Health Information Management

Review your policies to ensure compliance with new, revised Joint Commission RC standard EPs

HIM-HIPAA Insider, February 1, 2011

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by Laure Dudley, RN, MS, CSHA, senior consultant with The Greeley Company

Are you questioning your readiness for the recently approved Joint Commission patient-provider communication standards? Although these standards don’t have a firm implementation date when they will actually be scored, they are available and surveyors will be assessing for compliance in 2011.
Standard RC.02.01.01 in record of care includes EP 28, requiring data collection of race and ethnicity, and a new note under EP 1 includes noting the patient’s, guardian’s, or designated advocate’s preferred language for discussing healthcare issues to support the role of the medical record in handoffs. The intent is for hospitals to evaluate the aggregated data, understand cultural
issues, and plan for services (e.g., determine what documents should be translated based on your data).
EPs 28 and 29, scored at the “A” level, have been added to RI.01.01.01 focusing on access of a “support individual” to be present for the patient as much as possible while prohibiting discrimination.
This forces hospitals to review visitor restriction policies. Do you currently allow friends or same-sex partners unlimited visits in the ICU? Review your restrictions to see whether they need revision. Of course, you will need to determine exceptions to the “open-access designee” for important considerations such as infection control or safety reasons.
Editor’s note: For more, see the February issue of Briefings on The Joint Commission.

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