Surgery Procedural Services

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.13.01.09

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.13.03.01

The hospital provides services that meet patient needs.

The hospital must provide services that meet patient needs, including nursing, emergency, laboratory, and surgical care.

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.17.02.01

The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an o...

The standard requires objective, evidence-based criteria and procedures for granting, renewing, and documenting clinical privileges, including surgical and obstetrical privileges where applicable.

Citation

TJC NPG.01.06.01

The hospital conducts a preprocedure verification process.

The standard addresses verification of the correct patient, procedure, and site and availability of required procedure-related items before a procedure.

Citation

TJC NPG.01.06.02

The hospital marks the procedure site.

The standard addresses when and how procedure sites are marked, who may mark them, and alternative processes when marking is refused or impractical.

Citation

TJC NPG.01.06.03

The hospital performs a time-out before the procedure.

The standard requires a standardized team time-out immediately before invasive procedures or incisions and documentation of its completion.

Citation

TJC NPG.09.01.01

The hospital uses standardized procedures for managing tissues.

Requires the hospital to use standardized written procedures for tissue acquisition, storage, supplier verification, temperature monitoring, and organ procurement notification.

Citation

TJC NPG.09.02.01

The hospital traces all tissues bi-directionally.

Requires the hospital to maintain records enabling bi-directional tracing of all tissues from donor or supplier to recipient or final disposition.

Citation

TJC NPG.09.03.01

The hospital investigates adverse events related to tissue use or donor infections.

Requires the hospital to have a written procedure for investigating tissue-related adverse events, reporting to suppliers, sequestering suspect tissue, and informing recipients of donor infection risk.

Citation

TJC NPG.12.01.01

The hospital’s leadership team ensures that there is qualified ancillary staff required to me...

Hospital leadership ensures adequate qualified ancillary staff across service lines, including medical records, dietetic, pharmacy, infection prevention, and surgical services, with specified qualifications and supervision.

Citation

TJC NPG.14.03.01

The hospital labels all medications, medication containers, and other solutions on and off th...

Requires labeling of all medications, containers, and solutions on and off the sterile field in perioperative and other procedural settings, including required label content and two-person verification.

Citation

TJC PC.13.01.01

The hospital plans operative or other high-risk procedures.

Requires the hospital to plan operative and high-risk procedures and to ensure anesthesia is administered only by specified qualified practitioners.

Citation

TJC PC.13.01.03

The hospital provides the patient with care before and after operative or other high-risk pro...

Requires preanesthesia assessment, intraoperative and postanesthesia documentation, preprocedural education, immediate postoperative care, and qualified discharge.

Citation

TJC PC.13.01.05

The laboratory has written policies and procedures for the handling of tissue specimens remov...

Requires the laboratory to develop and implement written policies and procedures for collecting, preserving, transporting, receiving, and reporting tissue specimens removed during surgery.

Citation

TJC RC.12.01.03

The patient’s medical record contains documentation on any operative or other high-risk proce...

Requires the medical record to contain an operating room register and an operative or high-risk procedure report documenting surgical and anesthesia details.

Citation

TJC TS.11.01.01

The hospital, with the medical staff’s participation, develops and implements written policie...

Requires the hospital, with medical staff participation, to develop and implement written policies and procedures for donating and procuring organs, tissues, and eyes, including OPO and tissue/eye bank agreements, donor family notification, and documentation of donation decisions.

Citation

TJC TS.12.01.01

The hospital complies with organ transplantation responsibilities.

Requires hospitals performing organ transplants to comply with OPTN rules and provide required transplant data to designated entities.