Joint Commission Standards

Joint Commission Standards Applicable to the Provision of Respiratory Care Services In Hospitals

Compiled by:

Karen J. Stewart, MS, RRT
Assistant Administrator, Medicine Services

Charleston Area Medical Center
3200 MacCorkle Ave., SE
Charleston, WV 25304

304-388-4367 e-mail karen.stewart@camc.org

Preface:

This reference was developed to identify standards from the Comprehensive Accreditation Manual for Hospitals: The Official Handbook, (published by the Joint Commission) that are most likely applicable to the provision of respiratory care services in hospitals. Those standards are found in the first column which is labeled “Current Standards” ( as of May 2003 ).

The second column provides a brief comment relating to the standard and/or examples of evidence of compliance with the standard.

This reference is being reorganized into chapters that correspond to the current Accreditation Manual for Hospitals and is currently under construction.

This overview of JCAHO standards does not contain the standards for Governance, Management, Nursing or Medical Staff. Standards for Governance, Management and Nursing are not relevant to the Respiratory Care department. In the Medical Staff standard are the standards for medical directors. This author has not included those areas as they are typically a function of medical staff bylaws and are not the usual responsibility of a respiratory care service

Effective date is May 2003.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations

Section: Patients Rights and Organization Ethics
Section Indicator: RI
Current Standards
RI.1 The hospital addresses ethical issues in providing patient care. Respiratory care services understands how to access the ethics committee by inservice education to the staff.
RI.1.1 The patient’s right to treatment or service is respected and supported. Patients have the right to self determination.
RI.1.2 Patients are involved in all aspects of their care. Patients are educated and understand their respiratory care services.
RI.1.2.1 Informed consent is obtained. Policy and procedures are present for informed consent.
RI 1.2.1.1 All patients asked to participate in a research project are given a description of the expected benefits.
RI 1.2.1.2 All patients asked to participate in a research project are given a description of the potential discomforts and risks.RI 1.2.1.3 All patients asked to participate in a research project are given a description of alternative services that might also prove advantageous to them.
RI 1.2.1.4 All patients asked to participate in a research project are given a full explanation of the procedures to be followed, especially those that are experimental in nature.
RI 1.2.1.5 All patients asked to participate in a research project are told that they may refuse to participate, and that their refusal will not compromise their access to services.
Respiratory care services follows internal review board protocols for all research activities.
RI.1.2.2 The family participates in care decisions. Respiratory care services follow the patient’s Self Determination Act.
RI.1.2.5 The hospital addresses withholding resuscitative services. Respiratory care services follow orders as designated by the do not resuscitation policy.
RI.1.2.6 The hospital addresses forgoing or withdrawing life-sustaining treatment. Respiratory care services follow the patient’s Self Determination Act.
RI 1.2.8 The hospitals addresses care at the end of life. Respiratory cares services following the hospital policies and procedures regarding end of life care.
RI. 1.2.9 Patients have the right to appropriate assessment and management of pain. Respiratory care maintains policies and procedures directing staff to address a patient’s complaint of pain appropriately. This policy may direct the therapist to the other sources and assistance to alleviate pain.
RI 1.3 The hospital demonstrates respect for the following patient needs:RI. 1.3.1 confidentiality

RI. 1.3.2 privacy

RI. 1.3.3 security

Respiratory care services maintain a policy on confidentiality and privacy for a patient that includes instructions on appropriate level of conversation tone. Policies regarding restrictions are followed.
RI. 1.3.4 resolution of complaints Respiratory care services participates in a process to resolve patient complaints and all staff are instructed in the process.
RI. 1.3.5 pastoral care and other spiritual needs Staff in respiratory care services have knowledge in how to assist in obtaining pastoral care services for patients.
RI. 1.3.6 communicationRI 1.3.6.1 When the hospital restricts a patient’s visitors, mail, telephone calls or other forms of communication, the restrictions are evaluated for their therapeutic effectiveness.

RI 1.3.6.1.1 Any restrictions on communication are fully explained to the patient and family and are determined with their participation.

Policies are in place to provide communication assistance when necessary. Policies regarding communication restrictions are followed.
RI 1.4 Each patient receives a written statement of his or her rights. Respiratory care follows the hospital procedure regarding the delivery of patient rights documentation. Note that Out Patients receive similar information.
RI 1.5 The hospital supports the patient’s rights to protective services. In the event that a respiratory therapist learns of a patients need for protective services, the staff should be trained on how to access such services for the patient
RI 1.3 The hospital protects patients and their rights during research, investigation, and clinical trials involving human subjects. The respiratory care service when participating in research, investigation, and clinical trials involving human subjects demonstrates understanding of the patient’s rights and follows established policies and procedures.
RI.3.1 All consent forms address the information specified, in RI.1.2.1.1through RI.1.2.1.5; indicate the name of the person who provided the information and the date the form was signed; and address the participant’s right to privacy, confidentiality, and safety. Policy and procedures are present for informed consent and include all necessary information.
RI. 4. The hospital operates according to a code of ethical behavior.RI 4.1 The code addresses marketing, admission. transfer and discharge and billing practices.

RI.4.2 The code addresses the relationship of the hospital and its staff members to other health care providers, education institutions, and payers

RI 4.3 In hospitals with longer lengths of stay, the code addresses a patient’s rights to perform or refuse to perform tasks in and for the hospital.

RI 4.4 The hospital’s code of ethical business and professional behavior protects the integrity of clinical decision making, regardless of how the hospital compensates or shares financial risk with its leaders, managers, clinical staff and licensed independent practitioners.

Respiratory care services can provide documentation of its’ method to ensure ethical behavior. Staff are appropriately and completely trained. Methods to address staff concerns are included in the training.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations. Reprinted with Permission.

Section: Assessment of Patients
Section Indicator: PE
PE 1 Each patient’s physical, psychological, and social status are assessed. Patient assessment is documented in the patient medical record.
PE 1.1 The scope and intensity of any further assessment are based on the patient diagnosis, the care setting, the patients desire for care, and the patients response to any previous care. When necessary the respiratory care assessment specifically addresses the patient needs and desires.
PE 1.3 Functional status is assessed when warranted by the patient’s needs or condition. Patient assessment is documented in the patient medical record.
PE 1.3.1 All patients referred for rehabilitation services receive a functional assessment. Assessments are in place for all phases of pulmonary rehabilitation.
PE. 1.4. Pain is assessed in all patients Respiratory care maintains policies and procedures directing staff to address a patient’s complaint of pain appropriately. Respiratory Therapists should be familiar with the hospitals pain scoring system.
PE 1.5 Diagnostic testing necessary for determining the patient’s health care needs is performed. Protocols in place and pre-admission, preoperative testing protocols are in place.
PE 1.5.1 When a test report requires clinical interpretation, any relevant clinical information is provided with the request. Policy for documentation of all necessary information needed for patient assessment.
PE 1.6 The need for a discharge planning assessment is determined. There is a process in place for interdisciplinary discharge planning.
PE 1.7 Each admitted patient’s initial assessment is conducted within a time frame specified by hospital policy. Respiratory care shall have a policy or procedure addressing the timeliness of their patient assessment.
PE 1.8.1. Any patient for whom moderate or deep sedation or anesthesia is contemplated receives, pre-sedation or pre-anesthesia assessment. If the respiratory care service is involved in moderate sedation a method is in place to complete a pre sedation assessment.
PE 1.8.3 The patient is reevaluated immediately before moderate or deep sedation use or before anesthesia induction. If the respiratory care service is involved in moderate sedation a method is in place to complete immediate pre sedation reevaluation.
PE 1.9 Possible victims of abuse are identified using criteria developed by the hospital Respiratory care personnel have knowledge of the hospital criteria to identify abuse.
PE 1.10.2 While the patient is under the hospital’s care, all laboratory testing is done in the hospital’s laboratories or approved reference laboratories. Laboratory services provided by the hospital demonstrate evidence of quality and accuracy. If outside testing is performed documentation of medical staff approval is in place.
PE 1.10.2.2 Reference and contract laboratory services meet applicable federal standards for clinical laboratories.Testing methods classified as waived testing under federal law and regulation must be in compliance with PE.1.11 through PE.1.15.2. Compliance with CLIA standards or other regulatory agencies required by each state. Necessary documentation of compliance is present.
PE 1.12 The hospital identifies the staff members responsible for performing and supervising waived testing. Documentation of competencies in testing procedures and reevaluation of continuing competency.
PE. 1.13 Those performing tests have adequate, specific training and orientation to perform the tests, and demonstrate satisfactory levels of competence. Orientation and competency testing.
PE. 1.14 Policies and procedures governing specific testing-related processes are current and readily available. Policy and procedures are in place and available.
PE.1.15 Quality control checks, as defined by the hospital, are conducted on each procedure. Documentation of quality control is ongoing. and current data is available.
PE 1.15.1 At a minimum, manufacturers’ instructions are followed. Instruction manuals are readily available.
PE 1.15.2 Appropriate quality control and test records are maintained. Documentation of Quality control is maintained.
PE.2 Each patient is reassessed at points designated in hospital policy.PE. 2.1 Reassessment occurs at regular intervals in the course of care.

PE.2.2 Reassessment determines a patient’s response to care.

PE .2.3 Significant change in a patient’s condition results in reassessment.

PE.2.4 Significant change in a patient’s diagnosis results in reassessment.

Policy and procedure for reassessment.
PE.3 Staff members integrate the information from various assessments of the patient to identify and assign priorities to his or her care needs.
PE.3.1 Staff members base care decisions on the identified patient needs and care priorities.
Care maps and protocols are in place and have been approved according to hospital policy.
PE .4.1 – The hospital defines the scope of assessment performed by each discipline. Policy and procedures for assessment or assessment responsibilities for each department are defined.
PE.5 The assessment process for an infant, child, or adolescent patient is individualized. Age specific polices are present.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations, Reprinted with Permission.

Section: Care of Patients
Section Indicator: TX
TX.1 Care, treatment, and rehabilitation are planned to ensure that they are appropriate to the patient’s needs and severity of disease, condition, impairment, or disability. Care delivered is appropriate to the patient needs.
TX.1.2 Care is planned and provided in an interdisciplinary, collaborative manner by qualified individuals. The department participates in collaborative efforts in the delivery of patient care.
TX.1.2.1 Patient care procedures (such as bathing) are performed in a manner that respects privacy. Written policy and procedures addressing patient privacy.
TX. 1.3 Patients’ progress is periodically evaluated against care goals and the plan of care and when indicated, the plan or goals are revised. There should be a process of interdisciplinary planning and documentation of patient outcomes, with revision to outcome needs as necessary.
TX 2. Moderate or deep sedation and anesthesia are provided by qualified individuals.TX 2.1 A pre-sedation or pre-anesthesia assessment is preformed before beginning moderate or deep sedation and before anesthesia induction.

TX 2.3 Each patient’s physiological status is monitored during sedation or anesthesia administration.

TX 2.4 The patient’s post procedure status is assessed on admission to and before discharge from the post sedation or post anesthesia recovery area.

TX 2.4.1 Patients are discharged from the post sedation or post anesthesia recovery area and the organization by a qualified licensed independent practitioner or according to criteria approved by the medical staff.

The individual providing sedation at any level meets all regulatory requirements and hospital policies and procedures.An assessment is made prior to beginning moderate or deep sedation. Monitoring during the sedation is documented and meets all standards.
TX.3 Medication use processes are organized and systematic throughout the hospital. The department has policies and procedures dealing with medications and their use.
TX.3.1 The organization identified an appropriate selection of medications available for prescribing or ordering. Medications used in respiratory care are included in the hospital formulary.
TX.3.3 Policies and procedures support safe medication prescription or ordering. Policy and procedures regarding medication dosages and frequency requirements. Caution: if a therapist is to treat more than one patient at a time. Policy and procedure should clearly define the methods used to determine the patient’s ability to self administer medication and the written order should include such instruction from the physician.
TX.3.4 Preparing and dispensing medication(s) adhere to law, regulation, licensure, and professional standards of practice. Policy and procedures in place regarding professional standards for delivery of medications.
TX 3.5.2 Pharmacists review all prescriptions or orders. The respiratory care service has a system in place for pharmacist review of all medication orders.
TX.3.5.5 Emergency medications are consistently available, controlled, and secure in the pharmacy and patient care areas. Policy and procedure on security of medications and availability of medications.
TX.3.6 Prescriptions or orders are verified and patients are identified before medication is administered. Policy and procedure on medication delivery which included patient identification.
TX.3.9 Medication effects on patients are continually monitored. Policy on monitoring any adverse reactions and the necessary staff responsibilities.
TX.5.1 Determining the appropriateness of a procedure for each patient is based, in part, on a review of:TX 5.1.1 the patient’s history.

TX 5.1.2 the patient’s physical status
TX.5.1.3 diagnostic data.
TX.5.1.4 the risks and benefits of procedures.
TX.5.1.5 the need to administer blood or blood components.

Definition of appropriateness of care and the review of outcomes is in place.
TX.5.2 Before obtaining informed consent, the risks, benefits, and potential complications associated with procedures are discussed with the patient and family.TX 5.2.1 Alternative options are considered Policy and procedure on informed consent and which procedures require signed consent. Patients are presented with alternatives.
TX.6.1 Qualified professionals provide rehabilitation services, consistent with professional licensure laws, regulation, registration, and certification; and implement the rehabilitation plan of care with the patient and his or her family, social network, or support system. Job description and responsibility of the staff performing pulmonary rehabilitation. The written plan of care includes family members and or significant others.
TX.6.1.1 Discharge planning from rehabilitative services is integrated into the functional rehabilitation assessment. Assessment plan includes components of discharge planning.
TX.6.2 Reassessment of the patient receiving rehabilitation is an ongoing process. The program provides for regular and on going reassessment of patients.
TX.6.3 An interdisciplinary rehabilitation plan and goals, developed by qualified professionals, in conjunction with the patient and or his or her family social network or support system, and based on a functional assessment of patient needs, guide the provision of rehabilitative services, appropriate to the patient’s environment. The plan for pulmonary rehabilitative services is individualized to the patients needs based on an assessment of the needs.
6.4 Rehabilitation services are appropriate to the patient’s needs and severity of disease, condition, impairment, or disability. Services are individualized to the patient,s needs.
6.5 Rehabilitation outcomes are restoration, improvement or maintenance of the patient’s optimal level of functioning, selfcare, self-responsibility, independence and quality of life. Policies and procedures address individualized outcome planning.
TX.7 The hospital ensures that special treatment procedures are safely and appropriately used. Policy and procedures regarding appropriateness, contraindications, and indications for special treatment procedures.
TX 7.1.2 Staff are trained and competent to minimize the use of restraints and seclusion, and when their use is indicated to use them safely. Respiratory care staff are trained and competent in the policies regarding restraints.
TX 8 Effective resuscitation services are systematically available throughout the hospital. Policies are in replace defining the responsibility of the respiratory therapist in resuscitation.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations. Reprinted with Permission.

Section: Education
Section Indicator: PF
PF 1 The hospital pans for and supports the provision and coordination of patient education activities. There is a mechanism that is multidisciplinary in nature that addresses patient education need. Example a multidisciplinary education committee, with respiratory care participation.
PF.2 The patient education process is coordinated among appropriate staff or disciplines who are providing care or services. Documented evidence of patient education by discipline is evident. There should be a single location in the medical record that coordinates all patient education activity
PF. 3 The patient receives education and training specific to the patients assessed needs, abilities, learning preferences, and readiness to learn as appropriate to the care and services provided by the hospital Patient education and materials are appropriate for age and ability of the patient.
PF.3.1 Based on assessed needs, the patient is educated about how to safely and effectively use medications according to law and regulation, and the hospital’s scope of services. Documented evidence of patient education materials or teaching on medication and safety issues.
PF.3.3 The hospital assures that the patient is educated about how to safely and effectively use medical equipment or supplies, as appropriate. Documented evidence of patient education materials or teaching on medical equipment usage.
PF. 3.4 Patients are educated about pain and managing pain as part of treatment, as appropriate. Documented evidence of patient education about pain and managing pain. Especially important for respiratory therapists in pulmonary rehab programs.
PF. 3.5 Patients are educated about habilitation or rehabilitation techniques to help them be more functionally independent, as appropriate Documented evidence of patient education materials or teaching on habilitation or rehabilitation techniques.
PF. 3.6 The patient is educated about other resources, and when necessary, how to obtain further care, treatment to meet his or her identified needs. There is documentation of the education of resources available to the patient or instructions on how to obtain follow up care. For respiratory care this is important in the delivery of outpatient services.
PF 3.7 Education includes information about patient responsibilities in the patient’s care.PF 3.8 Education includes self care activities, as appropriate. Education plans include instructions of the patient’s responsibility for self care.
PF.3.9 Discharge instructions are given to the patient and those responsible for providing continuing care. Instructions are made available to all care givers at the time of discharge. Example home ventilator care training includes the training of the non family care givers if known at the time of discharge.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations. Reprinted with Permission.

Section: Continuum of Care
Section Indicator: CC
CC.3. The hospital ensures continuity over time among the care and services provided to a patient. Respiratory care services maintain the necessary information to provide the continuum of services.
CC. 3.1 The hospital provides for coordination of care and services among health professionals and settings. Respiratory care services participate in interdisciplinary planning and documentation to assure coordination of care.Respiratory care services offered by the facility outside the acute care setting will provide coordination between acute and other services.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations. Reprinted with Permission.

Section: Improving Organization Performance
Section Indicator: PI
PI.1.10 The organization collects data to monitor its performance.PI .2.10 Data are systematically aggregated and analyzed.

PI. 2.20 Undesirable patterns or trends in performance are analyzed.

The Respiratory Care Service participates in Performance Improvement. Data is collected to monitor the stability of processes, identify opportunity for improvement and to identify changes that will lead to or sustain improvement. The areas that are studies are selected by analyzing risks, sentinel events and or priorities set by the organization. There are methods in place to determine if changes have results in desired outThere is on ongoing process of performance improvement measurement that addresses existing processes. Processes are reviewed for improvement opportunities or methods in place to sustain the improvement. Example: if monitoring a protocol for appropriate use and there is a decline, efforts are made to correct and return to earlier status.
PI 2.30 Processes for identifying and managing sentinel events are defined and implemented All personnel in the respiratory care service should understand the process for notification of sentinel events.
PI 3.10 Information from analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events. Decisions to change processes that have undergone study are made from the analysis of the data.
PI 3.20 An ongoing, proactive program for identifying and reducing unanticipated adverse events and safety risks to patients is defined and implemented. Safety dialog should occur with the Respiratory Care Staff. An example would be a adding patient safety to each staff meeting discussing lesson learned from near misses or from information obtained in the literature.
PI.5 Improved performance is achieved and sustained. There is documentation of continuous and sustained improvement. Area with degradation of results should be targets for more in depth study.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations, Reprinted with Permission.

Section: Leadership
Section Indicator: LD
LD.1.1 Planning includes defining a mission, a vision, and values for the hospital and creating the strategic, operational, programmatic, and other plans and policies to achieve the mission and vision. Departmental strategic plan, mission, and vision statements.
LD.1.1.1 Planning addresses at least those important patient care and hospital wide functions identified by the chapter titles in this manual. Written documentation of scope of care provided.
L.D. 1.1.3 The hospital plans for the appropriate care of patients under legal or correctional restrictions. Respiratory care staff has knowledge of how to treat forensic patients.
L.D. 1.2 The leaders communicate the hospital’s mission, vision, and plans. Respiratory care staff know and understand the mission , vision and plans of the organization and department.
LD.1.3 The plan(s) includes patient care services based on identified patient needs and is consistent with the hospital’s mission. Patient -driven protocols.
Unit-specific protocols.
Department specific protocols.
LD.1.3.1 The leaders, and, as appropriate, community leaders and the leaders of other organizations, collaborate to design services. Community awareness surveys, community leader involvement.
LD.1.3.2 The design of hospital wide patient care services is appropriate to the scope and level of care required by the patients served. Written scope of care with emphasis on all aspects of care provided.
LD.1.3.3 Services are designed to respond to patient and family needs and expectations. Policy and procedures that are up to date and current with the trends in respiratory care.
LD.1.3.3.1 The leaders are responsible for gathering, assessing, and acting on information regarding patient and family satisfaction with the services provided. Survey results.
Plan for process improvement.
LD.1.3.4 The hospital provides services in a timely manner to meet patients’ needs. System in place to objectively match service demand to staffing levels.
LD.1.3.4.1 Patient care services are provided either directly or through referral, consultation, contractual arrangements, or other agreements. There are written guidelines for consultation, referral, and agreements with outside agencies.
LD.1.4 The planning process provides for setting performance-improvement priorities and identifies how the hospital adjusts priorities in response to unusual or urgent events. Hospital specific performance-improvement plan.
LD.1.5 The leaders develop an annual operating budget and long-term capital expenditure plan, including a strategy to monitor the plan’s implementation. Hospital specific mechanism in place.
LD.1.5.2 The budget review process considers the appropriateness of the hospital’s plan for providing care to meet patient needs. Hospital specific mechanism in place.
LD.1.6 The leaders provide for the uniform performance of patient care processes. Policies, procedures and performance standards must be uniform across the organization. Resources for the patient is based on the acuity of patient.
LD.1.7 The scope of services provided by each department is defined in writing and is approved by the hospital’s administration, medical staff, or both, as appropriate. Written scope of service that should include staffing patterns and ages of patients served.
LD.1.7.1 Each department provides patient care according to its written goals and scope of services. Documented evidence of scope of services is provided.
LD.1.8 The leaders and other relevant personnel collaborate in decision making. There should be a evidence of collaborative efforts such as, team meeting minutes and multi-disciplinary activities.
LD.1.9 The leaders develop programs for recruitment, retention, development, and continuing education of all staff members. Hospital specific documentation on retention and recruitment is in place.
LD.1.9.1 The leaders implement programs to promote staff members’ job-related advancement and educational goals. Educational programs and in-service education documentation present.
LD. 1.10 Clinical Practice Guidelines are used in designing or improving processes Respiratory care processes should have a foundation using Clinical Practice Guidelines. Example: Policies and Procedures site the AARC Clinical Practice Guideline as references.
LD 1.10.1 When clinical practice guidelines are used, the hospital leaders identify criteria for their selection and implementation of clinical practice guidelines There is a process in place for formal adoption of guidelines.
LD. 1.10.2 Appropriate leaders, practitioners, and health care professionals in the hospital review and approve clinical practice guidelines selected for implementation. A process in is place for the review and approval of clinical practice guidelines.
LD.1.10.3 Leaders evaluate outcomes related to the use of clinical practice guidelines and determine indicted refinements to improve pertinent processes. Variances in practice from the clinical practice guideline are reviewed and action is taken to correct the variance. Example: Respiratory care treatments not indicated or contraindicated. A plan is in place to address to correct the variance.
LD.2 Each hospital department has effective leadership. Department leader qualifications and job descriptions.
LD.2.1 Directors integrate their department’s services with the hospital’s primary functions. Continuum of Care is present and evident by multidisciplinary actions.
LD.2.2 Directors coordinate and integrate services within their department and with other departments. Multidisciplinary actions are present and documented in patient care, meeting minutes, process improvement plans, etc.
LD.2.3 Directors develop and implement policies and procedures that guide and support the provision of services. Policy and procedures.
LD.2.4 Directors recommend a sufficient number of qualified and competent persons to provide care. A plan is in place to determine staffing levels and requirements for delivery of Respiratory Care Services.
LD.2.5 Directors determine the qualifications and competence of department personnel who provide patient care services and who are not licensed independent practitioners. Job descriptions, licenses, and competency documentation of employees.
LD.2.6 Directors continuously assess and improve their department’s performance. Patient surveys, staff surveys, and quality improvement transactions.
LD.2.7 Directors maintain appropriate quality control programs. Quality control documentation.
LD.2.8 Directors provide for orientation, in-service training, and continuing education of all persons in the department. Orientation plan, in-service records, and continuing education documentation.
LD.2.9 Directors recommend space and other resources needed by the department. A plan is in place to address resource needs for each department.
LD.2.10 Directors participate in selecting outside sources for needed services. Written quotes and information received from outside vendors.
LD.2.11 Departments that are not medical staff services that provide patient care are directed by one or more qualified professionals. Documentation of the supervisory chain.
LD.2.11.1 Responsibility for administrative direction and clinical direction is defined in writing. Job descriptions and job responsibilities are written.
LD.2.11.2 A qualified professional with appropriate clinical training and experience is responsible for the clinical direction of patient care. Medical director’s job description and responsibilities are defined.
LD.2.11.3 When a department has more than one director, the responsibilities are clearly defined in writing. Job descriptions are clearly written with responsibilities defined for each director role.
LD.3 Patient care services are integrated throughout the hospital. The department demonstrates an integrated approach to the delivery of services through mechanisms such as multi-displinary quality improvement teams or collaborative practices teams. Policies which cover more than one department meet the same standard of care.
LD.3.2 The leaders foster communication and coordination among individuals and departments. The department has a plan of regular communication. Example: Regular staff meetings or team meetings with minutes.
LD.3.3 The leaders communicate with the leaders of health care delivery organizations corporately or functionally related to the hospital. There is a mechanism for communication between departments and to and from different levels of administration.
LD.3.4 All departments develop policies and procedures in collaboration with associated departments. Interdepartmental policy and procedures are present when different disciplines are to perform common tasks.
LD.4 The hospital’s leaders set expectations, develop plans, and manage processes to measure, assess, and improve the quality of the hospital’s governance, management, clinical, and support activities. There is a method of goal development which reflects the goals of the organization. A system should address the measurement of processes and include mechanisms for improvement.
LD.4.1 The leaders understand the approaches to and methods of performance improvement. There is a method of performance improvement in place in each department.
LD.4.2 The leaders adopt an approach to performance improvement. Hospital quality improvement plan is in place and at the department level.
LD.4.3 Leaders ensure that important processes and activities are measured, assessed, and improved systematically throughout the hospital. Quality improvement programs are in place and demonstrate improvement.
LD.4.3.1 All leaders participate in interdisciplinary, interdepartmental performance-improvement activities. Meeting activities and minutes are present from interdisciplinary performance activities.
LD.4.3.2 Relevant information is forwarded to leaders and coordinators of hospital wide performance-improvement activities. Ongoing departmental performance improvement plan.
LD.4.3.3 Responsibility for acting on recommendations generated through performance-improvement activities is assigned and defined in writing. The department develops a plan on how improvement recommendations are implemented.
LD.4.3.4 Leaders ensure that the processes for identifying and managing sentinel events are defined and implemented. All staff are trained in the policy and process of sentinel events.
LD.4.4 The leaders allocate adequate resources for measuring, assessing, and improving the hospital’s performance and for improving safety. The department allows time for the participation of staff in the improvement process and patient safety. Medical and hospital error reduction is part of the patient safety plan
LD.4.4.1 The leaders assign personnel needed to participate in performance-improvement activities and activities to improve patient safety. The department assigns personnel to participate in improvement processes and patient safety activities.
LD.4.4.2 The leaders provide adequate time for personnel to participate in performance- improvement activities and activities to improve patient safety. The department allows time for the participation of staff in the improvement process and patient safety activities.
LD.4.4.3 The leaders provide information systems and data management processes for ongoing performance improvement and improvement in patient safety. Staff who participate in improvement processes and patient safety activities are adequately trained.
LD.4.4.4 The leaders provide for staff training in the basic approaches to and methods of performance improvement and improvement in patient safety. The staff is adequately educated for participation in the performance improvement and patient safety process.
LD.4.5 The leaders measure and assess the effectiveness of their contributions to improving performance and improving patient safety. There is a method to review actions for their impact on improvement and patient safety.
LD. 5 The leaders ensure implementation of an integrated patient safety program throughout the organization.LD 5.1 Leaders ensure that the processes for identifying and managing sentinel events are defined and implemented.

LD 5.2 Leaders that an ongoing, proactive program for identifying risks to patient safety and reducing medical/health care errors is defined and implemented.

All services participate in patient safety activities and are educated in all activities, policies and procedures regarding patient safety as appropriate.
LD 5.3 Leaders ensure that patient safety issues are given high priority and addressed when processes, functions, or services are designed or redesigned When processes are designed or redesigned factors regarding patient safety are analyzed and addressed.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations, Reprinted with Permission.

Section: Management of the Environment of Care
Section Indicator: EC
EC.1.10 The organization manages safety risks. Departmental and hospital specific policy and procedures regarding safe environment and patient safety.
EC.2.10 The organization identifies and manages its security risks. Departmental and hospital specific policy and procedures regarding security.
EC. 3.10 The organization identifies and manages its hazardous materials and waste risks. Departmental and hospital specific policy and procedures regarding hazardous materials and waste utilized within the department and hospital.
EC. 4.10 The organization addresses emergency management. Department specific policy and procedures for CPR responsibilities and the departmental response and duties in emergency preparedness.
EC. 5.10 The organization manages fire safety risks. Department and hospital specific policies and procedures regarding fire.
EC. 6.10 The organization manages medical equipment risks. Department specific policy and procedures concerning equipment usage, equipment malfunctions, and procurement from outside agencies.
EC 6.20 Medical equipment is maintained, tested and inspected. The department has a plan to maintain, test and inspect all equipment on a regular basis.
EC.7.10 The organization manages its utility risks. Departmental and hospital specific policy and procedures regarding utilities. The plan may include bulk medical gas systems.
EC 7.50 The organization maintains, tests and inspects its medical gas and vacuum systems A process is in place for routine maintenance, testing and inspection of the medical gas and vacuum systems.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations, Reprinted with Permission.

Section: Management of Human Resources
Section Indicator: HR
HR.1 The hospital’s leaders define the qualifications and performance expectations for all staff positions. All personnel are trained and oriented with documented evidence of competency completed in all areas of care provided.
All job descriptions are inclusive of job responsibilities and performance expectations are developed.Clinical policies and procedures include qualifications and performance expectations of all staff performing clinical duties.
HR.2 The hospital provides an adequate number of staff members whose qualifications are consistent with job responsibilities. Job responsibilities are defined in the job description and by performance planning documentation.
Evidence of licensure, certification, etc.
HR 2.1 The organization uses data on clinical/ service screening indicators in combination with human resource screening indicators to assess staffing effectiveness. Each department must select at least 4 clinical indicators and compare to human resource indicators to determine if there is a correlation between the two. One example might be pneumonia compared to staff vacancy rate or pneumonia to staff turn over rate.Indicators are:

  • Overtime (HR)
  • Staff vacancy rate (HR)
  • Staff satisfaction (HR)
  • Staff turnover rate (HR
  • Understaffing as compared to organization’s staffing plan (HR)
  • Nursing care hours per patient day (HR)
  • Staff injuries on the job (HR)
  • On-call or per diem use (HR)
  • Sick time (HR)
  • Family complaints (C/S)
  • Patient complaints (C/S)
  • Patient falls (C/S) A
  • Adverse drug event (C/S)
  • Injuries to patients (C/S)
  • Skin breakdown (C/S)
  • Pneumonia (C/S) P
  • Postoperative infections (C/S)
  • Urinary tract infection (C/S)
  • Upper gastrointestinal bleeding (C/S)
  • Shock/cardiac arrest (C/S)
  • Length of stay (C/S)
HR.3 The leaders ensure that the competence of all staff members is assessed, maintained, demonstrated, and improved continually. Continual competency updates are ongoing, competency evaluations and performance documentation is presented on a routine basis or as needed.
HR.3.1 The hospital encourages and supports self-development and learning for all staff. Educational opportunities are provided to all employees.
HR.4 An orientation process provides initial job training and information and assesses the staff’s ability to fulfill specified responsibilities. Written guidelines for orientation are available and competency is assessed with the orientation process. Competency should be observed.
HR.4.2 Ongoing in-service and other education and training maintain and improve staff competence and support interdisciplinary approach to patient care. Inservice records, education certifications, and documentation of training received is present. Education should include issues dealing with medical and hospital errors and their avoidance.
HR.4.3 The hospital regularly collects aggregate data on competence patterns and trends to identify and respond to the staff’s learning needs. Hospital and departmental quality management plans are monitored and data collection is performed. Education survey results.
HR.5 The hospital assesses each staff member’s ability to meet the performance expectations stated in his or her job description. Job standards and performance evaluations.
HR.6 The hospital addresses a staff member’s request not to participate in any aspect of patient care. Organizational policies concerning removal of life support and any other related area that the respiratory care practitioner might be involved.
HR.6.1 The hospital ensures that a patient’s care will not be negatively affected if the hospital grants a staff member’s request not to participate in an aspect of patient care. Organizational policy includes options and procedure for processing staff request.
HR.6.2 Policies and procedures specify those aspects of patient care that might conflict with staff members’ cultural values or religious beliefs. Organizational policy.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations. Reprinted with Permission.

Section: Management of Information
Section Indicator: IM
IM.1 The hospital plans and designs information-management processes to meet internal and external information needs. Hospital wide and department specific system plan regarding design of information management.
IM.2 Confidentiality, security, and integrity of data and information are maintained. Policy on security of information systems and mechanism in place to protect patient information from being manipulation or destroyed.
IM.3 Uniform data definitions and data capture methods are used whenever possible. System configuration policy and procedures.
IM.5 Transmission of data and information is timely and accurate. Financial system report, Physician satisfaction survey results.
IM.5.1 The format and methods for disseminating data and information are standardized, whenever possible. Defined and documented through the hospital information system departments and medical records department.
IM.6 Adequate integration and interpretation capabilities are provided. Hospital definition of information flow and system workings.
IM.7 The hospital defines, captures, analyzes, transforms, transmits, and reports patient Ñspecific data and information related to care processes and outcomes. The department specifies information to be documented as a result of delivering patient care.
IM. 7.1.1 Only authorized individuals make entries in medical records The department specified who can make entries in the medical record. Determination is made whether students can make entry in the official medical record.
IM. 7.4 For patients receiving continuing ambulatory care services, the medical record contains a summary list of diagnoses, conditions procedures, drug allergies, and medications. The department has a policy addressing the contents of the medical record for those patients seen in a series of care. Examples would be patients seen in a Pulmonary Rehab program or those patients receiving regularly scheduled outpatient treatment.
IM. 7.4.1 This list is initiated for each patient by the third visit and maintained there after. Notes in the record should indicate the information was reviewed.
IM. 7.7 Verbal orders of authorized individuals are accepted and transcribes by qualified personnel who are identified by title or category in the medical staff rules and regulations. Rules and regulations for verbal orders at the department level reflect medical staff bylaws and meet all regulatory compliance.
IM. 7.8 Every medical record entry is dated, its author identified and when necessary authenticated. Department policy reflects the standard. In the case of electronic documentation the use of electronic signature is documented.
IM. 7.9 The hospital can quickly assemble and have access to all relevant information from components of a patients record when the patient is admitted or is seen in ambulatory or emergency care. If medical records are kept within the department there is a mechanism for access at all times.
IM. 7.10 Medical records are reviewed on an ongoing basis for completeness and timeliness of information, and action is taken to improve the quality and timeliness of documentation that impacts patient care Medical records such as those for continuing ambulatory care and pulmonary rehab that are kept in the department are checked on a regular basis for completeness.

American Association for Respiratory Care Management Section
JCAHO Guidelines

©Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL: Joint Commission on Accreditation of Healthcare Organizations, Reprinted with Permission.

Section: Surveillance, Prevention, and Control of Infection
Section Indicator: IC
IC.1.10 The organization uses a coordinated process to reduce the risks of endemic and epidemic nosocomial infections in patients and health care workers. Hospital and Department Infection Control policies are inclusive of nosocomial infections.
Orientation includes infection control policy.
IC.4.10 The hospital takes action to prevent or reduce the risk of nosocomial infections in patients, employees, and visitors. Education on Infection Control.
Reviews on methods to reduce infection rates.
IC.6.30 The infection control process includes at least one activity aimed at preventing the transmission of epidemiologically significant infections between patients and staff. Quality management indicator and monitor on reducing the endemic rate of ventilator-associated nosocomial pneumonia.