General Operations

Citation

TJC EM.13.01.01

The hospital has a continuity of operations plan.

The standard addresses a hospital continuity of operations plan for maintaining essential business functions and leadership authority during disruptions.

Citation

TJC HR.11.01.01

The hospital has the necessary staff to support the care, treatment, and services it provides.

The standard addresses competency of administrative and technical staff in hospital food and dietetic services.

Citation

TJC HR.11.01.03

The hospital determines how staff function within the organization.

The standard addresses current licensure, certification, registration, primary source credential verification, and documentation for staff who provide care, treatment, and services.

Citation

TJC HR.11.02.01

The hospital defines and verifies staff qualifications.

The standard addresses defining staff qualifications by job responsibility, including references to infection control, laboratory, rehabilitation, interpreter, and respiratory care qualifications.

Citation

TJC HR.11.03.01

The hospital provides orientation, education, and training to their staff.

The standard addresses hospital staff orientation, ongoing competency training, annual emergency services readiness training, documentation, and use of QAPI findings to inform training needs.

Citation

TJC HR.11.04.01

The hospital evaluates staff competence and performance.

The standard requires initial and periodic assessment and documentation of hospital staff competence according to policy, law, and regulation.

Citation

TJC LD.13.01.05

For hospitals that use Joint Commission accreditation for deemed status purposes:

The hospital must maintain an institutional plan that includes an annual operating budget and a three-year capital expenditure plan.

Citation

TJC LD.13.01.07

The hospital effectively manages its programs, services, sites, or departments.

The hospital must assign qualified leadership to oversee specific clinical programs, services, and departments.

Citation

TJC LD.13.03.03

Care, treatment, and services provided through contractual agreement are provided safely and...

The hospital must ensure that services provided through contractual agreements are safe, effective, and compliant with regulations.

Citation

TJC MM.12.01.01

The hospital selects and procures medications.

The hospital must maintain a formulary that includes medication strength and dosage, accessible to those managing medications.

Citation

TJC NPG.02.04.01

The hospital has a workplace violence prevention program.

The hospital must implement a multidisciplinary workplace violence prevention program that includes policies, incident reporting, victim support, staff training, and annual worksite analysis.

Citation

TJC NPG.04.01.01

Improving health outcomes for all the hospital’s patients is a quality and safety priority.

The hospital must designate leadership, assess health-related social needs, stratify quality data by sociodemographic characteristics, and develop action plans to improve health outcomes.

Citation

TJC PC.12.01.01

The hospital provides care, treatment, and services as ordered or prescribed and in accordanc...

Requires the hospital to provide care, treatment, and services as ordered by licensed practitioners in accordance with law, regulation, and professional standards, with specific conditions for outpatient orders, blood transfusions, IV medications, and rehabilitation services.