Joint Commission International (JCI)

Requirements Related to Safe Surgery

The following chart shows JCI requirements related to safe surgery, including
handling of tissue specimens. Requirements are listed alphabetically by three-letter
standards code (for example, ACC for standards covering Access to Care and
Continuity of Care).
Note: This list is not all-inclusive. For a complete list of requirements, consult the current JCI
accreditation manual for your program. All JCI requirements are in effect at the time of publication of the Safe
Surgery Guide (October 2010), except the hospital requirements, which are in effect as of January 1, 2011.

Joint Commission International (JCI) Requirements

Standard

Requirement

Applicable to

Access to Care and Continuity of Care (ACC)

ACC.1.1.1

ACC.3
ACC.3.3

ACC.3.4
ACC.3.5

ACC.5.2

Patients with emergent, urgent, or immediate

needs are given priority for assessment and
treatment.
There is a policy guiding the referral or discharge
of patients.
The clinical records of outpatients receiving
continuing care contain a summary of all known
significant diagnoses, drug allergies, current
medications, and any past surgical procedures
and hospitalizations.
Patients and, as appropriate, their families are
given understandable follow-up instructions.
The organization has a process for the
management and follow-up of patients who leave
against medical advice.
The receiving organization, during inter-facility
transfer, is given a written summary of the
patients clinical condition and the interventions
provided by the referring organization.

Hospital

Hospital
Hospital

Hospital
Hospital

Medical Transport

Assessment of Needs (AON)

AON.1

AON.2

AON.2.3

All individuals provided with care and services by

the organization have their needs identified
through an established assessment process.
Each individuals medical, nursing, and general
physical, activity, socialization, functional, and
cognitive needs are assessed.
Initial assessments for special populations are
appropriate to the population.

Care Continuum

Care Continuum

Care Continuum

Joint Commission International (JCI) Requirements Related to Safe Surgery

AON.2.5

AON.3

AON.4

AON.4.3

Individuals are referred for any additional

assessments when the need is identified through
findings from the initial assessment,
reassessments, the individuals need and desire
for services, the individuals response to previous
services, or the setting, and as required by law
and regulation.
All individuals are reassessed at appropriate
intervals to determine their response to care and
services and to plan for continued care and
services or discharge.
Laboratory services are available within a time
frame to meet individual needs, and all such
services meet applicable local and national
standards, laws, and regulations.
Policies and procedures address specific testingrelated processes.

Care Continuum

Care Continuum

Care Continuum

Care Continuum

Assessment of Patients (AOP)

AOP.1

AOP.1.1

AOP.1.2

AOP.1.3

AOP.1.3.1

AOP.1.4
AOP.1.5

AOP.1.5.1
AOP.1.6

AOP.1.7
AOP.1.11

All patients cared for by the organization have

their health care needs identified through an
established assessment process.
The organization has determined the scope and
content of assessments, based on applicable laws
and regulations and professional standards.
Each patients initial assessment(s) includes an
evaluation of physical, psychological, social, and
economic factors, including a physical
examination and health history.
The patients medical and nursing needs are
identified from the initial assessments and
recorded in the clinical record.
The initial medical and nursing assessments of
emergency patients are based on their needs and
conditions.
Assessments are completed in the time frame
prescribed by the organization.
Assessment findings are documented in the
patients record and readily available to those
responsible for the patients care.
The initial medical assessment is documented
before anesthesia or surgical treatment.
Patients are screened for nutritional status and
functional needs and are referred for further
assessment and treatment when necessary.
All inpatients and outpatients are screened for
pain and assessed when pain is present.
The initial assessment includes determining the
need for discharge planning.

Hospital

Hospital

Hospital

Hospital

Hospital

Hospital
Hospital

Hospital
Hospital

Hospital
Hospital

Joint Commission International (JCI) Requirements Related to Safe Surgery

All patients are reassessed at intervals based on
their condition and treatment to determine their
response to treatment and to plan for continued
treatment or discharge.
AOP.3
Qualified individuals conduct the assessments
and reassessments.
AOP.4
Physicians, nurses, and other individuals and
services responsible for patient care collaborate to
analyze and to integrate patient assessments.
AOP.5
Laboratory services are available to meet patient
needs, and all such services meet applicable local
and national standards, laws, and regulations.
AOP.5.3.1
There is a process for reporting critical results of
diagnostic tests.
AOP.5.6
Procedures for collecting, identifying, handling,
safely transporting, and disposing of specimens
are followed.
AOP.6
Radiology and diagnostic imaging services are
available to meet patient needs, and all such
services meet applicable local and national
standards, laws, and regulations.
Anesthesia and Surgical Care (ASC)

Hospital

ASC.1

Hospital

AOP.2

ASC.2

ASC.3
ASC.4
ASC.5
ASC.5.1

ASC.5.2
ASC.6

Anesthesia services (including moderate and

deep sedation) are available to meet patient
needs, and all such services meet applicable local
and national standards, laws, and regulations and
professional standards.
A qualified individual(s) is responsible for
managing the anesthesia services (including
moderate and deep sedation).
Policies and procedures guide the care of patients
undergoing moderate and deep sedation.
A qualified individual conducts a preanesthesia
assessment and preinduction assessment.
Each patients anesthesia care is planned and
documented in the patients record.
The risks, benefits, and alternatives are discussed
with the patient, his or her family, or those who
make decisions for the patient.
The anesthesia used and anesthetic technique
are written in the patient record.
Each patients postanesthesia status is monitored
and documented, and the patient is discharged
from the recovery area by a qualified individual or
by using established criteria.

Hospital
Hospital

Hospital

Hospital
Hospital

Hospital

Hospital

Hospital
Hospital
Hospital
Hospital

Hospital
Hospital

Joint Commission International (JCI) Requirements Related to Safe Surgery

ASC.7

ASC.7.1

ASC.7.2
ASC.7.3

ASC.7.4

Each patients surgical care is planned and

documented based on the results of the
assessment.
The risks, benefits, and alternatives are discussed
with the patient and his or her family or those who
make decisions for the patient.
There is a surgical report or a brief operative note
in the patients record to facilitate continuing care.
Each patients physiological status is continuously
monitored during and immediately after surgery
and written in the patients record.
Patient care after surgery is planned and
documented.

Hospital

Hospital

Hospital
Hospital

Hospital

Exposure to and Transmission of Biologic and Chemical Agents (BCA)

BCA.2
BCA.3

BCA.4

BCA.5

The organization establishes the focus of the

infection prevention and reduction program.
The medical transport organization identifies the
policies and processes associated with the risk of
infection and implements strategies to reduce
infection risk.
Gloves, masks, protective clothing, soap, and
disinfectants are available and used correctly
when required.
The organization has a plan for the inventory,
handling, storage, and use of stocked hazardous
materials and the control and disposal of selfgenerated hazardous materials and waste.

Medical Transport
Medical Transport

Medical Transport

Medical Transport

Care, Services and Support (CAS)

CAS.8.2.2

CAS.8.3

Policies and procedures govern an individuals

self-administration of medications, the control of
medication samples, the use of any medications
brought into the organization by the individual or
his or her family, and the dispensing of
medications at discharge.
Medications are stored, prepared, and dispensed
in a safe and clean environment.

Care Continuum

Care Continuum

Clinical Information Management (CIM)

CIM.3

The program uses standardized diagnosis codes,

procedure codes, symbols, abbreviations,
definitions, and methods for adding
comments/addenda.

Clinical Care
Certification

Joint Commission International (JCI) Requirements Related to Safe Surgery

Care of Patients(COP)
COP.3

COP.4

COP.5
COP.6
COP.6
COP.7
COP.8

Policies and procedures identify and guide the

care of high-risk patients and the provision of
high-risk services.
Policies and procedures identify and guide the
care of high-risk patients and the provision of
high-risk services.
Sedation is provided by qualified individuals.
Patients are supported in managing pain
effectively.
Each patients physiological status is monitored
during and following administration of sedation.
Each patients sedation is documented.
Invasive procedures are based on the results of a
patients assessment.

Hospital

Medical Transport

Medical Transport
Hospital
Medical Transport
Medical Transport
Medical Transport

Development and Control of Policies and Procedures (DCP)

DCP.2
DCP.2.1

DCP.2.2

DCP.4
DCP.5

Procedures for ordering tests are defined in

writing.
Policies and procedures are developed to provide
step-by-step specimen collection protocols for
each type of specimen submitted to the
laboratory.
Policies and procedures are developed to guide
how specimens are accessioned and processed
in the laboratory.
The laboratory develops policies, procedures, and
controls for the postexamination processes.
A written protocol defines the storage and
maintenance requirements for records, including
retained specimens, slides, tissues, and blocks.

Clinical Laboratory
Clinical Laboratory

Clinical Laboratory

Clinical Laboratory
Ambulatory Care,
Clinical Laboratory

Environmental Management and Safety (EMS)

EMS.3

EMS.4.3

EMS.4.4

EMS.4.5

The organization plans and implements a program

to ensure that all individuals, families, staff, and
visitors are safe from fire, smoke, or other
emergencies.
Potable water is available 24 hours a day, 7 days
a week, through regular or alternate sources, to
meet individuals care and services needs in the
organizations environment.
Electrical power is available 24 hours per day, 7
days per week, through regular or alternate
sources, to meet essential care and services
needs in the organizations environment.
The organization has emergency processes to
protect individuals served, families, staff, and
visitors in the event of water or electrical system
disruption within the organizations environment.

Care Continuum

Care Continuum

Care Continuum

Care Continuum

Joint Commission International (JCI) Requirements Related to Safe Surgery

EMS.6

EMS.8

The organization has a plan for the inventory,

handling, storage, and use of hazardous materials
and the control and disposal of hazardous
materials and waste.
Equipment is received and stored appropriately at
organization sites.

Care Continuum

Care Continuum

Facility Management and Safety (FMS)

FMS.2

FMS.2
FMS.2.1

FMS.5

FMS.7

FMS.7.1

FMS.7.2

FMS.10

The organization develops and maintains a written

plan(s) describing the processes to manage risks
to patients, families, visitors, and staff.
The organization plans and implements a program
to manage the physical environment.
The organization inspects for safety and has a
plan to reduce evident risks and provide a safe
physical facility for patients, families, staff, and
visitors.
The organization has a plan for the inventory,
handling, storage, and use of hazardous materials
and the control and disposal of hazardous
materials and waste.
The organization plans and implements a program
to ensure that all occupants are safe from fire,
smoke, or other emergencies in the facility.
The plan includes prevention, early detection,
suppression, abatement, and safe exit from the
facility in response to fires and nonfire
emergencies.
The organization regularly tests its fire and smoke
safety plan, including any devices related to early
detection and suppression, and documents the
results.
Electrical, water, waste, ventilation, medical gas,
and other key systems are regularly inspected,
maintained, and, when appropriate, improved.

Hospital

Medical Transport
Medical Transport

Hospital

Hospital

Hospital

Hospital

Hospital

Governance, Leadership, and Direction (GLD)

GLD.6.1

The organizations framework for ethical

management includes marketing, admissions,
transfer, discharge, and disclosure of ownership
and any business and professional conflicts that
may not be in patients best interests.

Hospital

Human Resource Management (HRM)

HRM.2.2

All staff/practitioners/students/volunteers/contract
workers understand and can demonstrate their
role relative to safety.

Ambulatory Care

Joint Commission International (JCI) Requirements Related to Safe Surgery

Individual and Family Education (IFE)
IFE.1

IFE.3

IFE.3.2
IFE.3.3
IFE.3.5

IFE.3.6

IFE.4

IFE.4.1

Education supports individual and family

participation in care and services decisions and
care and services processes.
Individual and family education includes the
following topics, as appropriate to the individuals
care and services: the safe use of medications,
the safe use of medical equipment, potential
interactions between medications and food,
nutritional guidance, and rehabilitation techniques.
Individual and family education includes
precautions to prevent and control infections.
Individual and family education includes managing
pain as part of treatment.
Individual and family education includes the
identification, handling, and disposal of hazardous
materials and wastes in a safe and sanitary
manner.
Individual and family education includes storage,
handling, and access to medical gases and
related supplies when applicable.
Education methods consider the individuals and
familys values and preferences and allow
sufficient interaction among the individual, family,
and staff for learning to occur.
The individual and family are taught in a format
and language that they understand.

Care Continuum

Care Continuum

Care Continuum
Care Continuum
Care Continuum

Care Continuum

Care Continuum

Care Continuum

Individual and Family Rights (IFR)

IFR.2.4
IFR.3

IFR.8.4

Individuals participate in decisions about transfer

or discharge.
The organization informs individuals and families
about how to choose to donate organs and other
tissues.
Informed consent is obtained before use of blood
and blood products and other high-risk treatments
and procedures.

Care Continuum
Care Continuum

Care Continuum

Infection Control and Facility Safety (IFS)

IFS.4

IFS.5

The infection prevention and control program is

based on current scientific knowledge, accepted
practice guidelines, and applicable law and
regulation.
The ambulatory care organization identifies the
procedures and processes associated with the
risk of infection and implements strategies to
reduce infection risk.

Ambulatory Care

Ambulatory Care

Joint Commission International (JCI) Requirements Related to Safe Surgery

IFS.7

IFS.8

IFS.12

The ambulatory care organizations facility is

designed to provide accessible, efficient, and safe
clinical care in a secure and supportive
environment.
The ambulatory care organization plans and
implements a program to ensure that all
occupants are safe from fire, smoke, or other
emergencies.
The ambulatory care organization has emergency
processes to protect facility occupants in the
event of water or electrical system disruption,
contamination, or failure.

Ambulatory Care

Ambulatory Care

Ambulatory Care

International Patient Safety Goals (IPSG)

ISPG.3

The organization develops an approach to

improve the safety of high-alert medications.

ISPG.4

The organization develops an approach to

ensuring correct-site, correct-procedure, and
correct-patient surgery.

ISPG.5

The organization develops an approach to reduce

the risk of health careassociated infections.

ISPG.6

The organization develops an approach to reduce

the risk of patient harm resulting from falls.

Hospital, Ambulatory
Care, Clinical
Laboratory, Primary
Care, Clinical Care
Program (Certification)
Hospital, Ambulatory
Care, Clinical
Laboratory, Primary
Care, Clinical Care
Program (Certification)
Hospital, Ambulatory
Care, Clinical
Laboratory, Primary
Care
Hospital, Ambulatory
Care, Clinical
Laboratory, Primary
Care, Clinical Care
Program (Certification)

Improvement in Quality and Patient Safety (IQS)

IQS.3

Quality monitoring includes both clinical and

managerial processes and outcomes as selected
by the ambulatory care organizations leaders.

Ambulatory Care

Management of Communication and Information (MCI)

MCI.13

MCI.19.1.1

The organization uses standardized diagnosis

codes, procedure codes, symbols, abbreviations,
and definitions.
The clinical record of every patient receiving
emergency care includes the time of arrival, the
conclusions at termination of treatment, the
patients condition at discharge, and follow-up
care instructions.

Hospital

Hospital

Joint Commission International (JCI) Requirements Related to Safe Surgery

Management and Leadership (MGT)
MGT.1.2.1

MGT.1.2.2

MGT.1.3

MGT.4.1.2
MGT.4.1.3

MGT.4.1.4

MGT.4.2.1

MGT.4.4

MGT.4.7

The laboratory director is responsible for assuring

the consistent performance of contract laboratory
services.
The laboratory director is responsible for assuring
the consistent performance of reference
laboratory services.
The leaders are responsible for providing
adequate resources for the provision of planned
laboratory services.
The leaders assign adequate resources to quality
management and improvement activities.
Leaders communicate the key elements of the
quality management and improvement program to
employees.
The leaders define performance and quality
control activities used to monitor the laboratorys
processes and the systems used to ensure proper
operation and control of these processes.
Quality measurement includes those aspects of
the following that are selected by leaders:
a) The laboratorys safety and infection control
programs
b) The laboratorys quality control programs
c) Preanalytic processes, including
patient preparation;
specimen quality processes (collection, labeling,
preservation, transportation, and rejection); and
completeness of requisitions.
d) Postanalytic processes, including
efficient transfer of information;
timeliness of reporting test results;
adequacy of documentation; and
accuracy of reports.
The frequency of data analysis is appropriate to
the process being studied and meets laboratory
requirements.
Improvement in quality and safety is sustained.

Clinical Laboratory

Clinical Laboratory

Clinical Laboratory

Clinical Laboratory
Clinical Laboratory

Clinical Laboratory

Clinical Laboratory

Clinical Laboratory

Clinical Laboratory

Medication Management and Use (MMU)

MMU.3
MMU.4.3
MMU.5
MMU.5.1

Medications are properly and safely stored.

Medications prescribed and administered are
written in the patients record.
Medications are prepared and dispensed in a safe
and clean environment.
Medication prescriptions or orders are reviewed
for appropriateness.

Hospital
Hospital
Hospital
Hospital

Joint Commission International (JCI) Requirements Related to Safe Surgery

Management of Information (MOI)
MOI.1.8

Standardized diagnosis codes, procedure codes,

symbols, and definitions are used in the
organization.

Care Continuum,
Medical Transport

Organization and Delivery of Services (ODS)

ODS.11

ODS.16

ODS.17

ODS.24.3

ODS.27.1

ODS.28

The primary care center uses standardized

diagnosis codes, procedure codes, symbols,
abbreviations, and definitions.
The primary care center facility is designed to
provide accessible, efficient, and safe clinical care
in a secure and supportive environment.
The primary care center plans and implements a
program to ensure that all occupants are safe
from fire, smoke, or other emergencies in all its
facilities.
All staff/practitioners/students/volunteers/contract
workers understand and can demonstrate their
role relative to safety.
Case findings and identification of
demographically important infections provide
surveillance data and data for reporting, when
appropriate, within the primary care center and to
public health agencies.
The primary care center identifies the procedures
and processes associated with the risk of infection
and implements strategies to reduce infection
risks.

Primary Care

Primary Care

Primary Care

Primary Care

Primary Care

Primary Care

Patient Access and Assessment (PAA)

PAA.1

PAA.2

PAA.3
PAA.4

PAA.8

10

Patients have access to services based on their

identified health care needs and the ambulatory
care organizations mission, resources, and scope
of services.
The ambulatory care organization seeks to reduce
physical, language, cultural, and other barriers to
access and delivery of services.
An initial assessment process is used to identify
the health care needs of all patients.
There is an established reassessment process for
patients requiring additional services or ongoing
care.
Pathology and clinical laboratory services and
consultation are readily available to meet patient
needs.

Ambulatory Care

Ambulatory Care

Ambulatory Care
Ambulatory Care

Ambulatory Care

Joint Commission International (JCI) Requirements Related to Safe Surgery

PAA.8.1

PAA.8.2

Laboratory services provided within the

ambulatory care organization meet applicable
local and national standards, laws, and
regulations; are directed and staffed by qualified
individuals; are organized with adequate supplies;
and have a quality control program.
Current written policies and procedures are
readily available and address, at a minimum
specimen collection;
specimen preservation;
instrument calibration;
quality control and remedial action;
equipment performance evaluation; and
test performance.

Ambulatory Care

Ambulatory Care

Patient Anesthesia and Surgery (PAS)

PAS.1

PAS.2

PAS.3
PAS.4

PAS.5

PAS.6
PAS.7
PAS.7.1
PAS.7.2

PAS.7.3

11

Anesthesia services (which includes general and

major regional anesthesia and moderate and
deep sedation), if provided by the organization,
meet professional standards and applicable local
and national standards, laws, and regulations.
A qualified individual(s) is responsible for
managing the anesthesia services and maintains
policies and procedures that guide the care of
patients undergoing anesthesia or sedation.
Policies and procedures guide the care of patients
undergoing moderate and deep sedation.
Informed consent is obtained before procedural
sedation, anesthesia, surgery, use of blood
products, or other high-risk
procedures/interventions.
The risks, benefits, potential complications, and
options of sedation/anesthesia are discussed with
the patient and, when appropriate, the family or
those who make decisions for the patient.
A qualified individual conducts a presedation/anesthesia assessment.
Each patients anesthesia care is planned and
documented.
The anesthesia used and the anesthetic
technique are documented in the patients record.
Each patients physiological status during
anesthesia administration is continuously
monitored and documented in the patients record.
Each patients postanesthesia status is monitored
and documented, and a qualified individual
discharges the patient using established criteria.

Ambulatory Care

Ambulatory Care

Ambulatory Care
Ambulatory Care

Ambulatory Care

Ambulatory Care
Ambulatory Care
Ambulatory Care
Ambulatory Care

Ambulatory Care

Joint Commission International (JCI) Requirements Related to Safe Surgery

PAS.8

PAS.9

PAS.9.1
PAS.9.2

PAS.9.3

The risks, benefits, potential complications, and

options of surgery/interventions are discussed
with the patient and, when appropriate, the family
or those who make decisions for the patient.
Each patients surgical care is planned and
documented based on the results of the
assessment.
The surgery performed is written in the patient
record.
Each patients physiological status is continuously
monitored during and immediately after surgery
and written in the patients record.
Patient care after surgery is planned and
documented.

Ambulatory Care

Ambulatory Care

Ambulatory Care
Ambulatory Care

Ambulatory Care

Patient Care and Continuity of Care (PCC)

PCC.3

PCC.5

Policies and procedures guide the care of highrisk patients and the provision of high-risk
services.
Medications available within the ambulatory care
organization for dispensing to patients or for
practitioner administration are organized efficiently
and effectively, and use is guided by policies and
procedures.

Ambulatory Care

Ambulatory Care

Prevention and Control of Infections (PCI)

PCI.2
PCI.3

PCI.4
PCI.5
PCI.6

PCI.7.1

PCI.7.2
PCI.7.3
PCI.9

12

The organization establishes the focus of the

infection prevention and reduction program.
The organization identifies the procedures and
processes associated with the risk of infection and
implements strategies to reduce infection risk.
Gloves, masks, soap/gel/rubs, and disinfectants
are available and used correctly when required.
Cultures are obtained from designated sites
associated with recurrent infections.
The organization uses a risk-based approach in
establishing the focus of the health care
associated infection prevention and reduction
program.
The organization reduces the risk of infections by
ensuring adequate equipment cleaning and
sterilization and the proper management of
laundry and linen.
The organization reduces the risk of infections
through proper disposal of waste.
The organization has a policy and procedure on
the disposal of sharps and needles.
Gloves, masks, eye protection, other protective
equipment, soap, and disinfectants are available
and used correctly when required.

Care Continuum
Care Continuum

Care Continuum
Care Continuum
Hospital

Hospital, Primary Care

Hospital
Hospital
Hospital

Joint Commission International (JCI) Requirements Related to Safe Surgery

Patient-Centered Services (PCS)
PCS.8

PCS.9.1

PCS.10.4

PCS.14.1

PCS.15

PCS.17

PCS.17.1

PCS.17.2

The primary care center is responsible for

providing processes that support patient and
family rights during care.
The primary care center lists those categories or
types of treatments and procedures that require
informed consent.
Patients are screened for behavioral health
needs, pain, and nutritional and functional needs,
and they are referred for full assessment,
treatment, and follow-up when indicated.
Medications available within the primary care
center for dispensing to patients or for practitioner
administration are organized efficiently and
effectively, and their use is guided by policies and
procedures.
Food, appropriate for each patient and consistent
with his or her condition, is made available for
patients who require an extended stay in the
primary care center.
Education supports patient and family
participation in care decisions and care
processes.
Education related to a patients immediate and
long-term health needs is recorded in the patients
record, and the patients and familys ability to
learn and willingness to learn are assessed.
Patient and family education include the following
topics, as appropriate to the patients care: health
promotion and disease prevention, the safe use of
medications, the safe use of medical equipment,
potential interactions between medications and
food, nutritional guidance, and rehabilitation
techniques, including ways to reduce falls and
other injuries at home.

Primary Care

Primary Care

Primary Care

Primary Care

Primary Care

Primary Care

Primary Care

Primary Care

Patient and Family Education (PFE)

PFE.1

PFE.1

PFE.1

PFE.1.1

13

The organization provides education that supports

patient and family participation in care decisions
and care processes.
Patient education is focused on patient and, when
appropriate, family participation in care decisions
and care processes.
Education supports patient and family
participation in care decisions and care
processes.
The medical transport provider educates patients
when they refuse treatment or transport or the
medical transport provider declines to treat or
transport them.

Hospital

Ambulatory Care

Medical Transport

Medical Transport

Joint Commission International (JCI) Requirements Related to Safe Surgery

PFE.2

PFE.3

PFE.4

PFE.5

PFE.6

The ambulatory care organization provides patient

and family education related to treatment and
services provided by the organization as well as
the patients immediate and ongoing health
needs.
Education methods incorporate the patients and
family's values and preferences and allow
sufficient interaction among the patient, family,
and staff for learning to occur.
Patient and family education includes the
following topics, related to the patients care: the
safe use of medications, the safe use of medical
equipment, potential interactions between
medications and food, nutritional guidance, pain
management, and rehabilitation techniques.
Education methods include the patients and
familys values and preferences and allow
sufficient interaction among the patient, family,
and staff for learning to occur.
Health professionals caring for the patient
collaborate to provide education.

Ambulatory Care

Ambulatory Care

Hospital

Hospital

Hospital

Patient and Family Rights (PFR)

PFR.2.4
PFR.3

PFR.6.4

PFR.10

PFR.11

The organization supports the patients right to

appropriate assessment and management of pain.
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 patients right to
participate in these processes.
Informed consent is obtained before surgery,
anesthesia, use of blood and blood products, and
other high-risk treatments and procedures.
The organization informs patients and families
about how to choose to donate organs and other
tissues.
The organization provides oversight of the
harvesting and transplantation of organs and
tissues.

Hospital
Medical Transport

Hospital

Hospital

Hospital

Program Leadership and Management (PLM)

PLM.12

PLM.15

14

Facilities where patients receive care maintain

and implement a program to ensure that all
occupants are safe from fire and smoke.
Facilities where patients receive care maintain
and implement a program to ensure that all staff
members receive education and training about
their roles in providing a safe and effective
environment.

Clinical Care Program

(Certification)
Clinical Care Program
(Certification)

Joint Commission International (JCI) Requirements Related to Safe Surgery

Pain Management (PME)
PME.4

Pain assessment and management in the

organization is designed to meet individual needs
and to support the care and services provided.

Care Continuum

Patient Record and Information Flow (PRI)

PRI.7

The ambulatory care organization uses

standardized diagnosis codes, procedure codes,
symbols, definitions, and abbreviations, and limits
the number of abbreviations allowed.

Ambulatory Care

Patient Rights and Responsibilities (PRR)

PRR.1.3

PRR.4.2

Children, disabled individuals, the elderly, and

other populations at risk receive appropriate
protection.
The organization lists those categories or types of
treatments and procedures that require specific
informed consent.

Ambulatory Care

Ambulatory Care

Patient Service Contracts (PSC)

PSC.1

Care, treatment, or services provided through

contractual agreement are provided safely and
effectively.

Ambulatory Care

Quality Control Processes (QCP)

QCP.10

QCP.11.1.1
QCP.11.5.1

QCP.12

QCP.12.2

QCP.12.3

QCP.12.6

15

The laboratory uses written quality control

procedures that provide diagnostic reliability and
patient and staff safety when it uses in vitro
radioisotopes.
A detailed history of a donor is performed prior to
selection for blood donation.
Storage areas used for blood and components are
appropriate for the volume and variety of
components stored.
When performing histocompatibility testing, the
laboratory uses appropriate screening techniques
for donors and recipients.
The laboratory performs HLA serologic typing of
both donor and recipient as appropriate to the
study or individual procedure performed.
Before transplantation is performed, the laboratory
crossmatches potential recipients and donors
using the most reactive and recent sera, as
appropriate to the study or individual procedure
performed.
Storage of records and specimens is addressed.

Clinical Laboratory

Clinical Laboratory
Clinical Laboratory

Clinical Laboratory

Clinical Laboratory

Clinical Laboratory

Clinical Laboratory

Joint Commission International (JCI) Requirements Related to Safe Surgery

Quality Management and Improvement (QMI)
QMI.2

QMI.2.2
QMR.2.4
QMI.3.2

The organizations leaders identify key measures

(indicators) to monitor the organizations clinical,
nonclinical, and managerial structures, processes,
and outcomes as appropriate to the mission, care,
and services provided.
Monitoring includes the effectiveness of the pain
management program.
Monitoring includes the use of antibiotics and
other medications and medication errors.
Monitoring includes invasive procedures.

Care Continuum

Care Continuum
Care Continuum
Medical Transport

Quality Improvement and Patient Safety (QPS)

QPS.3

QPS.3.1

QPS.3.2

QPS.3.3

The organizations leaders identify key measures

in the organizations structures, processes, and
outcomes to be used in the organizationwide
quality improvement and patient safety plan.
The organizations leaders identify key measures
for each of the organizations clinical structures,
processes, and outcomes.
The organizations leaders identify key measures
for each of the organizations managerial
structures, processes, and outcomes.
The organizations leaders identify key measures
for each of the International Patient Safety Goals.

Hospital

Hospital

Hospital

Hospital

Resource Management and Laboratory Environment (RSM)

RSM.4.2
RSM.6

RSM.6.1

RSM.6.3

RSM.7.1
RSM.7.1.1
RSM.7.2

Maintenance and inspection ensure that

equipment is safe.
The laboratory has a plan for inventory, handling,
storage, and use of hazardous materials and the
control and disposal of hazardous waste.
The laboratory uses a coordinated process to
reduce the risks of infection as a result of
exposure to biohazardous materials and waste.
If radioactive materials are used in the laboratory,
there are processes for safe handling and
monitoring of them.
Laboratory leaders address fire safety.
The laboratory conducts fire drills regularly.
Adequate safety devices and equipment are
provided.

Clinical Laboratory
Clinical Laboratory

Clinical Laboratory

Clinical Laboratory

Clinical Laboratory
Clinical Laboratory
Clinical Laboratory

Supporting Self-Management (SSM)

SSM.3

16

The program addresses the patients and, when

appropriate, the familys educational needs.

Clinical Care