We are pleased to present the publication of the first edition of the Health Authorty - Abu Dhabi Health Care Standards for Hospitals.

Transcription

1

2 ii

3 ESSAGE FRO THE CHAIRAN We are pleased to present the publication of the first edition of the Health Authorty - Abu Dhabi Health Care Standards for Hospitals. We expect major improvements in the health care system with tangible benefits for patients as these standars are applied in all health care provider facilities throughout the Emirate of Abu Dhabi. Dr. Ahmed ubarak Al azrouei iii

4 iv

5 FOREWORD The Health Authority Abu Dhabi (HAAD) is very pleased to present these Standards for Hospitals. HAAD was established to provide health care services for the residents of the Emirate of Abu Dhabi, to ensure that all facilities achieve defined standards, and encourage and support the provision of high quality health care services in accordance with international quality standards. The main function of HAAD is to regulate the Health Care Sector in the Emirate of Abu Dhabi, both Public and Private, through policies, laws, regulations, inspections and audits. The corporate office of HAAD is located in the capital of UAE, Abu Dhabi. HAAD is responsible for licensing, quality control, and regulating all of the health care facilities and health professionals in the Emirate of Abu Dhabi. This responsibility includes the oversight of the vision in developing health communities and monitoring health care facilities so that high quality health care services are delivered to its population in accordance with the best international practices and quality standards. Professional standards, regulations, and guidelines must be produced in HAAD related to health professionals, public health, facilities licensure and inspections, and drugs and medical devices. Standards for facilities and organizations should be consistent with the internationally recognized benchmark established by Joint Commission International (JCI). HAAD standards for health facilities are consistent with JCI standards, but focus on the elements of patient and facility safety. All health care facilities in the Emirate of Abu Dhabi must achieve the mandated or compulsory standards during an inspection to be licensed in the Emirate. In fulfillment of HAAD s mandate, the standards were developed by HAAD in collaboration with Joint Commission International (JCI), a world leader in health standards. These standards are consistent with international standards and they are the first step towards the highest level of achievement in health care. The standards are based on the JCI standards and the research processes and validation methodologies that were used in their development, as well as the regulatory requirements of HAAD. JCI was created in 1998 as the international arm of The Joint Commission (United States). JCI s mission to improve the safety and quality of patient care around the world and this mission is very supportive of the Health Authority s mission. JCI standards are truly international in their development and revision. The process of developing standards is actively overseen by an expert international task force, whose members are drawn from each of the world s populated continents. In addition, the standards were evaluated by individuals around the world via an internet-based field review, as well as considered by JCI Regional Advisory Councils in Asia Pacific, Europe, and the iddle East, and other experts from various health care fields. In addition, JCI standards have been used to develop and establish accreditation programs in many countries and have been used by public agencies, health ministries, and others seeking to evaluate and improve the safety and quality of patient care. Each new edition of the standards, which is conducted approximately every three years, reflects the dynamic changes occurring around the globe in health care. New technologies and treatments are in use; patients are traveling beyond borders to receive health care; v

6 physicians, nurses, and allied health professionals are moving across borders to seek better opportunities; and health care workers are faced with exposure to biological and other hazards. Each day, health care facilities serve as the training grounds for many students in the health professions; infectious agents are spreading rapidly across the globe; adverse health care errors continue to occur; and the number and variety of ethical and legal challenges to the delivery of health care continue to grow. Each new edition addresses these and other issues with new and revised standards. The standards emphasize the International Patient Safety Goals, and focus on patient and facility safety in general. The most critical elements related to safety are identified as andatory and have an designation. These standards must be met for any health care facility to be licensed vi

7 The standards were developed by HAAD in collaboration with Joint Commission International

8 HOSPITAL STANDARDS Table of Contents I. Introduction II. Patient Safety and Quality Improvement (PCQ) International Patient Safety Goals Quality Improvement Design of Clinical and anagerial Processes Data Collection Analysis of onitoring Data Sustained Improvement III. Communication (CCC) Admission to the Hospital Continuity of Care Discharge, Referral, and Follow-Up Transfer of Patients Transportation Patient and Family Rights Informed Consent Patient and Family Education IV. High Risk Care Processes (HRC) Assessment of Patients Care Delivery Provision of High-Risk Services Food and Nutrition Therapy Anesthesia, Sedation, and Surgical Care edication Use End-of-Life Care Pain anagement Infection Control V. Leadership (LDS) Governance of the Hospital Hospital Ethics Leadership of the Hospital Staffing Orientation and Education edical Staff Nursing Staff Other Professional Staff VI. Facility Safety (FSE) Leadership and Planning Hazardous aterials Emergency anagement Fire Safety edical Equipment Utility Systems Staff Education

9 I. Introduction HOSPITAL STANDARDS ANUAL These standards address the care of individuals with acute and emergent care needs. They are organized around the important functions necessary for the provision of safe, high-quality care in a wide range of settings from small specialty hospitals to large multi-specialty acute care hospitals. These standards provide hospitals with mechanisms to demonstrate the quality and safety that they are providing in their hospitals. The standards are designed to help each hospital standardize the care and services it provides, establish a quality and safety culture, and manage information in a manner that facilitates care and services across the hospital and during transfers to other health care facilities. The standards are organized around the following areas of focus: 1. Patient Safety and Quality Improvement (PCQ) 2. Communication (CCC) 3. High Risk Care Processes (HRC) 4. Leadership (LDS) 5. Facility Safety (FSE) As a general principle, licensed providers are expected to meet the following professional obligations: Ensure the clinical and other professional qualifications of all staff according to HAAD licensing policies; in turn licensed clinical staff is expected to act in a manner that is consistent with international good practice in the management of patients to maintain safety, and provide such benefit as they are able. Ensure their facilities and equipment are sufficient to deliver safe, high-quality care in accordance with international good practice. Ensure there are robust clinical and management processes for the tracking of patient safety and the effectiveness of treatment, including the keeping of accurate, fit-forpurpose clinical records. Report any occurrence that results in a risk to patient safety or compromises the delivery of high-quality care. Inspection Process The achievement of JCI accreditation is accepted for the purposes of initial licensure in the specific areas covered by the accreditation process. For example, if a hospital was accredited through JCI under hospital standards, this would be accepted for the initial HAAD hospital licensure. However, if the hospital has either ambulatory care and/or long term care facilities, the JCI hospital accreditation would not replace the appropriate HAAD licensing standards and process, necessitating the facility to obtain the relevant HAAD license through the inspection process. In addition, even if an organization has achieved JCI accreditation, HAAD inspectors will conduct full or limited inspections of the facility under the appropriate HAAD standards, unannounced within the duration of the period of accredited status

10

11 Patient Safety and Quality Improvement (PCQ)

12

13 II. Patient Safety and Quality Improvement (PCQ) This chapter describes a comprehensive approach to quality improvement and patient safety. Integral to overall improvement in quality is the ongoing reduction in risks to patients and staff. Such risks may be found in clinical processes as well as in the physical environment. This approach includes: leading and planning the quality improvement and patient safety program; designing new clinical and managerial processes well; monitoring how well processes work through indicator data collection; analyzing the data; and implementing and sustaining changes that result in improvement. Both quality improvement and patient safety programs are leadership driven; seek to change the culture of an organization; proactively identify and reduce risk and variation; use data to focus on priority issues; and seek to demonstrate sustainable improvements. Quality and safety are rooted in the daily work of individual health care professionals and other staff. As physicians and nurses assess patient needs and provide care, this chapter can help them understand how to make real improvements to help their patients and reduce risks. Similarly, managers, support staff, and others can apply the standards to their daily work to understand how processes can be more efficient, resources can be used more wisely, and physical risks can be reduced. This chapter emphasizes that continuously planning, designing, monitoring, analyzing, and improving clinical and managerial processes must be well organized and have clear leadership to achieve maximum benefit. This approach takes into account that most clinical care processes involve more than one department or unit and may involve many individual jobs. This approach also takes into account that most clinical and managerial quality issues are interrelated. Thus, efforts to improve those processes must be guided by an overall framework for quality management and improvement activities in the hospital, and be overseen by a quality improvement and patient safety oversight group or committee

14 PCQ.1 # STANDARD AND SCORING REQUIRENTS N N/A International Patient Safety Goals Goal 1 Identify Patients Correctly The hospital develops an approach to improve accuracy of patient identifications. 1. A collaborative process is used to develop policies and/or procedures that address the accuracy of patient identification. 2. The policies and/or procedures require the use of two patient identifiers, not including the use of the patient s room number or location. 3. Patients are identified before administering medications, blood or blood products. 4. Patients are identified before taking blood and other specimens for clinical testing. 5. Patients are identified before providing treatments and procedures. PCQ.2 Goal 2 Improve Effective Communication The hospital develops an approach to improve the effectiveness of communication among caregivers. 1. A collaborative process is used to develop policies and/or procedures that address the accuracy of verbal and telephone communications. 2. The complete verbal and telephone order or test result is written down by the receiver of the order or test result. 3. The complete verbal and telephone order or test result is read back by the receiver of the order or test result. 4. The order or test result is confirmed by the individual who gave the order or test result. PCQ.3 Goal 3 Improve the Safety of High-Alert edications The hospital develops an approach to improve the safety of high-alert medications. 1. A collaborative process is used to develop policies and/or procedures that address the location, labeling, and storage of concentrated electrolytes. 2. Concentrated electrolytes are not present in patient care units unless clinically necessary, and actions are taken to prevent inadvertent administration in those areas where permitted by policy

15 # STANDARD AND SCORING REQUIRENTS N N/A PCQ.4 Goal 4 Eliminate Wrong-Site, Wrong-Patient, Wrong Procedure Surgery The hospital develops an approach to eliminating wrong-site, wrong-patient, and wrong-procedure surgery. 1. A collaborative process is used to develop policies and/or procedures that will establish uniform processes to ensure the correct site, correct patient, and correct procedure, including procedures done in settings other than the operating theatre. 2. The hospital uses a clearly understood mark for surgical site identification and involves the patient in the marking process. 3. The hospital uses a process to verify that all documents and equipment needed are on hand, correct, and functional prior to the procedure. 4. The hospital uses a checklist and time-out procedure just before starting a surgical procedure and in the same room in which the procedure will take place. PCQ.5 Goal 5 Reduce the Risk of Healthcare-Associated Infections The hospital develops an approach to reduce the risk of health care-acquired infections. 1. A collaborative process is used to develop policies and/or procedures that address reducing the risk of health careassociated infections. 2. The hospital has adopted or adapted currently published and generally accepted hand hygiene guidelines. 3. The hospital implements an effective hand hygiene program. PCQ.6 Goal 6 Reduce the Risk of Patient Harm Resulting from Falls The hospital develops an approach to reduce the risk of patient harm resulting from falls. 1. A collaborative process is used to develop policies and/or procedures that address reducing the risk of patient harm resulting from falls in the hospital. 2. The hospital implements a process for the initial assessment of patients for fall risk and reassessment of patients when indicated by a change in condition, medications, etc. 3. easures are implemented to reduce fall risk for those assessed to be at risk

16 # STANDARD AND SCORING REQUIRENTS N N/A Quality Improvement PCQ.7 Those responsible for governing and managing the hospital participate in planning and monitoring a quality improvement and patient safety program. 1. The hospital s leadership participates in developing the plan for the quality improvement and patient safety program. 2. The hospital s leadership participates in monitoring the quality improvement and patient safety program. 3. The hospital s leadership establishes the oversight process or mechanism for the organization s quality improvement and patient safety program. 4. The hospital s leadership reports on the quality and patient safety program to governance. 5. There is a written plan for the quality improvement and patient safety program. PCQ.8 The leaders prioritize which processes should be monitored and which improvement and patient safety activities should be carried out. 1. The leaders set priorities for monitoring activities. 2. The leaders set priorities for improvement and patient safety activities. 3. The priorities include the implementation of the International Patient Safety Goals. PCQ.9 The leaders provide technological and other support to the quality improvement and patient safety program. 1. The leaders understand the technology and other support requirements for tracking and comparing monitoring results. 2. The leaders provide technology and support, consistent with the hospital s resources, for tracking and comparing monitoring results. PCQ.10 Quality improvement and patient safety information is communicated to staff. 1. Information on the quality improvement and patient safety program is communicated to staff. 2. The communications are on a regular basis through effective channels. 3. The communications include progress on compliance with the International Patient Safety Goals

17 # STANDARD AND SCORING REQUIRENTS N N/A PCQ.11 All staff members are trained to participate in the program. 1. There is a training program for staff, including leadership, that is consistent with their role in the quality improvement and patient safety program. 2. A knowledgeable individual provides the training. 3. Staff members participate in the training as part of their regular work assignment. Design of Clinical and anagerial Processes PCQ.12 The hospital designs new and modified systems and processes according to quality improvement principles. 1. Quality improvement principles and tools are applied to the design of new or modified processes. 2. Design elements are considered when relevant to the process being designed or modified. Good process design: a) is consistent with the hospital s mission and plans; b) meets the needs of patients, families, staff, and others; c) uses current practice guidelines, clinical standards, scientific literature, and other relevant evidencebased information on clinical practice design; d) is consistent with sound business practices; e) considers relevant risk management information; g) builds on the best/better/good practices of other hospitals; h) uses information from related improvement activities. 3. Indicators are selected to measure how well the newly designed or redesigned process operates. 4. Indicator data are used to evaluate the ongoing operation of the process for at least 4 months following full implementation. Data Collection PCQ.13 The hospital s leaders identify key measures (indicators) to monitor the organization s clinical and managerial structures, processes, outcomes, and the International Patient Safety Goals. 1. The leaders identify key measures to monitor. 2. The scope, method, and frequency are identified for each measure. 3. The monitoring is part of the quality improvement and patient safety program

18 # STANDARD AND SCORING REQUIRENTS N N/A 4. The results of monitoring are communicated to the oversight mechanism (Quality Committee) and, periodically, to the leaders and governance structure of the hospital. The required measures include: 5. patient assessment; 6. laboratory services; 7. radiology and diagnostic imaging services; 8. surgical procedures; 9. antibiotic and other medication use; 10. medication errors; 11. anesthesia and sedation use; 12. use of blood and blood products; 13. availability, timeliness, content, and use of patient records; 14. infection control, surveillance, and reporting; 15. timely procurement of routinely required supplies and medications essential to meet patient needs; 16. reporting of activities as required by law and regulation; 17. risk management; 18. utilization management; 19. patient and family expectations and satisfaction; 20. staff expectations and satisfaction; 21. patient demographics and clinical diagnoses; PCQ.14 PCQ financial management; 23. prevention and control of events that jeopardize the safety of patients, families, and staff, including the International Patient Safety Goals. Analysis of onitoring Data Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the organization. 1. Data are aggregated, analyzed, and transformed into useful information. 2. Individuals with appropriate clinical or managerial experience, knowledge, and skills participate in the process. 3. Statistical tools and techniques are used in the analysis process. The frequency of data analysis is appropriate to the process being studied and meets organization requirements. 1. The frequency of data analysis is appropriate to the process under study. 2. The frequency of data analysis is at least quarterly

19 # STANDARD AND SCORING REQUIRENTS N N/A PCQ.16 The analysis process includes comparisons internally, with other hospitals when available, and with scientific standards and desirable practices. 1. Comparisons are made over time within the hospital. 2. Comparisons are made with similar hospitals, when possible, and with scientific standards and desirable practices. PCQ.17 The hospital uses a defined process for identifying and managing sentinel events. 1. The hospital leaders have established a definition of a sentinel event that at least includes: Unanticipated death unrelated to the natural course of the patient s illness or underlying condition; ajor permanent loss of function unrelated to the natural course of the patient s illness or underlying condition; Wrong site, wrong procedure, wrong patient surgery; Any other events as may be required by law or regulation or viewed by the hospital as appropriate to add to its list. 2. All events that meet the above definition are assessed by completing a credible root cause analysis within 45 days of the knowledge of the event. 3. When the root cause analysis reveals that system improvements or other actions can prevent or reduce the risk of such sentinel events recurring, the hospital redesigns the processes and takes what ever other actions are appropriate to do so. PCQ.18 Data are analyzed when undesirable trends and variation are identified. 1. All confirmed transfusion reactions are analyzed. 2. All serious adverse drug events are analyzed. 3. All significant medication errors are analyzed. 4. All major discrepancies between preoperative and postoperative diagnoses are analyzed. 5. Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use are analyzed

20 # STANDARD AND SCORING REQUIRENTS N N/A PCQ.19 Sustained Improvement Improvement in quality and safety is achieved and sustained. 1. The hospital uses a consistent process to plan and implement improvements. 2. The hospital documents the improvements achieved and sustained. 3. Priority areas are identified and improvements are planned for these areas. 4. Responsibility for planning and implementing an improvement is assigned. 5. Data are collected to determine the effectiveness of any planned changes. 6. Effective changes are incorporated into standard operating policies and procedure. 7. Appropriate staff are educated about the changes. 8. Data are collected to show sustained improvement for a minimum of four months. TOTAL PERCENT OF COPLIANCE

21 Communication (CCC)

22

23 III. Communication (CCC) This chapter focuses on the importance of communication in hospitals. Providing patient care is a complex endeavor that is highly dependent on the communication of information. This communication is to and with the community, patients and their families, and to other health professionals. Failures in communication are one of the most common root causes of patient safety incidents. To provide, coordinate, and integrate services, hospitals rely on information about the science of care, individual patients, care provided, results of care, and their own performance. Like human, material, and financial resources, information is a resource that must be managed effectively by the hospital s leaders. Every hospital must seek to obtain, manage, and use information to improve patient outcomes as well as individual and overall performance

24 CCC.1 # STANDARD AND SCORING REQUIRENTS N N/A Admission to the Hospital Patients are admitted to receive inpatient care based on their identified health care needs and the hospital s mission and resources. 1. Screening is initiated at the point of first contact within or outside the hospital. 2. Based on the results of screening, it is determined if the needs of the patient match the hospital s mission and resources. 3. Patients are accepted only if the hospital can provide the necessary services and the appropriate inpatient setting for care. 4. There is a process to provide the results of diagnostic tests within a three to four hour time frame to those responsible for determining if the patient is to be admitted, transferred, or referred. 5. Policies identify which screening and diagnostic tests are standard before admission, if any. 6. Patients are not admitted, transferred, or referred before the test results required for these decisions are available. 7. Policies define how patients are informed when there will be a wait or delay in care and treatment and the reasons for the delay or wait. 8. Policies define how the information told to the patient will be documented. CCC.2 The hospital has a process for admitting inpatients. 1. Policies and procedures are used to standardize the inpatient admitting process. 2. Staff members are familiar with the policies and procedures and follow them. 3. The policies and procedures address admitting emergency patients to inpatient units. 4. The policies and procedures address holding patients for observation. 5. The policies and procedures address managing patients when bed space is not available on the desired service or unit or elsewhere in the hospital. CCC.3 Patients with emergency or immediate needs are given priority for assessment and treatment. 1. The hospital has established criteria to prioritize patients with immediate needs. 2. The criteria are physiologic-based. 3. Staff members are trained to use the criteria

25 # STANDARD AND SCORING REQUIRENTS N N/A 4. Patients are prioritized based on identified needs according to established criteria. CCC.4 On admission to the hospital, patients and families receive information on the proposed care, the expected outcomes of that care, and any expected cost to the patient for the care. CCC.5 CCC.6 1. Provide the patient/family with care and services information at admission to include: 2. Information on any expected costs to the patient or family. 3. Information sufficient to make knowledgeable decisions about their hospitalization. 4. Information about his or her rights in writing. The organization seeks to reduce physical, language, cultural, and other barriers to access and delivery of services. easurable Elements 1. The organization has identified the barriers in its patient population. 2. There is a process to overcome or limit barriers during the entry process. 3. There is a process to limit the impact of barriers on the delivery of services. 4. These processes are implemented and documented. Admission or transfer to or from units providing intensive or specialized services is determined by established criteria. 1. The hospital has established entry and/or transfer criteria for its intensive and specialized services or units. 2. The criteria are physiologic-based. 3. Appropriate individuals, such as physicians and nurses, are involved in developing the criteria. 4. Staff members are trained to apply the criteria. 5. Patients transferred or admitted to intensive and specialized units/services meet the criteria and this is documented in the patient s record. 6. Patients who no longer meet criteria to remain in the unit are transferred or discharged. Continuity of Care CCC.7 During all phases of care, there is a qualified individual identified as responsible for the patient s care. 1. The individual responsible for the patient s care is identified. 2. The individual is qualified to assume responsibility for the patient s care. 3. The individual is known to the hospital s staff. 4. The individual is known to the patient and family

26 CCC.8 # STANDARD AND SCORING REQUIRENTS N N/A Discharge, Referral, and Follow-Up There is a policy guiding the appropriate referral or discharge of patients. 1. There is a policy guiding the appropriate referral and/or discharge of patients. 2. The referral and/or discharge is based on the patient s needs for continuing care. 3. The patient s readiness for discharge is determined. 4. Hospital policy guides the process of patients on pass for a defined period of time. The policy should also CCC.9 address patient responsibility. Patient records contain a copy of the discharge summary. 1. A discharge summary is prepared at discharge by a qualified individual. 2. All discharge summaries contain the following items: a) Reason for admission; b) Significant physical and other findings; c) Significant diagnoses and co-morbidities; d) Diagnostic and therapeutic procedures performed; e) Significant medications and other treatments received; f ) The patient s condition at the time of discharge; g) Discharge medications, including all of the medications to be taken at home; h) Follow-up instructions; i) When and how to obtain urgent or emergent care. 3. A copy of the discharge summary is placed in the patient record and given to the patient. 4. A copy of the discharge summary is provided to the practitioner responsible for the patient s continuing or follow-up care. Transfer of Patients CCC.10 There is a policy guiding the appropriate transfer of patients to another hospital or organization to meet their continuing care needs. 1. There is policy guiding the appropriate transfer of patients. 2. The transfers are based on the patient s needs for continuing care. 3. The process addresses the transfer of responsibility to another provider or setting

27 # STANDARD AND SCORING REQUIRENTS N N/A 4. The process addresses criteria that define when transfer is necessary. 5. The process addresses who is responsible during transfer. 6. The process addresses the situation in which transfer is not possible. 7. Patients are appropriately transferred to other hospitals or organizations. CCC.11 The referring hospital organization determines that the receiving hospital can meet the patient s continuing care needs. 1. The referring hospital determines that the receiving hospital can meet the needs of the patient to be transferred. 2. Patient clinical information or a clinical summary is transferred with the patient. 3. The clinical summary includes: a) patient status; b) procedures and other interventions provided; CCC.12 c) the patient s continuing care needs. During direct transfer, a qualified staff member monitors the patient s condition. 1. All patients are monitored during direct transfer to another hospital. 2. The qualifications of the staff member monitoring the patient during transfer are appropriate for the patient s condition. CCC.13 The transfer process is documented in the patient s record. 1. The records of transferred patients note the name of the hospital and name of the individual agreeing to receive the patient. 2. The records of transferred patients note the reason(s) for transfer. 3. The records of transferred patients note any special conditions related to transfer. 4. The records of transferred patients note any change of patient condition or status during transfer. Transportation CCC.14 The process for referring, transferring, or discharging the patient considers transportation needs. 1. The process for referring patients considers transportation needs

28 # STANDARD AND SCORING REQUIRENTS N N/A 2. The process for transferring patients considers transportation needs. 3. The process for discharging patients considers transportation needs. 4. Transportation is appropriate to the patient s needs. Patient and Family Rights CCC.15 The hospital takes measures to protect patients possessions from theft or loss. CCC The organization has determined its level of responsibility for patients possessions. 2. Patients receive information about the hospital s responsibility for protecting personal belongings. Patient information is confidential and protected from loss or misuse. 1. Patients are informed about how their information will be kept confidential and about laws and regulations that require the release of and/or require confidentiality of patient information. 2. Patients are requested to grant permission for the release of information not covered by law and regulation. 3. The hospital respects patient health information as confidential. 4. Policies and procedures to prevent the loss or misuse of patient information are implemented. CCC.17 The hospital informs patients and families about how they will be told about the outcomes of care and treatment, including unanticipated outcomes, and who will tell them. CCC Patients and families understand how they will be told and who will tell them of the outcomes of care and treatment. 2. Patients and families understand how they will be told and who will tell them of any unanticipated outcomes of care and treatment. The hospital informs patients and families about their rights and responsibilities related to refusing or discontinuing treatment. 1. The hospital informs patients and families about their rights to refuse or discontinue treatment. 2. The hospital informs patients about the consequences of their decisions. 3. The hospital informs patients and families about their responsibilities related to such decisions

29 # STANDARD AND SCORING REQUIRENTS N N/A 4. The hospital informs patients about available care and treatment alternatives. 5. When a patient refuses or discontinues treatment, the above communication of information is documented in the patient s medical record. CCC.19 The hospital supports the patient s right to appropriate assessment and management of pain. CCC.20 CCC The hospital respects and supports the patient s right to assessment and management of pain. 2. The hospital s staff members understand the personal, cultural, and societal influences on the patient s right to report pain, and accurately assess and manage pain. The hospital supports the patient s right to respectful, compassionate, and culturally sensitive care at the end of life. 1. The hospital recognizes that dying patients have unique needs. 2. The hospital s staff respects the right of dying patients to have those unique needs addressed in the care process. The hospital informs patients and families about its process to receive and act on complaints, conflicts, and differences of opinion about patient care and the patient s right to participate in these processes. 1. Patients are aware of their right to voice a complaint and the process to do so. 2. Complaints are reviewed according to the hospital s mechanism. 3. Dilemmas that arise during the care process are reviewed according to the hospital s mechanism. 4. Policies and procedures identify participants in the process. 5. Policies and procedures identify how the patient and family participate. 6. Policies and procedures identify how soon the patient and family can expect to a response to their complaint. Informed Consent CCC.22 Patient informed consent is obtained through a process defined by the hospital and carried out by trained staff. 1. The hospital has a clearly defined informed consent process described in policies and procedures. 2. Designated staff members are trained to implement the policies and procedures. 3. Patients are informed about potential benefits, likelihood of successful results and drawbacks to the proposed treatment(s)

30 # STANDARD AND SCORING REQUIRENTS N N/A 4. Patients are informed about possible alternatives to the proposed treatment. 5. Patients are informed about possible results of non treatment. CCC.23 The hospital establishes a process, within the context of existing law and culture, for when others can grant consent. 1. The hospital has a process for when others can grant informed consent. 2. The process respects law, culture, and custom. 3. Individuals, other than the patient, granting consent and their relationship to the patient are noted in the patient s record. CCC.24 Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures. 1. Consent is obtained before surgical or invasive procedures. 2. Consent is obtained before anesthesia and moderate or deep sedation. 3. Consent is obtained before the use of blood and blood products. 4. Consent is obtained before other high-risk procedures and treatments, and these procedures and treatments are documented and listed in an organizational policy. 5. The list is developed collaboratively by those physicians and others who provide the treatments and perform the procedures. 6. The identity of the individual providing the information to the patient and family is noted in the patient s record. 7. Consent is documented in the patient s record by signature or record of verbal consent. Patient and Family Education CCC.25 The patient s and family s ability to learn, willingness to learn, and barriers to learning are assessed. 1. The patient and family are assessed on: a) the patient s and family s beliefs and values; b) their literacy, educational level, and language; c) emotional barriers and motivations; d) physical and cognitive limitations; and e) the patient s willingness to receive information. 2. The assessment findings are documented and used to plan the education. 3. There is a uniform process for recording patient education information

31 # STANDARD AND SCORING REQUIRENTS N N/A CCC.26 Patient and family education include the following topics, as appropriate to the patient s care: 1. Patients and families learn about how to grant informed consent. 2. Patients and families are educated about the safe and effective use and potential side effects of their medications. 3. Patients and families are educated about the safe and effective use of medical equipment. 4. Patients and families are educated about preventing interactions between prescribed medications and other medications (including over-the-counter preparations) and food. 5. Patients and families are educated about appropriate diet and nutrition. 6. Patients and families are educated about pain management. 7. Patients and families are educated about rehabilitation techniques. CCC.27 Education methods allow sufficient interaction among the patient, family, and staff for learning to occur. CCC Interaction among staff, the patient, and family is documented and indicates the information shared and the level of understanding. 2. Those who provide education encourage patients and their families to ask questions and speak up as active participants. 3. Verbal information is reinforced with written material as appropriate to the patient s needs and learning preferences. Health professionals caring for the patient collaborate to provide and document education. 1. Patient and family education is provided collaboratively. 2. Those who provide education have the subject knowledge to do so. 3. Those who provide education have adequate time to do so. 4. Those who provide education have the communication skills to do so. TOTAL PERCENT OF COPLIANCE

32

33 High Risk Care Processes (HRC)

34

35 IV. High Risk Care Processes (HRC) A hospital s main purpose is patient care. Providing the most appropriate care in a setting that supports and responds to each patient s unique needs requires a high level of planning and coordination. This chapter focuses on the high risk processes of care. Certain activities are basic to all patient care. For all disciplines that care for patients, these activities include: planning and delivering care to each patient; monitoring the patient to understand the results of the care; modifying care when necessary; completing the care; and planning the follow-up. any physicians, nurses, pharmacists, rehabilitation therapists, and other types of health care providers carry out these activities. Each provider has a clear role in patient care. That role is determined by licensure, credentials, certification, law, and regulation. An individual s particular skills, knowledge, and experience are defined in medical staff privileging or job description documents. Some care may be carried out by the patient, his or her family, or other trained caregivers

36 # STANDARD AND SCORING REQUIREENTS N N/A Assessment of Patients HRC.1 Care and services are respectful of individuals need for privacy. 1. An individual s need for privacy is respected for all examinations, procedures, and treatments. HRC.2 HRC.3 HRC.4 Each patient s initial assessment(s) include an evaluation of physical, psychological, social, and economic factors, including a physical examination and health history. 1. All inpatients have an initial assessment(s). All assessments are documented. 2. The medical assessment includes a health history and a physical examination consistent with the scope and content defined in hospital policy. 3. Each patient receives an initial psychological assessment. 4. Each patient receives an initial social and economic assessment. 5. The initial assessment(s) results in understanding any previous care and the care the patient is currently seeking. 6. The initial assessment(s) results in an initial diagnosis. 7. The patient s medical and nursing needs are identified from the initial assessments The initial medical and nursing assessment of emergency patients is appropriate to their needs and conditions. 1. For emergency patients, the medical assessment is appropriate to their needs and condition. 2. For emergency patients, the nursing assessment is appropriate to their needs and condition. 3. If emergency surgery is performed, there is, at minimum, a brief note and preoperative diagnosis recorded before surgery. The initial medical and nursing assessments are completed within the first 24 hours after the patient s admission to the hospital or earlier as indicated by the patient s condition. 1. The initial medical assessment is conducted within the first 24 hours of admission as an inpatient or earlier as indicated by the patient s condition. 2. The initial nursing assessment is conducted within the first 24 hours of admission as an inpatient or earlier as indicated by the patient s condition

37 # STANDARD AND SCORING REQUIREENTS N N/A 3. Initial medical assessment(s) conducted prior to admission to the hospital are no older than 30 days or the medical history has been updated and the physical exam repeated. 4. For any assessment less than 30 days old, any significant changes in the patient s condition since the assessment are noted in the patient s record within the first 24 hours of admission. 5. Patients for whom surgery is planned have a medical assessment performed before the surgery and/or anesthesia and it is documented prior to surgery. 6. Those caring for the patient can find and retrieve assessments as needed from the patient s record or other standardized accessible location. HRC.5 Patients are screened for nutritional status and are referred for further assessment and treatment when necessary. 1. Qualified individuals develop criteria to identify patients who require further nutritional assessment. 2. Patients are screened for nutritional risk as part of the initial assessment. 3. Patients at risk for nutritional problems, according to the criteria, receive a nutritional assessment. HRC.6 Patients are screened for functional needs and are referred for further assessment and treatment when necessary. 1. Qualified individuals develop criteria to identify patients who require further functional assessment. 2. Patients are screened for their need for further functional assessment as part of the initial assessment. 3. Patients in need of a functional assessment, according to the criteria, are referred for such an assessment. HRC.7 The hospital conducts individualized initial assessments for special populations cared for by the hospital. 1. The hospital identifies those patient populations, such as pediatric patients, psychiatric patients, older patients, or obstetrical patients for whom the initial assessment process is modified. 2. The hospital identifies those special situations, including dental, hearing and language, that receive individualized assessments

38 # STANDARD AND SCORING REQUIREENTS N N/A HRC.8 The initial assessment includes determining the need for discharge planning. HRC.9 1. There is a process to identify on admission those patients for whom discharge planning is critical. 2. Planning for discharge for these patients begins soon after admission. All patients are screened for pain and assessed when pain is present. 1. All patients are screened for pain on admission. 2. When pain is identified, the patient is referred or a comprehensive assessment is performed, appropriate to the patient s age and measuring pain intensity and quality such as pain character, frequency, location, and duration. 3. The assessment is recorded in a way that facilitates regular reassessment and follow-up according to criteria developed by the organization and the patient s needs. HRC.10 All patients are reassessed at appropriate intervals to determine their response to treatment and to plan for continued treatment or discharge. HRC Patients are reassessed to determine their response to treatment and plan for continued treatment or discharge. 2. A physician reassesses patients daily, including weekends, during the acute phase of their care and treatment. 3. Organization policy defines the circumstances and/or types of patients or patient populations for whom a physician s assessment may be less than daily and identifies the reassessment interval for these patients. 4. Reassessments are documented in the patient s record. Qualified individuals conduct the assessments and reassessments. 1. Individuals qualified to conduct patient assessments and reassessments are identified by the organization. 2. Only those individuals permitted by licensure, applicable laws and regulations, or certification perform patient assessments. 3. Emergency assessments are conducted by individuals qualified to do so

39 # STANDARD AND SCORING REQUIREENTS N N/A 4. Nursing assessments are conducted by individuals qualified to do so. 5. Those qualified to conduct patient assessments and reassessments have their responsibilities defined in writing. HRC.12 edical, nursing, and other individuals and services responsible for patient care collaborate to analyze and integrate patient assessments. HRC.13 HRC Patient assessment data and information are analyzed and integrated. 2. Those responsible for the patient s care participate in the process. 3. Patient needs are prioritized based on assessment results. Care Delivery Policies and procedures and applicable laws and regulations guide the uniform care of all patients. 1. The hospital s leaders collaborate to provide uniform care processes. 2. Policies and procedures guide uniform care and reflect relevant laws and regulations. 3. Uniform care is provided that meets the following requirements: a) Access to and appropriateness of care and treatment do not depend on the patient s ability to pay or the source of payment. b) Access to appropriate care and treatment by qualified practitioners does not depend on the day of the week or time of day. c) Acuity of the patient s condition determines the resources allocated to meet the patient s needs. d) The level of care provided to patients (for example, sedation care) is the same throughout the hospital. e) Patients with the same nursing care needs receive comparable levels of nursing care throughout the hospital. The care provided to each patient is planned and written in the patient s record. 1. The care for each patient is planned by the responsible physician, nurse, and other health professionals within 24 hours of admission to the hospital. 2. The planned care is individualized and based on the patient s initial assessment data

40 # STANDARD AND SCORING REQUIREENTS N N/A 3. The care planned for each patient is written in the patient s record. 4. The planned care is provided. 5. The care provided for each patient is written in the patient s record by the health professional providing the care. 6. The plan is updated or revised, as appropriate, based on the reassessment of the patient by the care providers. HRC.15 Those permitted to write patient orders write the order in the patient record in a uniform location. 1. Orders are written when required, are legible, and follow organization policy 2. Only those permitted to write orders do so. 3. Orders are found in a uniform location in patient records. Provision of High-Risk Services HRC.16 HRC.17 Policies and procedures guide the care of high-risk patients and the provision of high-risk services. 1. Policies and procedures guide: a) the care of emergency patients. b) the care of immune-suppressed patients; c) the use of resuscitation services throughout the organization; d) the handling, use, and administration of blood and blood products; e) the care of patients on life support or who are comatose f) the care of patients with a communicable disease; g) the care of patients on dialysis; h) the use of restraint and the care of patients in restraint; i) the care of elderly patients, disabled individuals, children and populations at risk for abuse; j) the care of patients receiving chemotherapy or other high-risk medications. Food and Nutrition Therapy A variety of food choices, appropriate for the patient s nutritional status and consistent with his or her clinical care, are regularly available. 1. All patients have an order for food in their record. 2. The order is based on the patient s nutritional status and needs

41 # STANDARD AND SCORING REQUIREENTS N N/A 3. Patients have a variety of food choices consistent with their condition and care. 4. When families provide food, they are educated about the patient s diet limitations. HRC.18 Food preparation, handling, storage, and distribution are safe and comply with laws, regulations, and current acceptable practices. 1. Food is prepared in a manner that reduces risk of contamination and spoilage. 2. Food is stored in a manner that reduces risk of contamination and spoilage. 3. Enteral nutrition products are stored according to manufacturer recommendations and organization policy. 4. The distribution of food is timely, and special requests are met. 5. Practices meet applicable laws, regulations, and acceptable practices. Anesthesia, Sedation, and Surgical Care HRC.19 Anesthesia services are available to meet patient needs, and all such services meet applicable local and national standards, laws, regulations, and professional standards. 1. Anesthesia services meet applicable local and national standards, laws, and regulations. 2. Adequate, regular and convenient anesthesia services are available to meet patient needs. 3. Anesthesia services are available for emergencies after normal hours of operation. HRC.20 A qualified individual(s) is responsible for managing the anesthesia services. 1. Anesthesia services are under the direction of one or more qualified individuals. 2. Responsibilities include developing, implementing, and maintaining policies and procedures. 3. Responsibilities include administrative oversight. 4. Responsibilities include maintaining quality control programs. 5. Responsibilities include recommending outside sources of anesthesia services. 6. Responsibilities include monitoring and reviewing all anesthesia services. 7. The individual(s) carries out the responsibilities