Accreditation

Hospitals get new JCAHO requirements, revised patient safety goal

Accreditation Connection, March 7, 2005

What's new

HR.1.20--There are two new elements of performance (EP) tacked on to this standard, which says an organization has to be sure a person's qualifications are in line with job responsibilities. EP 47--Current licensure, certification, or registration are verified from the primary source at time of hire for all care providers who are required by the organization or by law to have them. EP 48--Renewed licensure, certification, or registration is verified from the primary source on expiration for all care providers who are required by the organization or by law to have them.

PI.1.10--A new EP requires organizations to measure the effectiveness of organ procurement, EP 29--Conversion rate data are collected and analyzed to track the effectiveness of organ procurement. Action is taken to improve the conversion rate, whenever possible.

What's revised

Goal #2b--The prohibited abbreviations list covers all orders and all medication-related documentation that are: handwritten, entered "free-text" into a computer, and printed on a form that is pre-printed. Compliance requirements are 100% for pre-printed forms and 90% for handwritten and free-text entry. However, the prohibited list won't be surveyed this year for pre-programmed electronic displays and computer-generated printouts, the JCAHO says. For more about this goal, see the March issue of BOJ.

What's corrected
There are three language changes:

1. EC.8.10--The word "and" is removed from the language in EP 12 concerning emergency access.
2. PC.13.20--Licensed independent practitioners have been replaced with "individuals" in EP 1 concerning qualified staff present for sedation/anesthesia.
3. EC.5.20--For this standard, which requires that buildings are designed and kept in line with the Life Safety Code® (LSC), EP 6 has been added that says organizations establish the qualifications of the person(s) they select for executing the Statement of Conditions. The JCAHO offers no requirements for education or experience, but says they should at least match what's required by the activities dictated in the LSC.

There are two scoring changes:
1. IM.3.10--The scoring track for EP 2 (abbreviations, acronyms, and symbols are uniform and there is a list of prohibited ones) has been changed to A.
2. IC.4.10--The scoring track for EP 2 (hand hygiene program complies with Centers for Disease Control and Prevention guidelines) has been changed to A. This is also Goal #7a.

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