Quality Governance

Citation

TJC APR.04.01.01

The hospital selects and uses performance measures from among those available that are releva...

The hospital must select and report relevant performance measures to The Joint Commission to meet ORYX requirements.

Citation

TJC APR.09.02.01

Any individual who provides care, treatment, and services can report concerns about safety or...

The hospital must educate staff and medical staff on their right to report safety or quality concerns to The Joint Commission without fear of retaliation or disciplinary action.

Citation

TJC EM.09.01.01

The hospital has a comprehensive emergency management program that utilizes an all-hazards ap...

The hospital must maintain a written, comprehensive, all-hazards emergency management program that includes leadership accountability, risk assessment, and preparedness activities.

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 EM.15.01.01

The hospital has an emergency management education and training program.

The standard addresses hospital emergency management education and training for staff, arranged-service personnel, and volunteers.

Citation

TJC EM.16.01.01

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

The standard addresses hospital exercises to test emergency operations plans and response procedures, including documentation of exercises and incidents.

Citation

TJC EM.17.01.01

The hospital evaluates its emergency management program, emergency operations plan, and conti...

The standard addresses hospital review of emergency exercises, disaster incidents, after-action reports, improvement plans, and periodic updates to emergency management documents.

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 IC.04.01.01

The hospital has a hospitalwide infection prevention and control program for the surveillance...

The hospital must maintain a comprehensive infection prevention and control program that includes surveillance, staff training, and standardized policies for device reprocessing.

Citation

TJC IC.05.01.01

The hospital’s governing body is accountable for the implementation, performance, and sustain...

The hospital's governing body is responsible for providing the resources and oversight necessary to ensure the infection prevention and control program is effective and sustainable.

Citation

TJC LD.11.01.01

The governing body is ultimately accountable for the safety and quality of care, treatment, a...

The governing body is responsible for the hospital's legal conduct, medical staff oversight, grievance processes, and quality assessment programs.

Citation

TJC LD.12.01.01

Leaders establish priorities for performance improvement.

The hospital must implement a data-driven quality assessment and performance improvement program to enhance patient safety and outcomes.

Citation

TJC LD.13.01.03

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

The hospital must maintain a utilization review plan and committee to ensure the medical necessity of services provided to Medicare and Medicaid patients.

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.13.01.09

The hospital has policies and procedures that guide and support patient care, treatment, and...

The hospital must develop and implement policies to guide patient care, including medication safety and surgical standards.

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.15.01.01

The hospital safely prepares medications.

The standard addresses pharmacist supervision, sterile compounding policies, staff competency, compounding environments, storage, labeling, quality assurance, and radiopharmaceutical preparation oversight.

Citation

TJC MM.17.01.01

The hospital responds to actual or potential adverse drug events, significant adverse drug re...

The standard addresses hospital policies and processes for reporting and evaluating adverse drug events, adverse drug reactions, medication incompatibilities, and medication administration errors.

Citation

TJC MM.18.01.01

The hospital establishes antibiotic stewardship as an organizational priority through support...

The standard addresses leadership, coordination, documentation, training, guideline adherence, and tracking for a hospitalwide antibiotic stewardship program.

Citation

TJC MS.15.01.01

There is a medical staff executive committee.

Addresses the existence, composition, attendance, bylaw conformity, and governing body recommendations of the medical staff executive committee.

Citation

TJC MS.16.01.01

The organized medical staff oversees the quality of patient care, treatment, and services pro...

Addresses organized medical staff responsibility for care quality, privileges, patient safety, histories and physicals, emergency care policies, and selected radiology and nuclear medicine staff qualifications.

Citation

TJC MS.16.02.01

In hospitals participating in a professional graduate education program(s), the organized med...

Hospitals participating in professional graduate education programs must define medical staff supervision, role descriptions, order-writing limits, communications, and compliance with review committee citations.

Citation

TJC MS.16.03.01

The organized medical staff leads and participates in organizationwide performance improvemen...

The organized medical staff must lead and participate in performance improvement activities addressing care quality, patient safety, pain management, opioid prescribing, records, and practitioner competence.

Citation

TJC MS.17.02.03

The organized medical staff reviews and analyzes all relevant information regarding each requ...

The standard requires the organized medical staff to review relevant practitioner qualifications and complete privileging decisions using health care quality-related criteria without specified discriminatory factors.

Citation

TJC MS.18.02.01

The organized medical staff defines the circumstances requiring monitoring and evaluation of...

The organized medical staff defines and implements criteria, triggers, monitoring plans, and resolution measures for evaluating practitioner performance.

Citation

TJC MS.18.02.03

Ongoing professional practice evaluation information is factored into the decision to maintai...

Ongoing professional practice evaluation information is used to determine whether existing clinical privileges should be continued, limited, revised, or revoked.

Citation

TJC MS.18.03.01

The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts on repo...

The hospital and organized medical staff maintain a defined process for collecting, investigating, and addressing concerns about privileged practitioners’ clinical practice or competence.

Citation

TJC MS.18.04.01

There are mechanisms for a fair hearing and appeal process to address adverse decisions regar...

The organized medical staff must have a fair hearing and appeal process for adverse privilege and reappointment decisions related to quality of care issues.

Citation

TJC MS.19.01.01

All physicians and other licensed practitioners privileged through the medical staff process...

Privileged physicians and other licensed practitioners must participate in continuing education that is documented and considered in reappointment and privileging decisions.

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 MS.20.01.03

For originating and distant sites:

Medical staffs at originating and distant sites recommend which clinical services are appropriately delivered through a telemedicine link and ensure offered services align with accepted quality standards.

Citation

TJC NPG.01.02.01

The hospital reports critical results of tests and diagnostic procedures on a timely basis.

The hospital maintains written procedures for defining, reporting, timing, and evaluating critical results of tests and diagnostic procedures.

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.01.05.01

The hospital improves the safety of clinical alarm systems.

The hospital identifies important alarm signals and establishes policies for alarm settings, authority, monitoring, response, and signal checks.

Citation

TJC NPG.01.05.03

Resuscitative services are available throughout the hospital.

The hospital provides resuscitative services under standards and policies, makes equipment available for the population served, and trains involved staff.

Citation

TJC NPG.01.05.05

The hospital reviews resuscitation cases to identify opportunities for improvement.

The standard addresses interdisciplinary review of resuscitation cases and data to identify practice and system improvement opportunities.

Citation

TJC NPG.02.01.01

The mission, vision, and goals guide the hospital’s actions.

The standard requires hospital governing, senior, and medical staff leaders to create and communicate mission, vision, and goals that guide leadership actions.

Citation

TJC NPG.02.02.01

The hospital addresses conflicts of interest and ethics.

The standard requires hospital leaders to define, disclose, and manage conflicts of interest and to provide a process for staff, patients, and families to address ethical issues.

Citation

TJC NPG.02.03.01

The hospital’s leaders design work processes to focus individuals on safety and quality issues.

The standard requires hospital leaders to implement patient safety program structures, reporting systems, event analyses, risk assessments, communication processes, safety culture evaluation, and conduct management.

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.03.01.01

Hospital leaders provide oversight and support of the emergency management program.

Hospital leadership must provide oversight and support for the emergency management program, including the appointment of a qualified lead and the establishment of a multidisciplinary committee.

Citation

TJC NPG.03.02.01

The hospital develops an emergency operations plan based on an all-hazards approach.

The hospital must maintain an all-hazards emergency operations plan that includes a scalable incident command structure and designated authority for activation.

Citation

TJC NPG.03.04.01

The hospital has an emergency management education and training program.

The hospital maintains emergency management education and training, including duty-specific training for incident command staff.

Citation

TJC NPG.03.06.01

The hospital evaluates its emergency management program, emergency operations plan, and conti...

The hospital evaluates its emergency management program and related plans and forwards after-action reports and improvement recommendations to senior leaders for review.

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 NPG.05.03.01

The hospital complies with either the current Centers for Disease Control and Prevention hand...

The hospital must implement a hand hygiene program that adheres to current Centers for Disease Control and Prevention or World Health Organization guidelines.

Citation

TJC NPG.06.01.01

Pain assessment and pain management, including safe opioid prescribing, are identified as an...

The hospital establishes leadership, staff education, and resources for pain management and safe opioid prescribing practices.

Citation

TJC NPG.06.03.01

The hospital collects data on pain assessment and management.

Requires the hospital to collect and analyze data on pain assessment and management to identify opportunities for improving safety and quality.

Citation

TJC NPG.07.01.01

The hospital respects the patient's right to receive information in a manner the patient unde...

Requires the hospital to respect the patient's right to effective communication and to provide interpreting, translation, and accommodation services for patients with language, vision, speech, hearing, or cognitive impairments.