Facility Operations

Citation

TJC EM.12.02.11

The hospital has a plan for managing essential or critical utilities during an emergency or d...

The standard addresses a hospital plan for maintaining essential or critical utility systems during an emergency or disaster incident.

Citation

TJC MM.11.01.01

The hospital safely manages pharmaceutical services.

The hospital must procure, store, control, and distribute drugs and biologicals in accordance with laws and standards.

Citation

TJC MM.13.01.01

The hospital safely stores medications.

The hospital must safely store medications, including controlled substances and radiopharmaceuticals, to prevent diversion.

Citation

TJC MS.17.01.01

Prior to granting a privilege, the hospital determines if the resources necessary to support...

Before granting a privilege, the hospital must determine whether sufficient space, equipment, staffing, and financial resources are available to support it.

Citation

TJC MS.20.01.01

Physicians or other licensed practitioners who are responsible for the care, treatment, and s...

The originating hospital must credential and privilege telemedicine practitioners or include specified safeguards when relying on distant-site credentialing and privileging decisions.

Citation

TJC NPG.01.03.01

The hospital manages the flow of patients throughout the hospital.

The hospital measures, sets goals, reviews results, and takes leadership action to manage patient flow, bed availability, throughput, support services, and emergency department boarding.

Citation

TJC NPG.03.02.04

The hospital has a plan for providing patient care and clinical support during an emergency o...

The standard addresses emergency planning for patient care and clinical support, including procedures for non-patient individuals and coordination for unidentified or deceased patients.

Citation

TJC NPG.03.02.05

The hospital has a plan for safety and security measures to take during an emergency or disas...

The standard addresses hospital planning for safety and security measures and coordination with community security agencies during emergencies or disasters.

Citation

TJC NPG.03.03.01

The hospital has a disaster recovery plan.

The hospital maintains a written disaster recovery plan addressing damage assessments, restoration of critical systems and essential services, return to operations, and family reunification coordination.

Citation

TJC NPG.03.05.01

The hospital plans and conducts exercises to test its emergency operations plan and response...

The hospital plans and conducts exercises to test emergency operations and response procedures, including annual exercises for covered freestanding outpatient care buildings when not included in hospital exercises.

Citation

TJC NPG.05.01.01

The hospital implements its infection prevention and control program through surveillance, pr...

The hospital must implement an infection prevention and control program by identifying and reviewing risks for infection, contamination, and exposure.

Citation

TJC PE.01.01.01

The hospital has a safe and adequate physical environment.

Requires the hospital to maintain a building, space, and premises that are constructed, arranged, and kept clean and orderly to support safe patient access and care.

Citation

TJC PE.02.01.01

The hospital manages risks related to hazardous materials and waste.

Requires the hospital to inventory, label, handle, store, and dispose of hazardous materials and waste, including radioactive, chemical, gas, vapor, and regulated medical waste, while protecting patients and staff.