Title Page
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Conducted on
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Location
JCI standards Audit Tool Compliance
INTERNATIONAL PATIENT SAFETY GOALS
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Patients are identified using two patient identifiers, not including the use of the patient’s room number and location in the hospital
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Patients are identified before performing diagnostic procedures, providing treatments, and performing other procedures
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The hospital ensures the correct identification of patients in special circumstances, such as the comatose patient or newborn who is not immediately named
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The complete verbal order is documented and read back by the receiver and confirmed by the individual giving the order. national Pat
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The complete telephone order is documented and read back by the receiver and confirmed by the individual giving the order
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The complete test result is documented and read back by the receiver and confirmed by the individual giving the result
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The hospital has defined critical values for each type of diagnostic test
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The hospital has identified by whom and to whom critical results of diagnostic tests are reported
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The hospital has identified what information is documented in the medical record
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Standardized critical content is communicated between health care practitioners during handovers of patient care
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Standardized forms, tools, or methods support a consistent and complete handover process
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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
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The hospital identifies in writing its list of high-alert medications and develops and implements a process for managing these high-alert medications
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The hospital has a list of look-alike/sound-alike medications and develops and implements a process for managing look-alike sound-alike medications
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The process for managing high-alert medications and the process for managing look-alike/sound alike Medications are uniform throughout the hospital
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The hospital has a process that prevents inadvertent administration of concentrated electrolytes
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Concentrated electrolytes are present only in patient care units identified as clinically necessary in the concentrated form
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Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a manner that restricts access and promotes safe use
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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
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The hospital uses an instantly recognizable and unambiguous mark for identifying the surgical/invasive site that is consistent throughout the hospital
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Surgical/invasive site marking is done by the person performing the procedure and involves the patient in the marking process
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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.
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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
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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
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The hospital has adopted current evidence-based hand-hygiene guidelines
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The hospital implements a hand-hygiene program throughout the hospital
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Hand-washing and hand-disinfection procedures are used in accordance with hand-hygiene guidelines throughout the hospital
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The hospital implements a process for assessing all inpatients for fall risk and uses assessment tools/ methods appropriate for the patients being served
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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
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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)
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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
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Patients with emergent, urgent, or immediate needs are given priority for assessment and treatment
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The hospital considers the clinical needs of patients and informs patients when there are unusual delays for diagnostic and/or treatment services
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The hospital has a process for admitting inpatients and for registering outpatients
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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
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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
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The hospital develops a process to manage the flow of patients throughout the hospital
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Admission to departments/wards providing intensive or specialized services is determined by established criteria
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Discharge from departments/wards providing intensive or specialized services is determined by established criteria
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The hospital designs and carries out processes to provide continuity of patient care services in the hospital and coordination among health care practitioners
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During all phases of inpatient care, there is a qualified individual identified as responsible for the patient’s care
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Information related to the patient’s care is transferred with the patient. Discharge, Referral, and Follow-Up
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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
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Patient and family education and instruction are related to the patient’s continuing care needs
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The hospital cooperates with health care practitioners and outside agencies to ensure timely referrals
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The complete discharge summary is prepared for all inpatients
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Patient education and follow-up instructions are given in a form and language the patient can understand
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The medical records of inpatients contain a copy of the discharge summary
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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
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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
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The hospital has a process for the management of patients who leave the hospital against medical advice without notifying hospital staff
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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
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The referring hospital develops a transfer process to ensure that patients are transferred safely
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The receiving organization is given a written summary of the patient’s clinical condition and the interventions provided by the referring hospital
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The transfer process is documented in the patient’s medical record
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The hospital’s transportation services comply with relevant laws and regulations and meet requirements for quality and safe transport
PATIENT AND FAMILY RIGHTS (PFR)
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The hospital is responsible for providing processes that support patients’ and families’ rights during care
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The hospital seeks to reduce physical, language, cultural, and other barriers to access and delivery of services
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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
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The patient’s rights to privacy and confidentiality of care and information are respected
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The hospital takes measures to protect patients’ possessions from theft or loss
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Patients are protected from physical assault, and populations at risk are identified and protected from additional vulnerabilities
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Patients are informed about all aspects of their medical care and treatment and participate in care and treatment decisions
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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
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The hospital supports the patient’s right to assessment and management of pain and respectful compassionate care at the end of life
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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
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All patients are informed about their rights and responsibilities in a manner and language they can understand
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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
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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
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Informed consent is obtained before surgery, anesthesia, procedural sedation, use of blood and blood products, and other high-risk treatments and procedures
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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
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The hospital establishes a process, within the context of existing law and culture, for when others can grant consent
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The hospital informs patients and families about how to choose to donate organs and other tissues
ASSESSMENT OF PATIENTS (AOP)
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All patients cared for by the hospital have their health care needs identified through an assessment process that has been defined by the hospital
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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
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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
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The initial medical and nursing assessments of emergency patients are based on their needs and conditions
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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
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A preoperative medical assessment is documented before anesthesia or surgical treatment and includes the patient’s medical, physical, psychological, social, economic, and discharge needs
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Patients are screened for nutritional status, functional needs, and other special needs and are referred for further assessment and treatment when necessary
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All inpatients and outpatients are screened for pain and assessed when pain is present
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Individualized medical and nursing initial assessments are performed for special populations cared for by the hospital
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Dying patients and their families are assessed and reassessed according to their individualized needs
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The initial assessment includes determining the need for discharge planning
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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
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Qualified individuals conduct the assessments and reassessments
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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)
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Uniform care of all patients is provided and follows applicable laws and regulations
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There is a process to integrate and to coordinate the care provided to each patient
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An individualized plan of care is developed and documented for each patient
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The hospital develops and implements a uniform process for prescribing patient orders
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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
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The care of high-risk patients and the provision of high-risk services are guided by professional practice guidelines, laws, and regulations
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Clinical staff are trained to recognize and respond to changes in a patient’s condition
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Resuscitation services are available throughout the hospital
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Clinical guidelines and procedures are established and implemented for the handling, use, and administration of blood and blood products
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A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical care, is available
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Patients at nutrition risk receive nutrition therapy
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Patients are supported in managing pain effectively
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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
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The hospital’s leadership provides resources to support the organ/tissue transplant program
PATIENT AND FAMILY EDUCATION (PFE)
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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
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The patient’s and family’s ability to learn and willingness to learn are assessed
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Education methods take into account the patient’s and family’s values and preferences and allow sufficient
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interaction among the patient, family, and staff for learning to occur
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Health care practitioners caring for the patient collaborate to provide education
MOI ( Management of Information ) Team 2
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To what extent the hospital leadership and responsible staff member of information management are aware of the requirements of law and regulations ?
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Does the hospital plan and implement process to meet the information needs of those who provide clinical services ?
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Does the hospital store all it.s record and information according to law and regulations ?
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what is the criteria needed to be implemented in planning ?
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what is the hospital process to grant authorized individual access privileges to data and information ?
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What is the next step ( process ) if the hospital monitors are not secured ?
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what is the retention time of the pt medical record and other data information and complies with laws and regulations ?
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what is the policy for discarding medical record ?
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Does the staff are signed confidentiality agreement in each staff member's personal life ?
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what type of coding system you use ?
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what is the hospital monitor use of abbreviations ?and where is the list. ?
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Are there standardized formats for all similar documents ?
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compliance of medical record audit.?
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if there is committee for medical record review?
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do medical record contain adequate information to identify the patient?
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identification of the time of each entry in the patient medical record.
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what is the hospital policy in case of pland shutdown system?
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does it require that all staff members and providers are trained on how to maintain privacy and confidentiality of protective health information.
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does the hospital allow patient data and information to be transmitted through text messaging and how to be secured?
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what are the schedule basis for data backup system ?
