JCI standards Audit Tool Compliance

INTERNATIONAL PATIENT SAFETY GOALS

Patients are identified using two patient identifiers, not including the use of the patient’s room number and location in the hospital

Patients are identified before performing diagnostic procedures, providing treatments, and performing other procedures

The hospital ensures the correct identification of patients in special circumstances, such as the comatose patient or newborn who is not immediately named

The complete verbal order is documented and read back by the receiver and confirmed by the individual giving the order. national Pat

The complete telephone order is documented and read back by the receiver and confirmed by the individual giving the order

The complete test result is documented and read back by the receiver and confirmed by the individual giving the result

The hospital has defined critical values for each type of diagnostic test

The hospital has identified by whom and to whom critical results of diagnostic tests are reported

The hospital has identified what information is documented in the medical record

Standardized critical content is communicated between health care practitioners during handovers of patient care

Standardized forms, tools, or methods support a consistent and complete handover process

Data from adverse events resulting from handover communications are tracked and used to identify ways in which handovers can be improved, and improvements are implemented

The hospital identifies in writing its list of high-alert medications and develops and implements a process for managing these high-alert medications

The hospital has a list of look-alike/sound-alike medications and develops and implements a process for managing look-alike sound-alike medications

The process for managing high-alert medications and the process for managing look-alike/sound alike Medications are uniform throughout the hospital

The hospital has a process that prevents inadvertent administration of concentrated electrolytes

Concentrated electrolytes are present only in patient care units identified as clinically necessary in the concentrated form

Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that restricts access and promotes safe use

The hospital implements a preoperative verification process through the use of a checklist or other mechanism to document, before the surgical/invasive procedure, that the informed consent is appropriate to the procedure; that the correct patient, correct procedure, and correct site are verified; and that all required documents, blood products, medical equipment, and implantable medical devices are on hand, correct, and functional

The hospital uses an instantly recognizable and unambiguous mark for identifying the surgical/invasive site that is consistent throughout the hospital

Surgical/invasive site marking is done by the person performing the procedure and involves the patient in the marking process

The full team actively participates in a time-out process, which includes a) through c) in the intent, in the area in which the surgical/invasive procedure will be performed, immediately before starting the procedure. Completion of the time-out is documented.

Before the patient leaves the area in which the surgical/invasive procedure was performed, a sign-out process is conducted, which includes at least d) through g) in the intent

When surgical/invasive procedures are performed, including medical and dental procedures done in settings other than the operating theatre, the hospital uses uniform processes to ensure safe surgery

The hospital has adopted current evidence-based hand-hygiene guidelines

The hospital implements a hand-hygiene program throughout the hospital

Hand-washing and hand-disinfection procedures are used in accordance with hand-hygiene guidelines throughout the hospital

The hospital implements a process for assessing all inpatients for fall risk and uses assessment tools/ methods appropriate for the patients being served

The hospital implements a process for the reassessment of inpatients who may become at risk for falls due to a change in condition, or are already at risk for falls based on the documented assessment

Measures and/or interventions to reduce fall risk are implemented for those identified inpatients, situations, and locations within the hospital assessed to be at risk. Patient interventions are documented

Access to Care and Continuity of Care (ACC)

Patients who may be admitted to the hospital or who seek outpatient services are screened to identify if their health care needs match the hospital’s mission and resources

Patients with emergent, urgent, or immediate needs are given priority for assessment and treatment

The hospital considers the clinical needs of patients and informs patients when there are unusual delays for diagnostic and/or treatment services

The hospital has a process for admitting inpatients and for registering outpatients

Patient needs for preventive, palliative, curative, and rehabilitative services are prioritized based on the patient’s condition at the time of admission as an inpatient to the hospital

At admission as an inpatient, the patient and family receive education and orientation to the inpatient ward, information on the proposed care and any expected costs for care, and the expected outcomes of care

The hospital develops a process to manage the flow of patients throughout the hospital

Admission to departments/wards providing intensive or specialized services is determined by established criteria

Discharge from departments/wards providing intensive or specialized services is determined by established criteria

The hospital designs and carries out processes to provide continuity of patient care services in the hospital and coordination among health care practitioners

During all phases of inpatient care, there is a qualified individual identified as responsible for the patient’s care

Information related to the patient’s care is transferred with the patient. Discharge, Referral, and Follow-Up

There is a process for the referral or discharge of patients that is based on the patient’s health status and the need for continuing care or services

Patient and family education and instruction are related to the patient’s continuing care needs

The hospital cooperates with health care practitioners and outside agencies to ensure timely referrals

The complete discharge summary is prepared for all inpatients

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

The medical records of inpatients contain a copy of the discharge summary

The records of outpatients requiring complex care or with complex diagnoses contain profiles of the medical care and are made available to health care practitioners providing care to those patients

The hospital has a process for the management and follow-up of patients who notify hospital staff that they intend to leave against medical advice

The hospital has a process for the management of patients who leave the hospital against medical advice without notifying hospital staff

Patients are transferred to other organizations based on status, the need to meet their continuing care needs, and the ability of the receiving organization to meet patients’ needs

The referring hospital develops a transfer process to ensure that patients are transferred safely

The receiving organization is given a written summary of the patient’s clinical condition and the interventions provided by the referring hospital

The transfer process is documented in the patient’s medical record

The hospital’s transportation services comply with relevant laws and regulations and meet requirements for quality and safe transport

PATIENT AND FAMILY RIGHTS (PFR)

The hospital is responsible for providing processes that support patients’ and families’ rights during care

The hospital seeks to reduce physical, language, cultural, and other barriers to access and delivery of services

The hospital provides care that supports patient dignity, is respectful of the patient’s personal values and beliefs, and responds to requests for spiritual and religious observance

The patient’s rights to privacy and confidentiality of care and information are respected

The hospital takes measures to protect patients’ possessions from theft or loss

Patients are protected from physical assault, and populations at risk are identified and protected from additional vulnerabilities

Patients are informed about all aspects of their medical care and treatment and participate in care and treatment decisions

The hospital informs patients and families about their rights and responsibilities to refuse or discontinue treatment, withhold resuscitative services, and forgo or withdraw life-sustaining treatments

The hospital supports the patient’s right to assessment and management of pain and respectful compassionate care at the end of life

The hospital informs patients and families about its process to receive and to act on complaints, conflicts, and differences of opinion about patient care and the patient’s right to participate in these processes

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

General consent for treatment, if obtained when a patient is admitted as an inpatient or is registered for the first time as an outpatient, is clear in its scope and limits

Patient informed consent is obtained through a process defined by the hospital and carried out by trained staff in a manner and language the patient can understand

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

Patients and families receive adequate information about the patient’s condition, proposed treatment(s) or procedure(s), and health care practitioners so that they can grant consent and make care decisions

The hospital establishes a process, within the context of existing law and culture, for when others can grant consent

The hospital informs patients and families about how to choose to donate organs and other tissues

ASSESSMENT OF PATIENTS (AOP)

All patients cared for by the hospital have their health care needs identified through an assessment process that has been defined by the hospital

Each patient’s initial assessment includes a physical examination and health history as well as an evaluation of psychological, spiritual/cultural (as appropriate), social, and economic factors

The patient’s medical and nursing needs are identified from the initial assessments, which are completed and documented in the medical record within the first 24 hours after admission as an inpatient or earlier as indicated by the patient’s condition

The initial medical and nursing assessments of emergency patients are based on their needs and conditions

The hospital has a process for accepting initial medical assessments conducted in a physician’s private office or other outpatient setting prior to admission or outpatient procedure

A preoperative medical assessment is documented before anesthesia or surgical treatment and includes the patient’s medical, physical, psychological, social, economic, and discharge needs

Patients are screened for nutritional status, functional needs, and other special 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

Individualized medical and nursing initial assessments are performed for special populations cared for by the hospital

Dying patients and their families are assessed and reassessed according to their individualized needs

The initial assessment includes determining the need for discharge planning

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

Qualified individuals conduct the assessments and reassessments

Medical, nursing, and other individuals and services responsible for patient care collaborate to analyze and integrate patient assessments and prioritize the most urgent/important patient care needs

CARE OF PATIENTS (COP)

Uniform care of all patients is provided and follows applicable laws and regulations

There is a process to integrate and to coordinate the care provided to each patient

An individualized plan of care is developed and documented for each patient

The hospital develops and implements a uniform process for prescribing patient orders

Clinical and diagnostic procedures and treatments are carried out and documented as ordered, and the results or outcomes, are recorded in the patient’s medical record

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

Clinical staff are trained to recognize and respond to changes in a patient’s condition

Resuscitation services are available throughout the hospital

Clinical guidelines and procedures are established and implemented for the handling, use, and administration of blood and blood products

A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical care, is available

Patients at nutrition risk receive nutrition therapy

Patients are supported in managing pain effectively

The hospital provides end-of-life care for the dying patient that addresses the needs of the patient and family and optimizes the patient’s comfort and dignity

The hospital’s leadership provides resources to support the organ/tissue transplant program

PATIENT AND FAMILY EDUCATION (PFE)

The hospital provides education that supports patient and family participation in care decisions and care processes. Each patient’s educational needs are assessed and recorded in his or her medical record

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

Education methods take into account the patient’s and family’s values and preferences and allow sufficient

interaction among the patient, family, and staff for learning to occur

Health care practitioners caring for the patient collaborate to provide education

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.