
identified as unacceptable; (3) and gathering, analysis, and use of information and data
from staff surveys and other sources regarding the culture of safety in the hospital. The
intent also explains how each medical staff member may have varying degrees, and
ways on how they can identify growth and improvement in different important
dimensions of health care and professional practice. Some of the acceptable
professional growth examples outlined in the intent include improving provision of care,
medical/clinical knowledge, and interpersonal and communication skills.
Furthermore, the intent provides examples of measures for the different dimensions of
health care and professional practice that organizations may use. Areas of achievement
and improvement opportunities must be applicable to the roles and responsibilities of
each medical staff member who is being evaluated. For example, professional growth
opportunities for pathologists may include expanding his or her clinical knowledge in the
application of the newest technologies in laboratory medicine. As part of SQE.11, ME2,
results of ongoing professional practice evaluation must be compared with other
department/service staff members to reduce variation in behaviors, professional growth,
and clinical results.
Because medical/clinical knowledge varies in each specialty, comparison of clinical

results related to specific clinical expertise may be focused within relevant department
staff in the same clinical setting. However, comparison of professional growth
opportunities may be conducted between different departments to reduce variations on
patient care practices within the organizations. When available, the organization may
also use objective, evidence- based best practice or benchmark sources of clinical result
data and information from external organizations within their region.

10 SQE.11 External Benchmarking During our JCI survey visit It is correct in that this is one of the more frequently scored standards/MEs in many parts
this past year, the following of the world. During the development of the 7th Edition standards, we conducted focus
measurable element was groups with some of our accredited organizations via phone conference and many of these
cited: groups identified difficulty in participating in external benchmarking, particularly for
individual physicians. We see more and more hospitals and physician practices moving
SQE 11, ME 3 towards “group practice” as opposed to individual practice. In such circumstances, the
Unavailability of externally patient's outcomes cannot necessarily be attributed to a single physician, but rather to the
benchmarked Physicians’ group. JCI believes that there is still value in performing external benchmarking for
clinical Indicators individual physicians in areas of practice where benchmarks are available such as surgery,
pathology, emergency medical practice, and interventional cardiology. However, after
It worth mentioning that much discussion and additional exploration, it was determined that having a requirement
the above-mentioned for external benchmarking was burdensome for many international organizations.
citation was one of the top Therefore, for the 7th Edition of the hospital standards, SQE.11, ME 3 has been revised
25 most commonly citated and combined with SQE.11, ME 2. The new requirement (ME 2) is as follows:
findings.
SQE.11, ME 2 – “The ongoing professional practice evaluation process identifies areas
We have difficulty finding of achievement and potential improvement related to the behaviors, professional growth,
external benchmarks for and clinical results of the medical staff member, and the results are reviewed with
clinical indicators. Can you objective and evidence-based information as available. These results are compared to
identify sources of external other department/service medical staff members.”
benchmarks to help us meet
the standard?
Management of Information (MOI)

1 MOI.4 Medical Record Is there a list of criteria The Joint Commission International recognizes that nonuniform or non-standardized use of
Abbreviation regarding abbreviations abbreviation is a contributing factor to patient safety incidents due to potentially
used in medical records that inconsistent interpretation or misunderstanding of medical records. The intent of Standard
JCI uses for accreditation MOI.4 states that “abbreviations can be problematic and at times even dangerous,
purposes? particularly in the context of prescribing medications. For this reason, some hospitals do
not allow the use of abbreviations in their organizations at all. When abbreviations are
allowed in the hospital, processes are implemented to prevent or reduce risks to patient
safety.”
In regard to a list of criteria regarding abbreviations used in medical records for

JCI accreditation purposes, the intent of Standard MOI.4 also specifies the
following:
• Abbreviations are not used on informed consent documents, patient
rights documents, discharge instructions, and discharge summaries.
• When a hospital uses abbreviations, the hospital develops and
implements a process for the uniform use of approved abbreviations,
such as through the use of a list. This uniform use includes each
abbreviation having only one meaning.
• When a hospital uses abbreviations, the hospital develops and/or adopts
a do-not- use list of abbreviations and symbols. For example, the Institute
for Safe Medication Practices (ISMP) maintains a list of abbreviations,
symbols, and dose designations that should never be used when
communicating medical information.
Each measurable element of Standard MOI.4 also outlines critical requirements

with which JCI-accredited organizations must comply related to the uniform use
of approved symbols and abbreviations across the hospital.
2 MOI.7.1 Implementation of How should organizations The intent of Standard MOI.7.1 requires that policies and procedures are implemented
Policies, Procedures monitor the throughout the hospital because they standardize care processes and help to improve
and Plans - Monitoring implementation of policies, care quality and ensure patient and staff safety. JCI does not require that all the hospital’s
procedures and plans? policies and procedures be monitored. Resources must be utilized to assess those
policies and procedures that are high-risk, new, recently updated/modified, low-volume, or
those that govern care processes related to sentinel/adverse events.
MOI.7.1 ME 4 states that “the implementation of policies, procedures, and plans is

monitored, and the information supports full implementation.” Monitoring full
implementation of policies can be done in a variety of ways and it is up to the organization
to establish this monitoring process. For example, standard IPSG.1 requires the use of at
least two patient identifiers to identify patients and label elements associated with the
patient’s care and treatment plan. In order to monitor compliance, the hospital may
randomly audit specimens, intravenous medications, special dietary trays, and other
elements associated with the patient’s care for proper labeling.
Similarly, if the hospital has recently implemented a procedural sedation policy that
describes a protocol for monitoring of vital signs and the use of capnography throughout
the procedure, a random sample of charts can be reviewed to assess that vital signs were
monitored and documented at the correct intervals and that capnography was used during
the procedure.
When the hospital is reviewing charts or using other methods to audit care in order to
assess compliance with policies, a representative sample must be used. A representative
sample is based on the volume of the procedure or process that is being assessed,
therefore; if a certain procedure is completed only 10 times per year, then all 10 instances
would be reviewed; but if 1000 procedures are completed a sample would be sufficient.
3 MOI.10 Review of Medical Does a physician or nurse Standard MOI.10, ME 2 requires that “the medical record review is conducted by
Records have to check the sample physicians, nurses, and others authorized to make entries in patient medical records or to
of charts? Can the manage patient medical records.”
assessment of the medical
record be done by any Authorized personnel are other clinicians who are also authorized to make entries in the
trained and competent patient medical record. These may include pharmacists, social workers, nutritionists, and
person? the like. During the patient medical record review, each professional group authorized to
make entries must be represented to ensure accuracy and completeness of the record
and clinical information.
The review of collated medical record data by authorized personnel will allow the team to
assess identified gaps in the accuracy and completeness of documentation and address
these gaps. The staff that gather the data from the medical records and collate this data
into a usable format for review do not need to be the same as the authorized personnel that
complete the review, for example, staff trained in quality that support the quality
department can gather and collate this data.
Additionally, a representative sample of medical records from all services must be

reviewed at least quarterly or more frequently as determined by laws and regulations per
MOI.10, ME 1.
The sample medical records must also include active and discharged medical records and
inpatient and outpatient medical records.
4 MOI.10 Legibility of Information MOI.10 ME 3 what type of MOI.10, ME 3 states that “The review focuses on the timeliness, accuracy, completeness,
legibility are you looking and legibility of the medical record.”
for in the electronic
medical record? The increasing use of electronic health records helps address the issue of illegible
medical records. However, there are still instances where organizations must pay
attention to ensure legibility of information in electronic medical records. For example,
areas in electronic medical record where providers can enter free text information.
Information that has been typed by the provider must be legible and understandable by
other authorized personnel who may need to access these records.
5 MOI.10 Legibility and Accuracy Is use of abbreviation The use of abbreviation focuses on accuracy and consistent use across the organization.
of Information part of legibility or As stated in Standard MOI.4, “The hospital uses standardized diagnosis and procedure
accuracy? codes and ensures the uniform use of approved symbols and abbreviations across the
hospital.” For example, when the organization is using the abbreviation “MS,” it must be
clear across the organization if this abbreviation stands for multiple sclerosis or magnesium
sulfate.
MOI.10, ME 3 states that “The review focuses on the timeliness, accuracy, completeness,
and legibility of the medical record.” Regarding MOI.10, accuracy in the use of
abbreviation could apply to ensure that all information in the medical records is understood
in the same manner across the organization.

6 MOI.10 Accuracy of Information What are the Ensuring accuracy of information in the medical records means ensuring that there are no
components of accuracy discrepancies, such as comparing the lab results against the lab reporting system or
of documentation? ensuring that when abbreviations are used, they refer to the terms that they are intended to
abbreviate according to the hospital’s list of approved abbreviations. Another example that
is often seen with electronic medical records is misuse of copy and paste (this is described
in the intent of MOI.8 and assessed at MOI.8 ME 3). For example, when reviewing the daily
progress notes on an intubated patient in the ICU, staff reviewing the medical record could
compare the notes stating whether the patient is or isn’t extubated against other
documentation of the patient’s airway status.
7 MOI.10 Accuracy of Information What is an appropriate The intent of MOI.10 explains that patient medical record review is based on a sample
sample size for MOI.10, representing the practitioners providing care in outpatient, inpatient, and other
especially for a large services provided.
hospital and the number or
outpatient and inpatient The intent also states that” a representative sample means medical records from all
records required? services and not a specific sample size; however, it should make sense for the
organization. For example, random sampling and selecting approximately 5% of medical
records may achieve a representative sample.”
While the standard does not specify the sample size requirement, organizations may use
the 5% representative sample size that was provided as an example in the intent and
expand this number based on organization’s own assessment. Please also note that the
sample of medical records must also include active and discharged medical records and
inpatient and outpatient medical records. For example, if there are 100 patient medical
records in labor and delivery, the organization may randomly select 5 records for review
from labor and delivery. This would be in addition to the other 5% of patient medical
records from different departments including outpatients.
8 MOI.11 Qualifications for the How can you judge The intent of MOI.11 states “leadership identifies a qualified individual to oversee health
Individual Overseeing "qualified" for the personal information technology systems in the organization. The individual is qualified by
Information Technology that oversees the health education, training, and/ or experience relevant to the role and responsibilities.” The job
Systems information technology description should match the individual’s qualification through his or her training records,
systems? education, and/or experience.
9 MOI.12 Criteria for a Secure How do you judge what Secure platforms can be described as platforms that can only be accessed by authorized
Mobile Device is a secure platform? users. The intent of MOI.12 states that in addition to implementing a secure mobile
Platform platform, the hospital system can remotely disable or remove patient data and information
from the mobile devices if they are lost or stolen. Other forms of security controls are also
identified in the intent in letters a) through e).

10 MOI.12 Quality Assurance in How to ensure the When mobile devices and text messaging are used for patient care, the organization
Mobile Patient quality of patient care, ensures that all information is accurate, delivered in a timely manner, and clearly
Communication specifically in texts? understood by the receiver of the information. MOI.12, ME 3 requires “that text messages
and e-mails on mobile devices that have data and information relating to a patient’s care
are documented in the patient’s medical record.”
One way to assess the quality of patient care when using text messages is verifying that
the information on the patient’s medical record accurately reflects the information that
was communicated about the patient through a text messaging platform.
11 MOI.12 ISO27001 and MOI.12 If the hospital uses texting ISO/IEC 27001 is a comprehensive document that examines the organization's
through a service provider information security risks, taking account of the threats, vulnerabilities, and impacts.
that has ISO27001 There are organizations who are certified under this ISO standard document. Because
(international Standard that ISO 27001 is recognized as an international standard that provides a framework for
describes the requirements Information Security Management Systems that provides continued confidentiality,
for an information security integrity, and availability of information within an organization, having an up-to-date, non-
management system), will expired ISO 27001 certification indicates that the organization has established a secure
this meet the requirement platform.
for a secure platform? Or
are there any further During a survey, it is important to determine the scope of ISO 27001 certification and
specific questions we need make sure that they cover all aspects of the health information technology that the
to ask the org? organization is using for patient care. For example, if the organization allows the use of
mobile devices, the surveyor will discuss with the organization if the use of mobile
devices is part of their ISO 27001 certification.
12 MOI.12 Security of Patient How does the hospital Text messaging is becoming more popular in many hospitals with clinical staff using third-
Information Via Text ensure that a secure party messaging apps on smartphones and tablets to contact other doctors and nurses.
Messaging messaging platform is Several concerns arise with the use of text messaging in hospitals including security and
implemented to meet the timely receipt of information. As identified in MOI.12, when organizations choose to
elements a) through e) in communicate via a text messaging platform, the organization must ensure the
the intent of MOI.12 and are confidentiality and security of information, as well as the timely receipt and verification of
there any specific that information.
applications we should use?
Most apps don’t contain strong enough protections for protected health information and
any breaches could put these details into the wrong hands. In addition, when a text
message about a patient's condition is sent through a personal mobile device, there is no
assurance that the message will be viewed. JCI does not recommend or endorse any
particular platform or app for text messaging in hospitals. There are several secure text
messaging apps designed specifically for healthcare professionals. These specially
designed text messaging apps can provide the following:
• integrate messages with a hospital’s electronic health records (EHR) system
and alarm systems
• use different alert sounds for texts based on priority
• pull information about scheduling directly from the hospital’s internal network
• transmit messages using encryption
• create PINs so the app isn’t always accessible when the device is in use, and
• track when messages were sent, delivered and answered for a clear audit trail.
The availability of specialized apps may be dependent on a particular region or country.

JCI does not maintain a list of organizations that utilize texting and therefore would not be
able to provide contact information. You may want to contact the provider of your
electronic medical record (EMR) to see if they have worked with apps that integrate with
the EMR. You may also consider contacting mobile device carrier companies to determine
if there are specific apps/platforms available for healthcare institutions.
Medical Professional Education (MPE)

1 MPE.6 Monitoring of Data Should the hospital quality The intent of Standard MPE.6 states that “although it would be desirable for each medical
Collection for Medical and patient safety student and trainee to have basic education on quality and patient safety in his or her
Students monitoring include medical respective academic program.” Thus, the hospital must have a planned and deliberate
students and trainees for program to introduce such concepts, support the medical students and trainees in
their compliance with complying with relevant policies and guidelines, and include medical students and trainees
program elements like in all quality and safety monitoring programs.”
IPSGs and medical record
documentation? For the Standard MPE.6, ME 2 where it states that “medical students and trainees are
included in the data collection for the hospital’s quality monitoring programs,” the
expectation is that the hospital would include medical students and trainees in all of the
organization’s quality and safety monitoring programs. Medical students or trainees are not
expected to complete the data gathering, but rather that the care delivered by medical
students and trainees is included in the data gathered. For example, catheter-associated
urinary tract infection (CAUTI) data from patients where the medical students or trainees
inserted the catheters would be included along with data from hospital staff who may have
much more experience inserting the catheters.
2 MPE.6 Residents and We have developed a Medical staff are required to provide patient care as indicated by their licensure and clinical
Physician Performance matrix of objective physician privileges, as reflected in standards SQE.10 and SQE.11. Residents would not fall under
Evaluations performance evaluations. this category because they may not have privileges to independently provide patient care.
Should we include In addition, residents typically provide patient care as “medical students” or “trainees”
residents? Does it fall under under the supervision of licensed and privileged medical staff, which aligns with Standard
MPE, or is it not required at MPE.6.
all?
If the hospital considers a resident a “trainee” as defined in Standard MPE.7, “Medical
trainees who provide care or services within the hospital—outside of the parameters of
their academic program—are granted permission to provide those services through the
hospital’s established credentialing, privileging, job specification, or other relevant
processes,” then his or her work is evaluated as required by the SQE standards, as
defined in the intent: “In these circumstances, the individual trainee must be evaluated
and given permission to provide those services through the normal established processes
for such professionals as described in the Staff Qualifications and Education (SQE)
standards.”
Survey Process Guide Questions

1 N/A – SPG related Look-Back Period Can you clarify the We recognize that due to the COVID-19 pandemic, hospitals are focused on ensuring
expectations for the look safe, quality patient care and may have altered the services normally provided to patients
back period? within their community. As such, JCI has decided to postpone the implementation of the
36-month look back indefinitely. This pertains only to the new extended look-back process
that was first
announced in July 2018 and was scheduled for implementation on 1 January 2021.
The original look-back process remains effective for all hospitals and academic
medical centers and will remain in effect for surveys conducted in 2021. The original
look-back process for all hospitals and academic medical centers is as follows:
• A 12-month look-back period of compliance for triennial surveys
• A 6-month look-back period of compliance for initial surveys
• No look-back period for a follow up survey; sustainability of improvement is used
to evaluate compliance.
The Joint Commission International Hospital Standards are intended to promote

continuous, systematic and organization-wide improvement in daily performance and in
the outcomes of patient care. It is JCI’s expectation that all hospitals will maintain
compliance with the JCI standards in such a way as to provide safe, quality patient care
during the pandemic and develop a plan of action to address the return to continuous
compliance with the JCI standards in the near future.
JCI Survey Process Guide for Hospitals to address this clarification. The errata are
available on the Joint Commission International website and can also be accessed through
the following link:
Errata to JCI Survey Process Guide for Hospitals, 7th Edition
2 N/A- SPG Related Scoring Rules Is value weighted for each Compliance with the requirements of the Measurable Elements is documented as the rate
result of fully met, partially (percentage) of compliance demonstrated by the hospital. The scoring guidelines are
met, and not met equating written in the positive, which is the percentage of compliance required to achieve a score
to 1, 0.5, and 0 when the of:
score is calculated?

• fully met (compliance rate of 90% or greater),
• partially met (compliance rate of 50% to 89%), or
• not met (compliance rate of 49% or fewer).
Whenever possible, the demonstrated compliance is reported as “compliance rate” (%).

For example, 10 of 15 (67% compliance rate) initial nursing assessments were
completed within 24 hours of inpatient admission to the medical/surgical inpatient units
(3W, 2E, 4S, and 4N), as required by the hospital’s policy. The score for this finding is
“partially met,” because the compliance rate percentage for the finding is between 50%
and 89%.
The actual percentages are not used in calculating scores used in the Decision Rules.
The percentages are converted as follows:
• fully met (compliance rate of 90% or greater) is identified as “10”

• partially met (compliance rate of 50% to 89%) is identified as “5”
• not met (compliance rate of 49% or fewer) is identified as “0”
Decision Rule 1 states: The organization demonstrates acceptable compliance with

each standard. Acceptable compliance is a score of at least “5” on each standard. (See
page 17 from the Survey Process Guide).
As an example of how this is calculated, a standard with 3 measurable elements could be

scored as:
• ME 1 is scored as “fully met” which equals “10”
• ME 2 is scored as “partially met” which equals “5”
• ME 3 is scored as “not met” which equals “0”
Calculation: 10+5+0=15. The total score of 15 is divided by 3 MEs and equals “5”.
Therefore, Decision Rule #1 is Met because the total score of the standard is “5”
In regard to weight of each result when the score is calculated, the Survey Process
Guide also explains the Accreditation Decision Rules and how each organization meets
various criteria for being accredited.
3 Survey Process Virtual Survey How are we expected to Organizations may contact the Joint Commission International Account Executive for
Document Submission submit live documents such instructions on how to upload documents prior to and/or during the virtual survey. In
as patient records during addition, information about video surveys and directions are also posted on Direct
the virtual survey? Connect.
COVID-Related Questions

1 N/A -COVID testing COVID-19 Impact After we receive the impact The COVID-19 Impact Assessment process is currently applicable to all hospitals
Assessment and assessment for our next undergoing a survey until July of 2021. However, JCI recognizes that the COVID-19
Survey Process survey, are we expected to pandemic is unprecedented and is currently an evolving situation. Due to this, JCI is
continuously update the continually monitoring the situation and will extend the timeframe that the COVID-19 Impact
impact assessment even Assessment process applies to, if needed. If this decision is made, JCI will communicate
after the survey? this with the organizations that will be affected by this decision.
The COVID-19 Impact Assessment is sent by the team leader to the survey coordinator
approximately 4-6 weeks prior to the survey and the information gathered is intended to
help the team leader plan the survey agenda. The COVID-19 Impact Assessment is only
designed to be taken once. The survey team will further assess the impact of COVID-19
on the hospital during the survey.
To note: the information gathered from the COVID-19 Impact Assessment will not be used
to evaluate compliance with the JCI Standards.
2 Survey Process COVID-19 Impact Would you tell us what to The COVID-19 Impact Assessment is a tool that is sent from the survey team leader to the
Assessment enter in the COVID-19 hospital’s survey coordinator in the form of an Excel spreadsheet. The assessment is sent
Impact Assessment? approximately 4-6 weeks prior to the scheduled survey and contains specific questions for
the survey coordinator to answer, such as the hospital’s role in responding to COVID-19 in
the community, availability of personal protective equipment, and suspension of services.
The information gathered from this assessment is used by the team leader to plan the
survey agenda and prepare the survey team, it is not used to determine standards
compliance and does not factor into the overall survey results.


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Standards Interpretation FAQs

Standards Subject Interpretation Question Response

In situations such as this,

Standard MMU.6.1 provides further guidance by requiring that medication administration

JCI Accreditation Standards for Hospitals, 7th Edition Page 7 of 63

JCI Accreditation Standards for Hospitals, 7th Edition Page 8 of 63

When an organization determines the need to store concentrated electrolytes outside of

JCI Accreditation Standards for Hospitals, 7th Edition Page 10 of 63

JCI Accreditation Standards for Hospitals, 7th Edition Page 12 of 63

JCI Accreditation Standards for Hospitals, 7th Edition Page 13 of 63

Access to Care (ACC)

Patient-Centered Care (PCC)

Assessment of Patients (AOP)

JCI Accreditation Standards for Hospitals, 7th Edition Page 18 of 63

JCI Accreditation Standards for Hospitals, 7th Edition Page 20 of 63

Care of Patients (COP)

JCI Accreditation Standards for Hospitals, 7th Edition Page 21 of 63

As identified in COP.8.5, ME 5, providing the potential transplant recipient with potential

JCI Accreditation Standards for Hospitals, 7th Edition Page 24 of 63

Anesthesia and Surgical Care (ASC)

Medication Management and Use (MMU)

JCI Accreditation Standards for Hospitals, 7th Edition Page 28 of 63

Additionally, Standard ACC.4.3 describes the information that is required to be in the

Errata to JCI Accreditation Standards for Hospitals, 7th Edition

Based on these statements, when medications are being transferred to a Ziplock or

Quality Improvement and Patient Safety (QPS)

JCI Accreditation Standards for Hospitals, 7th Edition Page 38 of 63

Prevention and Control of Infections (PCI)

Errata to JCI Accreditation Standards for Hospitals, 7th Edition

Governance, Leadership, and Direction (GLD)

GLD.6.2, ME 3 relates to independent practitioners contracted to provide services on the

JCI Accreditation Standards for Hospitals, 7th Edition Page 41 of 63

JCI Accreditation Standards for Hospitals, 7th Edition Page 42 of 63

Facilities Management and Safety (FMS)

But, according to the

Staff Qualifications and Education (SQE)

Because medical/clinical knowledge varies in each specialty, comparison of clinical

JCI Accreditation Standards for Hospitals, 7th Edition Page 54 of 63

Management of Information (MOI)

In regard to a list of criteria regarding abbreviations used in medical records for

Each measurable element of Standard MOI.4 also outlines critical requirements

MOI.7.1 ME 4 states that “the implementation of policies, procedures, and plans is

Additionally, a representative sample of medical records from all services must be

JCI Accreditation Standards for Hospitals, 7th Edition Page 57 of 63

JCI Accreditation Standards for Hospitals, 7th Edition Page 58 of 63

The availability of specialized apps may be dependent on a particular region or country.

Medical Professional Education (MPE)

Survey Process Guide Questions

The Joint Commission International Hospital Standards are intended to promote

Errata to JCI Survey Process Guide for Hospitals, 7th Edition

JCI Accreditation Standards for Hospitals, 7th Edition Page 61 of 63

Whenever possible, the demonstrated compliance is reported as “compliance rate” (%).

• fully met (compliance rate of 90% or greater) is identified as “10”

Decision Rule 1 states: The organization demonstrates acceptable compliance with

As an example of how this is calculated, a standard with 3 measurable elements could be

JCI Accreditation Standards for Hospitals, 7th Edition Page 62 of 63

JCI Accreditation Standards for Hospitals, 7th Edition Page 63 of 63

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