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

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 Ambulatory Care. 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

FOREWORD The Health Authority Abu Dhabi is very pleased to present these Standards for Ambulatory Care. 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 should be produced in HAAD related to health professionals, public health, facilities licensure and inspections, and drugs and medical devices. Standards for facilities and organizations are 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; physicians, nurses, and allied health professionals are moving across borders to seek better opportunities; - 1 - v

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. - 2 - vi

The standards were developed by HAAD in collaboration with Joint Commission International. - 3-1

ABULATORY CARE STANDARDS Table of Contents I. Introduction... 53 II. Patient Safety and Quality Improvement (PCQ)... 7 International Patient Safety Goals... 8 Quality Improvement... 10 Design of Clinical & anagerial Processes... 11 Data Collection... 12 Analysis of onitoring Data... 12 Sustained Improvement... 14 III. Communication (CCC)... 15 17 Access... 16 18 Providing Continuity of Services... 18 20 Transfer for Continuing Care... 19 21 Informed Consent... 20 22 Patient and Family Education... 22 24 IV. High Risk Care Processes (HRC)... 24 29 The Assessment Process... 25 30 Care Delivery... 28 33 Care of High-Risk or Complex Patients... 29 34 Sedation, Anesthesia, and Surgery... 30 35 edication Use... 32 37 Infection Control... 35 40 anagement of the Infection Control Program... 36 41 V. Leadership (LDS)... 38 45 Governance of the Organization... 39 46 Leaders of the Organization... 39 46 Directors and Senior anagement... 41 48 Staff Qualifications and Education... 42 49 Staffing... 44 50 Orientation and Education... 45 52 edical Staff... 47 54 Nursing Staff... 49 56 Other Professional Staff... 50 57 VI. Facility Safety (FSE)... 52 61 Leadership and Planning... 53 62 Physical Environment... 53 62 Security... 54 63 Fire Safety... 54 63 Community Planning and Participation... 55 64 Hazardous aterials... 56 65 Equipment and Utility Testing and onitoring... 56 65-4 - 2

ABULATORY CARE STANDARDS ANUAL I. Introduction These standards address the care of individuals in ambulatory care environments. They are organized around the important functions necessary for the provision of safe, high-quality care in a wide range of settings from ambulatory surgery centers to dialysis facilities to outpatient clinics. The standards are applicable to a variety of service models, including organizations that provide acute minor illness care, outpatient chronic care management, or even a broad array of medical and surgical services in free-standing facilities. Providing excellent patient care requires effective leadership. That leadership comes from many sources in an ambulatory organization, including governing leaders and others who hold positions of leadership, responsibility, and trust. Each ambulatory organization must identify these individuals and involve them in ensuring that the organization is an effective, efficient resource for the community and its patients. In particular, these leaders must identify the ambulatory organization s mission and make sure that the resources needed to fulfill this mission are available. For many ambulatory organizations, this does not mean adding new resources, but more efficiently using current resources, even when they are scarce. Also, leaders must work together well to coordinate and integrate all activities, including those designed to improve patient care and clinical services. Effective leadership begins with understanding the various responsibilities and authority of individuals and how these individuals work together. Those who govern, manage, and lead have both authority and responsibility. Collectively and individually, they are responsible for complying with law and regulation and for meeting the ambulatory organization s responsibility to the patient population served. Laws, regulations, and inspections by local authorities determine in large part how a facility is designed, used, and maintained. All ambulatory organizations, regardless of size and resources, must comply with these requirements as part of their responsibilities to their patients, families, staff, and visitors. 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. - 5-3

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-for-purpose 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 an organization was accredited through JCI under the appropriate applicable standards, this would be accepted for the initial HAAD licensure. 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. - 6-4

Patient Safety and Quality Improvement (PCQ)

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. 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 organization, overseen by a quality improvement and patient safety oversight group or committee. - 7-57

REQUIREENTS International Patient Safety Goals PCQ.1 Goal 1 Identify Patients Correctly The organization develops an approach to improve accuracy of patient identifications. easurable Elements: 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 organization develops an approach to improve the effectiveness of communication among caregivers. easurable Elements: 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 organization develops an approach to improve the safety of high-alert medications. easurable Elements: 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. N N/A - 8-8

REQUIREENTS PCQ.4 Goal 4 Eliminate Wrong-Site, Wrong-Patient, Wrong- Procedure Surgery The organization develops an approach to eliminating wrong-site, wrong-patient, and wrong-procedure surgery. PCQ.5 PCQ.6 easurable Elements: 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 organization uses a clearly understood mark for surgical site identification and involves the patient in the marking process. 3. The organization uses a process to verify that all documents and equipment needed are on hand, correct, and functional prior to the procedure. 4. The organization 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. Goal 5 Reduce the Risk of Healthcare-Associated Infections The organization develops an approach to reduce the risk of health care-acquired infections. easurable Elements: 1. A collaborative process is used to develop policies and/or procedures that address reducing the risk of health care-associated infections. 2. The organization has adopted or adapted currently published and generally accepted hand hygiene guidelines. 3. The organization implements an effective hand hygiene program. Goal 6 Reduce the Risk of Patient Harm Resulting from Falls The organization develops an approach to reduce the risk of patient harm resulting from falls. easurable Elements: 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 organization. 2. The organization 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. N N/A - 9 -

REQUIREENTS 3. easures are implemented to reduce fall risk for those assessed to be at risk. Quality Improvement PCQ.7 PCQ.8 PCQ.9 PCQ.10 Those responsible for governing and leading the organization participate in planning and monitoring a quality improvement and patient safety program. easurable Elements: 1. Those who govern participate in planning and monitoring the quality improvement and patient safety program. 2. Clinical leaders participate to plan and carry out the quality improvement and patient safety program. 3. anagerial leaders participate to plan and carry out the quality improvement and patient safety program. 4. The quality improvement and patient safety program is organization-wide. 5. There is a written plan for the quality improvement and patient safety program. The leaders prioritize which processes should be monitored and which quality improvement and patient safety activities should be carried out. easurable Elements: 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. The leaders provide technological and other support to the quality improvement and patient safety program. easurable Elements: 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 organization s resources, for tracking and comparing monitoring results. The quality improvement and patient safety program is coordinated, and program information is communicated to staff. easurable Elements: 1. The organization s quality improvement and patient safety program is coordinated. 2. Information regarding the organization s quality improvement and patient safety program is communicated to the staff at least quarterly. N N/A - 10-10

REQUIREENTS 3. Both managerial and clinical staff closest to the activities being monitored, studied, or improved, participate in quality improvement and patient safety activities. PCQ.11 All staff members are trained to participate in the program. easurable Elements: 1. There is a training program for staff that is consistent with their role in the quality improvement and patient safety program. 2. A knowledgeable individual provides the training. 3. Staff members are permitted to participate in the training as part of their work assignment. Design of Clinical & anagerial Processes PCQ.12 The organization designs new and modified systems and processes according to quality improvement principles. easurable Elements: 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 organization 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 available knowledge and skills in the organization; h) uses information from related improvement activities. 3. Indicators are selected and used to measure how well the newly designed or redesigned process operates. N N/A - 11 11 -

PCQ.13 PCQ.14 # STANDARD AND SCORING REQUIREENTS Data Collection The organization s leaders identify key measures (indicators) to monitor the organization s clinical and managerial structures, processes, and outcomes. easurable Elements: 1. Clinical monitoring includes: a)patient assessment; b)laboratory safety and quality control programs; c) radiology safety and quality control programs; d)surgical procedures when provided; e) the use of anesthesia when provided; f) the use of blood and blood products; g)the use of antibiotics and other medications; h)medication errors; i) the availability, content, and use of patient records; j) infection control, surveillance, and reporting; k)the procurement of routinely required supplies and medications essential to meet patient needs; l) reporting of activities as required by law and regulation; m) risk management; n)utilization management; o)patient and family expectations and satisfaction; p)staff expectations and satisfaction; q)patient demographics and clinical diagnoses; r) financial management; s) the surveillance, control, and prevention of events that jeopardize the safety of patients, families, and staff. Analysis of onitoring Data Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the organization. easurable Elements: 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. N N/A - 12-12

REQUIREENTS PCQ.15 The frequency of data analysis is appropriate to the process being studied and meets organization requirements. easurable Elements: 1. The frequency of data analysis is appropriate to the process under study. 2. The frequency of data analysis is at least quarterly. PCQ.16 Data are intensively assessed when significant unexpected events, undesirable trends, and variations occur. easurable Elements: 1. Intense analysis of data takes place when significant adverse levels, patterns, or trends occur. 2. The organization has established which events are significant. Each organization establishes an operational definition of a sentinel event that includes at least: 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; and Wrong site, wrong-procedure, wrong-patient surgery. And any other events as may be required by law or regulation or viewed by the organization as appropriate to add to its list. 3. All events that meet the above definition are assessed by performing a credible root cause analysis within 45 days of the knowledge of the event. 4. When the root cause analysis reveals that system improvements or other actions can prevent or reduce the risk of such sentinel events recurring, the organization redesigns the processes and takes what ever other actions are appropriate to do so. PCQ.17 The analysis process includes comparisons internally, with other organizations when available, and with scientific standards and desirable practices. easurable Elements: 1. Comparisons are made over time within the organization. 2. Comparisons are made with similar organizations when possible, when possible, and with scientific standards and desirable practices. N N/A - 13 13 -

PCQ.18 # STANDARD AND SCORING REQUIREENTS 3. Comparisons are made with known desirable practices. Data are analyzed when undesirable trends and variation are identified. easurable Elements: 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. Sustained Improvement PCQ.19 Improvement in quality is achieved and sustained. easurable Elements: 1. The organization uses a consistent process to plan and implement improvements. 2. The organization 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 procedure. 7. Appropriate staff are educated about the changes when necessary. 8. Data are collected to show sustained improvement. TOTAL PERCENT OF COPLIANCE N N/A - 14-14

Communication (CCC)

III. Communication (CCC) This chapter focuses on the importance of communication in Ambulatory Care Organizations. 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, organizations 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 organization s leaders. Every health care organization must seek to obtain, manage, and use information to improve patient outcomes as well as individual and overall performance. - 15-17

CCC.1 CCC.2 # STANDARD AND SCORING REQUIREENTS Access Patients have access to ambulatory services based on their assessed health care needs and the ambulatory care organization s mission and resources. easurable Elements: 1. Screening is initiated at the point of first contact. 2. Based on screening, the patient is matched with the organization s mission and resources. 3. Patients are accepted only if the organization can provide the necessary services and settings for care. The organization has a process for registering patients for treatment. easurable Elements: 1. Policies and procedures are used to standardize the patient registering process. 2. Staff members are familiar with the policies and procedures and follow them. 3. The policies and procedures address the registering of emergency patients. 4. The policies and procedures address the holding of patients for observation. 5. The policies and procedures address the management of patients when space is not available for the desired CCC.3 CCC.4 service. The organization initiates and maintains a clinical record for every patient assessed or treated. easurable Elements: 1. A clinical record is initiated for every patient assessed or treated by the organization. 2. Patient clinical records are maintained through the use of an identifier unique to the patient. Patient information is confidential and protected from loss or misuse. easurable Elements: 1. The organization respects patient health information as confidential. 2. Policies and procedures to prevent the loss of patient information are implemented. 3. Policies and procedures to prevent the misuse of patient information are implemented. 4. There is a process for patients to grant release of patient information. N N/A - 16-18

REQUIREENTS CCC.5 Patients with urgent or immediate needs are given priority for assessment and treatment. easurable Elements: 1. The organization has established criteria to prioritize patients with immediate needs. 2. Staff members are trained to use the criteria. 3. Patients are prioritized based on the urgency of their needs. CCC.6 The availability of services and timeliness of appointments meets patient needs. easurable Elements: CCC.7 CCC.8 1. There is a process to provide information about the availability of appointments. 2. There is a process to provide information about the timeliness of appointments. 3. There is a process for patients to have timely appointments that meet patient needs. The health care organization provides the following information to patients and appropriate family members or decision makers: information on the proposed care, the expected results of that care, and any expected cost to the patient for the care. easurable Elements: 1. There is a process to provide the patient/family with care and services information at registration. 2. The process includes information on the proposed care. 3. The process includes information on the expected results of care. 4. The process includes information on any expected costs to the patient or family. 5. Patients receive sufficient information to make knowledgeable decisions. All patients are informed about their rights in a manner they can understand. easurable Elements: 1. Each patient receives information about his or her rights and responsibilities. This information can be posted in an easily visible area in a language the patients understand. 2. There is a process to provide this information to patients in a language that the patient understands. N N/A - 17 19 -

REQUIREENTS CCC.9 Diagnostic tests for determining patient needs are completed and used to determine whether the patient should be treated, transferred, or referred. easurable Elements: 1. There is a process to provide the results of diagnostic tests to those responsible for determining if the patient is to be treated, transferred, or referred. Providing Continuity of Services CCC.10 CCC.11 CCC.12 CCC.13 During all phases of care, there is a qualified individual identified as responsible for the patient s care. easurable Elements: 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 patient and family. 4. The individual is known to the hospital s staff. Information about the patient s care and response to care is shared among medical, nursing, and other care providers. easurable Elements: 1. Information exchanged includes the patient s health status. 2. Information exchanged includes a summary of the care provided. 3. Information exchanged includes the patient s progress. 4. When a transfer occurs, the reason for the transfer is communicated. The patient s record(s) is available to the care providers to facilitate the exchange of information. easurable Elements: 1. Policy establishes those care providers who have access to the patient s record. 2. The record(s) is available to those providers. 3. The records are up-to-date to ensure the transfer of the latest information. There is a process to appropriately refer patients to other providers or health care settings for continuing care. easurable Elements: 1. There is an organized process to refer patients. 2. The referral is based on the patient s needs for continuing care. N N/A - 18-20

REQUIREENTS CCC.14 The organization cooperates with health care practitioners and outside agencies to ensure timely and appropriate referrals. easurable Elements: 1. The discharge planning process considers the need for both support services and continuing medical services. 2. The organization becomes familiar with the health care providers in its community. 3. Referrals outside the organization are to specific individuals and agencies in the patient s home community whenever possible. CCC.15 Patients and, as appropriate, their families are given understandable follow-up instructions. easurable Elements: CCC.16 CCC.17 1. Follow-up instructions are provided in an understandable form and manner. 2. The instructions include any return for follow-up care. 3. The instructions include when and how to obtain urgent care. 4. The instructions include relevant health education. 5. Families are also provided the instructions, as appropriate to the patient s condition. 6. Instruction provided to patient and their families are appropriately documented in the medical record. Transfer for Continuing Care There is a process to appropriately transfer patients to another organization to meet their continuing care needs. easurable Elements: 1. There is a process to transfer 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. 4. The process addresses criteria that define when transfer is appropriate. 5. The process addresses who is responsible during transfer. 6. Patients are appropriately transferred to other organizations. The process for referring or transferring the patient considers transportation needs. easurable Elements: 1. The process for referring patients considers transportation needs. N N/A - 19 21 -

REQUIREENTS 2. The process for discharging patients considers transportation needs. 3. Transportation is appropriate to the patient s needs. CCC.18 The organization informs patients and families about their rights and responsibilities related to refusing or discontinuing treatment. easurable Elements: CCC.19 CCC.20 1. The organization informs patients and families about their rights to refuse or discontinue treatment. 2. The organization informs patients about the consequences of their decisions. 3. The organization informs patients and families about their responsibilities related to such decisions. 4. The organization 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. The organization 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. easurable Elements: 1. Patients are aware of their right to voice a complaint and the process to do so. 2. Complaints are reviewed according to the organization s mechanism. 3. Dilemmas that arise during the care process are reviewed according to the organization s mechanism. 4. Policies and procedures identify participants in the process. 5. Policies and procedures identify how the patient and family participate. Informed Consent Patient informed consent is obtained through a process defined by the organization and carried out by trained staff. easurable Elements: 1. The organization has a clearly defined consent process described in policies and procedures. 2. There is a list of those procedures and services that require an informed consent. 3. Designated staff members are trained to implement the policies and procedures. 4. Patients give informed consent consistent with the policies and procedures. N N/A - 20-22

REQUIREENTS CCC.21 Patients and families receive adequate information about the illness, proposed treatment, and care providers so that they can make care decisions. easurable Elements: CCC.22 CCC.23 1. Patients are informed of their condition. 2. Patients are informed about the proposed treatment. 3. Patients are informed about potential benefits and drawbacks to the proposed treatment. 4. Patients are informed about possible alternatives to the proposed treatment. 5. Patients are informed about the likelihood of successful treatment. 6. Patients are informed about possible problems related to recovery. 7. Patients are informed about possible results of nontreatment. 8. When treatments or procedures are planned, patients know who is authorized to perform the procedure or treatment. The organization establishes a process, within the context of existing law and culture, for when others can grant consent. easurable Elements: 1. The organization 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 are noted in the patient s record. Informed consent is obtained before surgery, anesthesia, use of blood and blood products, and other high-risk treatments and procedures. easurable Elements: 1. Consent is obtained before surgical or invasive procedures. 2. Consent is obtained before anesthesia. 3. Consent is obtained before the use of blood and blood products. 4. Consent is obtained before other high-risk procedures and treatments which have been identified and listed in an organizational policy. 5. The identity of the individual providing the information to the patient and family is noted in the patient s record. N N/A 23-21 -

REQUIREENTS Patient and Family Education CCC.24 Each patient s educational needs are assessed and recorded in his or her record. easurable Elements: CCC.25 CCC.26 CCC.27 1. The patient s and family s education needs are assessed. 2. The patient s and family s ability to learn and readiness to learn are assessed. 3. The findings of the assessment are recorded in the patient s record. 4. There is a uniform process for recording patient education information. Each patient and his or her family receive education to help them give informed consent, participate in care processes, and understand any financial implications of care choices. easurable Elements: 1. Patients and families learn about informed consent. 2. Patients and families learn about participation in care decisions. 3. Patients and families learn about participation in the care process. 4. Patients and families learn about any financial implications of care decisions. Education and training help meet patients ongoing health needs. easurable Elements: 1. Patients are referred to these sources when appropriate. 2. The organization identifies and establishes relationships with community resources that support continuing health promotion and disease prevention education. 3. Education resources are organized in an efficient and effective manner. Patient and family education include the following topics, as appropriate to the patient s care. easurable Elements: 1. Patients and families are educated about the safe and effective use of medications and potential side effects of medications. 2. Patients and families are educated about the safe and effective use of medical equipment. N N/A - 22-24

REQUIREENTS 3. Patients and families are educated about the prevention of interactions between medications and food. 4. Patients and families are educated about appropriate diet and nutrition. 5. Patients and families are educated about pain management. 6. Patients and families are educated about rehabilitation techniques. 7. Patients and families are educated about prevention activities related to their condition and treatment (A healthy life style, exercise, smoking, etc.). CCC.28 Education methods consider the patient s and family s values and preferences and allow sufficient interaction among the patient, family, and staff for learning to occur. easurable Elements: CCC.29 CCC.30 1. Education methods are selected on the basis of: 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. Interaction among staff, the patient, and family confirms that the information was understood. The patient and family are taught in a format and language that they understand. easurable Elements: 1. The patient and family are taught in a format they understand. 2. The patient and family are taught in a language they understand. Health professionals caring for the patient collaborate to provide education. easurable Elements: 1. Patient and family education is provided collaboratively and documented. 2. Those who provide education have the knowledge and communication skills to do so. TOTAL PERCENT OF COPLIANCE N N/A - 23 25 -

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Hight Risk Care Processes (HRC)

IV. High Risk Care Processes (HRC) An Ambulatory Care Facility s main purpose is patient care and prevention of illness. Providing the most appropriate care and services 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 ambulatory care and 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 may 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. - 24-29

HRC.1 # STANDARD AND SCORING REQUIREENTS The Assessment Process All patients cared for by the organization have their health care needs identified through an established assessment process. easurable Elements: 1. Organization policy and procedure define the information to be obtained for ambulatory patients. 2. Organization policy and procedure define who performs the assessment. 3. The scope and content of assessments by each discipline are defined in writing. 4. Only those individuals permitted by licensure, applicable laws and regulations, or certification perform the assessments. 5. The assessment activities performed in different HRC.2 settings are defined in writing. Assessment findings are documented in the patient s record and are readily available to those responsible for the patient s care. easurable Elements: 1. Appropriate time frames for performing initial assessments and complete assessments are established for all settings and services. 2. These assessments are completed within the time frames established by the organization and at a minimum by the third visit for a complete assessment. HRC.3 Each patient s initial assessment includes an evaluation of physical, psychological, social, and economic factors, and each complete assessment includes a physical examination and health history. easurable Elements: 1. Each patient receives an initial physical assessment. 2. The complete physical assessment includes a physical exam and health history. 3. Each patient receives an initial psychological assessment. 4. Each patient receives an initial social and economic assessment. 5. The initial assessment results in understanding the care the patient is seeking. 6. The initial assessment results in selecting the best setting for the care. 7. The initial assessment results in an initial diagnosis. N N/A - 25-30

REQUIREENTS 8. The initial assessment results in understanding any previous care. 9. The initial assessment results in the identification of the patient s initial needs. 10. The complete assessment results in the identification of the patient s continuing needs and prevention activities. HRC.4 Pain is assessed in all patients. easurable Elements: 1. All patients are assessed for pain. 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 needs. HRC.5 Patients are screened for nutritional status and are referred for further assessment and treatment when necessary. easurable Elements: HRC.6 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 established criteria receive a nutritional assessment. Patients are screened for functional needs and are referred for further assessment and treatment when necessary. easurable Elements: 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 established criteria are referred for such an assessment. N N/A - 31 26 -

REQUIREENTS HRC.7 The organization conducts individualized assessments for special populations cared for by the organization. easurable Elements: HRC.8 HRC.9 HRC.10 1. The organization identifies those patient populations and special situations for which the initial assessment process is modified, such as pediatric patients, obstetrical patients, geriatric patients, etc. 2. These special patient populations receive individualized assessments. All patients are reassessed at each appointment or at appropriate intervals to determine their response to treatment and to plan for continued treatment or referral. easurable Elements: 1. Patients are reassessed to determine their response to treatment. 2. Patients are reassessed to plan for continued treatment or discharge. 3. A physician reassesses patients at each appointment. 4. Organization policy defines the circumstances or types of patients for which a physician s assessment may be less than each appointment and identifies the reassessment interval for these patients. 5. Patients receiving continued ambulatory care for one year receive a complete physical examination and annually thereafter. 6. Reassessments are documented in the patient s record. The patient s immediate and continuing medical and nursing needs are identified from the assessment process. easurable Elements: 1. 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. 4. The patient and his or her family participate in the decisions about the priority needs to be met. The medical assessment is documented before anesthesia or surgical treatment. easurable Elements: 1. Surgical patients have a medical assessment including a physical examination performed before surgery. 2. The medical assessment of surgical patients is documented before surgery. N N/A - 27-32

REQUIREENTS 3. Surgical patients have the results of pre-surgical diagnostic tests recorded before surgery. 4. Surgical patients have a preoperative diagnosis recorded before surgery. 5. The anesthesia assessment determines if the patient is an appropriate candidate for the planned anesthesia. HRC.11 Qualified individuals conduct the assessments and reassessments. easurable Elements: HRC.12 HRC.13 HRC.14 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. 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. Care Delivery Care is respectful of the patient s need for privacy during examinations and treatments. easurable Elements: 1. A patient s need for privacy is respected for all examinations, procedures, and treatments. The care provided to each patient is planned and written in the patient s record. easurable Elements: 1. The care for each patient is planned. 2. The care planned for each patient is noted in the patient s record. 3. The planned care is provided and documented. 4. Any patient care team meetings or other discussions are noted in the patient s record. 5. The patient s plan of care is modified as the patient s needs change. Each care provider has access to the patient care notes recorded by other care providers, consistent with organization policy. easurable Elements: 1. There is a method for one care provider to have access to the care notes of other providers. 2. The care notes of all providers are timely and are completed at a minimum the day the patient was seen. N N/A 33-28 -

REQUIREENTS HRC.15 Those permitted to write patient orders write the order in the patient record in a uniform location. easurable Elements: HRC.16 1. Orders are legibly written. 2. Only those permitted to write orders do so. 3. Orders are found in a uniform location in patient records. The organization follows applicable laws and regulations regarding retention time and has a policy on the retention time of patient records, data, and other information easurable Elements: 1. The organization follows applicable laws and regulations regarding retention time and has a policy on the retention of patient clinical records and other data and information. 2. The retention process provides expected confidentiality and security. 3. Records, data, and information are destroyed HRC.17 HRC.18 appropriately. Procedures performed are written into the patient s record. easurable Elements: 1. The results of procedures performed are entered into the patient s record. Care of High-Risk or Complex Patients Policies and procedures guide the care of high-risk patients and the provision of high-risk services. easurable Elements: 1. Policies and procedures guide: a) the care of emergency patients; b) the use of resuscitation services throughout the organization; c) the handling, use, and administration of blood and blood products; d) the care of patients with a communicable disease and immunesuppressed patients; e) the care of patients on dialysis; f) the use of restraint and the care of patients in restraint; g) the care of vulnerable elderly patients and of children; h) the care of patients undergoing moderate and deep sedation. N N/A - 29-34

REQUIREENTS 2. Staff members have been trained and use the policies and procedures to guide care. 3. Patients receive care consistent with the policies and procedures. Sedation, Anesthesia, and Surgery HRC.19 Policies and procedures guide the care of patients undergoing moderate and deep sedation. easurable Elements: 1. Sedation policies and procedures identify: a) how planning will occur including the identification of differences between adult and pediatric populations; b) special consent considerations; c) patient monitoring requirements; d) special qualifications or skills of staff involved in sedation process; e) availability and use of specialized equipment. 2. The qualifications of the physician, dentist, or other qualified individual responsible for the patient receiving moderate and deep sedation should be competent in: a) techniques of various modes of sedation; b) appropriate monitoring; c) response to complications; d) use of reversal agents; and e) at least basic life support. 3. The responsible qualified individual conducts a presedation assessment of the patient to ensure the planned sedation and level of sedation is appropriate for the patient. 4. In addition to the physician or dentist, a qualified individual is responsible for providing uninterrupted monitoring of the patient s physiological parameters and assistance in supportive or resuscitation measures. HRC.20 A qualified individual conducts a pre-anesthesia assessment. easurable Elements: 1. A pre-anesthesia assessment is performed for each patient before anesthesia induction. 2. A qualified individual performs the assessment. 3. The anesthesia assessment is recorded before the use of anesthesia. 4. The anesthesia care of each patient is planned based N N/A - 30 35 -