Joint Commission Requirements

The EOP identifies the individuals with the authority to activate the response and recovery phases of the emergency response. The EOP must identify alternative sites for care, treatment, and services that meet the needs of the hospital patients during emergencies. The Joint Commission spells out emergency management related responsibilities in its Emergency Management Standard. 

The Joint Commission reqnires hospitals to conduct an annual review of its planning activities to identify snch changes and support decision making regarding how the hospital responds to emergencies. The hospital must also conduct an annual review of its risks, hazards, and potential anergencies as defined in its HVA. The hospital must conduct an annual review of the objectives and scope of its EOP. The findings must be documented. 

Facilities must conduct exercises to assess EOP appropriateness, adequacy, and the effectiveness. Key areas to evaluate include logistics, human resources, training, policies, procedures, and protocols. Exercises should stress the limits of the plan to support assessment of preparedness and performance. 

The facility must map and document distribution of its utility systems. The facility must also label utility system controls to facilitate partial or complete emergency shutdowns. The facility must also develop written procedures for responding to utility system disruptions. 

Equipment function (diagnosis, care, treatment, or monitoring) 

Clinical nse or application Maintenance requirements Equipment incident history 

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Peroutka JA. Designing drug-usage evaluation to meet Joint Commission requirements. Pharm. Pract. Manage. Q. 1996 16(2) 26-35. 

The Joint Commission requires that two patient identifiers be used to determine the right patient. Most health-care faeilities use the elient s name and date of birth as these identifiers. 

Importance of Core Measures The Joint Commission requires implementation of a series of core measures related to conunon diseases and conditions. 

Surveys can help to define the components of disclosure that matter most to patients and their families (1) disclosure of all harmful errors, (2) an explanation as to why the error occurred, (3) how to minimize the error s effects, and (4) steps the physician and organization will take to prevent recurrences. Full disclosure of an error incorporates these components as weU as acknowledgement of responsibility and an apology by the physician. Many physicians choose their words carefully by failing to clearly explain the error or its effects on the patient s health. Circumstances surrounding an error can become complex. Physicians may not know how much information to disclose and how to explain the error to the patient. Recently developed guidelines should assist physicians with this process. Since 2001, the Joint Commission requires disclosure of unanticipated outcomes of care. In 2006, the National Quality Forum endorsed fuU disclosure of serious unanticipated outcomes as one of its 30 safe practices for healthcare. 

The Joint Commission on Accreditation of Healthcare Organizations standards require a nutrition screening typically within 24 to 72 hours of hospital admission. Patients determined not to be at risk for malnutrition should be reevaluated every 7 to 14 days. Patients determined to be at risk for malnutrition need a nutrition assessment and care plan. 

With Medicare s Hospital Insurance Trust Fund, also known as Medicare Part A, workers make required contributions to the fund while fhey are employed. Upon retirement, workers receive health care benefits. By law, employers and their employees are required to pay equal portions of a payroll tax, which totals 2.9% of earned income.In 1997, almost 90% of the trust fund s income was from payroll taxes. The remaining income was generated from fhe inferesf earned from the trust fund. A beneficiary s Medicare Parf A insurance is limifed to only those hospitals accredited by the Joint Commission on Accreditation for Healthcare Organizations (JCAHO). The JCAHO accreditation standards include explicit and extensive professional pharmacy acfivifies, indirectly supporting professional trends for clinical pracfice (see Chapfer 18). 

The Joint Commission on Accreditation of Healthcare Organizations requires that all patients receive a pain assessment and appropriate pain-relief measures. Various pain scales are available to measure pain in preverbal and verbal children nurses should administer... 

The Joint Commission, which implements standards that must be met for hospitals to receive accreditation, has also established specific HAZMAT guidelines for hospitals. Locate a copy of these guidelines and identify the primary requirements they con-... 

List the Joint Commission and Occupational Safety and ffealth Administration (OSffA) requirements for emergency deparfmenf preparedness for chemical incidents. 

In addition to specialty nursing accreditation bodies, the Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), mandates specific areas in which health care institutions must ensure that employees are prepared. As part of the national emergency preparedness plan, JCAHO (2001) has mandated that all health care institutions be required to design and implement an emergency preparedness plan. In addition, each institution must establish an orientation and education program for staff and must conduct emergency preparedness drills at least twice a year. 

For-profit home infusion providers range from singlesite, private companies to multiple-site, million-dollar companies. All home care providers are licensed by the state and can chose to become accredited by several accrediting bodies (e.g.. Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Accreditation Commission for Health Care, Inc. (ACHC), Community Healthcare Accreditation Program (CHAP)). Accreditation is a requirement for many insurance companies to serve as a provider for their members. 

Laboratory inspection programs assure that the laboratory maintains up-to-date documentation, procedure manuals, qualified personnel, and properly maintained laboratory equipment. Successful laboratory inspections are required to maintain accreditation by the Joint Commission on Health Care Organizations and the HCFA. 

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