Jci Tool 7th Edition - HN Version

INTERNATIONAL PATIENT SAFETY GO
Chapter Standard
The hospital develops and

implements a process to improve
IPSG.1 accuracy of patient
identifications.

IPSG.2 the effectiveness of verbal
and/or telephone 2
communications among
caregivers

implements a process for 2
IPSG.2.1
reporting critical results of
diagnostic tests.
3
1
The hospital develops and 2

IPSG.2.2 implements a process for
handover communication.
1
IPSG.3
the safety of high-alert
medications. 2
1
IPSG.3.1 the safety of look-alike/sound-
2
alike medications
The hospital develops and 2

implements a process to manage
IPSG.3.2
the safe use of concentrated
electrolytes
3
1
implements a process for the
IPSG.4 preoperative verification and
surgical/invasive
procedure site marking

implements a process for the
time-out that is performed
IPSG.4.1 immediately prior to the
start of the surgical/invasive 2
procedure and the sign-out that
is conducted after the procedure
The hospital adopts and 1

implements evidence-based
IPSG.5 hand-hygiene guidelines to
2
reduce the risk of health care–
associated infections.
3
1
Hospital leaders identify care
processes that need
improvement and adopt and
IPSG.5.1 implement evidence-based 2
interventions to improve patient
outcomes and reduce the risk of
hospital-associated infections.
Hospital leaders identify care
processes that need
improvement and adopt and
IPSG.5.1 implement evidence-based
interventions to improve patient
outcomes and reduce the risk of
hospital-associated infections.
3

implements a process to reduce
IPSG.6 the risk of patient harm resulting
from falls for the
inpatient population
2

implements a process to reduce
IPSG.6.1 the risk of patient harm resulting
from falls for the
outpatient population
2
from falls for the
outpatient population
2
3
INTERNATIONAL PATIENT SAFETY GOALS(IPSG)
Measurable Elements
At least two patient identifiers, that do not include the use of the patient’s room number or location
in the hospital, are used to identify the patient and to label elements associated with the patient’s
care
and treatment plan.
Patients are identified before performing diagnostic procedures, providing treatments, and
performing
other procedures.
The hospital ensures the correct identification of patients in special circumstances, such as the
comatose
patient or newborn who is not immediately named.
Complete verbal orders are documented and read back by the receiver and confirmed by the
individual
giving the order.
Complete telephone orders are documented and read back by the receiver and confirmed by the
individual giving the order.
Complete test results are documented and read back by the receiver and confirmed by the individual
giving the result.
The hospital defines critical results that may represent urgent or emergent life-threatening values for
diagnostic tests.
The hospital develops a formal reporting process, used throughout the hospital, that identifies how
critical results of diagnostic tests are reported/communicated to health care practitioners.
The hospital identifies what information is documented in the medical record.

Standardized critical content is communicated between health care practitioners during handovers of
patient care.
Standardized forms, tools, or methods that support a consistent and complete handover process are
utilized.
Data from adverse events resulting from handover communications are tracked and used to
identifyways in which handovers can be improved, and improvements are implemented.
The hospital identifies in writing its list of high-alert medications.
The hospital develops and implements a process for reducing the risk and harm of high-alert
medications
that is uniform throughout the hospital.
The hospital annually reviews and, as necessary, revises its list of high-alert medications.
The hospital identifies in writing its list of look-alike/sound-alike medications.
The hospital develops and implements a process for managing look-alike/sound-alike medications
that is uniform throughout the hospital.
The hospital annually reviews and, as necessary, revises its list of look-alike/sound-alike medications.
Only qualified and trained individuals have access to concentrated electrolytes, and they are clearly
labeled with appropriate warnings and segregated from other medications.
The hospital only stores vials of concentrated electrolytes outside of the pharmacy in situations
identified
in the intent.
Standard protocols are followed for adult, pediatric, and/or neonatal electrolyte replacement
therapy to treat hypokalemia, hyponatremia, and hypophosphatemia.
The hospital implements a preoperative verification process through the use of a checklist or other
mechanism to document, before the surgical/invasive procedure, that the informed consent is
appropriate to the procedure; that the correct patient, correct procedure, and correct site are
verified; and that all required documents, blood products, medical equipment, and implantable
medical devices are on hand, correct, and functional.
The hospital uses an instantly recognizable and unambiguous mark for identifying the
surgical/invasive site that is consistent throughout the hospital.
Surgical/invasive site marking is done by the person performing the procedure and involves the
patient in the marking process.
The full team actively participates in a time-out process, which includes a) through c) in the intent, in
the area in which the surgical/invasive procedure will be performed, immediately before starting
the procedure. Completion of the time-out is documented and includes date and time
Before the patient leaves the area in which the surgical/invasive procedure was performed, a sign-
out process is conducted, which includes at least d) through g) in the intent.
When surgical/invasive procedures are performed, including medical and dental procedures done in
settings other than the operating theatre, the hospital uses uniform processes to ensure safe surgery.
The hospital has adopted current evidence-based hand-hygiene guidelines.
The hospital implements a hand-hygiene program throughout the hospital.

Hand-washing and hand-disinfection procedures are used in accordance with hand hygiene
guidelines throughout the hospital.
Hospital leaders identify priority areas for improvement of hospital-acquired infections.
Hospital leaders identify and implement evidence-based interventions (such as bundles) for all
applicable
patients.
Evidence-based interventions (such as bundles) used to reduce the risk of health care–associated
infections are evaluated by health care practitioners for compliance and improvement in clinical
outcomes.
The hospital implements a process for assessing all inpatients for fall risk and uses assessment tools/
methods appropriate for the patients being served.
The hospital implements a process for the reassessment of inpatients who may become at risk for
falls due to a change in condition or are already at risk for falls based on the documented
assessment.
Measures and/or interventions to reduce fall risk are implemented for those identified inpatients,
situations, and locations within the hospital assessed to be at risk. Patient interventions are
documented.
The hospital implements a process for screening outpatients whose condition, diagnosis, situation, or
location may put them at risk for falls and uses screening tools/methods appropriate for the patients
being served.
When fall risk is identified from the screening process, measures and/or interventions are
implemented to reduce fall risk for those outpatients identified to be at risk, and the screening and
interventions are documented
When fall risk is identified from the screening process, measures and/or interventions are
implemented to reduce fall risk for those outpatients identified to be at risk, and the screening and
interventions are documented
Measures and/or interventions to reduce fall risk are implemented in situations and locations in the
outpatient department(s) assessed to be a risk for falls.
Related Documents Section
Policy No. 4.1, 4.3,4.5,4.14

Patient Identification Procedure No. 6.1.3, 6.1.9, ,
6.3, 6.5
Collection, Handling and Storage

of Expressed Breast Milk in NICU
Patient Identification Procedure No. 6.1.10
Patient Identification Procedure No. 6.3
Procedure No. 6.1.2, 6.1.2.2,

Reporting and Documentation of Verbal and Telephone Order
6.1.2.3
Procedure No. 6.1.2, 6.1.2.2,

Reporting and Documentation of Verbal and Telephone Order
6.1.2.3
Policy No. 2.3,2.6.1,

Laboratory Critical Test and CriticalProcedure
Result Reporting
No. 6.2.9
Laboratory Critical Test and CriticalDefinition

of Terms,
Result Reporting
Appendices 9.1- 9.3
Laboratory Critical Test and CriticalProcedure

Result Reporting
No. 7.2
Laboratory Critical Test and CriticalPolicy

ResultNo.
Reporting
2.5
Critical Test Result Form Policy 4.1

Hands-Off/Hand Over Communication (ISBAR Communication and Ticket to Ride
I-SBAR Handover Communication Tool
Hands-Off/Hand Over Communication

Resp.3.1
(ISBAR Communication and Ticket to Ride
Incident Report Form
High Alert Medications

Appendix A
High Alert Medications Policy No. 2.1 - 2.10
High Alert Medications Policy No. 2.13
Look Alike Sound Alike MedicationsAppendix 2
Look Alike Sound Alike MedicationsPolicy 4.1, 4.2, 4.3,
Look Alike Sound Alike MedicationsPolicy 4.1, 4.2, 4.3, 4.8
Handling Concentrated ElectrolytesPolicy 2.2, 2.3, 2.5,

Proceddure 6.2
Handling Concentrated ElectrolytesAppendix A
Guidelines for Management of Hypokalemia
Potassium Dosing for

Hypokalemia in Neonates
Ensure Safe Surgery Preoperative Checklist Form
Ensure Safe Surgery Procedure 6.2.2
Ensure Safe Surgery Procedure 6.2.1, 6.2.3
Ensure Safe Surgery Procedure 4.6
Ensure Safe Surgery Procedure 4.7
Procedure 6.6(6.6.1.1-
Ensure Safe Surgery
6.6.1.17) 6.6.1.18
Hand Hygiene Purpose 2.1
Healthcare Associated Infections (HAIs)

PolicySurveillance
3.2
Care Bundles
Care Bundles Procedure 7.3.2 - 7.3.4
Fall Prevention and Management Policy 4.2
Falls Assessment Tool (Adult)Morse Falls Scale (MFS)
Falls Assessment Tool (Pediatric)The Humpty Dumpty Scale
Fall Prevention and Management
Fall Prevention Intervention Checklist (Outpatient)

Fall Prevention Intervention Checklist
Policy
(Outpatient)
4.3.3
ACCESS TO CARE AND CONTINUITY OF CARE (AC
Chapter Standard
Patients who may be admitted to the

hospital or who seek outpatient services
are screened to identify if their health
ACC.1 care needs match the hospital’s mission
and resources, and those with emergent,
urgent, or immediate needs are given
priority for assessment and treatment
4
6
1
The hospital considers the clinical needs
of patients and informs patients when
ACC.1.1
there are unusual delays for diagnostic
and/or treatment services
The hospital has a process for managing 3

the flow of patients throughout the
ACC.2
hospital that includes admitting inpatients
and registering outpatients 4
1
Patient needs for preventive, palliative,
curative, and rehabilitative services are 2
ACC.2.1 prioritized based on the patient’s
condition at the time of admissio as an
inpatient to the hospital.
3
1
At admission as an inpatient, the patient
and family receive education and
orientation to the inpatient ward, 2
ACC.2.2
information on the proposed care and any
expected costs for care, and the expected
outcomes of care
At admission as an inpatient, the patient
and family receive education and
orientation to the inpatient ward,
ACC.2.2 information on the proposed care and any
expected costs for care, and the expected
outcomes of care 3
The hospital establishes criteria for

admission to and discharge from
ACC.2.3 3
departments/wards providing intensive or
specialized services
4
4
The hospital designs and carries out 3

processes to provide continuity of patient
care services in the hospital, coordination
ACC.3
among health care practitioners, and 4
access to information related to the
patient’s care
During all phases of inpatient care, there

ACC.3.1 is a qualified individual identified as
responsible for the patient’s care 2
3
1
The hospital develops and implements a

discharge planning and referral process 4
ACC.4
that is based on the patient’s readiness
for discharge.
The hospital’s discharge planning process 3

addresses patient and family education
ACC.4.1 and instruction related to the patient’s
ongoing need for continuing care and
services. 4
The complete discharge summary is

prepared for all inpatients, and a copy of
ACC.4.2
the discharge summary is contained in the
patient’s medical record.
The complete discharge summary is 3
prepared for all inpatients, and a copy of
ACC.4.2 the discharge summary is contained in the
The medical records of patients receiving

emergency care include the time of arrival 2
and departure, the conclusions at
ACC.4.2.1
termination of treatment, the patient’s
condition at discharge, and follow-up care
instructions. 3
The records of outpatients requiring

complex care or with complex diagnoses
contain profiles of the medical care and 2
ACC.4.3 are made available to health care
practitioners providing care to those
patients 3
The hospital has a process for the 4

management and follow-up of patients
ACC.4.4 who notify hospital staff that they intend
to leave against medical advice
The hospital has a process for the
management and follow-up of patients
ACC.4.4
who notify hospital staff that they intend
to leave against medical advice
2
The hospital has a process for the
management of patients who leave the
ACC.4.4.1
hospital against medical advice
without notifying hospital staff. 3
The hospital develops a process to

transfer patients to other health care 3
organizations based on status, the need to
ACC.5
meet their continuing care needs, and the
ability of the receiving organization to
meet patients’ needs.
4
meet patients’ needs.
The receiving organization is given a

written summary of the patient’s clinical
condition and the interventions provided
ACC.5.1 by the referring hospital, and the process
is documented in the patient’s medical
record 3
The hospital’s transportation services

comply with relevant laws and regulations
ACC.6
and meet requirements for
quality and safe transport.
The hospital’s transportation services
comply with relevant laws and regulations
ACC.6
and meet requirements for
quality and safe transport.
3
5
ACCESS TO CARE AND CONTINUITY OF CARE (ACC)
Measurable Elements Related Documents
Based on the results of screening, patients are accepted for

outpatient treatment or inpatient care if it is determined that
Admission Policy
the needs of the patient match the hospital’s mission and
resources.
If the patient’s needs do not match the hospital’s mission and Admission Policy
resources, the hospital will transfer, refer, or assist the patient
in identifying and/or obtaining appropriate sources of care.
Transfer Policy
Staff utilize a recognized triage process that includes early

recognition of communicable diseases, to prioritize and treat Triage
patients with immediate needs.
Medical Assessment and Reassessment in Emergency
Emergent patients are assessed and stabilized within the Patient Referral
capacity of the hospital prior to transfer, and treatment is
documented in a record maintained by the transferring
hospital. Transfer Policy
Management of Patient Flow in PSMMC
There is a process to provide the results of diagnostic tests to

those responsible for determining if the patient is to be Admission Policy
admitted, transferred, or referred.
Specific screening tests or evaluations are identified when the

Patient Referral
hospital requires them prior to admission or registration.
Inpatients and outpatients are informed when there will be a
Admission Policy
delay in care and/or treatment.
Patients are informed of the reasons for the delay and provided
with information on available alternatives consistent with their Admission Policy
clinical needs.
The information on unusual delay and reasons for the delay are Admission Policy
documented in the medical record.
The hospital develops and implements a process that supports
the flow of patients through the hospital that addresses at least Management of Patient Flow in PSMMC
a) through g) in the intent.
There is a process for admitting emergency patients to
Admission Policy
inpatient units.
There is a process for holding patients for observation when
needed. Admission Policy
The hospital plans and provides for the care of patients needing
admission who are boarded in the ED and other temporary Management of Patient Flow in PSMMC
holding areas in the hospital.
The hospital identifies and implements a time limit on boarding Management of Patient Flow in PSMMC
patients waiting for inpatient beds
The individuals who manage patient flow processes review the

effectiveness to identify and implement process improvements. Management of Patient Flow in PSMMC
The screening assessment helps health care practitioners

Admission Policy
identify the patient’s needs.
The service or unit selected to meet these needs is based on
Admission Policy
the screening assessment findings.
Patients’ needs related to preventive, curative, rehabilitative,

Admission Policy
and palliative services are prioritized.
On admission as an inpatient, the patient and family receive Admission Policy

education and orientation to the inpatient ward.
The patient and family receive information on the proposed Patient and Family Rights and Responsibilities
care.
The patient and family receive information on the expected
Patient and Family Rights and Responsibilities
outcomes of care.
The patient and family receive information on any expected Patient and Family Rights and Responsibilities
costs related to the proposed care.
General Intensive Care unit 1 and 2 (GICU1, GICU2)Admission
Admission and Discharge for Burn Intensive Care Unit (B-ICU)
The hospital has established entry and/or transfer criteria for

admission to intensive and specialized departments/wards to
meet special patient needs. Admission and Discharge Maternity Intensive Care Unit2
Admission and Discharge Crieteria for Respiratory Intensive C
Admission and Discharge for Trauma Intensive Care Unit (TICU
The criteria utilize prioritization, diagnostic, and/or objective

parameters, including physiologic based criteria when possible.
The hospital has established discharge and/or transfer criteria

from intensive and specialized departments/wards to a Admission and Discharge Maternity Intensive Care Unit2
different level of care.
Admissiom and Discharge Crieteria for Respiratory Intensive C
The medical records of patients who are admitted to

departments/wards providing intensive/specialized services
contain evidence that they meet the criteria for services.
The medical records of patients who are admitted to

departments/wards providing intensive/specialized services
contain evidence that they meet the criteria for services. Admission and Discharge Maternity Intensive Care Unit2
Admissiom and Discharge Criteria for Respiratory Intensive Ca
The medical records of patients who are transferred or

discharged from departments/wards providing intensive or
specialized services contain evidence that they no longer meet
the criteria for those services.
The leaders of departments and services design and implement

processes that support continuity and coordination of care, Continuity of Care
including at least a) through e) identified in the intent.
The patient’s medical record(s) is available to those

practitioners who are authorized to have access and need it for Continuity of Care
the care of the patient.
The patient’s medical record(s) is up to date to ensure
Continuity of Care
communication of the latest information.
The patient’s medical record(s) or a summary of patient care
information is transferred with the patient to another service or Continuity of Care
unit in the hospital
If a summary of information is transferred with the patient, the

Continuity of Care
summary contains at least f ) through l) of the intent.
Continuity and coordination of care processes are supported by

the use of tools, such as care plans, guidelines, or other such Continuity of Care
tools.
A qualified individual(s) responsible for the coordination of the

patient’s care is identified in the patient’s medical record and is Patient Referral
available through all phases of inpatient care
There is a process for transferring the responsibility for

Patient Referral
coordination of care from individual to individual.
The process identifies how these individuals assume the

transferred responsibility and document their participation or Patient Referral
coverage.
The hospital develops and implements a discharge planning and
referral process that starts at the beginning of care and is based Discharge Policy
on the patient’s readiness for discharge.
The patient’s readiness for discharge is determined by the use

Discharge Policy
of relevant criteria or indications that ensure patient safety
The discharge planning process includes the need for both Discharge Policy
support services and continuing medical needs.
Patients not directly referred or transferred are provided with

the name and location of a site(s) for continuing care. Discharge Policy
Patients not directly referred or transferred are provided

instructions, in writing, on when to returnto the hospital for
Discharge Policy
continued care, if appropriate, and when and how to obtain
urgent care.
Discharge planning and instructions are documented in the

Discharge Summary form
patient record and provided to the patient in writing.
Patient and family education and instruction are related to the Discharge Policy
patient’s ongoing need for continuing care and services.
Patients and families are provided with a complete list of

medications to be taken at home. Discharge Policy
Patients and families are educated about the safe and effective
use of all medications, potential side effects, and the
Discharge Policy
prevention of potential interactions with over-the-counter
medications and/or food.
Patients and families are educated about proper diet and

Discharge Policy
nutrition.
Patients and families are educated about pain management as

appropriate. Discharge Policy
Patients and families are educated about safe and effective use
of medical equipment and rehabilitation techniques as Discharge Policy
appropriate.
A discharge summary is prepared by a qualified individual. Discharge Policy
The discharge summary contains at least a) through g) of the

Discharge Policy
intent.
A copy of the discharge summary is provided to the practitioner
Discharge Policy
responsible for the patient’s continuing or follow-up care.
A copy of the discharge summary is provided to the patient in

cases in which information regarding the practitioner
Discharge Policy
responsible for the patient’s continuing or follow-up care is
unknown
A copy of the completed discharge summary is placed in the

patient’s medical record in a time frame identified by the Discharge Policy
hospital.
The medical records of all emergency patients include arrival
Triage Dispostion Form
and departure times.
The medical records of discharged emergency patients include
conclusions at the termination of Triage Dispostion Form
treatment.
the patient’s condition at discharge.
any follow-up care instructions.
The hospital identifies the types of outpatients receiving

complex care and/or with complex diagnoses who require an
outpatient profile
The clinician(s) who treats the patient identifies necessary Medical Records Content and Documentation Standards
information to be included in the outpatient profile.
The hospital uses a process that will ensure the outpatient

Medical Records Content and Documentation Standards
profile is easy to retrieve and review
The process is evaluated to see if it meets the needs of the
clinicians and improves the quality and safety of outpatient
clinical visits
There is a process for managing inpatients and outpatients who

notify staff that they are leaving against medical advice.
The process includes informing the patient of the medical risks

of inadequate treatment
The patient is discharged according to the hospital discharge

process.
Leave Against Medical Advise
(LAMA)
If the family physician of a patient leaving against medical
advice is known and has not been
involved in the process, the physician is notified.
The process is consistent with applicable laws and regulations,
including requirements for reporting cases of infectious disease
and cases in which patients may be a threat to themselves or
others
When consistent with regional laws and regulations, the

hospital develops a process for allowing patients to leave the
Patient Out On Pass
hospital during the planned course of treatment on an
approved pass for a defined period of time.
There is a process for the management of inpatients and

Management of Absconded/ Left
outpatients who leave the hospital against medical advice
without being seen
without notifying hospital staff
There is a process for the management of outpatients receiving Leave Against Medical Advise (LAMA)
complex treatment who do not return for treatment.
If the family physician is known and has not been involved in

Leave Against Medical Advise (LAMA)
the process, the physician is notified.
The process is consistent with applicable laws and regulations,

including requirements for reporting cases of infectious disease
and cases in which patients may be a threat to themselves or Leave Against Medical Advise (LAMA)
others.
The hospital develops a transfer process that is based on

Transfer Policy
criteria to address patients’ needs for continuing care.
The transfer process addresses how and when responsibility for

continuing care is moved to another practitioner or setting and
determines that the receiving organization can meet the needs Transfer Policy
of the patient to be transferred.
The transfer process identifies who is responsible for Transfer Policy

monitoring the patient during transfer and the staff
qualifications required for the type of patient being transferred
Escort for Patient Transfer
The transfer process identifies the medications, supplies, and

medical equipment required during Transfer Policy
transport.
The transfer process addresses a follow-up mechanism that
provides information about the patient’s condition upon arrival Transfer of Patient to Outside Organization Form
to the receiving organization
The transfer process addresses the situations in which transfer

Transfer Policy
is not possible.
Transfer of Patient to Outside Organization Form

A patient clinical summary document is transferred with the
patient and includes at least a) through c) of the intent.
Transfer of Patient Between PSMMC Specialties

The medical records of transferred patients identify the name
of the receiving health care organization and the name of the
individual agreeing to receive the patient.

The medical records of transferred patients contain
documentation or other notes as required by the policy of the
transferring hospital
The medical records of transferred patients state the reason(s)

for transfer and any special conditions related to transfer.
The process for referring and/or discharging patients includes

an assessment of transportation needs for patients who may Patient Transport
require assistance
Transportation services, including contracted services, and

transport vehicles owned by the hospital meet relevant laws
Patient Transport
and regulations and the hospital’s requirements for quality and
safe transport.
All vehicles used for transportation, contracted or hospital
owned, comply with the infection prevention and control
program and have appropriate medical equipment, supplies, Patient Transport
and medications to meet the needs of the patient being
transported.
The transportation provided or arranged is appropriate to the

Patient Transport
needs and condition of the patient
There is a process in place to monitor the quality and safety of

transportation provided or arranged by the hospital, including a Patient Transport
complaint process.
Section
Policy 4.4,
Policy 4.5
Policy 3.5
Procedure 5.3
Policy 4.6
Policy 4.2
Policy 4.7
Policy 4.7
Policy 4.7
Policy 3.1
Policy 4.9.1
Policy 4.10
Procedure 5.9
Procedure 5.9
Policy 3.13
Procedure 5.5.1
Procedure 5.5.1, 5.5.2
Policy 4.3
Procedure 5.1.11.3
Procedure 6.1.15
Procedure 6.1.15
Policy 4.5
Policy 5.2,5.3, 5.4
Procedure 6.3
Procedure 6.1
Policy 5.1
Policy 5.2
Procedure 6.6
Policy 5.3
Policy 5.3
Policy 2.3
Policy 2.8, 2.9
Policy 2.8, 2.9

policy 4.1
Policy 4.4
Procedure 5.2
Policy 4.8
Discharge Sdummary Form
Policy 4.7
Policy 4.7
policy 4.7.3
policy 4.7.5
policy 4.7.6
policy 4.7.7
policy 4.13
policy 5.3.4
procedure 5.3.3
procedure 5.3.3
procedure 5.3.2
procedure 6.1
policy 3.2
policy 3.3
procedure 6.2
policy 3.5
Resposibility 3.1
Introduction
Procedure 6.12
Procedure 6.4/6.10
Policy 3.5
Policy 4.1, Procedure

6.1.6
Policy 4.11
Policy 4.9
Policy 4.9
transfer of the patient forms
within and outside the
organization
Policy 4.7

organization

organization

organization

organization

organization

organization

organization

organization
policy 5.4
policy 5.5
policy 5.5
policy 5.1
procedure 6.2.6
PATIENT - CENTERED CARE (PCC)
Chapter Standard
The hospital is responsible for providing processes 4

PCC.1 that support patients’ and families’ rights during
care
The hospital seeks to reduce physical, language, 2

cultural, and other barriers to access and delivery
of services
PCC.1.1 and provides information and education to
patients and families in a language and manner
they can 3
understand.
4
understand.
The hospital provides care that supports patient

dignity, is respectful of the patient’s personal
PCC.1.2 values and beliefs, and responds to requests for 2
spiritual and religious
observance.
The hospital establishes a process to ensure 3

patient privacy and confidentiality of
PCC.1.3 care and information and allows patients the right
to have access to their health information within
the context of existing law and culture. 𝖯
4
The hospital takes measures to protect patients’

PCC.1.4
possessions from theft or loss.
2
The hospital takes measures to protect patients’
PCC.1.4
possessions from theft or loss.
Patients are protected from physical assault, and 2

PCC.1.5 populations at risk are identified and protected
from additional vulnerabilities.
3
2
Patients and families are engaged in all aspects of
their medical care and treatment through
PCC.2 education and participation in care and treatment
decisions and care processes. 𝖯 3
The hospital informs patients and families about

their rights and responsibilities to refuse or 3
PCC.2.1 discontinue treatment, withhold resuscitative
services, and forgo or withdraw life-sustaining
treatments. 𝖯
4
5
treatments. 𝖯
The hospital supports the patient’s right to 2

PCC.2.2 assessment and management of pain and
respectful compassionate care at the end of life.
2
The hospital measures, analyzes, and—when
necessary—improves the patient experience in
PCC.3 order to
enhance the quality of patient care. 𝖯
3

its process to receive and to act on complaints,
PCC.3.1 conflicts, and differences of opinion about patient 2
care and the patient’s right to participate in these
processes. 𝖯
its process to receive and to act on complaints,
PCC.3.1 conflicts, and differences of opinion about patient
care and the patient’s right to participate in these
processes. 𝖯
2
General consent for treatment, if obtained when a
patient is admitted as an inpatient or is registered
PCC.4
for the first time as an outpatient, is clear in its
scope and limits. 𝖯 3
Patient informed consent is obtained through a

process defined by the hospital and carried out by 3
PCC.4.1
trained staff in a manner and language the patient
can understand. 𝖯
4
Informed consent is obtained before surgery, 3

anesthesia, procedural sedation, use of
PCC.4.2
blood and blood products, and other high-risk
treatments and procedures. 𝖯
Informed consent is obtained before surgery,
anesthesia, procedural sedation, use of
PCC.4.2
blood and blood products, and other high-risk
treatments and procedures. 𝖯
4
Patients and families receive adequate information 2

about the patient’s condition, proposed
PCC.4.3 treatment(s) or procedure(s), and health care
practitioners so that they can
grant consent and make care decisions.
1
The hospital establishes a process, within the
PCC.4.4 context of existing law and culture, for when 2
others can grant consent.
2
The hospital provides an education program that is
based on its mission, services provided, and 3
PCC.5 patient population, and health care practitioners
collaborate to provide education.
Each patient’s educational needs and ability and

PCC.5.1 willingness to learn are assessed and 2
recorded in his or her medical record.
Education methods take into account the patient’s

1
Education methods take into account the patient’s

and family’s values and preferences and allow
PCC.5.2 sufficient interaction among the patient, family,
and staff for learning to 2
occur.
2
PCC.6
how to choose to donate organs and other tissues.
3
The hospital provides oversight for the process of 2

PCC.6.1
organ and tissue procurement. 𝖯
4
PATIENT - CENTERED CARE (PCC)
Hospital leadership works collaboratively to protect and to Patient and Family Rights and Responsibilities
advance patient and family rights.
Hospital leadership implements patient and family rights as

identified in laws and regulations.
Hospital leadership protects patient and family rights in relation
to the cultural practices of the community Patient and Family Rights and Responsibilities
or individual patients served.
Hospital leadership protects the patient's right to identify who

the patient wishes to participate in Patient and Family Rights and Responsibilities
care decisions.
The hospital has a process to determine the patient’s

preference, and in some circumstances the
patient’s family’s preference, in determining what information Patient and Family Rights and Responsibilities
regarding the patient’s care would be
provided to family or others, and under what circumstances.
All health care practitioners are trained on the processes for and
their role in supporting patient and family rights and Patient and Family Rights and Responsibilities
participation in care.
The department/service leaders and staff of the hospital identify

their patient population’s most common and challenging Reduce Barriers to Healthcare
barriers to accessing and receiving care.
The department/service leaders develop and implement a

process to overcome or limit barriers to
Reduce Barriers to Healthcare
access to care and their impact on service delivery for patients
seeking care.
Information about aspects of the patient’s medical care and

treatment are provided in a manner and Patient and Family Rights and Responsibilities
language the patient understands.
Information about patient rights and responsibilities is provided

Patient and Family Rights and
to each patient in writing or other
Responsibilities handouts
method, in a language the patient understands.
The statement of patient rights and responsibilities is posted or Patient and Family Rights and
otherwise available from staff at all Responsibilities acrylic posters
times. posted in the wards and leaflets
Staff provide care that is respectful and considerate of the

patient’s dignity and self-worth.
The patient’s spiritual and cultural beliefs and the patient’s

Spiritual Care for Inpatients
values are respected.
The hospital responds to routine as well as complex requests Spiritual Care for Inpatients
related to religious or spiritual support.
Staff members meet patient expectations and needs for privacy,

Patient Privacy and Confidentiality
when expressed, during care and treatment.
A patient’s expressed need for privacy is respected for all clinical

interviews, examinations, procedures/ treatments, and Patient Privacy and Confidentiality
transport.

Confidentiality of patient information is maintained according to
laws and regulations.
Information Privacy, Confidentiality and Security
The hospital has a process for patients to grant permission for

the release of information not covered by laws and regulations.
The hospital has a process for providing patients with access to

their health information within the context of existing laws, Patient and Family Rights and Responsibilities
regulations, and culture.
Access to health information is timely, and cost does not

prevent access to this information for the purpose of Acces and Availability and/or Release of Medical Records
maintaining continuity of care.
Protecting Patient Belongings and Properties
The hospital has determined its level of responsibility for

patients’ possessions.
Safekeeping of In-patient Property and Valuables within the
Patients receive information about the hospital’s responsibility

Protecting Patient Belongings and Properties
for protecting personal belongings.
Patients’ possessions are safeguarded when the hospital
assumes responsibility or when the patient is unable to assume Protecting Patient Belongings and Properties
responsibility.
The hospital develops and implements a process to protect all

Physical Assaults and Verbal Combative Abuse (Code White)
patients from assault.
The hospital identifies vulnerable populations with additional

Care of Vulnerable Patients
risks of assault.
The hospital develops and implements a process to protect Care of Vulnerable Patients
vulnerable populations from other safety issues.
The hospital monitors remote or isolated areas of the facility. Security Rounds Policy and Reports
The hospital supports and promotes patient and family

engagement through participation in care processes and in Patients and Family Participation in Care Process
decision making to the extent they wish.
Participation in the care process includes educating patients and

family about their medical conditions, any confirmed diagnosis, Patients and Family Participation in Care Process
and the planned care and treatment(s).
Patients are informed about the expected outcomes of care and

Patients and Family Participation in Care Process
treatment.
Patients are told of any unanticipated outcomes that may have
occurred during the course of their Patients and Family Participation in Care Process
care and treatment.
The hospital facilitates a patient’s request to seek a second

opinion without fear of compromise to his Patients and Family Participation in Care Process
or her care within or outside the hospital.
The hospital identifies its position on withholding resuscitative Do Not Resuscitate

services and forgoing or withdrawing life-sustaining treatments.
The hospital’s position conforms to its community’s religious

Do Not Resuscitate
and cultural norms and any legal or regulatory requirements.
The hospital informs patients and families about their rights to

refuse or to discontinue treatment and the hospital’s Patient and Family Rights and Responsibilities
responsibilities related to such decisions.
The hospital informs patients about the consequences of their
Refusal of Treatment
decisions.
The hospital informs patients about available care and
treatment alternatives. Patient and Family Rights and Responsibilities
The hospital guides health care practitioners on the ethical and
legal considerations in carrying out patient wishes regarding Do Not Resuscitate
treatment alternatives.
The hospital respects and supports the patient’s right to

assessment and management of pain.
The hospital respects and supports the patient’s right to

assessment and management of the dying patient’s needs.
The hospital’s staff understand the personal, cultural, and

societal influences on the patient’s experiences with pain. Care of End of Life and Dying Patient
The hospital’s staff understand the personal, cultural, and

societal influences on the patient’s experiences with death and Care of End of Life and Dying Patient
dying.
Leadership develops and implements a process for assessing the

MSD STRATEGIC PLAN
patient experience and its impact on patient care.
Data from the patient experience are aggregated, analyzed, and

transformed into information to identify strategies for
improving the patient experience.
PRESS GANEY PATIENT
EXPERIENCE SCORE CARDS
Leadership determines a priority area for improving the patient

experience that will positively impact patient care.
Identified strategies for improving the patient experience are ACTION PLAN OF PATIENT
implemented. EXPERIENCE
Improvements to the patient experience are analyzed and
revised in order to optimize their impact on quality of patient
care.
Patients are informed about the process for voicing complaints,

Handling Patients and Family Complaints and Conflicts
conflicts, and differences of opinion
Complaints, conflicts, and differences of opinion are

investigated by the hospital.
Complaints, conflicts, and differences of opinion that arise
during the care process are resolved
Patients and families participate in the resolution process.
Patients and families are informed as to the scope of a general

General and Informed Consent
consent, when used by the hospital.
The hospital defines how a general consent, when used, is

documented in the patient medical record.
Whether or not a general consent is obtained, all patients and

families are informed about which tests and treatments require General and Informed Consent
informed consent.
Whether or not general consent is obtained, all patients receive

information about the likelihood of students and trainees General and Informed Consent
participating in care processes.
The hospital develops and implements a clearly defined

informed consent process and trains designated staff in that General and Informed Consent
process
The hospital educates patients about the informed consent General and Informed Consent
process and when informed consent is required.
Patients learn about the process for granting informed consent General and Informed Consent
in a manner and language that the patient understands.
Patients give informed consent consistent with the process. General and Informed Consent
There is a uniform recording of informed consent. General and Informed Consent
The identity of the individual providing the information to the

patient and family is documented in the patient’s medical General and Informed Consent
record.
Consent is obtained before diagnostic or therapeutic surgical or

invasive procedures.
Consent is obtained before anesthesia and procedural sedation. General and Informed Consent
Consent is obtained before the use of blood and blood products. General and Informed Consent
The hospital lists those additional procedures and treatments General and Informed Consent
that require separate consent.
Consent is obtained before the additional and/or other high-risk

procedures and treatments.
Patients are informed of elements a) through h) in the intent as

part of the informed consent process when informed consent is General and Informed Consent
required for the treatment(s) or procedure(s).
When informed consent is not required, patients are informed

of elements a) through h) in the intent as relevant to their
condition and planned treatment(s) or procedure(s). a) The
patient’s condition.b) The proposed treatment(s) or General and Informed Consent
procedure(s)
c) The name of the person providing the treatment
d) Potential benefits and drawbacks
e) Possible alternatives
f ) The likelihood of success
g) Possible problems related to recovery
h) Possible results of nontreatment
Patient and Family Education Policy and Procedure
Patients know the identity of the physician or other practitioner

responsible for their care.
The hospital develops and implements a process to respond to a

patient’s request for additional information about the physician
or other practitioner responsible for his or her care.
The hospital develops and implements a process for when

others can grant informed consent. General and Informed Consent
The process respects law, culture, and custom. General and Informed Consent
The patient’s medical record lists the individual(s) granting

consent.
The hospital plans education consistent with its mission,

services, and patient population.
There is an established structure or mechanism and adequate Patient and Family Education Policy and Procedure
resources for education throughout the hospital
Patient and family education are provided collaboratively when

Multidisciplinary Inpatients Patient – Family Education Recor
indicated.
Multidisciplinary Patient - Family Education Record(Outpatie
Those who provide the education have the subject knowledge

and communication skills to do so. Patient and Family Education Policy and Procedure
Those who provide the education have the resources and time
to do so. Patient and Family Education Policy and Procedure

Each patient’s and, when appropriate, family’s educational
needs are assessed and recorded in the patient’s medical
record.

The patient’s and family’s barriers to learning are assessed and
documented
Outpatients Patient - Family Education Assessment
Education by hospital staff is provided to patients and families in

a manner that accommodates their Patient and Family Education Policy and Procedure
identified needs.

Education provided to patients and families is documented in
the patient medical record.
The education process takes into account the patient’s and

family’s values and learning preferences.
The education process takes into account the patient’s and
family’s values and learning preferences.

There is a process to verify that patients and families receive
and understand the education provided.
Those who provide education encourage patients and their

families to ask questions and to speak up as active participants.
Verbal information is reinforced with written material that is

related to the patient’s needs and consistent with the patient’s Patient and Family Education Policy and Procedure
and family’s learning preferences.
The hospital supports patient and family choices to donate

organs and other tissues.
The hospital provides information to patients and families on
the donation process.
The hospital provides information to the patient and family on

the manner in which organ procurement
is organized. Organ Donation and Transplantation Program
The hospital ensures that adequate controls are in place to

prevent patients from feeling pressured to donate.
The hospital defines the organ- and tissue-donation processes

and ensures that the process is consistent with the region’s
laws and regulations and its religious and cultural values.
The hospital identifies consent requirements and develops a

consent process consistent with those requirements. Organ Donation and Transplantation Program
Staff are trained in the issues and concerns related to organ

donation and the availability of transplants.
The hospital cooperates with relevant hospitals and agencies in

the community to respect and to implement choices to donate.
Section
policy 4.1
policy 4.2
policy 4.2
policy 4.3
policy 4.7
responsibility 4.1
policy 7.1.2
policy 4.5
Patient's Bill of Rights

and responsibilities.
Posted in the units.
procedure 6.1.3
policy 5.3
procedure 7.1
policy 4.1.1
policy 4.1.2
policy 4.1.3
purpose 1.2
policy 4.1.4
procedure 6.1.26
resposibility 2.3
responsibility section
Responsibility 4.1 - 4.4
Policy 5.2
policy 5.6.3, 5.6.4
procedure 4.1, 4.2
definition of terms
5.2&5.3
procedure 6.4
purpose
policy 4.5
policy 4.2
policy 4.3
policy 4.3
policy 4.4
responsibiity section
Appendix- Fatwa
procedure 6.1.6
policy 5.2
procedure 6.1.15
Procedure 6.2
procedure 6.1.20
6.1.21
procedure 4.4
procedures 7.4.7
policy 4.2
policy 4.2
policy 4.3
policy 4.3
policy 4.12
procedure 6.1
procedure 6.1.4
procedure 6.1.2.4
procedure 6.2.1
procedure 6.2.2
procedure 6.2.2
procedure 6.2.3
procedure 6.2.4
procedure 6.2.5
policy 4.3
policy 4.3
policy 4.3
procedure 6.3.8, 6.3.9,
6.3.10, 6.3.11, 6.3.12,
6.3.13, 6.3.14
procedure 6.3
procedure 6.7
procedure 6.7
procedure 6.4.4
procedure 6.1.25
procedure 6.8
definition 5.13
procedure 6.2.5
policy 5.1
procedure 6.6
policy 5.13
procedure 6.8
policy 5.3
policy 5.7
policy 5.9
policy 6.1.29
Procedure 6.3,6.4,6.5
Introduction line no 2
Policy 3.5
ASSESSMENT OF PATIENTS (AOP)
Chapter Standard
All patients cared for by the hospital 2

AOP.1
have their health care needs identified
through an assessment process that has
been defined by the hospital.
Each patient’s initial assessment includes a physical

examination and health history as well as an
AOP.1.1
evaluation of psychological, spiritual/cultural (as
appropriate), social, and economic factors.
2
4
1
The patient’s medical and nursing needs are

identified from the initial assessments,
which are completed and documented in the 2
AOP.1.2
medical record within the first 24 hours after
admission as an inpatient or earlier as indicated by
the patient’s condition.
The initial medical and nursing assessments of

2
AOP.1.2.1 emergency patients are based on their needs and
conditions. 𝖯
The hospital has a process for accepting initial

medical assessments conducted in a physician’s
2
The hospital has a process for accepting initial
medical assessments conducted in a physician’s
AOP.1.3 private office or other outpatient setting prior to
admission or outpatient
procedure.
A preoperative medical assessment is documented

before anesthesia or surgical treatment and
AOP.1.3.1 includes the patient’s medical, physical,
psychological, social, economic, and discharge 2
needs.
Patients are screened for nutritional status, 3

AOP.1.4 functional needs, and other special needs and are
referred for further assessment and treatment
when necessary.
Patients are screened for nutritional status,
functional needs, and other special needs and are
AOP.1.4 referred for further assessment and treatment
when necessary.
3
All inpatients, and those outpatients whose
condition, diagnosis, or situation may indicate they
AOP.1.5
are at risk for pain, are screened for pain and
assessed when pain is present
4
Individualized medical and nursing initial

AOP.1.6 assessments are performed for special
populations cared for by the hospital. 𝖯
Individualized medical and nursing initial
AOP.1.6 assessments are performed for special
populations cared for by the hospital. 𝖯
3
The initial assessment includes determining the

AOP.1.7
need for discharge planning. 𝖯
All patients are reassessed at intervals based on

AOP.2 their condition and treatment to determine their
response to treatment and to plan for continued
2
All patients are reassessed at intervals based on

their condition and treatment to determine their 3
AOP.2
treatment or discharge. 𝖯
2
Qualified individuals conduct the assessment and
AOP.3
reassessments. 𝖯
1
Medical, nursing, and other individuals and
services responsible for patient care collaborate to
AOP.4 analyze and integrate patient assessments and 2
prioritize the most urgent/important patient care
needs.
3
Laboratory services are available to meet patient

AOP.5 needs, and all such services meet applicable local
and national standards, laws, and regulations.
Laboratory services are available to meet patient 2
AOP.5 needs, and all such services meet applicable local
and national standards, laws, and regulations.
2
A qualified individual(s) is responsible for managing
the clinical laboratory service or pathology service,
and all laboratory staff have the required
AOP.5.1 education, training, qualifications, and experience 3
to administer and perform the tests and interpret
the
results. 𝖯
A qualified individual is responsible for the

AOP.5.2 oversight and supervision of the point-of care
testing program. 𝖯
3
testing program. 𝖯
A laboratory safety program is in place, followed,

and documented, and compliance
AOP.5.3
with the facility management and infection
prevention and control programs is maintained. 𝖯 3
2
The laboratory uses a coordinated process to
reduce the risks of infection as a result of exposure
AOP.5.3.1
to infectious diseases and biohazardous materials
and waste. 𝖯
3
and waste. 𝖯
Laboratory results are available in a timely way as

AOP.5.4
defined by the hospital. 𝖯 2
All equipment used for laboratory testing is

regularly inspected, maintained, and 3
AOP.5.5 calibrated, and appropriate records are maintained
for these activities. 𝖯
Essential reagents and supplies are available, and 2

AOP.5.6 all reagents are evaluated to ensure
accuracy and precision of results. 𝖯
4
1
3
Procedures for collecting, identifying, handling,
AOP.5.7 safely transporting, and disposing of
specimens are established and implemented. 𝖯
4
Established norms and ranges are used to interpret

AOP.5.8 and to report clinical laboratory 3
results
2
Quality control procedures for laboratory services
AOP.5.9 are in place, followed, and
documented. 𝖯 3
There is a process for proficiency testing of 2

AOP.5.9.1
laboratory services. 𝖯
There is a process for proficiency testing of
AOP.5.9.1
laboratory services. 𝖯
Reference/contract laboratories used by the

AOP.5.10 hospital are licensed and accredited or certified by 2
a recognized authority.
The hospital identifies measures for monitoring the

quality of the 2
AOP.5.10.1
services to be provided by the reference/contract
laboratory.
A qualified individual(s) is responsible for blood

bank and/or transfusion services and ensures that 2
AOP.5.11 services adhere to laws and regulations and
recognized standards of
practice. 𝖯
3
recognized standards of
practice. 𝖯
Radiology and diagnostic imaging services are

available to meet patient needs, and all such
AOP.6 services
meet applicable local and national standards, laws,
and regulations.
3
A qualified individual(s) is responsible for managing 2

the radiology and diagnostic imaging services, and
AOP.6.1 individuals with proper qualifications and
experience perform diagnostic imaging studies,
interpret the results, and report the results. 𝖯
3
4
5
A radiation and/or diagnostic imaging safety

program for patients, staff, and visitors is in place,
AOP.6.2 is followed, and is compliant with applicable
professional standards, laws, and
regulations. 𝖯 4
Radiology and diagnostic imaging study results are

AOP.6.3 available in a timely way as defined by the hospital. 2
𝖯
AOP.6.3 available in a timely way as defined by the hospital.
𝖯
All equipment used to conduct radiology and 3

diagnostic imaging studies is regularly inspected,
AOP.6.4 maintained, and calibrated, and appropriate
records are maintained for 4
these activities. 𝖯
Quality control procedures are in place, followed,

AOP.6.5 3
validated, and documented. 𝖯
2
The hospital regularly reviews quality control
AOP.6.6 results for all outside contracted sources of
diagnostic services.
The hospital regularly reviews quality control
AOP.6.6 results for all outside contracted sources of
diagnostic services.
3
4
ASSESSMENT OF PATIENTS (AOP)
The hospital defines the minimum content of

assessments for inpatients for each clinical
discipline that performs assessments and specifies In-patient Medical Assessment and Reassessment
the required elements of the history and physical
examination.
The hospital defines the minimum content of

assessments for outpatients for each clinical
discipline that performs assessments and specifies
the required elements of the history and physical
examination.
Initial Out-patient Medical Assessment and Reassessment
Only qualified individuals permitted by licensure,

applicable laws and regulations, or certification
perform the assessments.
The hospital identifies the information to be

In-patient Medical Assessment and Reassessment
documented for the assessments.

All inpatients and outpatients have an initial
assessment that includes a health history and
physical examination consistent with the
requirements defined in hospital policy.
The assessment includes a listing of the patient’s

current medications and known allergies.
The assessment includes a) through c) in the intent, In-patient Medical Assessment and Reassessment
as indicated by his or her needs.
The initial assessment results in an initial diagnosis.

The initial medical assessment, including health In-patient Medical Assessment and Reassessment
history, physical exam, and other assessments
required by the patient’s condition, is performed
and documented within the first 24 hours of
admission
as an inpatient or sooner as required by patient
condition. Initial Out-patient Medical Assessment and Reassessment

The initial medical assessment results in a list of
specific medical diagnoses that includes primary
and associated conditions requiring treatment and
monitoring.
The initial nursing assessment is performed and

documented within the first 24 hours of admission
as an inpatient or sooner as required by patient
condition.
Initial Nursing Assessment and Reassessment
The initial nursing assessment results in a list of

specific patient nursing needs or conditions that
require nursing care, interventions, or monitoring.
The medical assessment of emergency patients is

based on their needs and condition and Medical Assessment and Reassessment in Emergency
The nursing assessment of emergency patients is

based on their needs and condition and Initial Nursing Assessment and Reassessment
Before surgery is performed, there is at least a brief

note and preoperative diagnosis documented for Medical Assessment and Reassessment in Emergency
emergency patients requiring emergency surgery.
Initial medical assessments conducted prior to

admission to inpatient status or prior to an
outpatient procedure in the hospital are less than
or equal to 30 days old.
For assessments less than or equal to 30 days old,
any significant changes in the patient’s condition
since the assessment or “no change” are
documented in the patient’s medical record at the
time of admission as an inpatient or prior to an
outpatient procedure.
If the medical assessment is greater than 30 days

old at the time of admission as an inpatient or prior
to an outpatient procedure, the medical history is
updated and the physical examination repeated.
The findings of all assessments performed outside

the hospital are reviewed and/or verified at the
time of admission to inpatient status or prior to an
outpatient procedure.
A preoperative medical assessment is performed

before surgery for all patients for whom surgery is
planned.
The preoperative medical assessment includes the

patient’s medical, physical, psychological, social,
economic, and discharge needs.
The preoperative medical assessment of surgical

patients is documented in the medical record The Provision of Surgical Care Policy
before surgery.
Qualified individuals develop screening criteria to

identify patients who require further nutritional
assessment, and the criteria are implemented
consistently throughout the hospital where
needed. Nutritional Referral, Assessment and Reassessment
Patients at risk for nutritional problems receive a

nutritional assessment.
Qualified individuals develop screening criteria to

identify patients who require further functional
assessment, and the criteria are implemented Physiotherapy Referal Form
consistently throughout the hospital where
needed.
Patients in need of a functional assessment are
referred for such an assessment. Policy 4.2
When the need for additional specialized

assessments is identified, patients are referred
within the hospital or outside the hospital.
Specialized assessments conducted within the
hospital are completed and documented in the
All inpatients are screened for pain and the

screening is documented.
Outpatients whose condition, diagnosis, or

situation may indicate they are at risk for pain are
screened for pain. Pain Assessment and Management
When pain is identified in the inpatient, a
comprehensive assessment of the patient’s pain is
performed.
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.
Pain Assessment Tools
When pain is identified in the outpatient, the

patient may be more thoroughly assessed and
treated in the outpatient setting or provided with a
referral for further assessment and treatment.
The hospital identifies, in writing, those special

patient groups and populations it serves that In-patient Medical Assessment and Reassessment
require modifications to its assessment.
The assessment process for special-needs patient

Care of Vulnerable Patients
populations is modified to reflect their needs.
The modified assessment process is consistent with
local laws and regulations and incorporates Care of Vulnerable Patients
professional standards related to such populations.
Individualized medical and nursing assessments are

performed and documented.
Medical Records Content and Documentation Standards
Discharge Policy
General Intensive Care unit 1 and 2 (GICU1, GICU2)Admission and Dischar
The hospital begins the discharge planning process Admission and Discharge for Burn Intensive Care Unit (B-ICU)2
early in the assessment process to identify those
patients for whom discharge planning is critical.
Admission and Discharge Maternity Intensive Care Unit2
Admission and Discharge Crieteria for Respiratory Intensive Care Unit (RIC
Admission and Discharge for Trauma Intensive Care Unit (TICU)2
Discharge planning includes identifying special

needs and developing and implementing a plan to
address those needs.
Discharge Policy
Patients, family as appropriate, and staff involved
in the patient’s care participate in the discharge
planning process.
Patients are reassessed to determine their

treatment and/or discharge

Patients are reassessed at intervals based on their
condition and when there has been a significant
change in their condition, plan of care, or individual
needs.
A physician reassesses patients at least daily,

including weekends, during the acute phase of
their care and treatment. In-patient Medical Assessment and Reassessment
For non-acute patients, the hospital defines, in

writing, the circumstances in which, and the types
of patients or patient populations for which, a
physician’s assessment may be less than daily and
identifies the minimum reassessment interval for
these patients.
Reassessments are documented in the patient

medical record.
Individuals qualified to conduct patient

assessments and reassessments are identified and
have their responsibilities defined in writing.

Only those individuals permitted by licensure,
applicable laws and regulations, or certification
perform patient assessments.
Emergency assessments are conducted by

Medical Assessment and Reassessment in Emergency
individuals qualified to do so.
Nursing assessments are conducted by individuals

Initial Nursing Assessment and Reassessment
qualified to do so.
Patient assessment data and information are

analyzed and integrated.
Those responsible for the patient’s care participate Patient Plan and Delivery of Care
in the process.
Patient needs are prioritized based on assessment
results.
Laboratory services meet applicable local and Pathology Samples, Requisition,

national standards, laws, and regulations. Collection, Handling,
Transportation, Receiving,
Accessioning
Laboratory services are available to meet the needs
Pathology Samples, Requisition,
related to the hospital’s mission and patient
Collection, Handling,
population, the community’s health care needs, Transportation, Receiving,
and emergency needs, including after normal
Accessioning
hours.
Experts in specialized diagnostic areas are

contacted when needed.
Outside sources are selected based on an
acceptable record and compliance with laws and
regulations.
The clinical laboratory, and other laboratory

services throughout the hospital, are under the Staff file of the head of the
direction and oversight of one or more qualified pathology department
individuals.
Responsibilities of the qualified laboratory leader

include a) through e) of the intent. JD of the head of pathology dept.
All laboratory staff have the required education,

training, and qualifications to administer, perform, Staff file of laboratory staff
and interpret tests.
A staffing program is implemented that allows staff

to perform tests promptly and to provide staffing Lab. Staffing Plan
during all hours of operation and during
emergencies.
Laboratory supervisory staff are identified and have

the proper qualifications and experience. Staff file of Lab Supervisor
The person responsible for managing the

laboratory services, or a designee, provides
oversight and supervision of the POCT program.
Staff performing point-of-care testing have the

required qualifications and training and are
competent to perform POCT.
Point of Care Testing Program

The POCT program includes a defined process for
reporting abnormal test results, including reporting
critical results.
The POCT program includes quality control
performance, documentation, and evaluation.
The POCT program is monitored and evaluated and

included in quality improvement activities.
A laboratory safety program addresses potential

safety risks in the laboratory and other areas
Health and Safety Programs
outsidethe laboratory where laboratory services
are provided.
The laboratory safety program is part of the

hospital’s facility management program and
reports to the hospital safety structure at least
annually and when any safety events occur.
The laboratory safety program is part of the

hospital’s infection prevention and control
program and reports to the infection prevention
and control program at least annually and when
any infection control events occur.
Identified safety risks are addressed by specific

processes and/or devices to reduce the safety risks.
Laboratory staff are oriented to safety procedures

and practices and receive ongoing education and Departmental New Employee
Orientation
training for new practices and procedures.
The laboratory has a defined process for reducing

the risks of infection.
Infections acquired in the laboratory are reported,

as defined in the policy, and in compliance with
applicable laws and regulations
The laboratory follows biosafety rules for relevant

practices addressed in elements a) through g) in
the
intent.
When problems with practice are identified, or
accidents occur, corrective actions are taken,
documented,
and reviewed.
The hospital establishes the expected report time

Laboratory Critical Test and Critical Result Reporting
for results.
The hospital measures the timeliness of reporting Laboratory Critical Test and Critical Result Reporting
of urgent/emergency tests.
Laboratory results are reported within a time frame
Laboratory Critical Test and Critical Result Reporting
to meet patient needs.
The laboratory develops, implements, and

documents a program to manage laboratory
equipment, including a process for how equipment
is selected and acquired.
There is a documented inventory of all laboratory

equipment.
Laboratory equipment is inspected and tested

when new and according to age, use, and Equipment/Instruments
manufacturers’ recommendations thereafter, and Management Program
the inspections are documented.
Laboratory equipment is calibrated and maintained

according to manufacturers’ recommendations,
and the calibration and maintenance are
documented.
The hospital has a system in place for monitoring

and acting on laboratory equipment hazard
notices, recalls, reportable incidents, problems,
and failures.
Essential reagents and supplies are identified and

available, and there is a process to address when
essential reagents are not available.
All reagents are stored and dispensed according to

manufacturers’ directives or packaging
instructions.
The laboratory establishes and follows written

guidelines for the evaluation of all reagents to
ensure accuracy and precision of results.
All reagents and solutions are completely and

accurately labeled.
Procedures are established and implemented for
the ordering of tests.

the collection and identification of specimens.

the transport, storage, and preservation of
specimens.

the receipt and tracking of specimens.

the disposal of specimens.
The procedures are followed when

reference/contract laboratory services are used.
The laboratory establishes reference ranges for

each test performed.
The range is included in the medical record at the

time test results are reported
Ranges are furnished when tests are performed by

reference/contract laboratory services.
Ranges are appropriate to the hospital’s geography

and demographics.
The laboratory reviews and updates ranges as
needed.
The hospital establishes and implements a quality

control program for the clinical laboratory.
The program includes the validation of test

methods.
The program includes the daily surveillance and
documentation of test results.
The program includes testing of reagents.
The program includes rapid correction and
documentation of deficiencies.
The laboratory participates in a proficiency-testing
program, or an alternative, for all specialty
laboratory
services and tests.
For each specialty, subspecialty, analyte, or test,
the laboratory’s proficiency testing results meet
satisfactory
performance criteria in accordance with laws and
regulations.
The laboratory maintains records of its
participation in a proficiency-testing program.
The hospital maintains a copy of the license, from a

recognized licensing authority, for all
reference/contract laboratories used by the
hospital.
The hospital maintains a copy of the certificate or

letter of accreditation or certification, from a
recognized
laboratory accreditation or certification program,
for all reference/contract laboratories used
by the hospital.
The hospital maintains documentation that any

reference/contract laboratory used by the hospital
participates in an outside proficiency-testing
program.
The hospital determines the frequency and type of

performance expectation data from reference/
contract laboratories.
The qualified individual responsible for the

laboratory or a qualified designee reviews the
performance expectation data from
reference/contract laboratories and takes action
based on the results.
An annual report of the data from

reference/contract laboratories is provided to
those who make decisions to facilitate
management of contracts and contract renewals.
A qualified individual(s) is responsible for blood

bank and/or transfusion services.
The blood bank has established, implemented, and

documented processes for a) through f ) of the
intent.
Quality control measures are in place for all blood

bank and transfusion services and are established,
implemented, and documented.
The blood bank and transfusion services comply
with applicable laws and regulations and
recognized standards of practice.
Radiology and diagnostic imaging services meet

applicable local and national standards, laws, and
regulations.
Radiation Safety Program

available to meet the needs related to the
hospital’s mission and patient population, the
community’s health care needs, and emergency
needs, including after normal hours.
The hospital maintains a roster of experts in

specialized diagnostic areas and ensures that the
roster is accessible to staff who need it.
Outside sources are selected based on

recommendations of the individual responsible for
radiology and diagnostic imaging services and have
an acceptable record of timely performance and
compliance
with applicable laws and regulations.

under the direction of one or more qualified
individuals.
Responsibilities of the individual managing

radiology and diagnostic imaging services include Radiation Safety Program
a)through e) of the intent.
Staff with proper qualifications and experience

Radiology Staff file(SQE)
perform diagnostic and imaging studies.
Staff with proper qualifications and experience

interpret study results and verify and report the Radiologic and Diagnostic Critical
results. Test and Critical Result
There is an adequate number of staff to meet
patient needs. Radilogy Dept. Staffing Plan
Supervisory staff have proper qualifications and Radiology Staff file(SQE)
experience.
A comprehensive radiation and/or diagnostic

imaging safety program for patients, staff, and
visitors is in place, is followed, and is compliant Radiation Safety Program
with applicable professional standards, laws, and
regulations.
Radiology and diagnostic imaging staff are oriented

to safety precautions and procedures and receive
ongoing education and training for any new
procedures, equipment, and hazardous materials.
Safety protective equipment and devices

appropriate to the practices and hazards
encountered from radiation and diagnostic imaging
are available to staff, patients, and visitors, and in Radiation Safety Program
the area in which radiology and diagnostic imaging
services are provided.
Radiation safety includes education about dosing

and implementation of protocols that identify the Radiation Safety Program
maximum dose of radiation for each type of study.
Hazards from magnetic resonance imaging are

addressed using industry standards and evidence-
based guidelines (for example, identification of
safety zones, access restrictions, signage,
availability of non-ferromagnetic equipment, and
so on).
The radiation and/or diagnostic imaging safety

program is part of the organization’s facility
management and infection prevention and control
programs and provides reports to those programs Radiation Safety Program
at least annually and when any safety events and
infection control events occur.
The hospital establishes the expected report time Radiation Safety Program
for results.
The hospital measures the timeliness of reporting

of urgent/emergency studies.
reported within a time frame to meet patient Radiation Safety Program
needs
Radiology and diagnostic imaging develops,

implements, and documents a program to manage Radiation Safety Program
equipment
The program identifies how radiology equipment is Radiation Safety Program

selected and acquired.
There is a documented inventory of all radiology
equipment.
Radiology equipment is inspected and tested when
new and according to age, use, and manufacturers’ Radiation Safety Program
recommendations.
Radiology equipment is calibrated and maintained

according to manufacturers’ recommendations. Radiation Safety Program
The hospital has a system in place for monitoring

and acting on radiology equipment hazard notices,
recalls, reportable incidents, problems, and Radiation Safety Program
failures.
The hospital establishes and implements a quality

control program for the radiology and diagnostic
imaging services.
Quality control includes validating test methods.
Quality control includes regular surveillance and

documentation of imaging results.
Quality control includes testing reagents and
solutions, when used, and documenting test
results.
Quality control includes rapid correction and

documentation when a deficiency is identified.
The frequency and type of quality control data

from outside contracted sources are determined by
the hospital.
The qualified individual responsible for the

radiology quality control or qualified designee
reviews the quality control results from the outside
contracted source.
The responsible individual or qualified designee
takes action based on the quality control results.
An annual report of the quality control data from

the outside contracted source is provided to
hospital leadership to facilitate management of
contracts and contract renewal.
NOT REVIEWED - EXPIRED POLICY

Section
policy 2.1
policy 2.2
policy 2.3
policy 2.4.1
policy 2.5
policy 2.10
procedure3.1.7, 3.1.1
procedure 3.1.8, 3.1.6
policy 2.10
policy 2.5, 2.6, 2.7,2.8
Policy 2.1
policy 2.10
Policy 2.5, 2.7
procedure 4.1.4., policy 2.1
Policy 2.4
policy 2.1
policy 2.1
policy 2.4
policy 2.11
policy 2.11
policy 2.11
policy 2.12
policy 2.8
policy 2.10, 2.24.2
procedure 3.2
procedure 6.1.3
policy 5.1.1, 5.1.2

policy 2.16
policy 2.13
policy 3.3
Outpatient Initial Nursing

Assessment Form
procedure 5.2.1, 5.3.3
Policy 2.10
Policy 2.13
Procedure
6.1,6.2,6.3,6.4,6.5,6.6
Procedure 6.6.6
Appendix 1 - Emergency,
Inpatient Medical and
Nursing Assessment and
reassesment
Policy 4.1
Policy 4.6.1
Procedure 5.5
Policy 2.18
Policy 2.19, 2.20
Policy 2.18
Policy 2.19
Policy 2.20
Policy 2.3
Policy 2.2
Policy 2.2, 2.3
Policy 2.3,2.4,2.5
Policy 2.1
Policy 2.3.2.4,2.5
Applicability 1.2
Procedure 6.5, 6.6
Procedure 6.9.7
Procedure 6.8, 6.10
Appendix 9.2
Policy 2.1
Policy 2.2
Procedure 7.2.6.2
Procedure 7.2.1
Procedure 7.2.3 & 7.2.4, 7.4.2.10
7.6,
CARE OF PATIENTS (COP)
Chapter Standard
COP.1 Uniform care of all patients is provided and

follows applicable laws and regulations. 𝖯
There is a process to integrate and to coordinate 2

the care provided to each patient, and it includes
COP.2
a uniform
process for prescribing patient orders.
Clinical and diagnostic procedures and

treatments are carried out and documented as
COP.2.1 2
ordered, and the results or outcomes are
recorded in the patient’s medical record.
Clinical and diagnostic procedures and
treatments are carried out and documented as
COP.2.1
ordered, and the results or outcomes are
recorded in the patient’s medical record.
An individualized plan of care is developed and

COP.2.2 3
documented for each patient.
2
The care of high-risk patients and the provision of
high-risk services are guided by professional
COP.3
practice 3
guidelines, laws, and regulations. 𝖯
5
1
Reduce the risk of harm associated with clinical 2

alarms by developing and implementing risk
COP.3.1 reduction
strategies for managing clinical alarm systems
used for patient care. 𝖯 3
Clinical staff are trained to recognize and respond 3

COP.3.2
to changes in a patient’s condition.
Resuscitation services are available throughout

COP.3.3
the hospital.
2
Resuscitation services are available throughout

COP.3.3
the hospital.
Clinical guidelines and procedures are established

COP.3.4 and implemented for the handling, use, and 2
administration of blood and blood products.
3
The hospital has a process to identify patients at
COP.3.5
risk for suicide and self-harm. 𝖯
4
5
The hospital establishes and implements a

program for the safe use of lasers and other
COP.4 optical radiation devices used for performing
procedures and treatments. 𝖯 4
6
1
Adverse events resulting from the use of lasers

and other optical radiation devices are reported,
COP.4.1 and action plans
to prevent recurrence are implemented and 2
monitored.
A variety of food choices, appropriate for the

COP.5 patient’s nutritional status and consistent with
his or her clinical care, is available. 3
Patients at nutrition risk receive nutrition

COP.5.1 2
therapy.
1
2
Patients are supported in managing pain

COP.6
effectively. 𝖯
The hospital provides end-of-life care for the

dying patient that addresses the needs of the
COP.7
patient and family 3
and optimizes the patient’s comfort and dignity.
6
1
COP.8 The hospital’s leadership provides resources to 2

support the organ/tissue transplant program.
A qualified transplant program leader(s) is

COP.8.1 responsible for the transplant program. 2
The transplant program includes a

multidisciplinary team that consists of people
COP.8.2 with expertise in the relevant 3
organ-specific transplant programs.
2
There is a designated coordination mechanism
for all transplant activities that involves
COP.8.3
physicians, nurses, and
other health care practitioners.
There is a designated coordination mechanism
for all transplant activities that involves
COP.8.3
physicians, nurses, and
other health care practitioners.
The transplant program uses organ-specific 2

transplant clinical eligibility criteria and
COP.8.4
psychological and social suitability criteria for
transplant candidates.
3
The transplant program obtains informed

COP.8.5 consent specific to organ transplantation from
the transplant candidate. 𝖯
The transplant program obtains informed
COP.8.5 consent specific to organ transplantation from
the transplant candidate. 𝖯
3
The transplant program has documented
protocols, clinical practice guidelines, or
procedures for organ
COP.8.6 recovery and organ receipt to ensure the
compatibility, safety, efficacy, and quality of
human cells, tissues, and
organs for transplantation. 𝖯
The transplant program has documented
protocols, clinical practice guidelines, or
procedures for organ
COP.8.6 recovery and organ receipt to ensure the
compatibility, safety, efficacy, and quality of
human cells, tissues, and
organs for transplantation. 𝖯
Individualized patient care plans guide the care of

COP.8.7
transplant patients. 3
Transplant programs that perform living donor

transplantation adhere to local and regional laws
COP.9
2

transplantation adhere to local and regional laws
COP.9
and regulations and protect the rights of 3
prospective or actual living donors.
3
Transplant programs performing living donor
transplants obtain informed consent specific to
COP.9.1
organ donation
from the prospective living donor. 𝖯
1
2
3
transplants use clinical and psychological
COP.9.2 selection criteria to
determine the suitability of potential living
donors. 𝖯
4
Individualized patient care plans guide the care of

COP.9.3 living donors. 2
3
CARE OF PATIENTS (COP)
The hospital’s department/service leaders

Patient Plan and Delivery of Care
collaborate to provide uniform care processes.
The provision of uniform care reflects local and

regional laws and regulations.
Uniform care is provided and meets requirements a)

through e) in the intent.
Critical Care Area Acuity Tool
General Floor Acuity Scoring

System
Triage
Care planning and care delivery are integrated and

coordinated among settings, departments, and Patient Plan and Delivery of Care
services.
The hospital develops and implements a uniform

process for prescribing written/documented patient
orders that includes identifying orders that may be Patient Plan and Delivery of Care
received verbally, via telephone, and via text.
Diagnostic imaging and clinical laboratory test orders

include a clinical indication/rationale when required Patient Plan and Delivery of Care
for interpretation.
Orders are prescribed only by those qualified to do
so.
Orders are found in a uniform location in medical
records.
Procedures and treatments are carried out as

ordered and are documented in the patient’s medical
record.
The person requesting, and the reason for

requesting, the procedure or treatment are Patient Plan and Delivery of Care
documented in the patient’s medical record.
The results of procedures and treatments performed

are documented in the patient’s medical record.
The care for each patient is planned by the

responsible physician, nurse, and other health care
practitioners within 24 hours of admission as an
inpatient.
The plan of care is individualized based on the

patient’s initial assessment data and identified needs Patient Plan and Delivery of Care
and is documented in the patient’s medical record.
The plan of care is updated or revised by the

multidisciplinary team based on any changes in the
patient’s condition identified from the reassessment Patient Plan and Delivery of Care
of the patient by the health care practitioners, and is
The results or conclusions of any patient care team

meetings or other collaborative discussions are Multidisciplinary Team Form
The plan of care is provided to each patient and

evident in the patient’s medical record through
documentation by the health care practitioners
providing the care.
Hospital leadership identifies the high-risk patients

and services, including at least a) through j) of the High Risk Patients and High Risk Services Policy
intent when provided by the hospital.
Leadership establishes and implements policies,

procedures, and/or principles of care for those High Risk Patients and High Risk Services Policy
highrisk services provided by the hospital.
Staff are trained to utilize the written tools for care of

High Risk Patients and High Risk Services Policy
these high-risk patients and services.
Hospital leadership identifies additional risks that

may affect high-risk patients and services and
High Risk Patients and High Risk Services Policy
implements measures to reduce and/or prevent
additional risks.
The development of hospital-acquired risks is tracked

and included in the hospital’s quality improvement High Risk Patients and High Risk Services Policy
program.
Hospital leaders develop and implement an alarm
system management program for alarm signals that
pose a risk to patient safety.
The program identifies the most important alarm

signals to be managed based on the risk to patient
safety.
Hospital leaders develop strategies for managing

alarms that consider a) through e) of the intent.
Health care practitioners and other appropriate staff

are educated about the purpose and proper
operation of alarm systems for which they are
responsible.
Staff responsible for the management of clinical

alarms are trained and competent to do so.
The hospital develops and implements a systematic

process for staff recognition of and response to a Rapid Response Team
patient whose condition appears to be worsening.
The hospital develops and implements documented

age-specific criteria describing early warning signs of Rapid Response Team
a change or deterioration in a patient’s condition.
The hospital develops and implements a process that Rapid Response Team
identifies when and how to seek further assistance.
Based on the hospital’s early warning criteria, staff

seek additional assistance when they have concerns Rapid Response Team
about a patient’s condition.
The hospital informs the patient and family how to Patient and Family Education Policy and Procedure
seek assistance when they have concerns about a
patient’s condition.
Resuscitation services are available and provided to

all patients 24 hours a day, every day, throughout all Cardio-Pulmonary Resuscitation
areas of the hospital.
Medical equipment for resuscitation and medications
for basic and advanced life support are standardized Cardio-Pulmonary Resuscitation
and available for use based on the needs of the
population served.
In all areas of the hospital, basic life support is

implemented immediately upon recognition of or
Cardio-Pulmonary Resuscitation
respiratory arrest, and advanced life support is
implemented in fewer than 5 minutes.
The hospital reviews internal data from previous

emergency situations and identifies areas for Cardio-Pulmonary Resuscitation
improvement.
An individual with education, knowledge, and

Personal Staff File of the Director
expertise oversees the administration of blood and
of Central Lab
blood products.
Clinical guidelines and procedures are established

and implemented for the handling, use, and Blood Transfusion, Dispense and Administration of Blood Products
administration of blood and blood products.
Clinical guidelines and procedures address the

Blood Transfusion, Dispense and Administration of Blood Products
processes for a) through f ) in the intent.
The hospital establishes criteria for which patients

are screened for suicide and self-harm, as clinically
indicated.
The hospital uses evidence-based tools to assess

patients for suicidal ideation based on established
criteria. Patients who screen positive, are identified
as “at risk” for suicide and/or self-harm based on the
established criteria.
The hospital conducts an environmental risk

assessment that identifies features in the physical
environment that could be used in a suicide or self-
harm attempt; the hospital takes necessary action to
minimize the risk(s).
The hospital implements protocols and procedures to

mitigate the risk of patient suicide and/or self-harm.
The hospital monitors implementation and
effectiveness of protocols and procedures for the
prevention of patient suicide and/or self-harm by
analyzing data regarding self-harm, the incidents, or
deaths.
Staff are trained on screening criteria, screening

tools, and suicide and self-harm risk reduction
protocols and procedures.
The hospital’s program for the safe use of lasers and

optical radiation devices is based on industry
standards and professional guidelines and complies
A qualified individual with the appropriate training

and experience has oversight and supervision of the
laser and optical radiation safety program.
All staff involved in the use of lasers and optical

radiation devices receive safety training and
continuing education; the training and ongoing
education are documented.
The hospital establishes and implements

administrative and engineering controls for the laser
and optical radiation safety program to promote
safety and prevent injury for patients and staff.
Personal protective equipment appropriate to the

type of lasers and optical radiation devices and type
of procedures is available for staff and patients, and
staff use it correctly and ensure that patients are
protected during procedures.
The hospital has processes for inspection, testing,

and maintenance of lasers and optical radiation
devices, including routine calibration and alignment
checks of lasers, and these activities are performed
by qualified and trained individuals.
The laser safety and optical radiation program is part
of the hospital’s facility management and safety
structure and provides reports to the facility
management and safety structure at least annually
and when any safety events occur.
The laser safety and optical radiation program is part

of the hospital’s infection prevention and control
program and provides reports to the infection
prevention and control program at least annually and
when any infection control events occur.
When adverse events result from the use of lasers

and/or optical radiation devices, the adverse events
are reported, and action plans are identified and
implemented to prevent recurrence.
A variety of food choices or nutrition, consistent with

the patient’s condition, care, and needs, is regularly Nutrition Referral Assessment and Reassessment
available.
Prior to inpatients being fed, there is an order for

food in the patient’s medical record that is based on Nutrition Referral Assessment and Reassessment
the patient’s nutritional status and needs.
The distribution of food is timely, and special

requests are met.
When families provide food, they are educated about

Nutrition Referral Assessment and Reassessment
the patients’ diet limitations.
Food provided by family or others is stored under

proper conditions to prevent contamination.
Patients assessed at nutrition risk receive nutrition Nutrition Referral Assessment and Reassessment
therapy.
A collaborative process is used to plan, to deliver, and

to monitor nutrition therapy.
The patient’s response to nutrition therapy is

monitored and documented in the medical record.
Based on the scope of services provided, the hospital

Pain Assessment and Management
has processes to identify patients in pain.
When pain is an expected result of planned
treatments, procedures, or examinations, patients
Pain Assessment and Management
are informed about the likelihood of pain and options
for pain management.
Patients in pain receive care according to pain

management guidelines and according to patient Pain Assessment and Management
goals for pain management.
Based on the scope of services provided, the hospital Multidisciplinary Inpatients

has processes to communicate with and to educate Patient – Family Education
patients and families about pain. Record
Multidisciplinary Patient - Family

Education Record
Based on the scope of services provided, the hospital

has processes to educate staff about pain. Patient and Family Education Policy and Procedure
Staff are educated about the unique needs of

patients and their families at the end of life.
The health care needs of the patient and the support

service needs of the patient and the family are
identified as appropriate to their religious and Care of End of Life and Dying Patients
cultural preferences.
End-of-life care addresses the symptoms, conditions,

and health care needs of the dying patient as Care of End of Life and Dying Patients
indicated by his or her assessment.
End-of-life care addresses the dying patient’s pain Care of End of Life and Dying Patients
End-of-life care addresses the patient’s and family’s

psychosocial, emotional, cultural, and spiritual needs, Care of End of Life and Dying Patients
as appropriate, regarding dying and grieving.
The patient and family are involved in care decisions. Care of End of Life and Dying Patients
Trained staff are available to provide safe, high-
Organ Donation and Transplantation Program
quality care to the organ/tissue transplant program.
The hospital’s leadership allocates resources for the Organ Donation and Transplantation Program
organ/tissue transplant program.
Information management systems are used to
support the quality of the organ/tissue transplant Organ Donation and Transplantation Program
program.
The transplant program has an infrastructure capable

of supporting all aspects of the transplant program Organ Donation and Transplantation Program
activities.
One or more individuals are qualified to oversee the

scope and complexity of the organ/tissue transplant Organ Donation and Transplantation Program
program.
The individual(s) fulfills the program’s oversight

responsibilities as defined by the transplant program. Organ Donation and Transplantation Program
The transplant program documents the composition

of the tissue/organ-specific transplant team.
The transplant program documents the team Organ Donation and Transplantation Program
members’ responsibilities.
Based on the services provided by the transplant

team, the team includes individuals experienced in
medicine, nursing, nutrition, pharmacology, infection
prevention and control, social services, psychological
services, rehabilitative services, and transplant
coordination
The transplant program evaluates team members for

qualifications, training, and experience at the time Organ Donation and Transplantation Program
each individual is being considered for the transplant
team.
The individual responsible for the coordination of the

live donor’s and transplant recipient’s care is
identified and available through all phases of
transplant care.
The clinical transplant coordinator facilitates

continuity of care for transplant patients (candidates
and recipients) through the pre-transplant,
transplant, and discharge phases of transplantation.
The clinical transplant coordinator facilitates
continuity of care for living donors during the Organ Donation and Transplantation Program
evaluation, donation, and discharge phases of
donation.
The coordination of organ/tissue transplant activities

is communicated to all staff involved in the transplant Organ Donation and Transplantation Program
program activities.
The transplant program documents organ-specific Organ Donation and Transplantation Program
clinical eligibility criteria for the transplant candidate.
The transplant program documents the psychological

and social suitability criteria for the transplant Organ Donation and Transplantation Program
candidate.
The results of a medical evaluation are included in

the determination of suitability for Organ Donation and Transplantation Program
transplantation.
The transplant program documents organ

compatibility confirmation in the transplant Organ Donation and Transplantation Program
candidate’s medical record.
The transplant program follows the hospital’s policy

when obtaining informed consent from transplant Organ Donation and Transplantation Program
candidates.
In addition to the information provided to any

surgical patient as part of the informed consent
process, the transplant program informs the Organ Donation and Transplantation Program
prospective transplant candidate of potential
psychosocial risks.

process, the transplant program informs the
prospective transplant candidate of organ donor risk Organ Donation and Transplantation Program
factors that could affect the success of the graft or
the candidate’s health as a recipient, including, but
not limited to, a) through d) of the intent.
prospective transplant candidate of the transplant
center’s observed and expected one-year survival
rate; or when the transplant program has been in
operation less than 18 months, the one-year survival
rate as documented in the literature.

prospective transplant candidate about potential
rejection rates, immunosuppressive drugs, and
possible associated costs.

process, the transplant program informs the Organ Donation and Transplantation Program
prospective transplant candidate of alternative
treatments.
The transplant team follows written organ recovery

protocols, clinical practice guidelines, or procedures,
which include reviewing the essential donor data and Organ Donation and Transplantation Program
recipient data to ensure compatibility before organ
recovery takes place
The transplant surgeon is responsible for confirming,

in writing, the medical suitability of donor organs for Organ Donation and Transplantation Program
transplantation into the recipient.
When an organ arrives at the transplant center, the

transplanting surgeon and at least one other licensed
health care practitioner at the transplant center
verify and document that the donor’s blood type and Organ Donation and Transplantation Program
other essential data are compatible with the
recipient prior to transplantation.
The transplant surgeon is responsible for confirming
that donor evaluation and donor testing for
infectious diseases and malignancy have been
completed, and are documented in the medical
record, before organ recovery and organ transplant
occur.
When an organ arrives at the transplant center, the

transplanting surgeon and at least one other licensed
health care practitioner at the transplant center
verify and document that evaluation and testing of
the donor organ shows no evidence of disease and
the condition of the organ is suitable for transplant.
The transplant program has documented organ-

specific clinical practice guidelines for the pre-
transplant, transplant, and discharge phases of
transplantation.
Each transplant patient is under the care of a

multidisciplinary patient care team coordinated by
the patient’s primary transplant physician throughout
the pre-transplant, transplant, and discharge phases
of transplantation.
Transplant candidates are evaluated for the

suitability of other medical and surgical therapies Organ Donation and Transplantation Program
that may yield short- and long-term survival rates
comparable to transplantation.
Transplant candidates receive a psychological

evaluation by a psychiatrist, psychologist, or social
worker with experience in transplantation to
determine the decision-making capacity of the
patient and screen for any preexisting psychiatric
illness.
The transplant program updates clinical information

in the transplant patient’s medical record on an
ongoing basis.

transplantation adhere to local and regional laws and
regulations.

The living organ donor has the right to make a
decision about donation in a setting free of coercion
and pressure.
An individual with knowledge of living organ

donation, transplantation, medical ethics, and Organ Donation and Transplantation Program
informed consent is identified and appointed as an
advocate for the living donor.
The individual appointed as the living donor advocate

is not involved in routine transplantation activities.
The individual appointed as the living donor advocate

informs, supports, and respects the living donor in a
culturally appropriate manner during decision
making.
Informed consent for living donation is obtained by

trained staff and is in a language the prospective
living donor can understand.

prospective living donor of potential psychological
risks of
donation.

prospective living donor of potential complications
and
risks associated with living organ donation. Organ Donation and Transplantation Program

prospective living donor of potential future health
problems.
The transplant program informs the prospective

living donor of alternative treatments for the
transplant candidate.
The transplant program informs the prospective

living donor of the donor’s right to opt out of
donation
at any time during the donation process.
The transplant program documents defined organ-

specific living donor selection criteria.
The transplant program’s living donor selection
criteria are consistent with laws and regulations and
the principles of medical ethics.
The results of a medical evaluation related to the

living donor’s own physical health are included in the
determination of suitability for donation.

The results of medical tests identifying infectious
diseases or malignancies are included in the
The results of a psychological evaluation conducted

by a psychiatrist, psychologist, or social worker with
experience in transplantation are included in the
The transplant program documents organ

compatibility confirmation in the living donor’s
medical record.

transplants are guided by documented living donor
guidelines for care in the evaluation, donation, and
discharge phases of donation.

transplants provide multidisciplinary care by a team Organ Donation and Transplantation Program
coordinated by a physician to each donor throughout
the donor evaluation, donation, and discharge phases
of donation.
The living donor candidate receives ongoing

psychological support following donation.
Section
policy 2.9
procedure 3.1
policy 2.3, 2.9 2.9.1-2.9.5
purpose 1.2, policy 2.1
procedure 2.18, 3.19.3,

3.19.4, 3.19.5
policy 2.15, 2.16
policy 2.12
policy 2.1.4
policy 2.1
procedure 3.19.1/ progress

notes/ doctors order form
policy 2.16
policy 2.3
policy 2.3
policy 2.7
policy 2.8
policy 2.2
policy 2.6
policy 2.5.1
policy 2.4
policy 2.7
policy needs to be initiated
intro.1.1
appendix 7.1 Early Warning

Scoring Sheet
procedure 5.1
procedure 5.2
responsibility 4.4.1
policy 5.1.4
Policy No. 4.13.2, Procedure

5.12.4
the entire policy applies
the entire policy applies
???
???
???
???
???
???
???
???
???
???
???
???
???
???
???
Policy 5.2.2
Policy 5.2.1
Policy 5.2.3
procedure 6.18.13-6.18.14
procedure 6.7
procedure 6.9
refer to entire policy

Policy 3.6.2
refer to entire policy
staff education?training?
competency?
procedure 6.7.4.9
ANESTHESIA AND SURGICAL CARE (ASC)
Chapter Standard
2
Sedation and anesthesia services are
available to meet patient needs, and all 3
ASC.1
such services meet professional standards
and applicable local and national standards,
laws, and regulations.
4
A qualified individual(s) is responsible for

ASC.2
managing the sedation and anesthesia 3
services.
ASC.3 The administration of procedural sedation is

standardized throughout the hospital. 3
Practitioners responsible for procedural

ASC.3.1 sedation and individuals responsible for
monitoring patients receiving 2
sedation are qualified.
Practitioners responsible for procedural
sedation and individuals responsible for
ASC.3.1
monitoring patients receiving
sedation are qualified.
1
Procedural sedation is administered and
ASC.3.2 monitored according to professional
practice guidelines. 2
1
The risks, benefits, and alternatives related
to procedural sedation are discussed with
ASC.3.3 the patient, his or her family, or those who
2
make decisions for the patient.
3
A qualified individual conducts a

ASC.4 2
preanesthesia assessment and preinduction
assessment.
3
Each patient’s anesthesia care is planned

ASC.5 and documented, and the anesthesia and 2
technique used are
documented in the patient’s record.
3
1
The risks, benefits, and alternatives related
to anesthesia are discussed with the
ASC.5.1 patient, his or her family, or those who 2
make decisions for the patient.
3
1
Each patient’s physiological status during
ASC.6 anesthesia and surgery is monitored
according to professional practice guidelines 2
and documented in patient's record.
3
Each patient’s postanesthesia status is

monitored and documented, and the
ASC.6.1 patient is discharged from the recovery area
by a qualified individual or by using
established criteria.
Each patient’s postanesthesia status is 2
monitored and documented, and the
patient is discharged from the recovery area
ASC.6.1
by a qualified individual or by using
established criteria. 3
Each patient’s surgical care is planned and 2

ASC.7
documented based on the results of the
assessment.
The risks, benefits, and alternatives are

ASC.7.1 discussed with the patient and his or her 2
family or those who make
decisions for the patient.
3
Information about the surgical procedure is 2

ASC.7.2 documented in the patient’s record to
facilitate continuing care.
3
2
Patient care after surgery is planned and
ASC.7.3 documented.
3
Patient care after surgery is planned and
ASC.7.3
documented.
1
Surgical care that includes the implanting of
a medical device is planned with special
ASC.7.4
consideration of how standard processes 2
and procedures must be modified.
3
ANESTHESIA AND SURGICAL CARE (ASC)
Sedation and anesthesia services meet professional standards and

applicable local and national standards, laws, and regulations.
Sedation and anesthesia services are available to meet patient needs.

Anesthesia
Sedation and anesthesia services are available for emergencies after
normal hours of operation.
Outside sedation and anesthesia sources are selected based on the

recommendations of the leader ofsedation and anesthesia services,
acceptable records of performance, and compliance with applicable
laws and regulations.
There is a contract for outside sedation and anesthesia services.
Sedation and anesthesia services are uniform throughout the hospital.
Sedation and anesthesia services are under the direction of one or

Anesthesia
more qualified individuals. (Also seeGLD.9)
Responsibilities for recommending outside sources of sedation and

Sedation
anesthesia services are defined and carried out.
Responsibilities for monitoring and reviewing all sedation and

anesthesia services are defined and carried out.
The administration of procedural sedation is standardized throughout

the hospital.
Standardization of procedural sedation includes identifying and
addressing at least a) through e) in the intent.
Emergency medical technology and supplies are readily available and Sedation
customized to the type of sedation being performed and the age and
medical condition of the patient.
An individual with advanced life-support training must be immediately

available when procedural sedation is being performed. (Also see
COP.3.2)
Health care practitioners responsible for providing procedural

sedation are competent in at least a)through d) of the intent.
The individual responsible for patient monitoring during procedural Sedation

sedation is competent in at least elements e) through h) in the intent.
Sedation
Procedural sedation competencies for all staff involved in sedation are

documented in the personnel files.
There is a presedation assessment performed and documented that

includes at least a) through e) to evaluate risk and appropriateness of
procedural sedation for the patient. (Also see AOP.1, MEs 1 and 2)
Sedation
A qualified individual monitors the patient during the period of
sedation and documents the monitoring.
Established criteria are used and documented for the recovery and
discharge from procedural sedation.
The patient, family, and/or decision makers are educated on the risks,
Genaral and Informed Consent
benefits, and alternatives of procedural sedation.
The patient, family, and/or decision makers are educated about

postprocedure analgesia. Patient and Family Education Policy and Procedure
A qualified individual provides the education.

A preanesthesia assessment is performed for each patient. (Also see
AOP.1, MEs 1 and 2)
A separate preinduction assessment is performed to reevaluate

Anesthesia
patients immediately before the induction of anesthesia.
The two assessments are performed by an individual(s) qualified to do

so and documented in the patient record.
The anesthesia care of each patient is planned and documented in the
patient's record.
The anesthesia agent, dose (when applicable), and anesthetic

Anesthesia
technique are documented in the patient’s anesthesia record.
The anesthesiologist and/or nurse anesthetist and anesthesia

assistants are identified in the patient’s anesthesia record.
The patient, family, and/or decision makers are educated on the risks,
benefits, and alternatives of anesthesia.
The patient, family, and/or decision makers are educated about
postoperative analgesia.
The anesthesiologist or another qualified individual provides and
documents the education.
The frequency and type of monitoring during anesthesia and surgery
are based on the patient’s preanesthesia status, the anesthesia used,
and the surgical procedure performed.
Monitoring of the patient’s physiological status is consistent with Anesthesia
professional practice.
The results of monitoring are documented in the patient’s record.
Patients are monitored during the postanesthesia recovery period.
Anesthesia
Monitoring findings are documented in the patient’s clinical record.
Patients are discharged from the postanesthesia unit (or recovery Anesthesia
monitoring is discontinued) in accordance with the alternatives
described in a) through c) in the intent.
Time recovery is started and time recovery phase is complete are
recorded in the patient’s record.
The assessment information used to develop and to support the

planned invasive procedure is documented in the patient’s record by
the responsible physician before the procedure is performed. (Also
see AOP.5.4, ME 3; and AOP.6.4, ME 3)
Each patient’s surgical care is planned based on the assessment

information. The Provision of Surgical Care Policy
A preoperative diagnosis and the planned procedure are documented

in the patient's record by the responsible physician prior to the
procedure.
The patient, family, and decision makers are educated on the risks,
benefits, potential complications,and alternatives related to the General and Informed Consent
planned surgical procedure.
The education includes the need for, risk and benefits of, and The Provision of Surgical Care Policy
alternatives to blood and blood-product use.
The patient’s surgeon or other qualified individual provides and

documents the education.
Surgical reports, templates, or operative progress notes include at
least a) through h) from the intent.
The hospital identifies information that may routinely be recorded in
other specific areas of the record. The Provision of Surgical Care Policy
The surgical report, template, or operative progress note is available
immediately after surgery before the patient is transferred to the next
level of care.
The postsurgical care provided by medical, nursing, and others meets

the patient’s immediate postsurgical needs.
The continuing postsurgical plan(s) is documented in the patient’s

record within 24 hours by the responsible surgeon or verified by a co-
signature from the responsible surgeon on the documented plan
entered by the surgeon’s delegate. The Provision of Surgical Care Policy
The continuing postsurgical plan of care includes medical, nursing, and

others as needed based on the patient’s needs.
The Provision of Surgical Care Policy
When indicated by a change in the patient’s needs, the postsurgical

plan of care is updated or revised based on the reassessment of the
patient by the health care practitioners.
The hospital’s surgical services define the types of implantable devices

that are included within its scope of services.
The Provision of Surgical Care Policy
Policies and practices include a) through g) in the intent.
Medical device implants are included in the department’s monitoring
priorities.
Section
MEDICATION MANAGEMENT AN
Chapter Standard
3
Medication use in the hospital is organized to meet
patient needs, complies with applicable laws and
regulations,
MMU.1
and is under the direction and supervision of a
licensed pharmacist or other qualified professional.
𝖯 4
The hospital develops and implements a program

for the prudent use of antibiotics based on the
MMU.1.1 2
principle of
antibiotic stewardship. 𝖯
3
4
5
There is a method for overseeing the hospital’s

medication list, including how listed medications
are used; a
method for ensuring medications for prescribing or
MMU.2
ordering are stocked; and a process for
medications not
1
There is a method for overseeing the hospital’s

medication list, including how listed medications
are used; a
method for ensuring medications for prescribing or
MMU.2
ordering are stocked; and a process for
medications not
stocked or not normally available to the hospital or
for times when the pharmacy is closed. 𝖯
3
MMU.3 Medications are properly and safely stored
1
1
2
Emergency medications are available, uniformly
stored, monitored, and secure when stored out of
MMU.3.1
the
pharmacy. 𝖯 3
MMU.3.2 The hospital has a medication recall system
The hospital identifies and documents a current list

of medications taken by the patient at home and
MMU.4 reviews 2
the list against all new medications prescribed or
dispensed. 𝖯
2
The hospital identifies those qualified individuals
MMU.4.1 permitted to prescribe or to order medications.
The hospital identifies those qualified individuals
MMU.4.1
permitted to prescribe or to order medications.
MMU.4.2
The hospital identifies safe prescribing, ordering,
and transcribing practices and defines the
elements of a
complete order or prescription. 𝖯 5
Medications are prepared and dispensed in a safe

MMU.5
and clean environment.
3
MMU.5
and clean environment.
3
Medication prescriptions or orders are reviewed
MMU.5.1
for appropriateness. 𝖯
A system is used to safely dispense medications in 2

MMU.5.2
the right dose to the right patient at the right time.
1
Qualified individuals permitted to administer
medications are identified and document the
MMU.6
medications that are administered in the patient’s 2
medical record.
3
1
2
Medication administration includes a process to
verify the medication is correct based on the 3
MMU.6.1
medication
prescription or order.
4
Policies and procedures govern medications 2

brought into the hospital by the patient or family
MMU.6.2
and medication prescribed for patient self-
administration. 𝖯
3
Policies and procedures govern medications

MMU.6.2.1
brought into the hospital as samples. 𝖯
2
2
MMU.7 Medication effects on patients are monitored. 𝖯
3
MMU.7 Medication effects on patients are monitored. 𝖯
The hospital establishes and implements a process

for reporting and acting on medication errors and 2
MMU.7.1
near
misses (or close calls). 𝖯
3
4
MEDICATION MANAGEMENT AND USE (MMU)
Measurable Elements
A written document addressing items a) through i) of the intent, as appropriate,

identifies how medication use is organized, managed, and overseen throughout the
hospital
All settings, services, and individuals who manage medication processes are included
in the organizational structure.
A licensed pharmacist or other qualified individual directly supervises the activities of
the pharmacy or pharmaceutical service and ensures compliance with applicable laws
and regulations
The hospital documents at least one review of the medication management system,
addressing items a) through i) of the intent as appropriate, annually.
A uniform medication dispensing and distribution system is available and complies

Appropriate sources of drug information are readily available to those involved in

medication use.
The hospital develops and implements a program for antibiotic stewardship that
involves infection prevention and control professionals, physicians, nurses,
pharmacists, trainees, patients, families, and
others
The program is based on scientific evidence, accepted practice guidelines, and local
laws and regulations
The program includes guidelines for the optimal use of antibiotic therapy for
treatment of infections, including the proper use of prophylactic antibiotic therapy.
There is a mechanism to oversee the program for antibiotic stewardship.

There is a mechanism to oversee the program for antibiotic stewardship.
There is a list of medications by both brand name and generic name, stocked in the
hospital or readily available from outside sources, and the list is reviewed annually.
There is a list of medications by both brand name and generic name, stocked in the
hospital or readily available from outside sources, and the list is reviewed annually.
The process used to develop and monitor the list (unless determined by regulation or
an authority outside the hospital) includes representation from health care
practitioners involved in ordering, dispensing, administering, and patient-monitoring
processes in the hospital.
There is a process for obtaining medications during the night or when the pharmacy is
closed and for obtaining medications not stocked or not normally available to the
hospital.
Medications are stored under conditions suitable for product stability, including
medications stored on individual patient care units and ambulances, as applicable.
Controlled substances are accurately accounted for according to applicable laws and
regulations.
There is a process for managing medications or products requiring special handling,

such as hazardous medications, radioactive medications, and investigational
medications.
Medications and chemicals used to prepare medications are accurately labeled with
contents, expiration dates, and warnings.
All medication storage areas, including medication storage areas on patient care units
and ambulances (as applicable), are periodically inspected to ensure that medications
are stored properly.
Medications are protected from loss or theft throughout the hospital.
Emergency medications are immediately available in the units where they will be
needed or are readily accessible within the hospital to meet emergency needs.
Emergency medications are immediately available in the units where they will be
needed or are readily accessible within the hospital to meet emergency needs.
The hospital establishes and implements a process for how emergency medications
are uniformly stored; maintained; replaced when used, damaged, or out of date; and
protected from loss or theft.
Access to emergency medications does not require a specific individual or keys to

unlock the emergency cart.
Emergency medications are monitored and replaced in a timely manner after use or
when expired or damaged.
The hospital uses a risk-based approach, as described in the intent, to identify and
implement strategies to improve the efficiency and accuracy of medication
administration during emergency resuscitation.
The hospital establishes and implements a process for receiving and acting on
notifications of medication recalls.
The process includes identifying, retrieving, and returning, or safely and properly
destroying, medications recalled by the manufacturer, supplier, or regulatory agency.
The recall process includes medications compounded within the hospital in which
products that have been recalled have been used.
The hospital establishes and implements a process for use of unopened, expired
medications and outdated medications.
The hospital establishes and implements a process for the destruction of medications
known to be expired or outdated
The hospital identifies the information needed to reconcile current and newly ordered
medications.
The patient’s medical records contain a list of current medications taken prior to
admission or registration as an outpatient, and this information is made available to
the patient’s health care practitioners and the pharmacy as needed.
Initial medication orders are compared to the list of medications taken prior to
admission, according to the hospital’s established process.
Only those permitted by the hospital and by relevant licensure, laws, and regulations
prescribe or order medications.
The hospital establishes and implements a process to place limits, when appropriate,
on the prescribing or ordering practices of individuals.
Individuals permitted to prescribe and to order medications are known to the
pharmaceutical service or others who dispense medications.
The hospital establishes, implements, and trains staff on a process for the safe
prescribing, ordering, and transcribing of medications in the hospital.
All orders and prescriptions contain the name of the drug, the dose, the frequency and
route of administration, the indication for prescribing the medication, and the
maximum dose.
Additional elements of complete medication orders or prescriptions include at least a)

through g) identified in the intent as appropriate to the order.
The hospital develops and implements a process to manage medication orders that
are incomplete, illegible, or unclear; including measures to prevent continued
occurrence.
The hospital develops and implements a process to manage special types of orders,
such as emergency, standing, or automatic stop, and any elements unique to such
orders.
Medications prescribed or ordered are documented in the patient’s medical record or

inserted into the patient’s medical record at discharge or transfer.
Medication preparation and dispensing adhere to laws, regulations, and professional

standards of practice.
Medications are prepared and dispensed in clean, uncluttered, safe, and functionally
separate areas with appropriate medical equipment and supplies.
Staff preparing/compounding sterile products/medications are trained and competent

in the principles of medication preparation and aseptic techniques and are provided
resources to support the medication preparation process.
Guidelines for use of single-use and multidose vials are identified and implemented in
the medication processes.
Medications stored, prepared, and dispensed from areas outside the pharmacy (for
example, patient care wards) comply with the same cleanliness measures required in
the pharmacy.
The hospital defines the patient-specific information required for an effective review
process, and the source or availability of this information is available at all times when
the pharmacy is open or closed.
Apart from exceptions identified in the intent, each prescription or order is reviewed
for appropriateness in a manner, identified by the hospital, that ensures a full
appropriateness review prior to
dispensing and administration and includes elements a) through g) in the intent.
Individuals permitted to conduct appropriateness reviews are judged competent to do

so, are permitted to do so by privileges or job descriptions, and are provided resources
to support the review process.
When the designated licensed professional is not available to perform the full
appropriateness review, a trained individual conducts and documents a review of
critical elements h) through k) in the intent
for the first dose, and a full appropriateness review is conducted within 24 hours.
Review is facilitated by the availability of appropriate patient clinical information for

all patients receiving medications, and this clinical information is available at all times
when the pharmacy is
open or closed.
Clinical decision support programs used for the full appropriateness review, as well as
other computer programs and print reference materials used to cross-check the
critical elements of an appropriateness review, are current and updated.
Medications are dispensed in the most ready-to-administer form available.
The system supports accurate and timely dispensing and documentation of dispensing
practices.
After preparation, medications not immediately administered are labeled with the
name of the medication, the dosage/concentration, the date prepared, the expiration
date, and two patient identifiers.
The hospital identifies those individuals, by job description or the privileging process,
authorized to administer medications
The hospital places limits, when appropriate, on the medication administration of

individuals.
Medication administration is recorded for each dose.
Medications are verified with the prescription or order.
The dosage amount of the medication is verified with the prescription or order
The route of administration is verified with the prescription or order.
Patients are informed about the medications that they are going to be given and have
an opportunity to ask questions
Medications are administered as prescribed on a timely basis and noted in the
The hospital establishes and implements a process that includes a) through e) of the
intent for medications brought in by the patient/family
The hospital performs a risk assessment for medications brought in by the

patient/family that addresses where and when the medication was obtained and how
the medication was stored at home.
The hospital establishes and implements a process to govern patient self-
administration ofmedications.
The hospital establishes and implements a process to govern the management, use,
and documentation of medication brought in by the patient/family.
The hospital establishes and implements a process that includes a) through e) of the
intent for medication samples.
The hospital performs a risk assessment for sample medications brought in by the
patient or provided by other sources that addresses where and when the medication
was obtained and how the medication was stored prior to arrival
The hospital establishes and implements a process to govern the availability,

management, use, and documentation of medication samples.
Medication effects on patients are monitored and documented when appropriate
Medication adverse effects on patients are monitored and documented
The hospital utilizes a standardized process for recording in the patient medical
record, adverse effects related to medication use and reporting adverse effects to the
hospital.
The hospital utilizes a standardized process for reporting adverse medication effects as
part of the hospital quality program.
Adverse effects are reported as identified by the process in the time frame required.
The hospital establishes a definition for a medication error and near miss.
The hospital establishes and implements a process for reporting and acting on
medication errors and near misses.
Those accountable for acting on the reports are identified.
The hospital uses medication errors and near misses reporting information to improve
medication use processes.
Policy & Purpose 2.1

Medication Management and Use
Safe Prescribing Guidelines
Medication Management and Use Policy & Purpose 2.7
Antimicrobial Stewardship Program
Medication Management and Use Procedure 3.7
Safe Storage of Dietary

Supplements Formulas
Storage Arrangements of Pharmaceutical Products

Ward Stock and Override List of Medication
Formulary Management
Ward Stock and Override List of Medication
Non-Formulary Medication Request
Handling of Controlled Substances
Management of Controlled Drugs in Automated dispensing Cabinets (ADC)
Handling Of Hazardous Agents
Storing, Preparing and Dispensing of Chemotherapeutic
Safe Handling of Cytotoxic Agents

and Wastes
Labeling of Medications Policy 2.1
Inspection of Medication Storage

Areas
Storage Arrangements of Pharmaceutical Products
Authorized Access to the

Medication Storage Areas
Medication Management and Use Procedure 3.2.17

Handling of Emergency MedicationPolicy 3.1
Handling of Emergency MedicationPolicy 3.7, 3.9
Medication Management and Use Procedure 3.2.17.2 - 3.2.17.4
Handling of Recalled and Damaged Medications
Handling of Recalled and Damaged Medications
Expired Medication Management
Expired Medication Management
Medication Reconciliation
Medication Management and Use Procedure 3.3.6.2
Safe Prescribing Guidelines Policy 5.1
Safe Prescribing Guidelines ???


Policy 5.4.1, 5.4.4, 5.4.8,
Routine, ASAP and STAT

Prescription
Procedure for Automatic Stop

and-or Review of Antimicrobial
Prescribed at 7 days
Medical Record Content and Documentation Standards
Discharge Policy
Transfer Policy
Proedure 3.4
Aseptic Technique Process of compounding Sterile Products

Procedure 6.3.1, 6.7
Aseptic Technique Process of compounding Sterile Products
Procedure 6.4
Drugs Expiry and Medication

Areas Inspection
Procedure 3.4.2

Appropriateness Review
Poster
JD of the SN 1, Clinical
Privilege of the Doctor
***Memo and poster re:

appropriateness review
IPPF
BNF
Labelling of Medication Policy Procedure 5.2
Responsibilities 4.1- 4.3

Medication Administration
Management of Patient Home Medications
***inquie from CQI
Medication Management and Use Procdure 3.4 , 3.7.4
Safe Prescribing Guidelines Policy 5.30
***inquie from CQI
Monitoring of Patient Response to Medications
Adverse Drug Reaction (ADR) Reporting

Adverse Drug Reaction (ADR) Reporting
Procedure 5.2.1
Medication Errors
QUALITY IMPROVEMENT AND PATIEN
Chapter Standard
2
A qualified individual(s) guides the implementation
of the hospital’s program for quality improvement
and patient safety and manages the activities
QPS.1
needed to carry out an effective program of
continuous quality improvement and patient safety
within the hospital. 𝖯 3
Quality and patient safety program staff support 2

the measure selection process throughout the
QPS.2 hospital and provide coordination and integration
of measurement activities throughout the
hospital.
4
1
Hospital leadership builds a culture and 2

environment that supports implementation of
evidencebased
QPS.3 care through the use of current scientific 3
knowledge and information to support patient
care, health professional education, clinical
research, and management. 4
The quality and patient safety program includes

the aggregation and analysis of data to support
QPS.4 patient care, hospital management, and the quality 3
management program and participation in external
databases.
Individuals with appropriate experience, 3

QPS.4.1 knowledge, and skills systematically aggregate and
analyze data in the hospital.
4
5
analyze data in the hospital.
The data analysis process includes at least one

determination per year of the impact of
QPS.5
hospitalwide priority improvements on cost and 2
efficiency
2
The hospital uses an internal process to validate
QPS.6
data. 𝖯
3
4
1
1
The hospital uses a defined process for identifying

QPS.7
and managing sentinel events. 𝖯
QPS.7
and managing sentinel events. 𝖯
4
5

QPS.7.1 and managing adverse, no-harm, and near miss
events. 𝖯 4
5
6
Data are always analyzed when undesirable trends

QPS.8 3
and variation are evident from the data. 𝖯
2
Improvement in quality and safety is achieved and
QPS.9
sustained. 3
An ongoing program of risk management is used to

identify and to proactively reduce unanticipated
QPS.10
adverse events and other safety risks to patients
and staff. 𝖯
An ongoing program of risk management is used to
QPS.10 identify and to proactively reduce unanticipated
adverse events and other safety risks to patients
and staff. 𝖯
5
QUALITY IMPROVEMENT AND PATIENT SAFETY (QPS)
Measurable Elements
An individual(s) who is experienced in the methods

and processes of improvement is selected to guide
the implementation of the hospital’s quality and
patient safety program.
The individual(s) with oversight for the quality

program selects and supports qualified staff for the
program and supports those staff with quality and
patient safety responsibilities throughout the
hospital.
The quality program provides support and

coordination to department/service leaders for like
measures across the hospital and for the hospital’s
priorities for improvement.
The quality program implements a training

program for all staff that is consistent with staff’s
roles in the quality improvement and patient safety
program.
The quality program is responsible for the regular

communication of quality issues to all staff.
The quality and patient safety program supports

the selection of measures throughout the hospital
at the hospitalwide level and at the hospital
department or service level.
The quality and patient safety program provides

coordination and integration of measurement
activities throughout the hospital.
The quality and patient safety program provides for

the integration of event reporting systems, safety
culture measures, and others to facilitate
integrated solutions and improvements.
The quality and patient safety program tracks the

progress on the planned collection of measure data
for the priorities selected.
Hospital leadership builds a culture and
environment that supports implementation of
evidence- based care.
Current scientific knowledge and information

supports patient care.
supports clinical education.
supports research.
Current professional knowledge and information
supports management.
Information is provided in a time frame that meets
user expectations.
The quality and patient safety program has a
process to aggregate data.
Aggregate data and information support patient

care, hospital management, professional practice
review, and the overall quality and patient safety
program.
Aggregate data and information are provided to

agencies outside the hospital when required by
laws or regulations.
There is a process to contribute to and learn from

external databases for comparison purposes.
Security and confidentiality are maintained when

contributing to or using external databases.
Data are aggregated, analyzed, and transformed

into useful information to identify opportunities for
improvement.
Individuals with appropriate clinical or managerial

experience, knowledge, and skills participate in the
process.
Statistical tools and techniques are used in the
analysis process when suitable.
The frequency of data analysis is appropriate to the
process or outcome being studied.
Results of analysis are reported to those
accountable for taking action.
Data analysis supports comparisons internally over
time, including comparisons with databases of like
organizations, with best practices, and with
objective scientific professional sources.
Data on the amount and type of resource use are

collected on at least one hospitalwide priority
improvement project per year before and following
the improvement.
The quality and patient safety program staff work

with other units such as human resources,
information technology, and finance in deciding
which data are to be collected.
The results of the analysis are used to refine the

process and are reported through the quality
coordination mechanism to leadership.
Data validation is used by the quality program as a

component of the improvement process selected
by leadership
Data are validated when any of the conditions

noted in a) through f ) in the intent are met.
An evidence-based methodology for data

validation is used.
Hospital leadership assumes accountability for the

validity of the quality and outcome data made
public.
Hospital leadership establishes a definition of a
sentinel event that includes at least a) through r)
found in the intent.Sentinel Events, Investigation,
Reporting and Follow-up a) Death
b) Permanent harm
c) Severe temporary harm, D)Suicide of any patient
receiving care, treatment, and services in a staffed
around-the-clock care setting
or within 72 hours of discharge, including from the
hospital’s emergency department (ED)
e) Unanticipated death of a full-term infant
f ) Discharge of an infant to the wrong family
g) Abduction of any patient receiving care,
treatment, and services
h) Any elopement (that is, unauthorized departure)
of a patient from a staffed around-the-clock care
setting (including the ED), leading to death,
permanent harm, or severe temporary harm to the
patient
i) Hemolytic transfusion reaction involving
administration of blood or blood products having
major blood group incompatibilities (ABO, Rh, other
blood groups)
j) Rape, assault (leading to death, permanent
harm, or severe temporary harm), or homicide of
any
patient receiving care, treatment, and services
while on site at the hospital
k) Rape, assault (leading to death, permanent
harm, or severe temporary harm), or homicide of a
staff
member, licensed independent practitioner, visitor,
or vendor while on site at the hospital (Also see
SQE.8.2)
l) Invasive procedure, including surgery, on the
wrong patient, at the wrong site, or that is the
wrong
(unintended) procedure
m) Unintended retention of a foreign object in a
patient after an invasive procedure, including
surgery
j) Rape, assault (leading to death, permanent
harm, or severe temporary harm), or homicide of
any
patient receiving care, treatment, and services
while on site at the hospital
k) Rape, assault (leading to death, permanent
harm, or severe temporary harm), or homicide of a
staff
member, licensed independent practitioner, visitor,
or vendor while on site at the hospital (Also see
SQE.8.2)
l) Invasive procedure, including surgery, on the
wrong patient, at the wrong site, or that is the
wrong
(unintended) procedure
m) Unintended retention of a foreign object in a
patient after an invasive procedure, including
surgery
n) Severe neonatal hyperbilirubinemia (bilirubin >
30 milligrams/deciliter)
o) Prolonged fluoroscopy with cumulative dose >
1,500 rads to a single field or any delivery of
radiotherapy to the wrong body region or > 25%
above the planned radiotherapy dose
p) Fire, flame, or unanticipated smoke, heat, or
flashes occurring during an episode of patient care
q) Any intrapartum (related to the birth process)
maternal death
r) Severe maternal morbidity (not primarily related
to the natural course of the patient’s illness or
underlying condition) when it reaches a patient and
results in permanent harm or severe temporary
harm
Hospital leaders complete a credible and thorough

comprehensive systematic analysis (for example,
root cause analysis) of all sentinel events within a
time period specified by hospital leadership that
does not exceed 45 days from the date of the
event or when made aware of the event.
The root cause analysis identifies all system and

process origins that may have contributed to the
event.
The hospital monitors the implemented corrective
actions for potential process failures (unintended
consequences), effectiveness, and sustainability
over time.
Hospital leadership establishes a definition of

adverse event, no-harm event, and near miss event
as defined in the intent.
Hospital leadership has a mechanism for blame-

free reporting of adverse events, no-harm events,
and
near miss events
Hospital leadership defines a process for managing

adverse events that includes an analysis of the
events to identify corrective actions.
Hospital leadership defines a process for managing

near miss events and no-harm events that includes
an analysis of the events to identify corrective
actions.
Hospital leaders implement corrective actions,

when appropriate, on the results of the analysis.
Hospital leaders monitor the implemented
corrective actions for potential process failures
(unintended consequences), effectiveness, and
sustainability over time.
Defined data gathering processes are developed

and implemented to ensure accurate data
gathering,
analysis, and reporting.
Intense analysis of data takes place when adverse

levels, patterns, or trends occur.
Data gathering and analysis are performed on
items a) through h) of the intent.
Results of analyses are used to implement actions
to improve the quality and safety of the service,
treatment, or function.
Outcome data are reported to the governing entity

as part of the quality improvement and patient
safety program.
Improvements in quality and patient safety are
planned, tested, and implemented.
Data are available to demonstrate that
improvements are effective and sustained.
Policy changes necessary to plan, to carry out, and

to sustain the improvement are made.
Successful improvements are documented.
The hospital’s risk management framework

includes a) through f ) in the intent.
a)risk identification;
b)risk prioritization;
c)risk reporting;
d)scope, objectives, and criteria for assessing risk;

e)risk management, to include risk analysis;
f)management of related claims.
Hospital leadership identifies and prioritizes the

potential risks that could have the greatest impact
on patient and staff safety and on the quality of
patient care.
At least annually, a proactive risk reduction

exercise is conducted on at least one of the priority
risk processes.
High-risk processes are redesigned and

implemented based on the results of the analysis
of the risk reduction exercise
Hospital leadership develops and implements

communication strategies to staff, governance, and
stakeholders as appropriate.
PATIENT SAFETY (QPS)
Quality Improvement, Patient Safety and Risk Management Plan

SAMPLE DATA
SAMPLE DATA
Performance Improvement and Data Validation
CQI&PS Committee MOM
Performance Improvement and Data Validation

Sentinel Event Investigation, Reporting and Follow-Up,
Sentinel Event Investigation, Reporting and Follow-Up,
Incident Reporting and Investigation
Incident Reporting and Investigation Pol. 5.13
Culture of Safety Policy

SAMPLE DATA
SAMPLE DATA

PREVENTION AND CONTROL OF INFECTION(PCI
Chapter Standard
One or more individuals oversee all infection

prevention and control activities. This individual(s)
PCI.1 is qualified in infection prevention and control
practices through education, training, experience, 4
certification, and/or clinical authority.
1
There is a designated coordination mechanism for
all infection prevention and control activities that
PCI.2
involves physicians, nurses, and others based on
the size and complexity of the hospital.
2
2
Hospital leadership provides resources to support
PCI.3
the infection prevention and control program.
Hospital leadership provides resources to support
PCI.3
the infection prevention and control program.
The hospital designs and implements a

comprehensive infection prevention and control
program 2
PCI.4 that identifies the procedures and processes
associated with the risk of infection and
implements
strategies to reduce infection risk. 𝖯
3
The hospital uses a risk-based data-driven

approach in establishing the focus of the health 2
PCI.5 care–
associated infection prevention and control
program. 𝖯
3
The hospital identifies areas at high risk for

PCI.5.1 infections by conducting a risk assessment,
develops interventions to address these risks, and
monitors the effectiveness.
The hospital identifies areas at high risk for 2
infections by conducting a risk assessment,
PCI.5.1
develops interventions to address these risks, and
monitors the effectiveness.
The hospital reduces the risk of infections

associated with medical/surgical equipment,
PCI.6 devices, and
supplies by ensuring adequate cleaning,
disinfection, sterilization, and storage. 𝖯 3
The hospital identifies and implements a process

for managing the reuse of singleuse devices
PCI.6.1 consistent with regional and local laws and
2
The hospital identifies and implements a process

for managing the reuse of singleuse devices 3
PCI.6.1 consistent with regional and local laws and
regulations and implements a process for
managing expired supplies. 𝖯
The infection prevention and control program

identifies and implements standards from 2
recognized
PCI.7 infection prevention and control programs to
address cleaning and disinfection of the
environment
and environmental surfaces. 𝖯
3

identifies standards from recognized infection
PCI.7.1 control health agencies related to cleaning and
disinfection of laundry,
identifies standards from recognized infection
PCI.7.1 control health agencies related to cleaning and 2
disinfection of laundry,
linens, and scrub attire provided by the hospital.
The hospital reduces the risk of infections through

proper disposal of waste, proper management of
PCI.8
human tissues, and safe handling and disposal of
sharps and needles. 𝖯 4
6
1
The hospital has a process to protect patients and 3

PCI.8.1 staff from bloodborne pathogens related to
exposure to blood and body fluids. 𝖯
4
The hospital reduces the risk of infections

PCI.9
associated with the operations of food services. 3
5
1
The hospital reduces the risk of infection in the

PCI.10 facility through the use of mechanical and
engineering controls. 2
The hospital reduces the risk of infection in the

PCI.11 facility associated with demolition, construction, 2
and renovation.
3
1
The hospital provides barrier precautions and

isolation procedures that protect patients, visitors,
and staff from communicable diseases and
PCI.12
protects immunosuppressed patients from
acquiring infections to which they are
uniquely prone. 𝖯
3
4
The hospital develops and implements a process to

manage a sudden influx of patients with airborne 2
PCI.12.1
infections and when negative-pressure rooms are
not available. 𝖯
The hospital develops, implements, and evaluates 2

an emergency preparedness program to respond
PCI.12.2
to the presentation of global communicable
diseases. 𝖯
5
1
Gloves, masks, eye protection, other protective 3

equipment, soap, and disinfectants are available
PCI.13
and
used correctly when required. 𝖯
The infection prevention and control process is

integrated with the hospital’s overall program for
PCI.14 quality improvement and patient safety, using
measures that are epidemiologically important to 3
the
hospital.
5
1
The hospital provides education on infection

prevention and control practices to staff, 2
PCI.15 physicians,
patients, families, and other caregivers when
indicated by their involvement in care. 𝖯
4
PREVENTION AND CONTROL OF INFECTION(PCI)
One or more individuals oversee the infection
prevention and control program and ensure that
Infection Prevention and Control Program
the program complies with local and national laws
and regulations.
The individual(s) is qualified for the hospital’s size,

complexity of activities, and level of risks, as well as Infection Prevention and Control Program
the program’s scope.
The individual(s) fulfills program oversight

responsibilities as assigned or described in a job JD of IC
description.
This individual(s) coordinates with hospital

leadership regarding priorities, resources, and
quality improvement opportunities related to the
infection prevention and control program.
The hospital reports infection prevention and

control program results to public health agencies Infection Prevention and Control Program
as required.
The hospital takes appropriate action on reports Infection Prevention and Control Program
from relevant public health agencies.
The designated mechanism, as described in the

intent, coordinates the infection prevention and
control program and involves infection prevention
and control professionals.
Infection prevention and control activities involve

physicians, nurses, and others based on the size Infection Prevention and Control Program
and complexity of the hospital.
All areas of the hospital are included in the
The infection prevention and control program is

staffed according to the hospital’s size, complexity
of IC Staffing Plan
activities, and level of risks, as well as the
program’s scope.
Hospital leadership approves and assigns staff

required for the infection prevention and control Credentialing of Staff in IC Dept.
program.
Hospital leadership approves and allocates
resources required for the infection prevention and Infection Prevention and Control Program
control
program.
Information management systems support the


comprehensive and crosses all levels of the
hospital, Infection Prevention and Control Program
to reduce the risk of health care–associated
infections in patients

comprehensive and crosses all levels of the
hospital Infection Prevention and Control Program
to reduce the risk of health care–associated
infections in hospital staff.
The hospital identifies those processes associated

with infection risk.
The hospital implements strategies, education, and

evidence-based activities to reduce infection risk Infection Prevention and Control Program
in those processes.
The hospital establishes the focus of the program

through the collection and tracking of data related
to a) through f ) in the intent.
The data collected in a) through f ) are analyzed to Infection Control and Prevention Risk Assessment and Control Plan
identify priorities for reducing rates of infection.
The hospital implements infection prevention and

control strategies to reduce the rates of infection
for the identified priorities.
Processes are redesigned based on risk, rate, and

Outbreak Management
trend data and information.
The hospital completes and documents a risk Infection Control and Prevention
assessment, at least annually, to identify and Risk Assessment and Control
prioritize areas at high risk for infections. Plan
The hospital identifies and implements Infection Control and Prevention
interventions to address infection risks identified Risk Assessment and Control
through the risk assessment. Plan
The hospital evaluates the effectiveness of the
interventions and makes appropriate changes to
the infection prevention and control program as Infection Control and Prevention
needed. Risk Assessment and Control
Plan
Infection Control and Prevention
The hospital performs ongoing data monitoring to
Risk Assessment and Control
ensure that risks are reduced or eliminated. Plan
The hospital follows professional practice

guidelines and manufacturer guidelines for
sterilization
techniques that best fit the type of situations for Cleaning Disinfection and Sterilization of Patient Care Items
sterilization and devices and supplies being
sterilized.
The hospital follows professional practice

guidelines and manufacturer guidelines for low-
Cleaning Disinfection and
and highlevel
Sterilization of Patient Care Items
disinfection that best fit the type of devices and
equipment being disinfected.
Staff processing medical/surgical equipment,

devices, and supplies are oriented to, trained
in,and demonstrate competency in cleaning, Cleaning Disinfection and
disinfection, and sterilization, and they receive Sterilization of Patient Care Items
proper
supervision.
Methods for medical/surgical cleaning,

disinfection, and sterilization are coordinated and Sterilization of Patient Care Items
uniformly applied throughout the hospital.
Clean and sterile supplies are properly stored in

designated storage areas that are clean and dry Cleaning Disinfection and
and protected from dust, moisture, and Sterilization of Patient Care Items
temperature extremes.

The hospital identifies single-use devices and
materials that may be reused in accordance with
local
and national laws and regulations.
Single Used disposable Medical Devices
The hospital utilizes a standardized process for
identifying when a single-use device is no longer Single Used disposable Medical Devices
safe
or suitable for reuse.
The hospital has a clear protocol for the cleaning,

disinfecting, and sterilization as appropriate, for
each reusable, single-use device.
The cleaning process for each device is followed as Cleaning Disinfection and
per protocol. Sterilization of Patient Care Items
The hospital identifies patients on whom reusable Cleaning Disinfection and

medical devices have been used. Sterilization of Patient Care Items
When adverse events resulting from reuse of Cleaning Disinfection and

single-use devices occur, patients using these Sterilization of Patient Care Items
devices are
tracked and an analysis is performed, with results
used to identify and implement improvements.
The hospital selects cleaning and disinfection

standards and procedures from recognized
infection Environmental Housekeeping Services Policy
prevention and control programs to maintain
environmental cleanliness.
Hospital leaders identify areas and situations that

are high risk for infection transmission and
implement Environmental Housekeeping Services Policy
additional cleaning and disinfection procedures as
indicated.
Cleaning of infectious rooms during the patient’s

hospitalization and after discharge follows infection Environmental Housekeeping Services Policy
prevention and control guidelines.
The hospital monitors environmental cleaning and

disinfection processes, and data are used to make Environmental Housekeeping Services Policy
changes to the process when applicable.
Laundering methods comply with local and

national laws and regulations and follow guidelines Laundry
from
recognized infection control agencies.
Standard precautions are used when handling
laundry, linens, and hospital-issued scrub attire,
and Laundry
appropriate transmission-based precautions are
used as indicated.
Laundry, linens, and hospital-issued scrub attire are

transported, processed, and stored in a manner
Laundry
that prevents cross contamination of soiled and
clean items.
Staff wear hospital-issued scrub attire where

Nursing Uniform
required.
The handling and disposal of infectious waste,

blood and blood components, body fluids, and
body Medical Waste Management
tissues is managed to minimize infection
transmission risk
The hospital identifies and implements practices to

reduce the risk of injury and infection from the Sharp Management and Disposal
handling and management of sharps and needles.
Sharps and needles are collected in dedicated,

closable, puncture-proof, leakproof containers that
Sharp Management and Disposal
are
not reused.
The hospital disposes of sharps and needles safely

or contracts with sources that ensure the proper
disposal of sharps containers in dedicated Sharp Management and Disposal
hazardous waste sites or as determined by national
laws and
regulations.
The mortuary and postmortem area operates in a

manner that adheres to laws, regulations, and local
Infection Control and Prevention in Postmortem Care
cultures/customs and is managed in a manner that
minimizes the risk of transmitting infections.
Staff are trained on preventing cross

contamination, maintaining chain of custody when
Infection Control and Prevention in Postmortem Care
needed, and
respectful, safe handling procedures.
The hospital identifies processes that could result
in patient or staff exposure to blood and body
fluids Management of Blood Spills and Spills of Other Potentially Infectious Mat
and implements practices to reduce the risk of
exposure.
The hospital utilizes a process for reporting patient

Post Exposure Management to Blood Borne Pathogens
and staff exposures to blood and body fluids.
The hospital utilizes a process for acting upon

patient and staff exposures to blood and body Post Exposure Management to Blood Borne Pathogens
fluids.
Staff are educated on the process for reporting an
exposure incident. Incident Report and Investigation
The hospital tracks and monitors incidents of

Incident Reporting and
patient and staff exposures to blood and body
Investigation
fluids.
Reports of exposure incidents are reviewed, and

actions are taken to minimize the risk of future Incident Report RCA and Action
exposures Plan
to blood and body fluids.
The hospital stores food and nutrition products in a

manner that reduces the risk of infection, Food and Nutrition Hygiene and Safety
including those stored outside of the kitchen and
food preparation areas
The hospital adopts and implements kitchen

sanitation measures and guidelines for preparation
areas Food and Nutrition Hygiene and Safety
to prevent the risk of cross contamination and
infection
The hospital prepares food and nutrition products

Food and Nutrition Hygiene and Safety
using proper sanitation and temperature.
The hospital utilizes a process to ensure that

proper food temperature is maintained during the
Food and Nutrition Hygiene and Safety
preparation,
transportation, and distribution process.
Professional guidelines are adopted for nutritional

products that have special storage and preparation Food and Nutrition Hygiene and Safety
requirements, such as human milk, baby formula,
and other enteral products
Positive Pressure Room Daily Monitoring
The hospital operates and maintains negative and
positive pressure ventilation systems in accordance
with local and national laws and regulations and
professional standards
Airborne Infection Isolation Room (AAIR) Daily Monitoring
The hospital operates and maintains temperature

controls for water, steam, and others in
accordance Utility System Program
with local and national laws and regulations and
professional standards.
The hospital operates and maintains airflow,

ventilation systems, and humidity controls in a
manner
that minimizes infection risk in the hospital in Utility System Program
accordance with local and national laws and
regulations
and professional guidelines.
The hospital has a program that uses risk criteria to

assess the impact of renovation or new
construction Pre-Consruction Risk Assessment for Facility Demolition, Construction and
and implements the program when demolition,
construction, or renovation take place.
The hospital assesses the risks and impact of

demolition, renovation, or construction activities
on air Pre-Consruction Risk Assessment for Facility Demolition, Construction and
quality and infection prevention and control
activities throughout the hospital.
The risks and impact of the demolition, renovation,

or construction are managed to protect patients, Pre-Consruction Risk Assessment for Facility Demolition, Construction and
staff, and visitors from infection.
Isolations Precautions
Isolation System A Quick
Reference Guide
The hospital utilizes a process to isolate patients

with infectious diseases, and staff use
Airborne Isolations Precautions
transmission- based precautions, in accordance
with recommended guidelines
Droplet Isolations Precautions
Contact Isolations Precautions
The hospital protects patients with

immunosuppression or other increased risks for
Immunocompromised
contracting a communicable disease through
isolation and the use of reverse/protective Patients(Non-Hematopoetic Stem
Cell Transplant)
isolation in accordance
with recommended guidelines.
Admitting Patients to Airborne

Infection Isolation Room
The hospital routinely monitors and makes

available negative-pressure rooms for infectious
patients
who require isolation for airborne infections.
Airborne Infection Isolation Room (AAIR) Daily Monitoring

When negative-pressure rooms are not
immediately available, temporary negative-
pressure rooms that follow acceptable guidelines Admitting Patients to Airborne
as described in the intent and adhere to building Infection Isolation Room
and fire codes may
be created.
The hospital develops and implements a process to

address managing patients with airborne infections Admitting Patients to Airborne
for short periods of time when negative-pressure Infection Isolation Room
rooms are not available
The hospital develops and implements a process Influx of People with Infectious
for managing an influx of patient with contagious
Disease
diseases.
Staff are educated in the management of infectious

Influx of People with Infectious
patients when there is a sudden influx or when
Disease
negative-pressure rooms are not available.
Hospital leaders, along with the individual(s)

responsible for the infection prevention and
control
program, develop and implement an emergency Emergency Management
preparedness program to respond to global Program
communicable
diseases that includes at least a) through f ) in the
intent.
The hospital identifies the first points of patient

entry into the hospital system and targets
education on early recognition and prompt action.
The hospital evaluates the entire program at least

Emergency Management
annually and, when applicable, involves local,
Program
regional, and/or national authorities
At the conclusion of every drill or tabletop exercise, Emergency Management

debriefing of the evaluation is conducted. Program
Follow-up actions identified from the evaluation

Emergency Management
process and debriefing are developed and
Program
implemented.
The hospital identifies situations in which personal
protective equipment is required and ensures that
Personal Protective Equipment(PPE)
it is available at any site of care at which it could be
needed.
Staff are trained and correctly use personal

Personal Protective Equipment(PPE)
protective equipment in each identified situation.
The hospital implements surface disinfecting

procedures for areas and situations in the hospital
Environmental Housekeeping Services Policy
identified
as at risk for infection transmission.
Liquid soap, disinfectants, and towels or other

means of drying are located in areas where hand-
washing Hand Hygiene
and hand-disinfecting procedures are required.
Patients and visitors are educated on when they

are required to disinfect their hands and how to Hand Hygiene
correctly use personal protective equipment.
The hospital integrates infection prevention and Quality Improvement, Patient

control activities into the quality improvement and Safety and Risk Management
patient safety program. Program/Plan
The hospital collects and analyzes data for the Quality Improvement, Patient
infection prevention and control activities, and the Safety and Risk Management
data include epidemiologically important infections Program/Plan
The hospital uses monitoring data to evaluate and Quality Improvement, Patient
support improvements to the infection prevention Safety and Risk Management
and control program at least annually. Program/Plan
Quality Improvement, Patient

Monitoring data include benchmarking infection
Safety and Risk Management
rates.
Program/Plan

documents monitoring data and provides reports IPC Committee TOR
of data analysis to leadership on a quarterly basis.
The hospital provides education about infection
prevention and control to all staff and other Infection Prevention and Control
Education
professionals when they begin work in the hospital.
The hospital provides ongoing education and

training to all staff related to the hospital’s
infection prevention and control program and Infection Prevention and Control
emerging trends in infection prevention and Education
control at least
annually.
The hospital provides education about infection Infection Prevention and Control
prevention and control to patients and families. Education
The hospital communicates findings and trends

Infection Prevention and Control
from quality improvement activities to all staff and
Education
included as part of staff education.
Section
5.2
Structure of the IPAC

Program 5.2
Structure of the IPAC
Program 7.1.2
policy 3.2
policy 3.5
policy 3.1
policy 3.3
policy 3.1
GOVERNANCE, LEADERSHIP AND DIRECTION(GLD
Chapter Standard
The structure and authority of the hospital’s

GLD.1 governing entity are described in bylaws, policies
and procedures,
or similar documents. 𝖯
2
The operational responsibilities and 2

GLD.1.1 accountabilities of the governing entity are
described in a written document(s). 𝖯
The governing entity approves the hospital’s

program for quality and patient safety and
GLD.1.2
regularly receives and acts on reports of the quality
and patient safety program. 𝖯
The governing entity approves the hospital’s 2
program for quality and patient safety and
GLD.1.2
regularly receives and acts on reports of the quality
and patient safety program. 𝖯
A chief executive(s) is responsible for operating the

GLD.2 hospital and complying with applicable laws and 3
regulations. 𝖯
Hospital leadership is identified and is collectively

responsible for defining the hospital’s mission and
GLD.3 creating the programs and policies needed to fulfill 2
the mission.
4
1
Hospital leadership identifies and plans for the 2

GLD.3.1 type of clinical services required to meet the needs
of the patients served by the hospital. 𝖯
Hospital leadership ensures effective

GLD.3.2
communication throughout the hospital. 𝖯 2
2
Hospital leadership ensures that there are uniform
GLD.3.3 programs for the recruitment, retention,
development, and continuing education of all staff. 3
4
1
Hospital leadership plans, develops, and

GLD.4 implements a quality improvement and patient
safety program.
3
Hospital leadership communicates quality 2

improvement and patient safety information to the
GLD.4.1 governing entity and hospital staff on a regular
basis.
The chief executive and hospital leadership

prioritize which hospitalwide processes will be
measured, which hospitalwide improvement and
The chief executive and hospital leadership
prioritize which hospitalwide processes will be 2
measured, which hospitalwide improvement and
GLD.5
patient safety activities will be implemented, and
how success of these
hospitalwide efforts will be measured
Hospital leadership is accountable for the review,

selection, and monitoring of clinical and nonclinical
GLD.6
contracts and inspects compliance with contracted
services as needed. 𝖯 3
Hospital leadership ensures that contracts and

other arrangements are included as part of the
GLD.6.1 hospital’s quality improvement and patient safety
program. 2
Hospital leadership ensures that contracts and
other arrangements are included as part of the
GLD.6.1 hospital’s quality improvement and patient safety
program.
Hospital leadership ensures that licensed health

care professionals and independent health care
practitioners not employed by the hospital have 3
GLD.6.2
the right credentials and are competent and/or
privileged for the services
provided to the hospital’s patients. 𝖯
6
1
3
Hospital leadership makes decisions related to the
purchase or use of resources—human and
GLD.7 technical—with an understanding of the quality
and safety implications of those decisions.
4
Hospital leadership seeks and uses data and 3

information on the safety of the supply chain to
GLD.7.1
protect patients and staff from unstable,
contaminated, defective, and counterfeit supplies.
Medical, nursing, and other leaders of

departments and clinical services plan and
GLD.8
2
Medical, nursing, and other leaders of
GLD.8 departments and clinical services plan and
implement a professional staff structure to support 3
their responsibilities and authority. 𝖯
One or more qualified individuals provide direction

GLD.9 for each department or service in the hospital. 𝖯
2
Each department/service leader identifies, in
writing, the services to be provided by the
GLD.10 3
department, and integrates or coordinates those
services with the services of other departments. 𝖯
4
5
1
Department/service leaders improve quality and 2

patient safety by participating in hospitalwide
GLD.11 improvement priorities and in monitoring and
improving patient care specific to the
department/service.
Measures selected by the department/service

leaders that are applicable to evaluating the
performance of 2
GLD.11.1 physicians, nurses, and other professional staff
participating in the clinical care processes are used
in the staff’s
performance evaluation.
Department/service leaders select and implement

clinical practice guidelines, and related clinical
GLD.11.2
pathways and/or clinical protocols, to guide clinical
care. 𝖯
Department/service leaders select and implement 2
clinical practice guidelines, and related clinical
GLD.11.2
pathways and/or clinical protocols, to guide clinical
care. 𝖯
3
Hospital leadership establishes a framework for

ethical management that promotes a culture of 2
ethical practices and decision making to ensure
GLD.12 that patient care is provided within business,
financial, ethical, and legal norms and protects
patients and their rights. 𝖯
3
1
The hospital’s framework for ethical management
addresses operational and business issues,
including 2
marketing, admissions, transfer, discharge, and
GLD.12.1
disclosure of ownership and any business and
professional
conflicts that may not be in patients’ best interests. 3
𝖯

GLD.12.2 addresses ethical issues and decision making in
clinical care.
GLD.12.2 addresses ethical issues and decision making in
clinical care.
3
Hospital leadership creates and supports a culture 2

GLD.13
of safety program throughout the hospital. 𝖯
Hospital leadership implements, monitors, and

GLD.13.1 takes action to improve the program for a culture 3
of safety throughout the hospital.
4
5
Health professional education, when provided

within the hospital, is guided by the educational
GLD.14
parameters defined by the sponsoring academic
program and the hospital’s leadership. 4
GLD.15 3
4
5
Patients and families are informed about how to

gain access to clinical research, clinical 4
GLD.16
investigations, or
clinical trials involving human subjects. 𝖯
Patients and families are informed about how

patients who choose to participate in clinical
GLD.17 2
research, clinical
investigations, or clinical trials are protected.
Informed consent is obtained before a patient

participates in clinical research, clinical
GLD.18
investigations, or clinical
trials. 𝖯
Informed consent is obtained before a patient
GLD.18 participates in clinical research, clinical
investigations, or clinical 2
trials. 𝖯
The hospital has a committee or another way to 2

GLD.19 oversee all research in the hospital involving
human subjects. 3
5
GOVERNANCE, LEADERSHIP AND DIRECTION(GLD)
The structure and authority of the hospital’s

governing entity is described in a written
document, bylaws, and/or policies and procedures Standardized Armed Forces Hospital Bylaws
with those responsible for governance of the
hospital identified.
The document(s) describes when and how the

authority of the governing entity and the chief Standardized Armed Forces Hospital Bylaws
executive can be delegated.
The governing entity is evaluated annually, and the

Standardized Armed Forces Hospital Bylaws
results are documented

strategic plans, operational plans, policies, and
procedures,
and approves, periodically reviews, and makes PSMMC'S Mission, Vision and
public the hospital’s mission statement. Values
The governing entity approves the hospital’s capital

and operating budget(s) and allocates other Capital and Operational Budgeting
resources required to meet the hospital’s mission.

participation in health care professional education
and research and in the oversight of the quality of Standardized Armed Forces Hospital Bylaws
such programs
The governing entity appoints, and annually

evaluates, the hospital’s chief executive(s), and the
evaluation
is documented.
The governing entity annually approves the

hospital’s program for quality and patient safety.
The governing entity at least quarterly receives and
acts on reports of the quality and patient safety
program, including reports of adverse and sentinel
events.
Minutes reflect actions taken and any follow-up on Hospital Quality and Patient
those actions. Safety Committee MOM
The education and experience of the chief

executive(s) match the requirements in the
position description.
The chief executive(s) manages the hospital’s day-

to-day operations, including those responsibilities
described in the position description.
The chief executive(s) recommends policies,

strategic plans, and budgets to the governing Standardized Armed Forces Hospital Bylaws
entity.
The chief executive(s) ensures compliance with
approved policies.
The chief executive(s) ensures compliance with

applicable laws and regulations
The chief executive(s) responds to any reports from

inspecting and regulatory agencies.
The chief executive(s) and hospital leadership are

identified by title and name, and their collective PSMMC Organizational Chart
accountabilities are described in written
documents.
General Executive Director Job
Description
Hospital leadership is responsible for defining the

hospital’s values and mission.
Hospital leadership is responsible for creating the

policies and procedures necessary to carry out the Standardized Armed Forces Hospital Bylaws
mission.
Hospital leadership ensures that policies and

procedures are followed.
Hospital leadership determines and plans with
department/service leaders the type of care and
services to be provided by the hospital that are
consistent with the hospital’s mission and needs of
the patients served by the hospital.
Hospital leadership communicates with key

stakeholders in its community to facilitate access
to care and access to information about its patient
care services.
Hospital leadership provides data and

communicates information related to safety and
quality of its services to stakeholders, which
include nursing staff, nonclinical and management Quality Improvement, Patient Safety and Risk Management Plan
staff, patients, families, and external interested
parties.
Hospital leadership describes and documents the

care and services to be provided. Scope of Service
Hospital leadership ensures that processes are in

place for communicating relevant information
throughout the hospital in a timely manner.
Hospital leadership ensures effective

communication among clinical and nonclinical Communication Plan
departments, services, and individual staff
members.
Hospital leadership communicates the hospital’s

vision, mission, goals, policies, and plans to staff.
The hospital develops and implements a process

Recruitment Process(International &Local)
for staff recruitment.

Employee Retention Plan
for staff retention.
for staff personal development and continuing Nursing Educational Plan
education.
The planning is collaborative and includes all

departments and services in the hospital.
Hospital leadership participates in developing and
implementing a hospitalwide quality improvement
and patient safety program.
Hospital leadership selects and implements a

hospitalwide process to measure, assess data, plan
change, and sustain improvements in quality and
patient safety, and provides for staff education on
this quality improvement process.

Hospital leadership determines how the program
will be directed and managed on a daily basis and
ensures that the program has adequate technology
and other resources to be effective.
Hospital leadership implements a structure and

process for the overall monitoring and
coordination of the quality improvement and
patient safety program.
Hospital leadership reports on the quality and

patient safety program at least quarterly to the Quality Improvement, Patient Safety and Risk Management Plan
governing entity.
Hospital leadership reports to the governing entity

include, at least quarterly, the number and type of
sentinel events and root causes, whether the
patients and families were informed of the sentinel Sentinel Event Investigation, Reporting and Follow-up
event, actions taken to improve safety in response
to sentinel events, and if the improvements were
sustained.
Hospital leadership regularly communicates

information on the quality improvement and
patient safety program to staff, including progress Quality Improvement, Patient Safety and Risk Management Plan
on meeting the International Patient Safety Goals
The chief executive and hospital leadership use

available data to set collective priorities for
hospitalwide measurement and improvement Performance Measurement and Data Validation
activities and consider potential system
improvements.
The chief executive and hospital leadership ensure
that, when present, clinical research and health
professional education programs are represented
in the priorities.
The chief executive and hospital leadership set

priorities for compliance with the International Performance Measurement and Data Validation
Patient Safety Goals.
The chief executive and hospital leadership assess

the impact of hospitalwide and
departmental/service improvements on efficiency
and resource use.
Hospital leadership is accountable for contracts to

meet patient and management needs.
The hospital has a written description of the nature

and scope of those services to be provided through
contractual agreements.
Contracts Oversight Policy

Department/service leaders share accountability
for the review, selection, and monitoring of clinical
and nonclinical contracts.
Hospital leadership inspects compliance with

contracted services as needed.
When contracts are renegotiated or terminated,
the hospital maintains the continuity of patient
services.
All contracts stipulate the quality data that are to

be reported to the hospital, the reporting
frequency
and mechanism, and how the hospital will respond
when quality requirements or expectations are not
met.
Quality data reported under contracts are Contracts Oversight Policy

integrated into the hospital’s quality monitoring
program.
Contracts Oversight Policy
The relevant clinical and managerial leaders

participate with the quality improvement program
in the
analysis of quality and safety information from
outside contracts.
Hospital leadership determines those services that

will be provided by independent practitioners
outside the hospital.
All diagnostic, consultative, and treatment services

provided by independent practitioners outside
the hospital, such as telemedicine, teleradiology,
and interpretations of other diagnostics, such as
electrocardiogram (ECG), electroencephalogram
(EEG), pathology, and the like, are credentialed and
privileged by the hospital to provide such services.
Independent practitioners who provide patient

care services on the premises of the hospital but
are not employees or members of the clinical staff Contracts Oversight Policy
are credentialed, privileged, and evaluated as
required in SQE.9 through SQE.12.
Any support staff accompanying independent

practitioners and providing care and services in the
hospital are compliant with requirements for
primary source verification.
The quality of services by independent

practitioners outside the hospital is monitored as a
component of the hospital’s quality improvement
program.
When the hospital utilizes staff contracts for

licensed health care professional staff the hospital
ensures that a credential review comparable to the
hospital’s review process is conducted.
Hospital leadership uses data and information on
the quality and safety implications of medical Medical Equipment Program
equipment choices
Hospital leadership uses data and information on

the quality and safety implications of staffing Safe Nursing Staffing Guidelines
choices.
Hospital leadership uses the recommendations of

professional organizations and other authoritative Standardized Armed Forces Hospital Bylaws
sources in making resource decisions.
Hospital leadership provides direction, support,

and oversight of information technology resources.

and oversight of the emergency and disaster
management
program(s).
Hospital leadership monitors the results of its

decisions and uses the data to evaluate and
improve the quality of its resource purchasing and
allocation decisions
Hospital leadership outlines the steps in the supply

chains for supplies defined as at most risk.
Hospital leadership identifies any significant risk

points in the steps of the supply chains.
Hospital leadership makes resource decisions

based on their understanding of the risk points in
the supply chains. Purchasing Policy
The hospital has a process for performing

retrospective tracing of supplies found to be
unstable, contaminated, defective, or counterfeit.
The hospital notifies the manufacturer and/or

distributor when unstable, contaminated,
defective, or counterfeit supplies are identified
There is a professional staff structure(s) used by

medical, nursing, and other department/service
leaders to carry out their responsibilities and
authority
Organizational Chart
The structure(s) is appropriate to the hospital’s size
and complexity.
The organizational structure(s) and processes
support a culture of safety and professional Organizational Chart
communication.

support clinical planning and policy development

support oversight of the quality of clinical services.
Each department or service in the hospital is

directed by an individual with the training,
Personnel File of CD
education, and experience comparable to the
services provided.
Department/service leaders recommend space,

medical equipment, staffing, technology, and other
resources needed by the department or service Crosstraining
and have a process in place to respond to
shortages.
Department/service leaders recommend criteria

for selecting the department’s or service’s
professional staff and choose or recommend
individuals who meet those criteria
Department/service leaders provide orientation

and training for all staff on the duties and
General Nursing Orientation Program(Non-Saudi Nurses)
responsibilities for the department or service to
which they are assigned.
Department/service leaders have selected and use

a uniform format and content for planning
documents.
The departmental or service documents describe

the current and planned services provided by each
department or service.
The departmental or service documents guide the
provision of identified services.
The departmental or service documents address
the staff knowledge and skills needed to assess and
to meet patient needs.
There is coordination and/or integration of services

within and with other departments and services.
Department/service leaders implement
hospitalwide quality measures that relate to the
services
provided by their department or service, including
any contracted services for which they are
responsible
Department/service leaders implement quality

measures to reduce variation and improve
processes within the department or service,
including implementation of measures found in the
Joint
Commission International Library of Measures or
other resources for well-defined, evidence-
basedclinical measures.
Department/service leaders select measures based

on the need for improvement, and when
improvementhas been sustained, select a new
measure.
Department and service quality measurement and

improvement activities are integrated into and
supported by the quality management and
coordination structure of the organization.
When applicable, assessment of participation in

quality activities and the results of
measurementactivities are included in the ongoing
professional practice evaluation of the
department’s or service’s
physicians.

quality activities and the results of
measurementactivities are included in the
performance evaluation of nursing staff.

quality activities and the results of measurement
activities are included in the performance
evaluation of other health practitioners.
On an annual basis, department/service leaders

collectively determine at least five hospitalwide
priority areas on which to focus the use of clinical
practice guidelines.
Department/service leaders follow the process
described in a) through h) of the intent in selecting
and implementing clinical practice guidelines.
Department/service leaders implement clinical

guidelines and any associated clinical pathways or
clinical protocols for each identified priority area as
relevant to the department/service.
Department/service leaders demonstrate how the

use of clinical practice guidelines, clinical pathways,
and/or clinical protocols has reduced variation in
processes and outcomes
Hospital leadership establishes a framework for the

hospital’s ethical management that promotes a
culture of ethical practices and decision making to
ensure the protection of patients and their rights.
The ethical framework ensures that patient care is

provided within business, financial, ethical, and
legal norms.
The hospital ensures nondiscrimination in

employment practices and provision of patient care
in the context of the cultural and regulatory norms
of the country.
Hospital leadership examines national and

international ethical norms for incorporation when
developing the hospital’s framework for ethical
conduct.
The hospital discloses its ownership and any

conflicts of interest.
The hospital honestly portrays its services to
patients.
The hospital accurately bills for services and

ensures that financial incentives and payment
arrangements do not compromise patient care.
establishes a mechanism by which health care
practitioners
and other staff may raise ethical concerns without
fear of retribution.
support oversight of professional ethical issues.
Support for identifying and addressing ethical
concerns is readily available and includes ethics
resources and training for health care practitioners
and other staff
The hospital provides an effective and timely

resolution to ethical conflicts that arise.
Hospital leadership establishes and supports an

organizational culture that promotes accountability
and transparency
Hospital leadership develops and documents a

code of conduct and identifies and corrects
behaviors that are unacceptable.
Hospital leadership provides education and

information (such as literature and advisories)
relevant to the hospital’s culture of safety to all
individuals who work in the hospital
Hospital leadership defines how issues related to a

culture of safety within the hospital are identified
and managed.
Hospital leadership provides resources to promote

and support the culture of safety within the
hospital.
Hospital leadership provides a simple, accessible,

and confidential system for reporting issues
relevant to a culture of safety in the hospital.
Hospital leadership ensures that all reports related

to the hospital’s culture of safety are investigated
in a timely manner.
The hospital identifies systems issues that lead

health care practitioners to engage in unsafe
behaviors.
Hospital leadership uses measures to evaluate and

monitor the safety culture within the hospital and
implements improvements identified from
measurement and evaluation
Hospital leadership implements a process to
prevent retribution against individuals who report
issues related to the culture of safety.
The hospital provides a mechanism(s) for oversight

of the training program(s).
The hospital obtains and accepts the parameters of

the sponsoring academic program.
The hospital has a complete record of all students

and trainees within the hospital.
The hospital has documentation of the enrollment

status, licensure or certifications achieved, and
academic classification of the students and trainees
The hospital understands and provides the

required level of supervision for each type and
level of student and trainee.
The hospital integrates students and trainees into

its orientation, quality, patient safety, infection
prevention and control, and other programs.
Hospital leadership identifies the official(s)

responsible for maintaining the development of
and compliance
with all human subjects research policies and
procedures
Hospital leadership assumes responsibility for

patient protection irrespective of the sponsor of
the
research.
Hospital leadership recognizes and establishes

mechanisms for compliance with all regulatory and
professional requirements related to research.
Hospital leadership ensures that there is a source

of indemnity insurance to adequately compensate
patients participating in clinical research who
experience an adverse event.
The hospital establishes entry and/or transfer
criteria for an admission to a specialized ward due
to
research and/or another specialized program to
meet patient needs.
As appropriate, patients and families are identified
and informed about how to gain access to clinical
research, clinical investigations, or clinical trials
relevant to their treatment needs.
Patients and families asked to participate are

informed about expected benefits.

informed about potential discomforts and risks

informed about alternatives that might also help
them.

informed about the procedures that must be
followed.
Patients and families are assured that their refusal

to participate or withdraw from participation will
not compromise their access to the hospital’s
services.
Patients and families are informed about the

research and the potential benefits and risks to
patients
who decide to participate
Patients and families are informed about their

rights related to withdrawing from participation.
Patients and families are informed about their

rights to confidentiality and security of
information.
Patients and families are informed about the
hospital’s process for obtaining consent.
Informed consent is obtained when a patient

decides to participate in clinical research, clinical
investigations,
or clinical trials.
The identity of the individual(s) providing the
information and obtaining the consent is noted on
the
informed consent document and stored in the files
for the research protocol.
Consent is documented and dated on the informed

consent document by signature or record of verbal
consent.
The hospital has a committee or other mechanism

such as a hospital-specific or shared Institutional
Review Board (IRB) to oversee all research within
the hospital.
The hospital develops a clear statement of purpose

for the oversight activities.
Oversight activities include a review process.
Oversight activities include a process to weigh
relative risks and benefits to subjects
Oversight activities include processes to provide

confidentiality and security of research information
Section
Resp.4.3
page 16
Pol.3.3.1
Pol.3.4
Pro.4.6.5
Proc.4.3.6
Proc.4.3.6
Expired 11/2020
IT policy re; information

management plan
Purchasing Committee
FACILITY MANAGEMENT AND SAF
Chapter Standard
The hospital complies with relevant laws, 3

FMS.1 regulations, building and fire safety codes, and
facility inspection requirements.
2
A qualified individual oversees the facility
FMS.2 management and safety structure to reduce and
control risks in the care environment.
2
A qualified individual oversees the facility
FMS.2 management and safety structure to reduce and
control risks in the care environment.
1
The hospital develops and documents a
comprehensive risk assessment based on facility
management and safety risks identified throughout
FMS 3
the organization, prioritizes the risks, establishes
goals, and implements improvements to reduce
and eliminate risks.
3
1
Data are collected and analyzed from each of the

facility management and safety programs to
reduce risks in the environment, track progress on 3
FMS.4
goals and improvements, and support planning for
replacing and upgrading facilities, systems, and
equipment.
The hospital develops and implements a program

FMS.5 to provide a safe physical facility through
inspection and planning to reduce risks. 𝖯 3
The hospital develops and implements a program 3

FMS.6 to provide a secure environment for patients,
families, staff, and visitors. 𝖯
5
1

FMS.7 for the management of hazardous materials and
waste. 𝖯
3
The hospital’s program for the management of
hazardous materials and waste includes the
FMS.7.1
inventory, handling, storage, and use of hazardous
materials. 𝖯
4
The hospital’s program for the management of

hazardous materials and waste includes the types,
FMS.7.2 2
handling, storage, and disposal of hazardous
waste. 𝖯
1
program for fire safety that includes an ongoing
FMS 8 assessment of risks and compliance with national
and local codes, laws, and regulations for fire
safety. 𝖯
program for fire safety that includes an ongoing 2
FMS 8 assessment of risks and compliance with national
and local codes, laws, and regulations for fire
safety. 𝖯
3
The fire safety program includes the early 2

FMS 8.1 detection, suppression, and containment of fire
and smoke. 𝖯
3
1
The fire safety program includes measures to
FMS 8.2 ensure safe exit from the facility when fire and
non-fire emergencies occur. 𝖯 2
All fire safety equipment and systems, including

FMS 8.3 devices related to early detection, alarm
notification, and suppression, are inspected, 2
tested, and maintained. 𝖯
FMS 8.4 The hospital involves staff in regular exercises to 2

evaluate the fire safety program. 𝖯
The fire safety program includes limiting smoking 2

FMS 8.5 by staff and patients to designated non–patient
care areas of the facility. 𝖯
3
The fire safety program includes limiting smoking
FMS 8.5 by staff and patients to designated non–patient
care areas of the facility. 𝖯

FMS 9 for the management of medical equipment
throughout the organization.
The medical equipment program includes

FM 9.1 inspection, testing, preventive maintenance, and 2
documenting the results. 𝖯
The hospital has a process for monitoring and

acting on medical equipment hazard notices, 2
FMS 9.2 recalls, reportable incidents, problems, and
failures. 𝖯

FMS 10 for the management of utility systems throughout
the organization.
The utility systems program includes inspection,

testing, and maintenance to ensure that utilities
FMS 10.1
operate effectively and efficiently to meet the
needs of patients, staff, and visitors. 𝖯
2
The utility systems program includes inspection,
FMS 10.1 testing, and maintenance to ensure that utilities
operate effectively and efficiently to meet the
needs of patients, staff, and visitors. 𝖯
3
The hospital utility systems program ensures that
essential utilities, including power, water, and
FMS 10.2 medical gases, are available at all times and
alternative sources for essential utilities are 4
established and tested. 𝖯
2
Designated individuals or authorities monitor
FMS 10.3
water quality regularly.
4
5
2
Quality of water used in hemodialysis is tested for
chemical, bacterial, and endotoxin contaminants,
FMS 10.3.1 and processes for hemodialysis services follow
professional standards for infection prevention and 3
control. 𝖯
The hospital develops, maintains, and tests an

emergency management program to respond to
FMS.11 internal and external emergencies and disasters
that have the potential of occurring within the
hospital and community. 𝖯
The hospital develops, maintains, and tests an
emergency management program to respond to
FMS.11 internal and external emergencies and disasters
that have the potential of occurring within the
hospital and community. 𝖯
1
When planning for construction, renovation, and
demolition projects, or maintenance activities that
FMS 12
affect patient care, the organization conducts a
preconstruction risk assessment. 𝖯
preconstruction risk assessment. 𝖯
4
Staff and others are trained and knowledgeable
FMS.13 about the hospital’s facility management and
safety programs and their roles in ensuring a safe
and effective facility.
5
6
FACILITY MANAGEMENT AND SAFETY (FMS)
Measurable Elements
Hospital leadership and the facility management and safety structure
understand and implement the national and local laws, regulations,
building and fire safety codes, and other requirements applicable to the
hospital’s facilities.
Hospital leadership and the facility management and safety structure

document corrective actions taken to meet the conditions of external
facility reports or citations from inspections by national and local
authorities.
Hospital leadership plans and budgets for replacing or upgrading facilities,

systems, and equipment needed to meet applicable requirements and for
the continued operation of a safe, secure, and effective facility.
Hospital leadership approves and allocates budgeted resources or

implements alternative strategies to reduce risks until the resources can
be allocated.
When the hospital is located inside a multiuse building, hospital

leadership obtains evidence of compliance with relevant laws,
regulations, codes, facility inspection reports, utility maintenance
requirements, and other requirements related to shared systems and
building issues.
Oversight and direction of the facility management and safety structure is

assigned to an individual qualified by experience and training, and
evidence of the experience and training is documented.
The qualified individual is responsible for elements a) through f ) of the

intent. a) Recommendations for space,
medical equipment, technology, and other resources to support the
facility management and safety structure are provided to hospital
leadership.
b) Facility management and safety programs are planned and developed
for the following: safety, security, hazardous materials and waste, fire
safety, medical equipment, utility systems, emergency and disaster
management and construction and renovation.
c) The facility management and safety programs are current and fully
implemented.
d) Staff and others are trained on the program.
e) The programs are evaluated and monitored.
f ) 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).
The qualified individual is responsible for elements a) through f ) of the
intent. a) Recommendations for space,
medical equipment, technology, and other resources to support the
facility management and safety structure are provided to hospital
leadership.
b) Facility management and safety programs are planned and developed
for the following: safety, security, hazardous materials and waste, fire
safety, medical equipment, utility systems, emergency and disaster
management and construction and renovation.
c) The facility management and safety programs are current and fully
implemented.
d) Staff and others are trained on the program.
e) The programs are evaluated and monitored.
f ) 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).
The qualified individual is responsible for coordinating and managing risk

assessment and risk reduction activities for the facility management and
safety structure.
When independent business entities are present within the organization,

the entities comply with the facility management and safety programs, as
applicable.
The risk assessments from all eight facility management and safety
programs listed as a) through h) in the intent are integrated to develop
and document a comprehensive, facility-wide risk assessment, at least
annually. a) Safety
b) Security
c) Hazardous materials and waste
d) Fire safety
e) Medical equipment
f ) Utility systems
g) Emergency and disaster management
h) Construction and renovation
The hospital prioritizes the risks, identifies goals and improvements, and
implements improvements to reduce and eliminate risks.
The hospital evaluates the effectiveness of the improvements, and based

on the results, the hospital updates the applicable facility management
and safety programs.
Monitoring data are collected and analyzed for each of the facility
management and safety programs and used to reduce risks in the
environment and support planning for replacing or upgrading
facilities,systems, and equipment.
Monitoring data for the facility management and safety programs are
documented and integrated into the hospital’s quality and patient safety
program.
The individual who oversees the facility management and safety

structure provides monitoring datareports that address the effectiveness
of each program and progress on goals to hospital leadership on a
quarterly basis, and leadership takes action.
The individual who oversees the facility management and safety

structure provides the comprehensive,facility-wide risk assessment and
planned and implemented improvements to hospital leadership at least
annually.
Hospital leadership provides an annual report to the governing entity on

the effectiveness of the facility management and safety programs, and
the governing entity takes action.
The hospital develops and implements a written program to provide a
safe physical facility.
The hospital has a documented, current, accurate inspection of its
physical facilities.
The results from the facility inspection are reviewed and addressed in a
safety risk assessment that is conducted and documented annually, and
safety risks are identified and prioritized from the risk assessment.
The hospital identifies goals, implements improvements, and monitors

data to ensure that safety risks are reduced or eliminated.
The hospital develops and implements a written program to provide a
secure environment.
A security risk assessment is conducted and documented annually
throughout the facility, and security risks are identified and prioritized
from the risk assessment.
The security program identifies all security risk areas and restricted areas
and ensures they are monitored and kept secure.
The security program ensures that all staff, students, trainees, contract
workers, volunteers, vendors, and individuals associated with
independent business entities are identified.
The hospital identifies goals and implements improvements in the

security program, and monitors data to ensure that security risks are
reduced or eliminated.
The hospital develops and implements a written program for the
management of hazardous materials and waste.
A hazardous materials and waste risk assessment is conducted and

documented annually throughout
the facility, and risks related to hazardous materials and waste are
identified and prioritized from the
risk assessment.

data to ensure that risks related to hazardous materials and waste are
reduced or eliminated.
The hazardous materials and waste program identifies the type,

quantities, and locations of hazardous materials and has a complete
inventory, which is updated at least annually, to reflect changes in the
hazardous materials used and stored in the organization.
The hazardous materials and waste program establishes and implements

procedures for safe handling, storage, and use of hazardous materials.

the proper protective equipment required during handling and use of
hazardous materials.

proper and clear labeling of hazardous materials that is consistent with
information from the safety data sheets (SDS).

procedures for the management of spills and exposures, including the use
of proper protective equipment and reporting of spills and exposures.
Information about the hazardous materials related to safe handling, spill-

handling procedures, and
procedures for managing exposures are up to date and available at all
times.
The hazardous materials and waste program establishes the types of

hazardous waste generated by the hospital and how they are identified.

procedures and the proper protective equipment required for safe
handling and storage of hazardous waste.
When required by local laws and regulations, the hazardous materials

and waste program documents the quantities of hazardous waste
generated by the hospital.
The fire safety program includes equipment/systems for the early
detection and alarm notification of fire and smoke.
The fire safety program includes equipment/systems for the suppression
of fire.
When required by local laws and regulations, the fire safety program
includes containment of fire and smoke, and these features are
maintained to ensure effectiveness and safety.
The fire safety program includes the safe exit from the facility through
free and unobstructed access to exits.
The fire safety program includes equipment/systems for the suppression
of fire.
When required by local laws and regulations, the fire safety program
includes containment of fire and smoke, and these features are
maintained to ensure effectiveness and safety.
The fire safety program includes the safe exit from the facility through
free and unobstructed access to exits.
The fire safety program includes clearly visible exit signage that is
understandable to the hospital’s occupants.
The fire safety program includes lighting for emergency exit corridors and
stairs.
All fire safety equipment and systems, including those for smoke and fire
detection and suppression,are inspected, tested, and maintained
according to manufacturers’ recommendations or as required by local
codes, laws, and regulations, whichever sets the more stringent
requirement.
Inspection, testing, and maintenance of all fire safety equipment and

systems are documented, including results and corrective actions.
Any deficiencies identified in fire safety equipment and systems are

immediately corrected, or interim measures are implemented to reduce
fire risk until deficiencies can be fully corrected.
Staff from all shifts, including the night shift and weekends, annually
participate in an exercise to evaluate the fire safety program.
Staff are knowledgeable of the fire safety program and can describe how
to bring patients to safety.
Results of exercises to evaluate the fire safety program are documented,

and staff who do not pass are reeducated and retested on the fire safety
program.
The fire safety program addresses eliminating or limiting smoking within

the hospital facility.
The program applies to patients, families, visitors, and staff.

The program identifies who may grant patient exceptions for smoking
and when those exceptions apply.
Smoking is prohibited in all areas under construction or renovation.
management of medical equipment throughout the hospital.
A medical equipment risk assessment is conducted and documented

annually throughout the hospital, and medical equipment risks are
identified and prioritized from the risk assessment.

data to ensure that medical equipment risks are reduced or eliminated.
The medical equipment program addresses hospital-owned and

nonhospital-owned medical equipmentin the organization, such as
equipment that is leased, rented, brought in by physicians and other
health care practitioners, brought in by patients, and so on.
The medical equipment program includes an inventory of all medical
equipment.
Medical equipment is inspected and tested when new and according to

age, use, and manufacturers’ recommendations thereafter.
The medical equipment program includes preventive maintenance and
calibration as applicable.
The hospital has a process for monitoring and acting on medical
equipment and implantable device hazard notices, recalls, reportable
incidents, problems, and failures.
The hospital reports any deaths, serious injuries, or illness that are a
result of medical equipment through the hospital’s incident and adverse
event reporting process.
The medical equipment management program addresses the use of any

medical equipment with a reported problem or failure, or that is the
subject of a hazard notice or is under recall.

management of utility systems throughout the hospital.
The hospital conducts and documents the utility systems risk assessment
annually throughout the hospital and prioritizes the utility systems risks
that are identified from the risk assessment.

data to ensure that the utility systems risks are reduced or eliminated.
The hospital inventories its utility systems components and maps the
current distribution of them.
The hospital identifies, in writing, the activities and intervals for
inspecting, testing, and conducting preventive and routine maintenance
on all operating components of the utility systems on the inventory,based
on criteria such as manufacturers’ recommendations, risk levels, and
hospital experience.
The hospital updates or replaces utility systems and components when
the need for improvement is identified through inspection, testing, and
maintenance.
The hospital labels utility system controls to facilitate partial or complete
emergency shutdowns
The hospital identifies the areas and services at greatest risk when
essential utilities (including power,water, and medical gas) become
unavailable.
The hospital ensures backup availability/continuity of essential utilities

(including power, water, and medical gas) 24 hours a day, 7 days a week.
The hospital assesses for and reduces the risks of interruption,

contamination, and failure of essential utilities (including power, water,
and medical gas).
The hospital tests the availability and quality of the alternative source(s)
of water at least annually ormore frequently if required by local laws and
regulations or conditions of the source of water. The hospital documents
the results of the tests.
The hospital tests alternative sources of power at least quarterly or more
frequently if required by local laws and regulations, manufacturers’
recommendations, or conditions of the source of power. The hospital
documents the results of the tests.
When emergency sources of power require a fuel source, the hospital

establishes and has available the necessary amount of on-site fuel stored
Quality of potable water is tested at least quarterly or more frequently
based on local laws and regulations, conditions of the sources for water,
and previous experience with water quality problems. The testing results
are documented.
Quality of non-potable water is tested at least every six (6) months or

more frequently based on local laws and regulations, conditions of the
sources for water, and previous experience with water quality problems.
The testing results are documented.
Preventive measures and strategies are implemented to reduce the risks

of contamination and growth of bacteria in water.
Actions are taken and documented when water quality is found to be
unsafe.
Dental unit waterlines are treated and tested according to
manufacturer’s guidelines, and treatments and testing are documented.
Hemodialysis services in the hospital follow industry standards and

professional guidelines for maintaining water quality and implementing
infection prevention and control measures.
Water used in hemodialysis is tested monthly for bacterial growth and

endotoxins and tested annually for chemical contaminants. The testing
results are documented.
The hospital performs routine disinfection of the hemodialysis water
distribution system.
The hospital conducts testing on all hemodialysis machines annually,

including machines not in use,and testing results are documented.
The hospital establishes and implements procedures for reprocessing

dialyzers, including, as applicable, frequency for reusing/replacing
dialyzers and processes for cleaning and testing dialyzers.
The hospital develops, evaluates, and maintains a written emergency and

disaster management program that identifies its response to likely
emergencies and disasters, including items a) through i) in the intent.
a) determining the type, likelihood, and consequences of hazards, threats,

and events;
b) identifying the structural and nonstructural vulnerabilities of the
hospital’s patient care environments and how the hospital will perform in
the event of an emergency or disaster; c) planning for
alternative sources of power and water in emergencies and disasters;
(Also see FMS.10.2)
d) determining the hospital’s role in such events;
e) determining communication strategies for events;
f ) managing resources during events, including alternative sources;
g) managing clinical activities during an event, including alternative care
sites;
h) identifying and assigning staff roles and responsibilities during an event
(including contract staff, vendors, and others identified by the hospital);
(Also see FMS.13) and
i) managing emergencies and disasters when personal responsibilities of
staff conflict with the hospital’s responsibility for providing patient care.
(Also see MOI.13)
The hospital has identified the major internal and external emergencies
and/or disasters such as community emergencies, and natural or other
disasters that pose significant risks of occurring, taking into consideration
the hospital’s geographic location.
The hospital identifies the probable impact that each type of disaster will
have on all aspects of care and services.
The entire program, or at least critical elements c) through i) of the
program, is tested annually.
At the conclusion of every test, debriefing of the test is conducted.

Follow-up actions identified from testing and debriefing are developed
and implemented.
When planning for construction, renovation, or demolition projects, or

maintenance activities that affect patient care, the hospital conducts a
preconstruction risk assessment (PCRA) for at least a) through j) in the
intent. a) air quality;
b) infection prevention and control; (Also see PCI.11)
c) utilities;
d) noise;
e) vibration;
f ) hazardous materials and waste;
g) fire safety;
h) security;
i) emergency procedures, including alternate pathways/exits and access
to emergency services; and
j) other hazards that affect care, treatment, and services.
The hospital takes action based on its assessment to minimize risks during
construction, renovation, and demolition projects, and maintenance
activities that affect patient care.
The hospital ensures that contractor compliance is monitored, enforced,
and documented.
All staff receive annual training and testing on each facility management
and safety program to ensure they can safely and effectively carry out
their responsibilities, and testing results are documented.
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.
Staff can describe and/or demonstrate their roles in response to a fire.

Staff can describe and/or demonstrate actions to eliminate, minimize, or
report safety, security, and other risks.
Staff can describe and/or demonstrate precautions and procedures for

handling and managing medical gases and hazardous materials and
waste, as applicable to the staff member’s role and responsibilities.
Staff can describe and/or demonstrate procedures for and their roles in
internal and community emergencies and disasters.
)
Safety Management Program
Facility Management and Safety

Programs
???
Staff Personnel file of Facility Safety and

Management Team Leader
Facility Management and Safety Satff

Orientation Policy PSMMC Staff
Hospital Facility Safety Committee

Programs


Physical Facility Inspection Policy
Security Management Program

Hazardous Materials Program
purpose 2.1
Fire Safety Program

Fire Safety Program
Fire Safety Program
Fire Safety Program
Fire Safety Program
Fire Safety Program
Fire Drill Policy EXPIRED 01.2021
No Smoking Policy
No Smoking Policy
Medical Equipment Program
Equipment Management Plan
Medical Devices and Medical Consumables Recall Notices Alert Systems
Utility System Program

Water Quality Monitoring at PSMMC

Action Plan for Dialysis Water Treatment System Failure
Hazard Vulnerability Analysis

Emergency Preparedness Policy Role and
Community Coordination
Emergency Preparedness Policy EXPIRED 05.2020
Communication and Technology
Emergency Preparedness Policy Staff
Conflict
Internal-Emergency Response Plan

-Natural- Flooding

-Natural- Sandstorm
Internal-Emergency Response Plan -Major

Fire In-Patient Building
Internal-Emergency Response Plan -Bomb

Threat and Suspicious Packages
External Emergency Response Plan

Receiving Hospital Mass Casualty Incident
Hazard Vulnerability Analysis
Pre-Consruction Risk Assessment for Facility

EXPIRED
Demolition,
09.2020
Construction and Renovation
Facility Management and Safety Staff Orientation Policy PSMMC Staff

Education Policy Contractors and Vendors
Fire Safety Program
On-line Annual Continued FMS Education Policy PSMMC Staff
Medical Gas Program

-Natural- Flooding
-Natural- Sandstorm
Internal-Emergency Response Plan -Major
Fire In-Patient Building
Internal-Emergency Response Plan -Bomb

Threat and Suspicious Packages
STAFF QUALIFICATION AND EDUCATION (SQE)
Chapter Standard
1
Leaders of hospital departments and services
SQE.1 define the desired education, skills, knowledge,
and other requirements of all staff members. 2
Each staff member’s responsibilities are defined in

SQE.1.1 2
a current job description. 𝖯
2
Leaders of hospital departments and services
develop and implement processes for recruiting,
SQE.2
evaluating, and appointing staff as well as other
related procedures identified by the hospital. 3
The hospital uses a defined process to ensure that

SQE.3 clinical staff knowledge and skills are consistent 3
with patient needs.
5
1
2
The hospital uses a defined process to ensure that
nonclinical staff knowledge and skills are consistent
SQE.4
with hospital needs and the requirements of the 3
position.
3
There is documented personnel information for
SQ.5
each staff member. 𝖯
1
A staffing strategy for the hospital, developed by
the leaders of hospital departments and services,
SQE.6
identifies the number, types, and desired
qualifications of staff. 𝖯 2
The staffing strategy is reviewed on an ongoing 2

SQE.6.1
basis and updated as necessary.
The staffing strategy is reviewed on an ongoing
SQE.6.1
basis and updated as necessary.
All clinical and nonclinical staff members are

oriented to the hospital, to the department or unit 2
SQE.7
to which they are assigned, and to their specific job
responsibilities at appointment to the staff.
Each staff member receives ongoing in-service and 3

SQE.8 other education and training to maintain or to
advance his or her skills and knowledge.
4
2
Staff members who provide patient care are
trained and demonstrate competence in the
SQE.8.1
resuscitative techniques specific to the level of 3
training identified.
Staff members who provide patient care are
trained and demonstrate competence in the
SQE.8.1
resuscitative techniques specific to the level of
training identified.
2
Other staff identified by the hospital are trained
SQE.8.1.1 and can demonstrate appropriate competence in
resuscitative techniques.
3
The hospital provides a staff health and safety
SQE.8.2 program that addresses staff physical and mental
health and safe working conditions. 𝖯
4
2
The hospital identifies staff who are at risk for
exposure to and possible transmission of vaccine-
SQE.8.3
preventable diseases and implements a staff
vaccination and immunization program. 𝖯
The hospital identifies staff who are at risk for
exposure to and possible transmission of vaccine-
SQE.8.3
preventable diseases and implements a staff
vaccination and immunization program. 𝖯 3
The hospital has a uniform process for gathering

the credentials of those medical staff members 2
SQE.9
permitted to provide patient care without
supervision. 𝖯
Medical staff members’ education,

licensure/registration, and other credentials 2
SQE.9.1
required by law or regulation and the hospital are
verified and kept current. 𝖯
3
1
There is a uniform, transparent decision process

SQE.9.2 for the initial appointment of medical staff
members. 𝖯 2
The hospital has a standardized, objective,

evidence-based procedure to authorize medical
SQE.10 staff members to admit and to treat patients 2
and/or to provide other clinical services consistent
with their qualifications. 𝖯
The hospital uses an ongoing standardized process

SQE.11 to evaluate the quality and safety of the patient
care provided by each medical staff member. 𝖯
The hospital uses an ongoing standardized process
SQE.11 to evaluate the quality and safety of the patient
care provided by each medical staff member. 𝖯
2
At least every three years, the hospital determines,
from the ongoing professional practice evaluation
SQE.12 of each medical staff member, if medical staff
membership and clinical privileges are to continue
with or without modification. 𝖯
2
The hospital has a uniform process to gather, to
verify, and to evaluate the nursing staff’s
SQE.13
credentials (license, education, training, and
experience). 𝖯
The hospital has a uniform process to gather, to
verify, and to evaluate the nursing staff’s
SQE.13
credentials (license, education, training, and
experience). 𝖯
3
1
The hospital has a standardized process to identify
job responsibilities and to make clinical work
SQE.14
assignments based on the nursing staff member’s
credentials and any regulatory requirements. 2
3
STAFF QUALIFICATION AND EDUCATION (SQE)
The hospital’s mission, volume, and mix of patients,
services, and medical equipment are used in
planning.
The desired education, skills, and knowledge are
defined for staff.
Applicable laws and regulations are incorporated
into the planning.
Each staff member not permitted to practice
independently has a job description.
Those individuals identified in a) through d) in the

intent, when present in the hospital, have job
descriptions appropriate to their activities and
responsibilities or have been privileged if noted as
an alternative.
Job descriptions are current according to hospital
policy.
to recruit staff.

to evaluate the qualifications of new staff.
to appoint individuals to the staff.

that is uniform across the hospital for similar types
of staff.
The hospital uses a defined process to match

clinical staff knowledge, skills, and competency
with patient needs.
New clinical staff members are evaluated before or

at the time they begin their work responsibilities.
The department or service to which the individual

is assigned conducts the evaluation.
The hospital defines the frequency of ongoing
clinical staff evaluation.
There is at least one documented evaluation of
each clinical staff member working under a job
description each year or more frequently as
defined by the hospital.
The hospital uses a defined process to match
nonclinical staff knowledge and skills with the
requirements of the position.
New nonclinical staff are evaluated before or at the

time they begin their work responsibilities.
The department or service to which the individual

is assigned conducts the evaluation.
The hospital defines the frequency of ongoing
nonclinical staff evaluation.
There is at least one documented evaluation of

nonclinical staff members each year or more
frequently as defined by the hospital.
Personnel files for each staff member are

standardized and current and maintained and kept
confidential according to hospital policy.
Personnel files contain the qualifications and the
work history of the staff member.
Personnel files contain the job description of the
staff member when applicable.
Personnel files contain a record of orientation to

the hospital and the staff member’s specific role
and in-service education attended by the staff
member.
Personnel files contain the results of performance
reviews.
Personnel files contain required health
information.
The hospital’s department/service leaders develop
a written strategy for staffing the hospital in a
manner that complies with local laws and
regulations
The number, types, and desired qualifications of

staff are identified in the strategy using a
recognized staffing method.
The strategy addresses the assignment and

reassignment of staff.
The effectiveness of the staffing strategy is
monitored on an ongoing basis.
The strategy is revised and updated when
necessary.
The strategy is coordinated through a process that
involves the department/service leaders.
New clinical and nonclinical staff members are

oriented to the hospital, to the department or unit
to which they are assigned, and to their job
responsibilities and any specific assignments
Contract workers are oriented to the hospital, to

the department or unit to which they are assigned,
and to their job responsibilities and any specific
assignments
Staff who accompany independent practitioners

and provide care and services are oriented to the
hospital.
Students, trainees, and volunteers are oriented to

the hospital and assigned responsibilities.
The hospital uses various sources of data and

information, including the results of quality and
safety measurement activities, to identify staff
education needs.
Education programs are planned based on these
data and information.
Hospital staff are provided ongoing in-service
education and training.
The education is relevant to each staff member’s

ability to meet patient needs and/or continuing
education requirements.
The hospital provides adequate time and facilities

for all staff to participate in relevant education and
training opportunities.
Staff members who provide patient care, including

physicians, are trained in at least basic life support
(BLS).
The hospital identifies the level of training (basic or

advanced life support), appropriate to their roles in
the hospital, for all staff who provide patient care.
There is evidence to show if a staff member passed
the training.
The desired level of training for each individual is
repeated based on the requirements and/or time
frames established by a recognized training
program, or every two years if a recognized
training program is not used.
If applicable, the hospital identifies other staff who

do not provide patient care to be trained in basic
life support (BLS).
When other staff who do not provide patient care

are trained in basic life support, there is evidence
to show if a staff member passed the training.
When other staff are trained, training for each

individual is repeated based on the requirements
and/ or time frames established by a recognized
training program, or every two years if a
recognized training program is not used.
The hospital provides a staff health and safety

program that is responsive to urgent and
nonurgent staff needs through direct treatment
and referral.
The staff health and safety program includes at
least a) through f ) in the intent.
The hospital identifies areas/situations for

potential workplace violence and implements
interventions to reduce the risk.
The hospital provides evaluation, counseling, and

follow-up treatment for staff who are injured as a
result of workplace violence.
The hospital provides education, evaluation,

counseling, and follow-up for staff who are second
victims of adverse or sentinel events.
The hospital promotes staff well-being by creating

a culture of wellness that supports physical well-
being and emotional health.
The hospital identifies epidemiologically significant

infections, as well as staff who are at high risk for
exposure to and transmission of infections.
The hospital develops and implements a staff
vaccination and immunization program.
The hospital evaluates the risks associated with
unvaccinated staff and identifies strategies for
reducingthe patient’s risk of exposure to infectious
diseases from unvaccinated staff.

guides the evaluation, counseling, and follow-up of
staff exposed to infectious diseases.
Education, licensure/registration, and other

credentials required by law or regulation or issued
by recognized education or professional entities as
the basis for clinical privileges are verified from the
original source that issued the credential.
Additional credentials required by hospital policy

are verified from the source that issued the
credential when required by hospital policy.
When third-party verification is used, the hospital

verifies that the third party (for example, a
government agency) implements the verification
process as described in policy or regulations and
that the process meets the expectations described
in the intent.
Education, licensure/registration, and other

credentials required by law or regulation or issued
by recognized education or professional entities as
the basis for clinical privileges are verified from the
original source that issued the credential.
Additional credentials required by hospital policy

are verified from the source that issued the
credential when required by hospital policy.
When third-party verification is used, the hospital

verifies that the third party (for example, a
government agency) implements the verification
process as described in policy or regulations and
that the process meets the expectations described
in the intent.
Medical staff appointments are made according to
hospital policy and are consistent with the
hospital’s patient population, mission, and services
provided to meet patient needs.
Appointments are not made until at least

licensure/registration has been verified from the
primary source, and the medical staff member then
provides patient care services under supervision
until all credentials required by laws and
regulations have been verified from the original
source, up to a maximum of 90 days.
The method of supervision, frequency of

supervision, and accountable supervisors are
documented in the credential file of the individual.
The privilege delineation process used by the

hospital meets criteria a) through e) found in the
intent.
The clinical privileges of all medical staff members

are made available by printed copy, electronic
copy, or other means to those individuals or
locations (for example, operating room, emergency
department) in the hospital in which the medical
staff member will provide services.
Each medical staff member provides only those

services that have been specifically granted by the
hospital.
All medical staff members are included in an

ongoing professional practice evaluation process as
defined by hospital policy and standardized
evaluation at the department/service level.
The ongoing professional practice evaluation

process identifies areas of achievement and
potential improvement related to the behaviors,
professional growth, and clinical results of the
medical staff member, and the results are reviewed
with objective and evidence-based information as
available. These results are compared to other
department/service medical staff members.
The data and information from the monitoring are
reviewed at least every 12 months by the
individual’s department or service head, senior
medical manager, or medical staff body, and the
results, conclusions, and any actions taken are
documented in the medical staff member’s
credential file and other relevant files.
When the findings affect the appointment or

privileges of the medical staff member, there is a
process to act on the findings, and such “for cause”
actions are documented in the practitioner’s file
and are reflected in the list of clinical privileges.
Notification is sent to those sites in which the
practitioner provides services.
Based on the ongoing professional practice

evaluation of the medical staff member, the
hospital determines, at least every three years, if
medical staff membership and clinical privileges are
to continue with or without modification.
There is evidence in the file of each medical staff

member that all credentials that require periodic
renewal, payment of a registration fee, or other
action by the medical staff member are current.
Credentials obtained subsequent to initial

appointment are evident in the file of the medical
staff member and have been verified from the
primary source prior to use in modifying or adding
to clinical privileges.
The renewal decision is documented in the medical

staff member’s credential file and includes the
identification of the reviewer and any special
conditions identified during the review.
The hospital has a standardized procedure to

gather and document the education, certifications,
and experience of each nursing staff member.
Education, training, and certifications are verified

from the original source according to parameters
found in the intent of SQE.9 and are documented.
Licensure is verified from the original source
according to the parameters found in the intent of
SQE.9 and is documented.
There is a record maintained of the credentials of
every nursing staff member.
The hospital has a process to ensure that the

credentials of contract nurses are valid and
complete prior to assignment.
Licensure, education/training, and experience of a
nursing staff member are used to make clinical
work assignments.
The process considers relevant laws and

regulations.
The process supports nurse staffing plans.
Section
MANAGEMENT OF INFORMATION (MOI)
Chapter Standard
2
The hospital plans and designs information
management processes to meet the information
needs of those who
MOI.1
provide clinical services, the hospital’s leaders, and
those outside the hospital who require data and
information 3
The hospital maintains the confidentiality, security, 3

MOI.2 privacy, and integrity of data and information
through processes to manage and control access.
5
6
The hospital maintains the confidentiality, security, 2

privacy, and integrity of data
MOI.2.1 and information through processes that protect
against loss, theft, damage, and
destruction. 3
The hospital determines the retention time of

MOI.3 patient medical records, data, and other 2
information
The hospital uses standardized diagnosis and

procedure codes and ensures the uniform use of
MOI.4
approved symbols and abbreviations across the 4
hospital.
procedure codes and ensures the uniform use of
MOI.4
approved symbols and abbreviations across the
hospital.
The data and information needs of those in and

outside the hospital are met on a timely basis in a 2
MOI.5
format that meets user expectations and with the
desired frequency
Clinical staff, decision makers, and other staff

members are educated and trained on information
MOI.6
systems, information security, and the principles of
information use and management
2
3
1
Documents, including policies, procedures, and

programs, are managed in a consistent and
MOI.7
uniform 2
manner. 𝖯
2
The policies, procedures, plans, and other
documents that guide consistent and
MOI.7.1
uniform clinical and nonclinical processes and
practices are fully implemented. 𝖯
3
The hospital initiates and maintains a standardized, 3

accurate medical record for every patient assessed
MOI.8 or treated
and determines the record’s content, format, and
location of entries. 𝖯
accurate medical record for every patient assessed
MOI.8 or treated
and determines the record’s content, format, and
location of entries. 𝖯
The medical record contains sufficient information

to identify the patient, to support the diagnosis, to 2
MOI.8.1 justify
the treatment, and to document the course and
results of treatment.
Every patient medical record entry identifies its 3

MOI.9 author and when the entry was made in the
medical
record.
4
medical
record.
As part of its monitoring and performance

improvement activities, the hospital regularly 2
MOI.10
assesses
patient medical record content.
Hospital leadership identifies a qualified individual

MOI.11 to oversee the hospital’s health information
technology systems and processes.
3
technology systems and processes.
When mobile devices are used for texting, e-

mailing, or other communications of patient data 3
and
MOI.12 information, the hospital implements processes to
ensure quality of patient care and maintains
security and confidentiality of patient
information. 𝖯
5
1
3
The hospital develops, maintains, and tests a
MOI.13 program for response to planned and unplanned
downtime of data systems. 𝖯
6
MANAGEMENT OF INFORMATION (MOI)
The hospital plans and implements processes to

meet the information needs of those who provide
clinical services

meet the information needs of the hospital’s
leadership and department/service leaders.

meet the information needs and requirements of
individuals, services, and agencies outside the
hospital.
The processes implemented are appropriate to the

hospital’s size, complexity of services, availability of
trained staff, technical resources, and other
resources
The hospital develops and implements processes

consistent with laws and regulations to ensure the
confidentiality, security, and integrity of data and
information
The hospital identifies those authorized to access

data and information, including those authorized
to make entries in the patient medical record, and
determines their level of access based on each
individual’s role and responsibilities.
The hospital has a process in place to grant

authorized individuals access privileges to data and
information in accordance with their level of
access.
The hospital implements processes to ensure that

data and information are accessed by authorized
individuals only and in accordance with their level
of access.
The hospital implements processes to ensure that

only authorized individuals make entries in the
patient medical record and in accordance with
their level of access.
The hospital monitors compliance with the
processes and takes actions when confidentiality,
security, or data integrity are violated or
compromised.
The hospital conducts and documents an annual

information security risk assessment throughout
the organization, and data security risks are
identified and prioritized from the risk assessment.
Data and information are stored in a manner that

protects against loss, theft, damage, and
destruction.
The hospital implements data security best

practices to protect and secure data and
information.
The hospital identifies goals, implements

improvements to address data security risks, and
monitors improvement data to ensure that risks
are reduced or eliminated.
The hospital determines the retention time of

patient medical records and other data and
information and complies with laws and
regulations.
The retention process provides expected

confidentiality and security.
Patient medical records, data, and other

information are destroyed or deleted in a manner
that does not compromise confidentiality and
security.
The hospital uses standardized diagnosis codes and

procedure codes.
The hospital implements the uniform use of

approved symbols and identifies those not to be
used.
If the hospital allows abbreviations, the hospital

implements the uniform use of approved
abbreviations, and each abbreviation has only one
meaning.
If the hospital allows abbreviations, the hospital

develops and/or adopts a do-not-use list of
abbreviations.
Abbreviations are not used on informed consent
and patient rights documents, discharge
instructions, and discharge summaries.
The hospital monitors the uniform use of codes,

symbols, and abbreviations throughout the
organization and takes actions to improve
processes when needed
Data and information dissemination meets the

needs of individuals and organizations within and
outside the hospital, including patients, health care
practitioners, hospital leadership, health care
services and organizations, and regulatory agencies
When data and information are required by

individuals or organizations for the care of a
patient, the hospital has processes to ensure that it
is received in a timely manner that supports
continuity of care and patient safety.
Individuals and organizations within and outside

the hospital receive data and information in a
format that facilitates its intended use.
Staff providing patient care have access to the data

and information needed to carry out their job
responsibilities and provide patient care safely and
effectively.
Clinical staff, decision makers, and others are

provided education and training on information
systems, information security, and the principles of
information use and management, as appropriate
to
their role and responsibilities.
Staff who use an electronic medical record system

receive education, ongoing training, and
assessment to ensure that they can effectively and
efficiently use the system to carry out their job
responsibilities.
Clinical and managerial data and information are

integrated as needed to support decision making.
There is a written guidance document that defines
the requirements for developing and maintaining
policies, procedures, and programs, including at
least items a) through h) in the intent.
There are standardized formats for all similar

documents; for example, all policies.
The requirements of the guidance document are

implemented and evident in the policies,
procedures, and programs found throughout the
hospital.
Required policies, procedures, and plans are

available, and staff understand how to access those
documents relevant to their responsibilities.
Staff are trained and understand those documents

relevant to their responsibilities
The requirements of the policies, procedures, and

plans are fully implemented and evident in the
actions of individual staff members.
The implementation of policies, procedures, and

plans is monitored, and the information supports
full implementation.
A medical record with at least two identifiers

unique to the patient is initiated for every patient
assessed or treated by the hospital
The specific content, format, and location of

entries for patient medical records is standardized
and determined by the hospital
The hospital establishes and implements guidelines

on the proper use of copy-and-paste, auto-fill,
auto-correct, and templates and provides
education and training on the guidelines to all staff
who
document in the electronic medical record.
The hospital has a process to monitor compliance
with the guidelines on the proper use of copy-
andpaste, auto-fill, auto-correct, and templates
and implements corrective action as needed.
The hospital establishes and implements processes

and guidelines to facilitate accurate and complete
documentation in patient medical records.
Patient medical records contain adequate

information to identify the patient

information to support the diagnosis and promote
continuity
of care.

information to justify and document the course
and results
of the patient’s care, treatment and services.
The author of each entry in the patient medical

record can be identified.
The date of each entry in the patient medical

record can be identified.
The time of each entry in the patient medical

record can be identified
There is a process that addresses how entries in

the patient medical record are corrected or
overwritten.
When scribes are used to assist with
documentation in the patient medical record, they
sign, date,
and time their entries, and there is a process for
the physician/health care practitioner to review
and authenticate the scribe’s entries
A representative sample of medical records that

includes active and discharged medical records and
inpatient and outpatient medical records, is
reviewed at least quarterly or more frequently as
determined
by laws and regulations
The review is conducted by physicians, nurses, and

others authorized to make entries in patient
medical records or to manage patient medical
records.
The review focuses on the timeliness, accuracy,

completeness, and legibility of the medical record.
Medical record content required by laws or

regulations is included in the review process.
The results of the review process are incorporated

into the hospital’s quality oversight mechanism.

and resources for health information technology in
the hospital.
Hospital leadership identifies a qualified individual

to oversee health information technology systems
in the hospital with responsibility for at least a)
through d) in the intent.
Stakeholders, such as clinical and nonclinical staff

and department/service leaders, participate in
processes
such as selection, testing, implementation, and
evaluation of new and evolving health information
technology systems
New and evolving health information technology
systems are monitored and evaluated for usability,
effectiveness, staff outcomes, and patient safety,
and improvements are identified and implemented
based on results.
Measurable Elements of MOI.12

q 1. When the hospital allows patient data and
information to be transmitted through text
messaging,
the hospital ensures that the process is through a
secure messaging platform and complies with a)
through e) in the intent.
When mobile devices are used for communicating

patient data and information, the hospital
implements
guidelines and processes to protect and secure
patient information.
The hospital establishes processes to ensure 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.
When the hospital implements a patient portal or

communicates with patients via text messages or
e-mails, the hospital first obtains consent from
patients to participate in the portal and/or receive
text messages or e-mails
When the hospital allows patient information to be

communicated via text messages, e-mail, and
patient portals, the hospital has a process to
ensure that questions that arise about the
information exchanged are addressed in a timely
manner and monitors for improvements needed to
the communication processes.
The hospital develops and maintains, and tests at
least annually, a program for response to planned
and unplanned downtime of data systems.
The hospital identifies the probable impact that

planned and unplanned downtime of data systems
will have on all aspects of care and services.
The program includes continuity strategies for the

provision of ongoing safe, high-quality patient
care and services, including services provided by
outside vendors, during planned and unplanned
downtime of data systems.
The program identifies internal and, when

applicable, external communication strategies for
planned
and unplanned downtime
The hospital identifies and implements downtime

recovery tactics and ongoing data backup
processes to recover and maintain data and ensure
data integrity and maintain confidentiality and
security of patient information.
Staff are trained in the strategies and tactics used

for planned and unplanned downtime of data
systems.
Section

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What processes does the hospital develop to improve patient safety?

What processes does the hospital develop to improve patient safety?

What processes does the hospital implement related to hand hygiene and infections?

What processes does the hospital implement related to hand hygiene and infections?

INTERNATIONAL PATIENT SAFETY GO

The hospital develops and

The hospital develops and

The hospital develops and

The hospital develops and 2

The hospital develops and 2

The hospital develops and

The hospital adopts and 1

The hospital develops and

The hospital develops and

The hospital identifies what information is documented in the medical record.

The hospital identifies in writing its list of high-alert medications.

The hospital identifies in writing its list of look-alike/sound-alike medications.

The hospital has adopted current evidence-based hand-hygiene guidelines.

The hospital implements a hand-hygiene program throughout the hospital.

Hospital leaders identify priority areas for improvement of hospital-acquired infections.

Policy No. 4.1, 4.3,4.5,4.14

Collection, Handling and Storage

Patient Identification Procedure No. 6.1.10

Patient Identification Procedure No. 6.3

Procedure No. 6.1.2, 6.1.2.2,

Procedure No. 6.1.2, 6.1.2.2,

Policy No. 2.3,2.6.1,

Laboratory Critical Test and CriticalDefinition

Laboratory Critical Test and CriticalProcedure

Laboratory Critical Test and CriticalPolicy

Critical Test Result Form Policy 4.1

I-SBAR Handover Communication Tool

Hands-Off/Hand Over Communication

Incident Report Form

High Alert Medications

High Alert Medications Policy No. 2.1 - 2.10

High Alert Medications Policy No. 2.13

Look Alike Sound Alike MedicationsAppendix 2

Look Alike Sound Alike MedicationsPolicy 4.1, 4.2, 4.3,

Look Alike Sound Alike MedicationsPolicy 4.1, 4.2, 4.3, 4.8

Handling Concentrated ElectrolytesPolicy 2.2, 2.3, 2.5,

Handling Concentrated ElectrolytesAppendix A

Guidelines for Management of Hypokalemia

Potassium Dosing for

Ensure Safe Surgery Procedure 6.2.2

Ensure Safe Surgery Procedure 6.2.1, 6.2.3

Ensure Safe Surgery Procedure 4.6

Ensure Safe Surgery Procedure 4.7

Hand Hygiene Purpose 2.1

Hand Hygiene Purpose 2.2

Hand Hygiene Purpose 2.2

Healthcare Associated Infections (HAIs)

Fall Prevention and Management Policy 4.2

Falls Assessment Tool (Adult)Morse Falls Scale (MFS)

Falls Assessment Tool (Pediatric)The Humpty Dumpty Scale

Fall Prevention and Management Policy 4.2

Fall Prevention and Management

Fall Prevention and Management Policy 4.3

Fall Prevention Intervention Checklist (Outpatient)