JCI 7th Edition Changes

Karien Uys, 2021

King Fahad Armed Forces Hospital-Jeddah
Summary of Changes to the Manual
• are effective as of 1 January 2021.

• KFAFH is responsible for meeting all applicable changes by this date.

• There are many changes to the Joint Commission International

Accreditation Standards for Hospitals Including Standards for
Academic Medical Center Hospitals, 7th Edition.

• A thorough review is strongly recommended.

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Major changes to the 7th edition include the following:
Safety Goals” (IPSG) chapter on :
1. IPSG 3
• Separate the High alert medication (IPSG.3),safety of lookalike/sound-alike
(LASA ) medication– (IPSG.3.1), and Concentrated electrolytes (IPSG.3.2)
• HAM list to be reviewed annually
• Standard protocols are followed for adult, pediatric, and/or neonatal electrolyte
replacement therapy to treat
• hypokalemia,
• hyponatremia, and
• hypophosphatemia.
2. (IPSG.5.added new requirements regarding the use of evidence-based
interventions or bundles to reduce identified HAI (IPSG.5.1).

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• Combined the “Patient and Family Rights” (PFR) and
“Patient and Family Education” (PFE) chapters to create
a new chapter, “Patient-Centered Care” (PCC) and
• introduced a new requirement to
• measure,
• analyze, and
• improve
• the patient experience to enhance the quality of patient
care (PCC.3)

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• Added standards to the “Care of Patients” (COP)
chapter on
• clinical alarm system management (COP.3.1),
• management of patients at risk of suicide or self-
harm (COP.3.5), and
• management of lasers (COP.4 and COP.4.1) (Radiology
already amended to include physiotherapy laser)

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 (QPS.7 and QPS.7.1) Intent
• Updated the definitions and requirements for sentinel events,

Severe temporary harm is defined as critical, potentially

life-threatening harm lasting for a limited time with no
permanent residual but requires transfer to a higher level
of care/monitoring for a prolonged period of time,
transfer to a higher level of care for a life-threatening
condition, or additional major surgery, procedure, or
treatment to resolve the condition. With added examples

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An adverse event is a patient safety event that resulted in
harm to a patient.
• A no-harm event is a patient safety event that reaches the
patient but does not cause harm.
• A near miss (or close call) is a patient safety event that did
not reach the patient.
• A hazardous (or “unsafe”) condition(s) is a circumstance
(other than a patient’s own disease process or condition) that
increases the probability of an adverse event

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QPS.7.
New ME 5.
• The hospital monitors the implemented corrective
actions for potential process failures (unintended
consequences), effectiveness, and sustainability over
time.

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QPS.7.1 (New standard)
1. Hospital leadership establishes a definition of adverse event, no-harm event, and near
miss event as defined in the intent.
2. Hospital leadership has a mechanism for blame-free reporting of adverse events, no-harm
events, and near miss events
3. Hospital leadership defines a process for managing adverse events that includes an
analysis of the events to identify corrective actions.
4. Hospital leadership defines a process for managing near miss events and no-harm events
that includes an analysis of the events to identify corrective actions.
5. Hospital leaders implement corrective actions, when appropriate, on the results of the
analysis.
6. Hospital leaders monitor the implemented corrective actions for potential process failures
(unintended consequences), effectiveness, and sustainability over time.

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• Introduced new standards in the “Prevention and
Control of Infections” (PCI) chapter on

• environmental cleanliness (PCI.7);

• cleanliness of laundry, linens, and scrubs (PCI.7.1); and on
• protection of patients and staff from blood borne pathogens
(PCI.8.1)

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Reorganized the “Facility Management and Safety” (FMS) chapter by
the eight areas required to have a written facility management and
safety program:
1. safety,
2. security,
3. hazardous materials and waste,
4. fire safety,
5. medical equipment,
6. utility systems,
7. emergency management, and
8. construction and renovation
—and introduced new requirements for monitoring each area

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• Created a new “Interim Measures” appendix in the
FMS chapter to address safety of the building’s
occupants during construction, maintenance, or a
breakdown or repair (addressed at FMS.8.3)

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• Updated and added additional evidence-
based references to support new and
revised standards throughout the manual

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• Moved standards cross-references throughout
the manual from measurable elements and
standards
to the standards’ intents and
revised them as needed
to align with standards renumbering and revisions
in the 7th edition

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• Completed a project to align glossaries across all
JCI accreditation and certification programs

Thank You

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 All changes
(excluding renumbering)

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Accreditation Participation Requirements
(APR)

Accreditation Participation Requirements (APR)

Added an example of inappropriate representation of
APR.8 Rationale accreditation status
Chapter
APR. changes Made minor editorial revisions throughout the chapter

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 See FMS.8 and FMS.8.3 for requirements related to
interim measures. The following are examples of interim
measures:
• The hospital initiates a fire watch, which involves a trained • The hospital enforces storage, housekeeping, and debris-removal
individual(s) patrolling the areas of the building affected by the practices that reduce the building’s flammable and combustible
impairment/fire safety risk to look for evidence of smoke, fire, or fire load to the lowest feasible level.
other abnormal conditions. For example, a fire watch is initiated
when a fire alarm system is out of service more than 4 out of 24 • The hospital provides additional training to staff on the use of
hours, or a sprinkler system is out of service more than 10 hours in firefighting equipment.
a 24-hour period. • The hospital conducts additional fire safety exercises with staff.
• The hospital posts signs identifying the location of alternative exits
to everyone in the affected area of the hospital (for example, when • The hospital inspects and tests temporary fire systems monthly.
normal exit pathways and/or exit doors are not accessible or not
• The hospital conducts education to promote awareness of fire
functional due to construction, maintenance activities, and so on).
safety–related building deficiencies, impairments, construction
• The hospital inspects exits in affected areas on a daily basis. hazards, and temporary measures implemented to maintain fire
• The hospital provides temporary but equivalent fire alarm and safety.
detection systems for use when a fire system is impaired.
• The hospital provides additional training to staff to compensate
• The hospital provides additional firefighting equipment.
for increased risks due to impaired structural or compartmental
• The hospital uses temporary construction partitions that are fire safety features.
smoke-tight or made of noncombustible or limited-combustible
material that will not contribute to the development or spread of • Other interim measures, as determined by the hospital and
fire. appropriate to the fire safety risk.
• The hospital increases surveillance of buildings, grounds, and
equipment, giving special attention to construction and storage
areas.

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Minor changes to the 7th edition include the following:
Safety Goals” (IPSG) chapter on :
IPSG 1 :
• Add “at least two identifiers are used for labeling elements e.g. expressed breast milk or other treatments specific
prepared for the patient.
IPSG 2 -2.1:
• Intent: “Communication can be verbal, electronic or written
• Revised to clarify the definition of critical results, urgent or emergent life threatening results
• To add protocol for Handover -between staff and patients/families, such as at discharge. (Also see ACC.4.1)

IPSG 3: Already discussed

IPSG 4: (No changes)

IPSG 5: Already discussed

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 Access to Care and Continuity of Care
(ACC)
 ACC4
New ME 4
• Added requirement added “to provide information on available site(s) for continuing
care to patients who are not directly referred or transferred

New ME 5
• Added requirement to provide information on when to return for care to patients who
are not directly referred or transferred

New ME 6
• Added requirement to provide written discharge planning and instructions to patients

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King Fahad Armed Forces Hospital-Jeddah
Based on the patient’s identified continuing care needs, discharge education and
instruction may include, but are not limited to, the following topics:
• Review of all medications to be taken at
home
• Safe and effective use of all medications,
including potential medication side effects
• Potential interactions between prescribed
medications and other medications
(including over-the- counter preparations)
and food
Currently no documentation in
• Diet and nutrition Medical record that patient
• Pain management as needed signed that he/she received
written instructions.
• Safe and effective use of medical (PFE form has element for
equipment, as appropriate written instructions)
• Rehabilitation techniques, as appropriate.

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International Patient Safety Goals (IPSG)

International Patient Safety Goals (IPSG)

Made minor editorial revisions throughout the chapter and specific changes include:

IPSG.1 Intent Revised to address the labeling of elements associated with patient care (for example,
dietary trays, mother’s milk) and clarified expectations for using two patient identifiers

  ME 1 Added requirement to include the labeling of elements related to patient care, using the
same two identifiers

IPSG.2. Intent of Revised to clarify the definition of critical results, including examples
IPSG.2-IPSG.2.2
Clarified the requirement to define critical results that may represent urgent or
  ME 1 emergent life-threatening values for diagnostic tests
IPSG.2.1 ME 2 Revised to focus on the development of a formal reporting process

Revised to include the Institute for Safe Medication Practices definition of high-alert
Intent of medication and examples; expanded to address new IPSG.3.1 on look-alike/ sound-alike
IPSG.3 IPSG.3-3.2 medications; provided further discussion of concentrated electrolytes, including
examples

Split previous ME 1 to focus on writing a list of high-alert medications (ME 1) and

  MEs 1 and 2 combined with previous
  ME 3 To focus a uniform process for reducing risk of King
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(ME 2)Hospital-Jeddah
 International Patient Safety Goals (IPSG)
  New ME 3 Added requirement that high-alert medication list be reviewed annually

IPSG.3.1 New Standard Introduced requirements for a process for managing look-alike/sound-alike medications
(previously addressed as part of IPSG.3 on high-alert medications)

Split and adapted previous IPSG.3, ME 2 to focus on a written look-alike/sound-alike

  MEs 1 and 2 medication list (ME 1) and combined with previous IPSG.3, ME 3 to focus on a uniform
process for reducing risk of harm from them (ME 2)

  New ME 3 Added requirement for hospital to annually review its look-alike/sound-alike list
IPSG.3.2 Standard Renumbered previous IPSG.3.1 to address hospital management of concentrated electrolytes

Renumbered previous ME 3 and added requirement that only trained staff access
  ME 1 concentrated electrolytes

  ME 2 Clarified that concentrated electrolytes are stored outside the pharmacy only in
circumstances as described in the intent of the standard

  New ME 3: Added requirement to follow standardized protocols for electrolyte replacement therapy
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 International PatienttoSafety
Intent of IPSG.5 Expanded Goals
address new IPSG.5.1(IPSG)
on evidence-based guidelines
IPSG.5
and IPSG.5.1 addressing hospital-associated infections

IPSG.5.1 New Standard: Introduced requirements for the use of evidence-based interventions
to reduce risk of hospital-associated infections

  New ME 1 Added requirement for hospital leaders to identify priority hospital-

acquired infections on which to focus improvements

  New ME 2 Added requirement that evidence-based interventions (such as

bundles) be applied to the identified hospital-acquired infections

Added requirement that the use of evidence-based interventions is

: New ME 3 monitored for compliance and improved outcomes

Intent of IPSG.6 and IPSG.6.1: Added information about high-risk area

IPSG.6.1 New Standard for falls and fall risk screening King Fahad Armed Forces Hospital-Jeddah
 Access to Care and Continuity of Care (ACC)
Added requirement to provide information on site(s) for continuing care to patients
 ACC4 New ME 4 who are not directly referred or transferred
Added requirement to provide information on when to return for care to patients
  New ME 5 who are not directly referred or transferred
  New ME 6 Added requirement to provide written discharge planning and instructions to
patients
ACC.4.1 Standard: Revised to address patient and family education and ongoing care needs in discharge
planning
  New ME 1: Added requirement to focus patient and family education on patient’s ongoing need
for continuing care and services
  New ME 2: Added requirement on providing patients and families with list of medications to be
taken at home

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 Patient-Centered Care (PCC)
Made minor editorial revisions throughout the chapter

Combined and reorganized previous chapters “Patient and Family Rights” (PFR)
PCC New Chapter: and “Patient and Family Education” (PFE) to create this new “Patient-Centered
Care” (PCC) chapter
  Overview: Revised the PFR overview to incorporate PFE concepts
PCC.1 Standard Renumbered previous Standard PFR.1
  ME 1 Renumbered previous PFR.1, ME 1
  ME 2 and 3 Split previous PFR.1, ME 2 to focus on implementing (ME 2) and protecting (ME 3)
patient and family rights
  New ME 4 Added requirement on patients’ right to identify who they wish to participate in
their care decisions

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 Patient-Centered Care (PCC)
Standard and Intent: Renumbered previous Standard PFR.1.3 and expanded to address
PCC.1.3 Standard patients’ right to have access to their health information

  MEs 1–3 Renumbered previous PFR.1.3, MEs 1–3

Clarified that the hospital must have a process to grant permission to release health
  ME 4
information to patients

Added requirement for a process to provide patients with access to their health
  New ME 5: information

  New ME 6: Added requirement to provide timely access to patient’s health information without a
prohibitive cost

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 Patient-Centered Care (PCC)

Standard and Renumbered previous Standard PFR.2 and expanded to include families and address
PCC.2 Intent engagement and education in care decisions and care processes

  MEs 1 and 2: Combined and renumbered previous PFR.2,

  MEs 1, 2, and 5 expected outcomes of care (ME 3) and unanticipated outcomes of care (ME 4)

  ME 5 Renumbered previous PFR.2, ME 4

PCC.2.1: Renumbered Renumbered previous Standard PFR.2.1 and its MEs 1–6

PCC.2.2 Renumbered Renumbered previous Standard PFR.2.2 and its MEs 1–4

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 Patient-Centered Care (PCC)
New Standard Introduced requirement to measure, analyze, and improve the patient
PCC.3 and Intent experience to enhance the quality of patient care

Added requirement for leaders to develop and implement a process for

  New ME 1
assessing patient experience

  New ME 2 Added requirement to aggregate and analyze patient experience data

  New ME 3 Added requirement for leaders to prioritize areas for improving the patient
experience

  New ME 4 Added requirement to implement strategies to improve the patient experience

  New ME 5 Added requirement to analyze the impact of improvements

PCC.3.1 Renumbered Renumbered previous Standard PFR.3 and its MEs 1–4
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 Patient-Centered Care (PCC)
Standard and
PCC 5.1 Intent Combined and renumbered previous Standards PFE.2 and PFE.2.1

Combined concepts from and renumbered previous PFE.2, MEs 1 and 2 and previous
  ME 1
PFE.2.1, ME 1
Combined, renumbered, and adapted previous PFE.2.1, ME 2 and previous PFE.2.1, MEs
  ME 2 3 and 4
Added requirement on accommodating patients’ and families’ identified needs when
  New ME 3 providing education
  ME 4 Renumbered and adapted previous PFE.2, ME 3

PCC.5.2 Renumbered Renumbered previous Standard PFE.3 and its MEs 1–4

PCC.6 Renumbered Renumbered previous Standard PFR.6 and its MEs 1–4

PCC.6.1 Renumbered Renumbered previous Standard PFR.6.1 and its MEs 1–4
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 Assessment of Patients (AOP)
Assessment of Patients (AOP)
Made minor editorial revisions throughout the chapter
Listed the types of assessments needed to be performed as part of the initial
patient assessment and clarified that listing patients’ current medications and
known allergies should be part of the health history
AOP.1.1 Intent (Each patient’s initial assessment includes a physical examination and health history as
well as an evaluation of
• psychological,
• spiritual/cultural (as appropriate),
• social, and economic factors) – only in ICS assessment from.
  ME 2 Revised to focus on listing of patient’s current medications and known
allergies as part of their assessment

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 Assessment of Patients (AOP)
AOP.1.5 Standard Clarified which outpatients the standard applies to (that is, those whose
condition, diagnosis, or situation may indicate they are at risk for pain)
  Intent Provided additional information about screening patients for pain
  ME 1 Revised requirement to focus on inpatients

  New ME 2 Added requirement for screening for pain in outpatients whose

condition, diagnosis, or situation may indicate a need for screening
Added requirement to guide assessment and referral for outpatients who
  New ME 5 positively screened for pain

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 Assessment of Patients (AOP)
Renumbered previous Standard AOP.6.3 and expanded to include diagnostic imaging in a
AOP.6.2 Standard radiation safety program; revised to require compliance with applicable professional
standards, laws, and regulations; and clarified that the program should include patients,
staff, and visitors

Added information about magnetic resonance imaging–related safety concerns and

  Intent clarified expectations for the radiation safety management program

  ME 1 Expanded to align with the revised standard

  New ME 5: Added requirements for addressing hazards related to magnetic resonance imaging .

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 Care of Patients (COP)
COP Overview Revised to address risk factors that can impact patient care and an example of patient
support

COP.2.2 Standard Renumbered previous Standard COP.2.1

  Intent Added additional information about multidisciplinary patient care conferences

  New ME 4 Added requirement to document results or outcomes from any patient care team meetings
or other collaborative discussions in the medical record

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 Care of Patients (COP)
Changed item j) in the list of potential high-risk services from patients at risk for suicide
COP.3 Intent
(now addressed at new standard COP.3.5) to patient receiving palliative care

Given the change to the intent, leaders will need to include those patients receiving
  ME 1
palliative care as they identify high-risk patients and services

COP.3.1 New Standard Introduced requirement on clinical alarm system management

and Intent

  New ME 1 Added requirement for hospital leaders to develop and implement an alarm system
management program
  New ME 2 Added requirement to prioritize alarm signals according to patient safety risk

  New ME 3 Added requirement for hospital leaders to develop strategies for managing alarms

  New ME 4 Added requirement to educate staff on the purpose and operation of alarm systems
Added requirement to ensure that responsible staff are trained and competent to
  New ME 5 manage clinical alarms
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 Care of Patients (COP)
Split previous COP.3.1, ME 2 to focus on early warning
COP.3.2 MEs 2 and 3 signs (ME 2) and when and how to seek further
assistance (ME 3)

COP.3.3 Standard Renumbered previous Standard COP.3.2 and its MEs 1–3
Added expectation for timely review of internal data on
  Intent resuscitations
Added requirement for the hospital to review internal
  New ME 4 data from previous emergency situations to identify
improvement opportunities

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 Care of Patients (COP)
New Standard Introduced requirement for hospitals to have a process to identify patients at risk of suicide
COP.3.5 and Intent or self-harm

  New ME 1 establish criteria to screen for suicide and self-harm

  New ME 2 to use evidence-based tools to assess patients for suicidal ideation

  New ME 3 to conduct environmental risk assessments and act to minimize risk

  New ME 4 to implement protocols and procedures to mitigate risk of suicide and self-harm

  New ME 5 to analyze data and monitor implementation and effectiveness of protocols and procedures

to ensure that staff are trained on screening criteria and tools as well as risk reduction
  New ME 6 protocols and procedures
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 Care of Patients (COP)
New Standard Introduced requirement to establish a program on safe use of lasers and other optical
COP.4
and Intent radiation devices

  New ME 1 to base the program on professional standards and applicable laws and regulations

  New ME 2 a qualified individual to oversee and supervise the program

  New ME 3 documented safety training and continuing education for staff

  New ME 4 administrative and engineering controls to promote program safety.

  New ME 5 correct, appropriate use of personal protective equipment for staff and patients

  New ME 6 qualified, trained individuals to conduct inspection, testing, and maintenance processes
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 Care of Patients (COP)

New Introduced requirement to report and address adverse events resulting

COP.4.1 Standard and
Intent from lasers and other optical radiation devices

  New ME 1
To integrate the safety program into the hospital’s facility management
and safety structure

  New ME 2
To integrate the safety program into the hospital’s infection prevention
and control program

  New ME 3
Toreport adverse events and identify and implement action plans to
prevent recurrence.

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 Care of Patients (COP)

COP.7 Intent Expanded discussion on needs of the end-of-life care for dying
patients (pulling in concepts from previous Standard AOP.1.7)

Added requirement to identify health care needs and support

  New ME 2 services needs of the patient and family as appropriate to their
religious and cultural preferences

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King Fahad Armed Forces Hospital-Jeddah
 M
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King Fahad Armed Forces Hospital-Jeddah
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 Anaesthesia and Surgical Care (ASC)

Anaesthesia and Surgical Care (ASC)

Made minor editorial revisions throughout the chapter

ASC.3 Intent Clarified the expectation that sedation policies and procedures are understood by
all practitioners permitted to administer procedural sedation
Clarified that practitioners who provide sedation must show evidence of
ASC.3.1 ME 1 competence
ASC.7.2, Intent Added new Note cross-referencing Standard COP.2.1 for information about
documentation on nonsurgical procedures and treatments

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 Medication Management and Use (MMU)
MMU Standard Renumbered previous Standard MMU.3.2
3.1
    Intent: Revised to provide guidance on safe practices for the use of
adult and pediatric emergency carts
  New ME 3 Added requirement regarding access to emergency medications
Added requirement that the hospital uses a risk-based approach to
  New ME 5 monitor emergency medication administration

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 Medication Management and Use (MMU)

MMU 3.2 Standard Renumbered previous Standard MMU.3.3

  Intent: Provided further information on what a medication recall is, why it might occur,
and the need to have a process for receiving notifications

Added requirement that the hospital has a process for identifying, retrieving, and
  New ME 2 returning or destroying recalled medications

  New ME 3 Added requirement that the recall process addresses medication compounded in
the hospital

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 Medication Management and Use (MMU)

New Introduced requirement for the hospital to have a process

MMU 4 Standard & for completing medication reconciliation on the current
Intent list of medications taken by the patient at home against all
newly prescribed or dispensed medications

  New ME 1 Added requirement for the hospital to collect information

required to conduct medication reconciliation

  New ME 2 Added requirement that all medication orders and

prescriptions contain the required listed elements

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 Medication Management and Use (MMU)

Revised to provide information on and examples of sterile

compounding, infection risks for single-use and multidose vials, safety
MMU.5 Intent measures, and maintaining a clean environment where medications
are dispensed

  New ME 4 Added requirement to use guidelines for the use of single-use and
multi-dose vials

Added requirement that medications stored, prepared, and dispensed

  New ME 5 outside the pharmacy comply with the same cleanliness measures as
the pharmacy

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 Medication Management and Use (MMU)
Revised and included additional examples addressing
MMU.
5.1 Intent appropriateness reviews for medication prescriptions and
orders

  ME 3 Clarified that individuals conducting reviews must be

permitted to do so
  ME 6 Included clinical decision support programs

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 Medication Management and Use (MMU)
MMU.6.1 Intent Added information about engaging and informing the patient about his or her
medications

Expanded intent to cover the two standards that were created from previous
Intent of Standard MMU.6.2; included further description of the labeling, storage, and
MMU.6.2 MMU.6.2 and control of the use of medications brought in by the patient or medication samples,
MMU.6.2.1 bringing concepts from the intent of previous Standard MMU.3.1; and introduced
the expectation to conduct appropriate risk assessments

Split previous Standard MMU.6.2 to focus on medications brought into the hospital
by the patient (MMU.6.2) and
MMU.6.2 Split sample medications (MMU.6.2.1);
clarified that self administered medications can be brought into the hospital by the
patient or can be prescribed for self-administration

  New ME 2 Added requirement for the hospital to perform a risk assessment for patient-
supplied medications

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 Medication Management and Use (MMU)

MMU.6.2.1Standard Split previous Standard MMU.6.2 to focus on medications brought into the hospital
by the patient (MMU.6.2) and sample medications (MMU.6.2.1)

  New ME 2 Added requirement for the hospital to perform a risk assessment for medication
samples

Clarified that the process for recording adverse effects in the medical record and
MMU.7 ME 3 reporting them to the hospital must be standardized

Added requirement for using a standardized reporting process for adverse

  ME 4 medication effects as part of the hospital quality program

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 Quality Improvement and Patient Safety (QPS)
Quality Improvement and Patient Safety (QPS)
Made minor editorial revisions throughout the chapter
Standard and
QPS.3 Intent Revised to address implementation of evidence-based patient care

Added requirement on hospital leadership’s role in building a culture and

  New ME 1 environment that supports implementation of evidence-based care MEs 2–
6:Renumbered previous MEs 1–5

QPS.7 New ME 1 Given the revised intent, increased the required elements hospital leaders must
include in a definition of sentinel event
  New ME 5 Added requirement for monitoring corrective actions

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 Quality Improvement and Patient Safety (QPS)
QPS.7.1 New Standard Introduced requirement for the hospital to identify and manage adverse events

  ME 1 Renumbered and expanded previous QPS.9, ME 1 to include adverse events, no-harm

events, and near miss events

Added requirement for a process to manage adverse, no-harm, and near miss events
  New ME 2 that includes a blame-free reporting mechanism (a concept from the intent of
previous Standard QPS.9)

Split, renumbered, and expanded previous QPS.9, ME 4 to focus on analyzing adverse

  MEs 3–5 events (ME 3) and near miss and no-harm events (ME 4) to identify corrective actions
and then implementing corrective actions on the results of those analyses (ME 5)
  New ME 6 Added requirement to monitor corrective actions

QPS.8 Intent Added adverse events related to patient identification to the list of required data
gathering and analysis

  ME 3 Given the change to the intent, expanded the list of data the hospital must gather and
analyze to include adverse events related to patient identification

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 Quality Improvement and Patient Safety (QPS)

Revised the list of essential components of a risk

QPS.10 Intent management program to include the scope, objectives,
and criteria for assessing risk

  ME 5 Added requirement for hospital leadership to implement

appropriate communication strategies

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 Prevention and Control of Infections (PCI)
Prevention and Control of Infections (PCI)
Made minor editorial revisions throughout the chapter
Added clinical authority to required qualifications for the individual
PCI.1 Standard overseeing infection prevention and control activities
Revised to address qualifications for the program leader and that the
  Intent program should collaborate with all areas
Added accountability to ensure that the program complies with laws and
  ME 1 regulations
Added requirement for the individual leading the program to coordinate
  ME 4 with hospital leadership
Provided additional information on the expectations for a designated
PCI.2 Intent mechanism to coordinate the overall infection surveillance, prevention,
and control program
Reinforced expectation that leadership supply staffing and infrastructure
PCI.3 Intent
to support the program

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 Prevention and Control of Infections (PCI)

Renumbered and adapted intent of PCI.6 and PCI.6.1; added

PCI.4 Intent information about and examples of risk assessment, evidence-based
interventions, and ongoing monitoring

Split and expanded the concepts from previous PCI.6.1, ME 3 to focus

PCI.5.1 ME 1 and 2 on completing an annual, documented risk assessment (ME 1),
implementing interventions based on that assessment (ME 2)

Added requirement to evaluate the effectiveness of those interventions

  New ME 3 mentioned

  New ME 4 Added requirement for ongoing data monitoring

King Fahad Armed Forces Hospital-Jeddah

 Prevention and Control of Infections (PCI)
Revised to recommend that the hospital use the Earle H.
Spaulding classification system to determine the
PCI.6 Intent appropriate level of sterilization/disinfection for each
medical device; added information on the expectations of
hospital leaders

PCI.6.1 Intent Added examples for the reuse of single-use devices and its
associated risks and the management of expired supplies

King Fahad Armed Forces Hospital-Jeddah

 Prevention and Control of Infections (PCI)
PCI.7 New Standard Moved the concept for identifying and implementing professional guidelines to address
and Intent environment cleaning from previous standard PCI.3 into a stand-alone standard.

  New ME 2 Added requirement for the hospital to identify high-risk areas for infection and use
appropriate cleaning processes

Added requirement for the hospital to monitor and improve environmental cleaning
  New ME 4 processes

New Standard Moved the concept for using professional guidelines to assess and manage the cleaning
PCI.7.1 and Intent and disinfection of laundry, linens, and scrubs provided by the hospital from PCI.3 into a
stand-alone standard.

  New ME 2 Added requirement to use standard precautions when handling laundry, linens, and
hospital-issued scrubs

  New ME 3 Added requirement to handle those items in a manner that prevents cross
contamination

  New ME 4 Added requirement for staff to wear hospital-issued scrubs where required
King Fahad Armed Forces Hospital-Jeddah
 Prevention and Control of Infections (PCI)

 PCI.8 Intent Revised to provide examples of and guidance on safe

handling of sharps and management of human tissues and
body parts
Added requirement for staff to be trained in preventing
  New ME 6 cross contamination, maintaining any needed chain of
custody, and safe handling procedures

King Fahad Armed Forces Hospital-Jeddah

 Prevention and Control of Infections (PCI)

PCI.8.1 New Standard Introduced requirement to protect patients and staff from bloodborne pathogen
and Intent exposure

  New ME 1
To identify areas of risk for exposure to blood and body fluids and reduce the risk

  New ME 2 To have a process for reporting exposure to blood and body fluids

  New ME 3 Tohave a process for responding to blood and body fluid exposure

  New ME 4 To educate staff on the process

  New ME 5 To track and monitor exposure incidents
  New ME 6 To use exposure data to prevent future exposures
King Fahad Armed Forces Hospital-Jeddah
 Prevention and Control of Infections (PCI)
 PCI.9 Added requirement for the hospital to use a process to maintain
New ME 4 proper food temperature
Moving content on demolition, construction, and renovation to
PCI.10 Standard
new Standard PCI.7.11
  Intent Revised to focus on mechanical and engineering controls used
to proactively prevent infection
Added requirement for the hospital to operate and maintain
  New ME 1 negative and positive pressure ventilation systems in
accordance with laws, regulations, and professional standards
Added requirement for the hospital to maintain temperature
  New ME 2 controls in accordance with laws, regulations, and professional
standards

King Fahad Armed Forces Hospital-Jeddah

 Prevention and Control of Infections (PCI)

 PCI.13 Intent Included expectation to educate patients and visitors as needed on proper hand-
disinfecting procedures and personal protective equipment

  New ME 5 Added requirement to educate patients and visitors on hand-disinfection practices

and how to correctly use personal protective equipment

 PCI.14 Intent Added examples of monitoring data

  New ME 4: Added requirement to include benchmarking infection rates in monitoring data

King Fahad Armed Forces Hospital-Jeddah

 Governance, Leadership, and Direction (GLD)
Standard and Standard and Intent: Revised to address the
GLD.6.2 Intent credentialing, competency, and privileging of all
contracted health care professionals

Added requirement to ensure a comparable

  New ME 6 credentials review of contracted licensed health
care professionals

King Fahad Armed Forces Hospital-Jeddah

 EVALUATE | EDUCATE |

EVALUATE ENGAGE

Determine your Measure your baseline.

status:
MATURITY LEVELS >
PRO G RE SS I VE JOURNEY TO SAFER PATIENT CARE

LEVEL LEVEL LEVEL LEVEL

1 2 3 4

BEGIN DEVELOP STANDARDIZE ADVANCE

Environment and processes of Stable environment and Environment and Consistent
patient care are prone to processes of patient care patient care processes implementation of
high risk. with adequate resources standardized with evidence-based practices
for operation. resources dedicated to mitigate risk in
to quality environment and patient
improvement. care processes. Consider
international
accreditation.

King Fahad Armed Forces Hospital-Jeddah

 EVALUATE | EDUCATE |

EVALUATE ENGAGE

Determine your status: Measure your baseline.

EVALUATE REPORT >

E
PL
AM
EX

King Fahad Armed Forces Hospital-Jeddah

 Governance, Leadership, and Direction (GLD)
Added requirement to provide leadership in the
GLD.7 New ME 5
emergency and disaster management programs
Expanded to include the assessment of participation in
quality activities as well as measurement activities in
GLD.11.1 MEs 1–3 ongoing professional practice evaluations and
performance evaluations of physicians, nurses, and
other professional staff
GLD.12.2 Intent Added an example of a conflict of interest

King Fahad Armed Forces Hospital-Jeddah

 Facility Management and Safety (FMS)
Added expectation to include a comprehensive facility-
wide risk assessment in the facility management and
FMS Overview safety program when needed; revised the list of
required written facility management and safety
programs, separating safety from security and adding
construction and renovation

FMS.1 Intent Revised to address safety of hospitals located inside

larger, multiuse buildings
Added requirement to address expectations for
  New ME 5 hospitals located inside multiuse buildings

King Fahad Armed Forces Hospital-Jeddah

 Facility Management and Safety (FMS)
 FMS.2 Revised to address leadership’s responsibility on assigning a qualified
Intent individual to oversee the facility management and safety structure

Added requirement for the individual who oversees the facility management
  New ME 3 and safety structure to be responsible for coordinating and managing facility
risk assessment and risk reduction activities

FMS.3 New Standard and Introduced requirement on development of an annual comprehensive,

Intent facility-wide risk assessment
Added requirement to integrate the risk assessments to all eight facility
  New ME 1 management and safety programs when developing risk assessment

  New ME 2 Added requirement to prioritize identified risks and implement improvements

to reduce risk

  New ME 3 Added requirement to evaluate the effectiveness of improvements that are

applicable to facility management and safety programs FMS.4

King Fahad Armed Forces Hospital-Jeddah

 Facility Management and Safety (FMS)
Added requirement to integrate data from the facility
 FMS 4
New ME 2 management and safety programs into the quality and patient
safety program

  New ME 4 Added requirement to annually provide comprehensive, facility-

wide risk assessment and improvements to hospital leadership

Moved previous FMS.3, intent letter f ) and added language to

  ME 5 clarify requirement for hospital leadership to provide an annual
report to the governing entity on the effectiveness of the facility
management and safety programs

King Fahad Armed Forces Hospital-Jeddah

 Facility Management and Safety (FMS)
Standard Renumbered previous Standard FMS.4 and its MEs 1–3

 FMS.5 Intent Split and adapted the previously combined intent into one
for safety (FMS.5) and one for security (FMS.6)

Added requirement for monitoring to ensure that safety

  New ME 4 risks are reduced or eliminated

 FMS.6 New ME 2 Added requirement for an annual security risk assessment

  New ME 5 Added requirement for monitoring to ensure that security

risks are reduced or eliminated

King Fahad Armed Forces Hospital-Jeddah

 Facility Management and Safety (FMS)
FMS.7 New Standard Introduced requirement to develop a program for the overall management of hazardous
and Intent materials and waste
Added requirement for the hospital to develop and implement a written program for
  New ME 1 managing hazardous materials and waste
Added requirement for the hospital to conduct an annual hazardous materials and
  New ME 2 waste risk assessment

  New ME 3 Added requirement for the hospital to monitor and ensure that hazardous materials and
waste risks are reduced or eliminated
Renumbered and split previous Standard FMS.5 into one for hazardous materials
FMS.7.1 Standard (FMS.7.1) and one for hazardous waste (FMS.7.2)

  ME 1 Renumbered and split previous FMS.5, ME 1, focusing on hazardous materials in

FMS.7.1, and added language to require an annual update to the inventory

  ME 2-4 Renumbered and split previous FMS.5, MEs 2–4, focusing on hazardous materials in
FMS.7.1, and added language to ME 4 referencing safety data sheets (SDS)
  ME 5 Combined, renumbered, and adapted previous FMS.5.1, MEs 1 and 2
  ME 6 Renumbered and expanded previous FMS.5.1, ME
King3 Fahad Armed Forces Hospital-Jeddah
 Facility Management and Safety (FMS)

 FMS.7.2 ME 1 Renumbered and split previous FMS.5, ME 1 to focus on identifying the types of hazardous
waste

  ME 3 Renumbered, split, and adapted previous FMS.5, ME 1 to focus on documenting quantities of

hazardous waste, with the added disclaimer when laws and regulations require it

Renumbered and adapted previous Standard FMS.7 to include ongoing assessment of risk
FMS.8 Standard and compliance with laws and regulations

Revised the list of items to include in fire safety risk assessment and expanded discussion to
  Intent include information about and examples of risk assessment and response, interim measures,
and reference to a new Appendix to the FMS chapter with additional interim measures

  New ME 3 Added requirement to implement interim measures when fire safety risks cannot be
immediately addressed

  New ME 4 Added requirement for monitoring to ensure that fire safety risks are reduced or eliminated
King Fahad Armed Forces Hospital-Jeddah
 Facility Management and Safety (FMS)
New Standard and Moved the concepts of early detection, suppression, and containment from
FMS.8.1 Intent previous Standard FMS.7 into a stand-alone standard

  New ME 3 Added requirement for the fire safety program for features for containment of
fire and smoke when required by local laws and regulations

FMS.8.2 New Standard and Moved the concept of a safe exit from the facility from previous Standard
Intent FMS.7 into a stand-alone standard
  New ME 2 Added requirement for clearly visible exit signage
  New ME 3 Added requirement for lighting of emergency exit corridors and stairs

FMS.8.3 New Standard and Moved the concept of fire safety equipment inspection, testing, and
maintenance from previous Standards FMS.7 and FMS.7.1 into a stand-alone
Intent standard and noted the application of new Appendix on interim measures.

  New ME 3 Added requirement on correction of deficiencies identified in fire safety

equipment and system inspections with interim measures until fully corrected

King Fahad Armed Forces Hospital-Jeddah

 Facility Management and Safety (FMS)
 FMS.8.4 New ME 3 Added requirement to document the results of fire
safety program exercises and reeducate staff who
did not pass the exercise

 FMS.8.5 Intent Added a description of what smoking includes

  New ME 4 Added requirement prohibiting smoking in any

area under construction or renovation

King Fahad Armed Forces Hospital-Jeddah

 Facility Management and Safety (FMS)

Renumbered and expanded intent from previous

Standard FMS.8 to include new Standard FMS.9.1 to
FMS.9 & FMS.9.1 Intent focus on management of medical equipment
throughout the organization, including an annual risk
assessment

Added requirement to document an annual medical

 FMS.9 New ME 2 equipment risk assessment

Added requirement for monitoring to ensure that

  New ME 3 medical equipment risks are reduced or eliminated

King Fahad Armed Forces Hospital-Jeddah

 Facility Management and Safety (FMS)
New Moved the concept of documented medical equipment inspection, testing, and preventive
FMS.9.1 Standard maintenance from previous Standard FMS.8 into a stand-alone standard

  New ME 1 Added requirement for the medical equipment program to address both hospital-owned
and nonhospital-owned medical equipment that is in the hospital

 FMS.9.2 Intent Added the expectation that the hospital conduct a root cause analysis in response to any
sentinel events

  ME 2 Clarified that reporting occurs through the hospital’s incident and adverse event reporting
process

FMS.10 Standard Renumbered previous Standard FMS.9; expanded definition of critical utilities to include
medical gases

Added requirement to develop and implement a written utility system management

  New ME 1 program

  New ME 2 Added requirement for annual utility system risk assessment

Added requirement for monitoring to ensure that utility system risks are reduced or
  New ME 3
eliminated (incorporating concepts from previous FMS.9.1, MEs
King Fahad 1–4)Forces Hospital-Jeddah
Armed
 Facility Management and Safety (FMS)
FMS.10.3 & Intent Revised intent of previous Standard FMS.9.3 and combined with additional information
for new Standard FMS.10.3.1 on water quality in dental services and hemodialysis and
FMS.10.3.1
acting to address problems with water quality

 FMS.10.3
New ME 5 Added requirement on testing and treatment of dental unit waterlines

FMS.10.3.1 New Standard Moved the concept to comply with professional standards for testing water used for
and Intent hemodialysis for contaminants from FMS.9.3 into stand-alone standard.

  New ME 1 Added requirement for hospital hemodialysis services to follow industry standards and
professional guidelines to maintain water quality and implement control measures

  New ME 3 Added requirement to perform routine disinfection of the hemodialysis water

distribution system

Added requirement to test all hemodialysis machines annually and document the
  New ME 4
results
  New ME 5 Added requirement to establish and implement a process for reprocessing dialyzers
King Fahad Armed Forces Hospital-Jeddah
 Facility Management and Safety (FMS)
FMS.11 Standard Renumbered and adapted previous Standard FMS.6 to reinforce that the hospital must
be prepared to respond to both internal and external emergencies

Revised to address what an evaluation of structural elements of hospital buildings

would include and planning for a response when staff may not be able to come to the
hospital in an emergency; revised the list of items for which the hospital must have a
  Intent process in its emergency and disaster management program, including adding planning
for alternative power and water sources (which is also part of revised Standard
FMS.10.2)

King Fahad Armed Forces Hospital-Jeddah

 Facility Management and Safety (FMS)
 FMS.12 Included examples of risks to individuals in the hospital; revised the list of critical
Intent elements to include in a preconstruction risk assessment, adding hazardous waste, fire
safety, security, and emergency procedures

Provided examples of interim measures, which are actions taken to ensure the safety
FMS New Appendix of the building’s occupants during times when features and systems for fire safety are
defective, compromised, or inoperable due to construction, maintenance, or a
breakdown or repair

 Note:  These measures are not required, but provide examples related to the requirements of Standards FMS.8
and FMS.8.3

King Fahad Armed Forces Hospital-Jeddah

 Staff Qualifications and Education (SQE)
Reinforced that credentialing licensed health care practitioners represents the first and most
  Overview important opportunity for the hospital to protect patients

Added expectation that the evaluation process for hiring qualified clinical staff members includes
SQE.3 Intent an assessment of the staff member’s ability to operate medical equipment and clinical alarms
and oversee medication management unique to the specific area

Split and clarified requirement on the orientation of staff who accompany independent
SQE.7 ME 3 practitioners and provide care and services
  ME 4 Combined with previous ME 3 to include volunteers in the hospital orientation program

Clarified that level of life support training (basic or advanced) must be appropriate to roles of
SQE.8.1 ME 2
staff providing clinical care

ME 3and Retained requirements for staff who provide clinical care in SQE.8.1 and duplicated them for staff
 
ME 4 who do not provide patient care in SQE.8.1.1 as MEs 2 and 3

King Fahad Armed Forces Hospital-Jeddah

 Staff Qualifications and Education (SQE)

Removed periodical preventive immunizations and examinations from the list of critical
SQE.8.2 Intent elements a staff health and safety program must address; added content on compassion
fatigue and staff burnout of health care practitioners;

  ME 2 Given the change to the intent, revised the list of critical elements the hospital must
address in a staff health and safety program

  New ME 6 Added requirement that the hospital creates a culture of wellness to support physical
and mental well-being

King Fahad Armed Forces Hospital-Jeddah

 Staff Qualifications and Education (SQE)
Changed the term ongoing monitoring and evaluation to ongoing
professional practice evaluation (here and throughout the
SQE.11 Intent manual) and revised the definition to align with current
professional practice

Intent: Clarified that primary source verification is carried out for

SQE.13 Intent all nurses; described a time-limited exception for a JCI initial
accreditation survey that refers only to the verification of
credentials
Clarified that primary source verification is carried out for all
other health care practitioners; described a time-limited
SQE.15 Intent exception (reduced from 3 years to 12 months) for a JCI initial
accreditation survey that refers only to the verification of
credentials

King Fahad Armed Forces Hospital-Jeddah

 Management of Information (MOI)
MOI Overview Emphasized the importance of protecting patient information

Specified groups with information needs from the information management

MOI.1 Standard and Intent process, including those who provide clinical services, the hospital’s leaders, and
those outside the hospital who require data and information from the
organization

Clarified that the hospital must plan and implement processes to meet, not
  MEs 1–3
simply consider, information needs

Expanded to include availability of trained staff, technical resources, and other

  ME 4
resources

Expanded to address measures to secure and protect data and information,

  Intent of MOI.2 and including paper and electronic medical records, security of electronic information
MOI.2.1 systems, the process for granting and monitoring access, and best practices for
security measures and strategies

Revised to require processes to manage and control access to data and

MOI.2 Standard information

  New ME 3 Added requirement for a process to grant authorized individuals access privileges
to data and information in accordance King
withFahad Armed
their level ofForces
accessHospital-Jeddah
 Management of Information (MOI)
 MO1.2.1 New ME 1 Added requirement to conduct and document an annual risk assessment to identify and
prioritize data security risks
  New ME 3 Added requirement to implement data security best practices to protect and secure data and
information
Added requirement to identify, implement, and monitor goals and improvements to reduce or
  New ME 4 eliminate data security risks
MOI.3 Intent Clarified that “other information” includes text messages and e-mails that contain information
for medical records
  ME 1 Clarified that retention times must comply with laws and regulations
Added information on patient and staff understanding of abbreviations and clarified that
MOI.4 Intent principles apply to medical records and any electronic communications, such as e-mail and
texting, that are used for communicating about patient care
MOI.5 Intent Expanded to address timely dissemination of data to both internal and external personnel
  ME 1 Expanded to identify groups with data and information needs
  ME 2 Clarified that data and information are received in a manner that supports continuity of care
  ME 3 Clarified that users may be within and outside the hospital
  ME 4 Emphasized that staff have access to data and information needed to provide care safely and
effectively

King Fahad Armed Forces Hospital-Jeddah

 Management of Information (MOI)
 MOI.6 Expanded description of benefits on education and training and provided information
Intent about and examples of ongoing training
Added requirement for the hospital to educate, train, and assess staff who use an
  New ME 2 electronic medical record system to ensure that they can effectively and efficiently use
the system to carry out their responsibilities
Added an additional key component to identify and track documents in circulation to be
 MOI.7
Intent included in the guidance document addressing policies and procedures (from previous
MOI.8, ME 3, to letter h)

  ME 1 Given the change to the intent, expanded the key components a written guidance
document must address

 MOI.8 Intent of MOI.8 Renumbered from intent of previous Standards MOI.9 and MOI.9.1 and revised to
address use of copy-and-paste, auto-fill, auto-correct, and other functions in
and MOI.8.1
documentation

King Fahad Armed Forces Hospital-Jeddah

 Management of Information (MOI)

 MOI.8 ME 1 Combined and expanded previous MOI.9, MEs 1 and 2, and

now requires two unique identifiers for patient medical
records
Renumbered previous MOI.9.1, ME 2 and clarified that
MOI.8.1ME 2 medical records contain adequate information to promote
continuity of care
Extracted applicable information from intent of previous
MOI.9 Intent Standards MOI.11 and MOI.11.1 and added information
about the use of documentation assistants or scribes
Added requirement to address the use of scribes who assist
  New ME 5: with documentation in the patient medical record

King Fahad Armed Forces Hospital-Jeddah

 Management of Information (MOI)
MOI.11 New Standard Introduced requirement for hospital leadership to identify a qualified individual to
and Intent: oversee health information technology systems

Built off intent of previous Standard MOI.13 and expanded to discuss the importance of
  Intent health information technology systems and the individual overseeing health
information technology, including identifying that individual’s key responsibilities

  New ME 2 Added requirement for qualified individual to oversee the hospital’s health information
technology systems

Renumbered and expanded previous MOI.13, ME 3, adding requirement for monitoring

  ME 4 health information technology systems and implementing improvements based on
evaluation results

King Fahad Armed Forces Hospital-Jeddah

 Management of Information (MOI)

MOI.12 New Standard Introduced requirement to maintain security and confidentiality of patient information
when the hospital allows mobile devices for texting, e-mailing, and/or other
and Intent
communications (pulling in some concepts from previous Standard COP.2.2)

Added requirement to implement information security guidelines and processes when

  New ME 2 mobile devices are used to communicate patient data and information

Added requirement to document any data and information provided via text messages
  New ME 3 or e-mails on mobile devices in the medical record

Added requirement to obtain patient consent to participate in an electronic patient

  New ME 4 portal and/or receive text messages or e-mails

  ME 5 Renumbered and adapted previous COP.2.2, ME 6 to expand potential communication

platforms to require the hospital to address questions in a timely way

King Fahad Armed Forces Hospital-Jeddah

 Management of Information (MOI)

 MOI.13 Revised to provide information about and examples of

Intent communication prior to planned downtime or during
unplanned downtime and strategies to recover
Renumbered and expanded previous MOI.14, ME 3 to
  ME 3 reinforce that services provided by outside vendors
must be included in the downtime response program
Added requirement to identify internal and external
  New ME 4 communication strategies for planned and unplanned
downtime

King Fahad Armed Forces Hospital-Jeddah

 Medical Professional Education (MPE)
Made minor editorial revisions throughout the chapter

Human Subjects Research Programs (HRP)

Not applicable to KFAFH
Made minor editorial revisions throughout the chapter

King Fahad Armed Forces Hospital-Jeddah