jci-amb-care_diagnostic-imaging-centers_standards.pdf

Applicable Standards for Diagnostic Imaging Centers

The following is a list of all standards from the Joint Commission International Accreditation Standards for Ambulatory Care, 4th Edition applicable to Diagnostic Imaging Centers. They are presented here for your convenience without their intent statements or measurable elements. For more information about these standards, please see the Standards, Intents, and Measurable Elements section of the applicable chapters in this document.

Note: This document does not include the Accreditation Participation Requirements (APR) that all JCI-accredited ambulatory care organizations must meet. The APRs can be found in the Joint Commission International Accreditation Standards for Ambulatory Care, 4th Edition.

Standard # Standard

International Patient Safety Goals (IPSG)

IPSG.1 The ambulatory care organization develops and implements a process to improve accuracy of patient identifications. ℗

IPSG.2 The ambulatory care organization develops and implements a process to improve the effectiveness of verbal and/or telephone communication among caregivers. ℗

IPSG.2.1 The ambulatory care organization develops and implements a process for report-ing critical results of diagnostic tests. ℗

IPSG.2.2 The ambulatory care organization develops and implements a process for hando-ver communication. ℗

IPSG.3 The ambulatory care organization develops and implements a process to improve the safety of high-alert medications. ℗

IPSG.5 The ambulatory care organization adopts and implements evidence-based hand-hygiene guidelines to reduce the risk of health care–associated infections. ℗

IPSG.6.1 The ambulatory care organization develops and implements a process to reduce the risk of patient harm resulting from falls for the organization’s patient popula-tion. ℗

Access to Care and Continuity of Care (ACC)

ACC.1 The ambulatory care organization informs the community about its services and how to obtain care and screens patients to identify whether their health care needs match the ambulatory care organization’s mission and resources. ℗

ACC.1.1 Patient flow in the ambulatory care organization is designed to provide efficient care and uniform access based on the needs of the patient. ℗

ACC.2 The ambulatory care organization designs and carries out processes to provide continuity of patient care services in the ambulatory care organization and coordi-nation among health care practitioners. ℗

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ACC.3 There is a qualified individual identified as responsible for the patient’s care. ℗

ACC.5 The ambulatory care organization develops and implements a process to refer patients to other health care practitioners, another level of care, other health care settings, or other organizations to meet their continuing care needs. ℗

ACC.5.1 The ambulatory care organization develops and implements a process to transfer patients to another organization to meet their continuing care needs. ℗

ACC.5.2 Information about the care and services that the patient will need when he or she is referred by the ambulatory care organization is communicated to the patient, family, and continuing care practitioner and/or setting.

ACC.6 Patient education and follow-up instructions are given in a form and language the patient can understand.

ACC.7 The process for referring or transferring the patient evaluates the need for transportation.

Patient and Family Rights (PFR)

PFR.1 The ambulatory care organization is responsible for developing and implementing processes that support patients’ and families’ rights during care. ℗

PFR.1.1 The ambulatory care organization seeks to reduce physical, language, cultural, and other barriers to access and delivery of services.

PFR.1.2 The ambulatory care organization provides care that is respectful of the patient’s dignity, personal values, and beliefs; and the patient’s rights to privacy and confi-dentiality of care and information are respected and protected. ℗

PFR.1.3 Patients are protected from verbal abuse and physical assault, and vulnerable populations are identified and protected from additional risks.

PFR.2 The ambulatory care organization provides care that is respectful of patients’ and families’ personal values and beliefs and supports their rights to participate in the care process. ℗

PFR.2.1 The ambulatory care organization identifies patient and family responsibilities in the care process. ℗

PFR.3 All patients are informed about their rights and responsibilities in a manner and language they can understand.

PFR.4 Patient informed consent is obtained through a process defined by the ambula-tory care organization and carried out by trained staff in a manner and language that the patient can understand. ℗

PFR.4.1 Informed consent is obtained before surgery, anesthesia, procedural sedation, use of blood and blood products, and other high-risk treatments and procedures. ℗

PFR.4.2 Patients and families receive adequate information about the illness, proposed treatment(s), and health care practitioners so that they can make care decisions.

PFR.4.3 The ambulatory care organization establishes a process, within the context of existing law and culture, for when others can grant consent. ℗

Assessment of Patients (AOP)

AOP.1 An initial assessment process is used to identify the health care needs of all patients. ℗

AOP.2 All patients are screened for pain and assessed when pain is present.

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AOP.3 The ambulatory care organization has a process for obtaining findings from rele-vant outside assessments and incorporating them into the organization’s patient assessment process.

AOP.4 There is an established reassessment process for patients requiring additional services or ongoing care. ℗

AOP.5 The time frame for initial assessments and, as appropriate, reassessment is con-sistent with each patient’s needs, organizational policy, and accepted professional guidelines.

AOP.6 Laboratory services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations.

AOP.6.1 A qualified individual(s) is responsible for managing the laboratory services within the ambulatory care organization, and all laboratory staff have the required cre-dentials to administer, perform, and interpret tests. ℗

AOP.6.1.1 A qualified individual is responsible for the oversight and supervision of point-of-care testing in the ambulatory care organization, and testing is performed by trained and competent staff. ℗

AOP.6.2 A laboratory safety program is in place, followed, and documented, and compli-ance with the facility management and infection prevention and control programs is maintained. ℗

AOP.6.2.1 The laboratory uses a coordinated process to reduce the risks of infection as a result of exposure to infectious diseases and biohazardous materials and waste. ℗

AOP.6.3 Laboratory services provided in the organization meet patient and staff needs, are organized with adequate supplies, and provide proper specimen management. ℗

AOP.6.4 All equipment used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities. ℗

AOP.6.5 Quality control procedures for laboratory services are in place, followed, and documented. ℗

AOP.6.5.1 There is a process for proficiency testing of laboratory services. ℗

AOP.6.6 Reference/contract laboratories used by the ambulatory care organization are licensed and accredited or certified by a recognized authority.

AOP.6.6.1 The ambulatory care organization identifies measures for monitoring the quality of the services provided by reference/contract laboratories.

AOP.7 Radiology and diagnostic imaging services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations.

AOP.7.1 A qualified individual(s) is responsible for managing the radiology and diagnostic imaging services. ℗

AOP.7.2 Individuals with proper qualifications and experience perform diagnostic imaging studies, interpret the results, and report the results.

AOP.7.3 A radiation and/or diagnostic imaging safety program for patients, staff, and visitors is in place, followed, and complies with applicable professional standards, laws, and regulations. ℗

AOP.7.4 Radiology and diagnostic imaging study results are available in a timely way as defined by the ambulatory care organization. ℗

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AOP.7.5 All equipment used to conduct radiology and diagnostic imaging studies is reg-ularly inspected, maintained, and calibrated, and appropriate records are main-tained for these activities. ℗

AOP.7.6 Quality control procedures for the radiology and diagnostic imaging services are in place, followed, validated, and documented. ℗

AOP.7.7 The ambulatory care organization regularly reviews quality control results for all outside contracted sources of radiology and diagnostic imaging services.

Care of Patients (COP)

COP.1 The ambulatory care organization provides care and treatment using uniform care processes to all patients that follow applicable laws and regulations. ℗

COP.2.1 Clinical practice guidelines and related clinical pathways and/or clinical protocols as well as other evidence-based recommendations are used to guide patient assessment and treatment and reduce unwanted variation. ℗

COP.3 The care of high-risk patients and the provision of high-risk services are guided by professional practice guidelines, laws, and regulations. ℗

COP.5 Resuscitation services are available throughout the ambulatory care organization.

COP.7 Patients are supported in managing pain effectively. ℗

Anesthesia and Surgery Care (ASC)

ASC.1 Sedation and anesthesia services, if provided by the ambulatory care organiza-tion, meet professional standards and applicable local and national standards, laws, and regulations.

ASC.2 A qualified individual(s) is responsible for managing the sedation and anesthesia services.

ASC.3 The administration of procedural sedation is standardized throughout the ambula-tory care organization. ℗

ASC.3.1 Practitioners responsible for procedural sedation and individuals responsible for monitoring patients receiving sedation are qualified. ℗

ASC.3.2 Procedural sedation is administered and monitored according to professional practice guidelines. ℗

ASC.3.3 The risks, benefits, and alternatives related to procedural sedation are discussed with the patient, his or her family, or those who make decisions for the patient.

Medication Management and Use (MMU)

MMU.1 Medication use in the ambulatory care organization is organized to meet patient needs, is appropriate to the organization’s mission and services, and complies with applicable laws and regulations. ℗

MMU.2 There is a method for overseeing the ambulatory care organization’s medication list, availability of medications, and medication use.

MMU.3 Medications, including emergency medications and medications that require spe-cial handling, are properly and safely stored. ℗

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MMU.4 The ambulatory care organization identifies a current list of medications taken by the patient at home and reviews the list against all new medication prescribed or dispensed in the organization.

MMU.4.1 Medications prescribed and/or administered within the ambulatory care organiza-tion follow standardized processes to ensure patient safety. ℗

MMU.5 Medications are monitored for patient adherence, clinical effectiveness, and adverse medication effects. ℗

MMU.5.1 The ambulatory care organization establishes and implements a process for act-ing on medication errors and near misses. ℗

Patient and Family Education (PFE)

PFE.1 The ambulatory care organization provides education that supports patient and family participation in care decisions and care processes.

PFE.2 Each patient’s educational needs related to immediate and ongoing health care needs are assessed and recorded in his or her medical record.

PFE.2.1 The patient’s and family’s ability to learn and willingness to learn are assessed.

PFE.3 Education methods include the patient’s and family’s values and preferences and allow sufficient interaction among the patient, family, and staff for learning to occur.

PFE.4 Health care practitioners caring for the patient collaborate to provide education and have the knowledge, time, and communication skills to do so.

Quality and Patient Safety (QPS)

QPS.1 The ambulatory care organization’s program for quality and patient safety includes both patient and staff safety and includes the organization’s risk man-agement and quality control activities. ℗

QPS.2 The quality and patient safety program includes the collection, aggregation and analysis of data to support patient care, organization management, and the qual-ity and patient safety program and participation in external databases.

QPS.2.1 Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the ambulatory care organization.

QPS.3 The ambulatory care organization uses an internal process to validate data. ℗

QPS.4 The ambulatory care organization uses a defined process for identifying and managing sentinel events. ℗

QPS.5 Data are always analyzed when undesirable trends and variation are evident from the data. ℗

QPS.6 The ambulatory care organization uses a defined process for the identification and analysis of near-miss events.

QPS.7 An ongoing program of risk management is used to identify and to proactively reduce unanticipated adverse events and other safety risks to patients and staff. ℗

Prevention and Control of Infections (PCI)

PCI.1 One or more individuals oversee all infection prevention and control activities.

This individual(s) is qualified in infection prevention and control practices through education, training, experience, or certification.

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PCI.2 There is a designated coordination mechanism for all infection prevention and control activities that involves physicians, nurses, and others based on the size and complexity of the ambulatory care organization.

PCI.3 The infection prevention and control program is based on current scientific knowl-edge, accepted practice guidelines, applicable laws and regulations, and stan-dards for sanitation and cleanliness.

PCI.4 The ambulatory care organization designs and implements a comprehensive program to reduce the risks of health care–associated infections in patients and staff. ℗

PCI.5 The ambulatory care organization identifies the procedures and processes associ-ated with the risk of infection and implements strategies to reduce infection risk. ℗

PCI.6 The ambulatory care organization reduces the risk of infections associated with medical/surgical/ dental equipment, devices, and supplies by ensuring adequate cleaning, disinfection, sterilization, and storage; and implements a process for managing expired supplies. ℗

PCI.7 The ambulatory care organization develops, implements, and tests strategies to respond to the presentation of global communicable diseases. ℗

PCI.8 The infection prevention and control process is integrated with the ambulatory care organization’s overall program for quality and patient safety program using measures that are epidemiologically important to the organization.

Governance, Leadership, and Direction (GLD)

GLD.1 The structure and authority of the ambulatory care organization’s governing entity are described in bylaws, policies and procedures, or similar documents. ℗

GLD.1.1 The operational responsibilities and accountabilities of the governing entity are described in a written document(s). ℗

GLD.2 A chief executive is responsible for operating the ambulatory care organization and complying with applicable laws and regulations. ℗

GLD.3 Ambulatory care organization leaders are identified and collectively responsible for defining the organization’s mission and creating the programs and policies needed to fulfill the mission.

GLD.4 Ambulatory care organization leaders plan, develop, and implement a quality and patient safety program and communicate quality and patient safety information to the governing entity.

GLD.5 The ambulatory care organization’s leaders prioritize which organization wide clinical and managerial processes and outcomes will be measured and which improvement and patient safety activities will be implemented.

GLD.5.1 The individuals leading the ambulatory care organization’s departments and services improve quality and patient safety by participating in organization wide improvement priorities and monitoring and improving the services specific to the department/service.

GLD.6 Ambulatory care organization leaders are accountable for the review, selection, and monitoring of clinical and nonclinical contracts. ℗

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GLD.6.1 Ambulatory care organization leaders ensure that contracts and other arrange-ments are included as part of the ambulatory care organization’s quality and patient safety program.

GLD.6.2 Ambulatory care organization leaders ensure that independent practitioners not employed by the ambulatory care organization have the right credentials and are privileged for the services that they provide to the organization’s patients. ℗

GLD.7 Ambulatory care organization leaders make decisions related to the purchase or use of resources—human and technical—with an understanding of the quality and safety implications of those decisions.

GLD.7.1 The ambulatory care organization seeks and uses data and information on the safety of the supply chain to protect patients and staff from unstable, contami-nated, defective, and counterfeit supplies.

GLD.8 The ambulatory care organization leaders plan and implement a professional staff structure to support their responsibilities and authority. ℗

GLD.9 The ambulatory care organization establishes a framework for ethical manage-ment that promotes a culture of ethical practices and decision making to ensure that patient care is provided within business, financial, ethical, and legal norms and protects patients and their rights. ℗

GLD.9.1 The ambulatory care organization’s framework for ethical management addresses operational and business conduct, including disclosure of ownership and any conflicts of interest, and honestly portraying its services to patients. ℗

GLD.10 Ambulatory care organization leaders create and support a culture of safety throughout the organization. ℗

GLD.11 Health professional education, when provided within the ambulatory care organi-zation, is guided by the educational parameters defined by the sponsoring aca-demic program and the ambulatory care organization’s leaders.

GLD.12 Human subjects research, when conducted within the ambulatory care organiza-tion, is guided by laws, regulations, and organization leaders. ℗

GLD.13 The ambulatory care organization has a committee or another way to oversee all research in the ambulatory care organization involving human subjects. ℗

Facility Management and Safety (FMS)

FMS.1 The ambulatory care organization assigns an individual(s) to manage the organi-zation’s facility management program and ensures compliance with relevant laws, regulations, building and fire safety codes, and facility inspection requirements.

FMS.2 When planning for demolition, construction, or renovation, the ambulatory care organization conducts a preconstruction risk assessment. ℗

FMS.3 The ambulatory care organization plans and implements a program to provide a safe physical facility through inspection and planning to reduce risks. ℗

FMS.3.1 The ambulatory care organization plans and implements a program to provide a secure environment for patients, families, staff, and visitors. ℗

FMS.4 The ambulatory care organization has a program for the inventory, handling, stor-age, use, control, and disposal of hazardous materials and waste. ℗

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FMS.6 The ambulatory care organization establishes and implements a program for the prevention, early detection, suppression, abatement, and safe exit from the facil-ity in response to fires and nonfire emergencies. ℗

FMS.6.1 The fire safety program includes limiting smoking by staff and patients to desig-nated non–patient care areas of the facility. ℗

FMS.6.1.1 The fire safety program includes limiting smoking by staff and patients to desig-nated non–patient care areas of the facility. ℗

FMS.7 The ambulatory care organization establishes and implements a program for inspecting, testing, and maintaining medical equipment. ℗

FMS.8 The ambulatory care organization establishes and implements a program to ensure that utility systems are inspected, tested, maintained, and improved. ℗

FMS.8.1 The ambulatory care organization has emergency processes to protect facility occupants in the event of power failure or interruption and water contamination. ℗

FMS.9 The ambulatory care organization educates and trains all staff members about their roles in providing a safe and effective patient care facility.

Staff Qualification and Education (SQE)

SQE.1 The ambulatory care organization develops a staffing plan that identifies the number of staff and defines the desired education, skills, knowledge, and other requirements of all staff members needed to meet the ambulatory care organiza-tion’s mission and provide safe patient care.

SQE.1.1 Each staff member’s responsibilities are defined in a current job description. ℗

SQE.2 The ambulatory care organization uses a defined process to ensure that clinical and nonclinical staff knowledge and skills are consistent with the requirements of the position.

SQE.3 All new clinical and nonclinical staff members are oriented to the ambulatory care organization and to their specific job responsibilities.

SQE.4 The competence to carry out job responsibilities to meet patient need is continu-ally assessed, maintained, improved, and documented for each staff member. ℗

SQE.5 Each staff member receives ongoing in-service and other education and training to maintain or to advance his or her skills and knowledge.

SQE.6 The ambulatory care organization develops and implements a staff health and safety program. ℗

SQE.7 The ambulatory care organization has a uniform process to gather, verify, and evaluate the credentials (education, licensure/registration, and other credentials) of those medical staff members permitted to provide patient care without supervi-sion. ℗

SQE.8 The ambulatory care organization has a standardized, objective, evidence-based procedure to authorize medical staff members to treat patients and/or to provide other clinical services consistent with their qualifications. ℗

SQE.9 The ambulatory care organization uses an ongoing standardized process to evaluate the quality and safety of the patient care provided by each medical staff member and uses this information to continue clinical privileges with or without modification. ℗

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SQE.10 The ambulatory care organization has a uniform process to gather, to verify, and to evaluate the nursing staff’s credentials (license, education, training, and expe-rience). ℗

SQE.11 The ambulatory care organization has a uniform process to gather, to verify, and to evaluate other health care practitioners’ credentials (license, education, train-ing, and experience). ℗

Management of Information (MOI)

MOI.1 The ambulatory care organization meets the information needs of all those who provide clinical services, those who manage the organization, and those outside the organization who require data and information from the ambulatory care organization.

MOI.2 Confidentiality, security, and integrity of data and information are maintained. ℗

MOI.3 The ambulatory care organization determines the retention time of records, data, and information. ℗

MOI.4 The ambulatory care organization uses standardized diagnosis and procedure codes and ensures the uniform use of approved symbols and abbreviations across the organization.

MOI.5 Records and information are protected against loss, destruction, tampering, and unauthorized access or use. ℗

MOI.6 Written documents, including policies, procedures, and programs, are managed in a consistent and uniform manner. ℗

MOI.6.1 The policies, procedures, programs, and other documents that guide consistent and uniform clinical and nonclinical processes and practices are fully imple-mented. ℗

MOI.7 The ambulatory care organization initiates and maintains a standardized medical record for every patient assessed or treated and determines the record’s content, format, and location of entries. ℗

MOI.7.1 The medical record contains sufficient information to identify the patient, sup-port the diagnosis, justify the treatment, and document the course and results of treatment.

MOI.8 The ambulatory care organization identifies those authorized to have access to and make entries in patient medical records. ℗

MOI.9 The ambulatory care organization has a process to address the proper use of the copy-and-paste, auto-fill, and auto-correct functions when electronic medical records are used. ℗

MOI.10 As part of its monitoring and performance improvement activities, the ambulatory care organization regularly assesses the content, completeness, and legibility of patient medical records.

MOI.11 Health information technology systems are assessed and tested prior to imple-mentation within the ambulatory care organization and evaluated for quality and patient safety following implementation.

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MOI.12 When electronic communication, such as mobile devices, e-mail, or patient-facing portals, are used for exchanging patient information, the ambulatory care orga-nization adopts guidelines to ensure quality of patient care and to ensure that security and confidentiality of information are maintained. ℗

MOI.13 The ambulatory care organization develops, maintains, and tests a program for response to planned and unplanned downtime of data systems. ℗