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[Page 1]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

SURVEY ELIGIBILITY CRITERIA

Page 1, 1st "BULLET"
*must be located within the United States or one of its territories or possessions; or, unless an exception is made by the president of JCAH, or in the absence of the president, the chairman of tbe Board of Commisioners. Yes_____  No_____

Page 1, 4th "BULLET" .
*must be a hospital where the median length of stay is 30 days or less (exceptions may be made bv the president of JCAH) or the treatment provided is of such a nature that patient would not ordinarily be transferred to mother facility for more intensive care. Yes_____  No_____

Page 2, 2nd, 3rd, and 4th "BULLET"
*must have at least one of the following acute te clinical services: medicinal/: obstetrics-gynecology/pediatrics/: surgery/: child. adolescent or adult psychiatry or alcoholism or drug abuse services. Yes_____  No_____

*must provide thet only a member of the organized staff, who has such privileges, has the authority to admit a patient to the hospital. Yes_____  No_____

*must provide that each individual who has been granted clinical privileges by the governing body practices only within the scope of those clinical privileges. .
Yes_____  No_____

COMMENTS

ANESTHESIA SERVICES
Page 5, line 7
Written policies of the anethesia services shall be approved by the medical staff, or the executive committee of the medical staff, reviewed annually and enforced. These policies shall provide for at least the following: Yes_____  No_____

Page 7, lines10-17
If anesthesia services are provided in a psychiatric/substance abuse hospital, the anesthesia services shall be provided in accordance with the needs of the patients and the nature of the psychiatric/ substance abusse services offered. Such psychiatric/substance abuse hospitals shall have a written description of ehe anesthesia services provided and the position of those servicer within the organization of the hospital. The hospital also shall comply with applicable standards in this section of the Manual. Yes_____  No_____

[Page 2]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

ANESTHESIA SERVICES (cont.)
Page 7, lines 18-47
Standard IV

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by the anesthesia department/service.

The anesthesia department/service has a program for the review and evaluation of patient care that is an integral part of the hospital quality assurance program. The physician director of the anesthesia department/service is responsible for implementing the program.

Through review end assessment of information obstained from ongoing monotoring activities and other data s o ur c es important problems in patient care and opportunities for improving care are identified .

Criteria that reflect current knowledge and clinical experience are used in these review and assessment activities.

Actions are taken to resolve identified problems, and the effectiveness of those actions is monitored.

Information obtained through the ongoing review and evaluation of care including ongoing monitorinq activities, and information about the impact of actions taken to resolve problems and to improve care is:
*documented, and
* integrated with the hospital's overall quality assurance program
When anesthesia services are provided bv source(s) outside the hospital, or when there is no designated a nesthesia depart-ment, either the medical staff or the chief executive officer ensures effective review and evaluation of the quality and appropriateness of the patient care provided bv the outside source(s).

Refer to the Quality Assurance Section of this Manual Yes_____  No_____

COMMENTS

BUILDING AND GROUNDS SAFETY

Page 8, lines  14-23
Standard I

In hospitals that provide only psychiatric/substance abuse services, the premises also shall be designed, constructed, maintained, equipped, and furnished in a manner consistent with the mission of the hospital. The physical environment of such hospitals shall be suitable to the nature of the services provided, the patient population served the therapeutic goals of the individual units of the hospital, and the ages of the patients served. The environment of such hospitals shall be designed to contribute to positive self-images in patients and to preserve their human dignity Yes_____  No_____

COMMENTS

[Page 3]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

DIETETIC SERVICES
Page 12, lines 19-24
Standard III

In hospitals with psychiatric/substance abuse departments/ services and in hospitals that provide only psychiatric/ substance abuse services,policies and procedures also shall relate to the method for assigning patients for dietary counseling and rehabilitation and to the method of recording special dietetic orders.
Yes _____  No _____

Page 13, lines 12-16
Standard V

Confirmation by the responsible practitioner of the diet order of patients receiving oral alimentation with the exception of designated psychiatric patients, uithin 24 hours of admission and within 24 hours after all subsequent orders for a diet modification.
Yes _____  No _____

Page 14, lines 1-33
Standard VI

*As appropriate the nutrient intake of patients is as-sessed ard recorded, including attention to emotional factors that contribute to patients' food habits.
Yes _____  No _____

* As appropriate. patients with special dietary needs receive instructions relative to their diets, and an indictation of the patient 's (or family's) understanding of these instructions is recorded in the medical record.

*As appropriate, patients who are discharged from the hospital on modified diets receive written instructions and individualized counseling before discharge. In hospital psychiatric/substance abuse departments/ services and in hospitals that provide only psychiatric/ substance abuse services, patients also are given written instructions and individualized counseling on potential drug-food interactions before discharge

*Qualified dietitians participate in committee activities concerned with nutritional care. In hospital psychiatric/substance abuse departments/services and in hospitals that provide only psychiatric/substance abuse services for qualified dietician in committee activities concerned with nutritional care.

*A maximum effort is made to assure the appetizing appearance, palatability, proper serving temperature, and retention of nutrient value of food. Whenever possible, special food preferences or the patient shall be respected and appropriate dietary substitutions made available. Surveys to determine pacient acceptance of food are encouraged, particularly in the case of long-stay long-stay patients.
Yes_____  No_____
 [Page 4]

Evaluation Forms
Proposed Revisions to the Accreditation Manual for Hospitals

DIETETIC SERVICES (cont.)

Page 15, lines 1-30
Standard VII

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by the dietetic department/service.

The dietetic department/service has a program for the review and evaluation of patient care that is an integral part of the hospital quality assurance program. The director of the dietetic department/service, with medical staff input, is responsible for implementing the program.
Through review and assessment of information obtained from ongoing monitoring activities and other data sources, important problems in patient care and opportunities for improving care are identified.
Criteria that reflect current knowledge and clinical experience are used in these review assessment activities.
Actions are taken to resolve identified problems, and the effectiveness of those actions is monitored.
Information obtained through the ongoing review and evaluation of care, including ongoing monitoring activities, and information about the impact of actions taken to resolve problems and to improve care is:
*documented, and
*integrated with the hospital's overall quality assurance program.
When dietetic services are provided by source(s) outside the hospital, either the medical staff or the chief executive officer ensures effective review and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).
Refer to the Quality Assurance Section of this Manual.
Yes_____  No_____
COMMENTS

EMERGENCY SERVICES
Page 18, lines 27-51
Standard I

In a hospital that provides only psychiatric/substance abuse services, emergency services for patients in the hospital may be provided directly by the hospital or through an arrangement with another health care facility that is accredited by JCAH or its equivalent. If emergency services are provided directly by the hospital, the hospital must comply with the standards in this section of the Manual. If the hospital has a transfer arrangement with another health care facility, the hospital policies and procedures shall clearly describe the transfer arrangement and the method for providing immediate care.

The policies and procedures also shall clearly delineate the staff in the hospital who are available to provide necessary emergency evaluations; the method for arranging for the patient's referral or transfer; the method of communication between the hospital and the health care facility providing emergency services; the arrangements for exchanging patient records when necessary for the care of the patient; and the method for assuring continuity in psychiatric treatment after transfer.

If the hospital elects to provide emergency services to the community as well as to patients in the hospital, the hospital must meet all the provisions in this section of the Manual. Hospitals that do not provide emergency services to the community shall be exempt from those standards and interpretations in this section of the Manual that relate to providing emergency services to the community.
Yes_____  No_____

[Page 5]

Evaluation Forms
Proposed Revisions to the Accreditation Manual for Hospitals

EMERGENCY SERVICES (cont.)

Page 21,  lines 15-44
Standard IX

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by the emergency department/service

The emergency department/service has a program for the review and evaluation of patient care that is an integral part of the hospital quality assurance program. The physician director of the emergency department/service is responsible for implementing the program.

Through review and assessment of information obtained from ongoing monitoring activities and other data sources, important problems in patient care and opportunities for improving care are identified.

Criteria that reflect current knowledge and clinical experience are used in these review and assessment activities.

Actions are taken to resolve identified problems. and the effectiveness of those actions is monitored.

Information obtained through the ongoing review and evaluation of care. includinq ongoing monitorinq activities, and information about the impact of actions taken to resolve problems and to improve care is:
*documented, and
*integrated with the hospital's overall quality assurance program.

When emerqency services are provided by source(s) outside the hospital, either the medical staff or the chief executive officer ensures effective review and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).

Refer to the Quality Assurance Section of this Manual.
Yes_____  No_____

COMMENTS

FUNCTIONAL SAFETY AND SANITATION

Page 24, lines 1-15
Standard II

Hospitals that provide only psychiatric/substance abuse services do not have to have an autonomous emergency power source if they do not adminsiter inhalation anesthetics or do not have patients who require electromechanical life-support systems. However, such hospitals must provide for the following in the event of a failure
of the normal power source:
*Egressillumination (corridors, stairways and landings. exit doors).
*Selected service and taskillumination in designated treatment rooms, desiqnated nurses' stations, and designated medication preparation areas.
*A method for issuing instructions during emerqencv conditions. A battery powered magaphone is considered adequate.
Yes_____  No_____

 [Page 6]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

FUNCTIONAL SAFETY AND SANITATION (cont.)

Page 24, lines 24-30
Standard II

In hospitals that provide only psychiatric/substance abuse abuse services such safety devices shall be installed as appropriate to the needs of patients. When grab bars are installed in penal and psychiatric facilities, they shall be nonremovable
Yes_____  No_____

Page 26, lines 1-4
Standard II

Unsupervised smoking by patients classified as not mentally or physically responsible for their actions , including patients so affected by medications, shall be discouraged,
Yes_____  No_____

Page 27, lines 48-51
Standard III

If a hospital that provides only psychiatric/substance abuse services has been designated as an external disaster emergency center, the hospital m us t meet requirements in this section of the Manual for an external disaster plan.

Yes_____  No_____

COMMENTS

GOVERNING BODY

Entire Chapter; Pages 34-36

STANDARD I

An organized governing body, or designated persons so functioning, is responsible for establishing policy, maintaining quality patient care, and providing for institutional management and planning.

REQUIRED CHARACTERISTICS

1. The governing body adopts bylaws in accordance with its legal account-ability and its responsibility to the patient population served. Yes_____  No_____

2 . The bylaws specify at least the following:
Yes_____  No_____

A. The role and purpose of the hospital:
Yes_____  No_____

B. The duties and responsibilities of the g o v e r n i n g b o d y;

2A. through 21.

C. The mechanism for selecting members of the governing body;

 [Page 7]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

GOVERNING BODY (cont.)

Standard I (cont.)

D. The governing body's organizational structure, including, but not limited to.

(1) The the mechanism for selecting officers;
(2) the responsibilities of officers;
(3) the procedures for meetings;
(4) the composition and responsibilities of governing body committees, if any, and
(5) the inclusion of organized staff members on governing body committees that deliberate issues affecting the discharge of organized staff responsibilities .

E. The relationship of responsibilities between the governing body those of

(1) any authority superior to the governing body, if such exists.
(2) the chief executive officer,
(3) and the organized staff.

F. The provision for the establishment of an organized staff;

G. The provision for the establishment of auxiliary organizations. if applicable;

H. The mechanism for adopting the governing body bylaws; and

I. The mechanism for review and revision of the bylaws.

3. When not legally prohibited, members of the organized staff are eligible for full membership on the governing body in the same manner as other individuals.
Yes_____  No_____

4. The organized staff has the right of representation (through attendance and voice) at meetings of the governing body by one or more organized staff members selected by the organized staff.
Yes_____  No_____

5. There is a systematic and effective mechanism for communication between members of the governing body the administration, and the organized staff.
Yes_____  No_____

6. Any auxiliary organizations and individual volunteers delineate their purpose and function for approval by the governing body.
Yes_____  No_____

7. A record of governing body proceedings is maintained.
Yes_____  No_____

8. The governing body provides for institutional planning. The administration the organized staff,the nursing department/service, and other departments/services, and appropriate advisers participate in the planning process.
Yes_____  No_____

9. The governing body approves an annual operating budget develops a long-term capital expenditure plan as required by applicable laws and regulations and monitors the implementation of the plan.
Yes_____  No_____

10. The governing body appoints a chief executive officer who is qualified for his responsibilities through education and experience.
Yes_____  No_____

11. The governing body designates a mechanism for monitoring the performance of the chief executive officer.
Yes_____  No_____

12. The governing body requires the organized staff make recommendations concerning organized staff appointments appointments termination of appointments, and the granting or revision of clinical privileges; any differences are resolved within a reasonable period of time by the governing body and the organized staff. The governing body acts on the recommendations.
Yes_____  No_____

 [Page 8]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

GOVERNING BODY (cont.)

Standard I (cont.)

13. The governing body evaluates its own performance.  The governing body requires that only a member of the organized staff with admitting privileges may admit a patient to the hospital and that individuals practice only within the scope of the privileges granted to then by the governing body.
Yes_____  No_____

14. The governing body requires the organized staff and staffs of the hospital departments/services to implement and report on the activities and mechanisms for monitoring the quality of patient care and identi-fying and resolving p r o b l e m as well as opportunities to improve patient care. The governing body,through the chief executive officer. provides the support necessary for montoring activities and for problem identification and resolution activities.
Yes_____  No_____

15. The governing body holds the organized staff responsible for the development. adoption, and periodic review of organized staff bylaws and rules and regulations that are consistent with hospital policy and with any applicable legal or other requirements. Organized staff bylaws and rules and regulations are subject to, and effective upon, approval by the governing body. Approval is not unreasonably withheld.
Yes_____  No_____

16. The governing body evaluates its own performance.
Yes_____  No_____

STANDARD II

The governing body avoids conflicts of interest.
Yes_____  No_____

REQUIRED CHARACTERISTICS

1. The governing body provides for full disclosure of hospital ownership and control.
Yes_____  No_____

2. The governing body develops and implements a written conflict-of-interest policy that includes guidelines for the resolution of any existing or apparent conflict of interest.
Yes_____  No_____

STANDARD III

All members of the governing body understand and fulfill their responsibilities.
Yes_____  No_____

REQUIRED CHARACTERISTICS

1. All new members of the governing body participate in an orientation program.
Yes_____  No_____

2. All members of the governing body are provided information relating to the governing body's responsibilities for quality care and the hospital's quality assurance program.
Yes_____  No_____

COMMENTS

 [Page 9]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

HOME CARE SERVICES

Page 40, lines 45-75
Standard V

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by the home care service.

The home care service has a program for the review and evaluation of patient care that is an integral part of the hospital quality assurance program. The director of the home care service, with medical staff input, is responsible for implementing the program.

Through review and from ongoing mo important problem assessment of information obtained nitoring activities and other data sources, s in patient care and opportunities for improving care are identified.

Criteria that reflect current knowledqe and clinical experience are used in these review and assessment activities.

Actions are taken to resolve identified problems, and the effectiveness of those actions is monitored.

Information obtained through the ongoing review and evaluation of care, including ongoing monitoring activities, and information about the impact of actions taken to resolve problems and to improve care is: . . .
*documented, and
*integrated with the hospital's overall quality assurance program.

When home care services are provided by source(s) outside the hospital, either the medical staff or the chief executive officer ensures effective review and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).
Refer to the Quality Assurance Section of this Manual

COMMENTS

HOSPITAL-SPONSORED AMBULATORY CARE SERVICES

Page 41, lines 14-20
Standard I

When hospital-sponsored ambulatory care services are provided to psvchiatric/substance abuse patients, thev shall be provided in a manner that is consistent with the psychiatric needs of those patients and that allows for multidisciplinary participation.
when appropriate. a written plan shell describe the manner in which the hospita1 will comply with all pertinent requirements in this and other sections of this Manual.
Yes_____  No_____

Page 45, lines 41-43
Standard VI

There is a quality assurance mechanism designed to sample outpatient care and to assure that patients are seen, when necessary. by a phvsician.
Yes_____  No_____

 [Page 10]

E v a l u a t i on Form
Proposed Revisions to the Accreditation Manual for Hospitals

HOSPITAL-SPONSORED AMBULATORY CARE SERVICES (cont.)

Page 46, lines l-29
Standard VII

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by the ambulatory care department/service.

The ambulatory care department/service has a program for the review and evaluation of patient care that is an integral part of the hospital quality assurance program. The physician director of the department/service is responsible for implementing the program.

Through review and assessment of information obtained from ongoing monitoring activities and other data sources, important problems in patient care and opportunities for improving care are identified.

Criteria that reflect current knowledge and clinical experience are used in these review and assessment activities.
Actions are taken to resolve identified problems, and the effectiveness of those actions is monitored.
Information obtained through the ongoing review and evaluation of care, including ongoing monitoring activities, and information about the impact of actions taken to resolve problems and to improve care is:

*documented, and
*integrated with the hospital's overall quality assurance program.

When ambulatory care services are provided by source(s) outside the hospital. either the medical staff or the chief executive officer ensures e f f e c t i v e review and evaluation of the quality and appropriateness of the patient care provided by the . out s ide source(s),.

Refer to the Quality Assurance Section of this Manual.
Yes_____  No_____

C O M M E N T S

MANAGEMENT AND ADMINISTRATIVE SERVICES

Entire Chapter; Pages 51-52

STANDARD I

The hospital is managed effectively and efficiently
Yes_____  No_____

REQUIRED CHARACTERISTICS

1. A chief executive officer appointed by the governing body is responsible for the operation of the hospital in a manner commensurate with the authority conferred by the governing body. The chief executive officer is qualified by education and experience that is appropriate to the fulfillment of his responsibilities.
Yes_____  No_____

2. The chief executive officer develops mechanisms to implement the policies established by the governing body.
Yes_____  No_____

 [Page 11]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

MANAGEMENT AND ADMINISTRATIVE SERVICES (cont.)
Standard I (cont.)

3. The chief executive officer takes all reasonable steps to provide that the hospital complies, with applicable laws and regulations; and

A. Reviews and acts promptly, consistent with governing body policy, upon the reports and recommendations of authorized planning. regulatory and inspecting agencies;

B. Reports and recommendations of such examining and reviewing agencies and any activities taken in responce to them, are available to the Joint Commission on Accreditation of Hospitals.
Yes_____  No_____
3A. and 3B.

4. The chief executive officer, through the management and administrative staff, provides, for the following:
Yes_____  No_____
4A. through 4L

A. The implementation of organized management and administrative . functions throughout the hospital,including the establishment of clear lines of responsibility and accountability within departments/ services and between department/service heads and administrative staff;

B. The establishment of departments/services necessary for the effective and efficient functioning of the hospital;

C. The implementation of effective communication mechanism between hospital departments/services, the organized staff, the adminis-. tration, and the governing body;

D. The designation of an individual to act in his absence.

E. The establishment of internal controls to safeguard physical. financial and human resources;

F. Monitoring of the accuracy and reliability of financial data;

G. The control of inventories and purchasing procedures:

H. The implemantation of a comprehensive management reporting system to account to the governing body;

I. The coordination of hospital services with the identified needs of the patient population served;

J. A hospital wide policy on patient's rights and responsibilities;

K. The development of a written plan for the care and/or appropriate referral of patients who are emotionally ill, who become emotion-ally ill while in the hospital, or who suffer the results of alcoholism or drug abuse; and

L. The spiritual needs of patients,either through hospital resources or through an arrangement with appropriate community resources.

5. The chief executive officer,through the management and administrative staff, provides for personnel policies and practices that pertain to the following:

The employment of personnel,without regard to sex, race, creed, or nationa1 origin, whose qualifications are commensurate with anticipated job responsibilities;
5A. through 5F.
Yes_____  No_____

The orientation of all new employees to the hospital and to personnel po1ices;

The maintenance of an accurate, current, and complete personnel record for each hospital employee;

The verification of applicable current licensure/certifiation;

 [Page 12]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

MANAGEMENT AND ADMINISTRATIVE SERVICES (cont.)
Standard I (cont.)

E. A p e r i o d i c perfomance evaluation o f e a c h e m p l o y e e based on a job description; and

F. The provision of employee health services, in consultation with the medical staff. .

6. The chief executive officer through the management and administrative staff provides written plans f o r the implementation o f financial polices and practices that pertain to the following:
Yes_____  No_____
6A. through 6C

A. A f o r m a l b u d g e t that reflects the organization of the hospital and i s d e v e l o p e d with the participation of the medical staff and staff of other departments/services;

B. Unless otherwise provided by law. an annual audit , by an independent public accountant, of the financial statements o f the hospital; and

C. The control of a cco un ts receivable and payable, the handling of cash, and the arrangements for c r e d i t.

7. The chief executive officer. through the management and administrative staff, provides sufficient and timely data for use in program planning and evaluation. The data are sufficient to keep responsible p e r s o ns adequately and currently informed.
Yes_____  No_____

COMMENTS

 [Page 13]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

MEDICAL RECORD SERVICES

Page 57, lines 1-42
Standard II

The inpatient medical records of patients admitted to psychiatric/substance abuse hospitals/departments/services must, in addition to meeting the other requirements in this section of the Manual, include the following:

*Specification of the treatment modality.
*Evidence of an assessment of the patient's emotional, behavioral, social, recreational, and, when appropriate, legal, educational, vocational, and nutritional needs. The behavioral and social assessment must include consideration of any history of previous problems, current behavior and emotional functioning/and drug and alcohol problems, and when indicated, psychological testing and other assessments of psychosocial or sensory-motor functioning. In programs for children and adolescents, an evaluation of developmental age factors and consideration of educational needs must also be included.

*A statement of therapeutic goals and therapeutic interventions and their frequency. as well as an evaluation of the effectiveness of interventions in achieving goals.
As appropriate, patient/family participation in planning for treatment. *Documentation of a discharge plan for the patient, including arrangements for aftercare. posttherapy planning, and following evaluations. Pre-discharge planning is an integral part of treatment and should be documented.
*When special treatment procedures are used. evidence that these pro-cedures are performed in accordance with medical staff bylaws, rules and regulations. Special treatment procedures include the following:

*Restraint and seclusion. When restraint or seclusion is employed. a time-limited order from a phvsician must be written within 8 hours after initial use of the procedure. In addition. there must be documentation that the needs of the patient. especially in regard to meals, bathing. and use of the toilet, are attended to at lease every 15 minutes. The patient's informed consent is not required for the use of restraint or seclusion.
*Electroconvulsive therapy. When electroconvulsive therapy is used, there must be documentation of the patient's condition before. during, and after anesthesia and a description of physiological and psychological events during anesthesia.
*Psychosurgery or other surgical procedures to alter or intervene in an emotional. mental, or behavioral disorder.
*Aversive conditioning to modify behavior.
*Special treatment procedures for children and adolescents.

When a multidisciplinary team approach to treatment is used, the inpatient medical records of patients admitted to psychiatric/substance abuse hospitals/department/services must also include the following:

* Evidence of individualized multidisciplinary treatment planning and the resulting treatment plan, within must include a statement of therapeutic goals and interventions.

Evidence,in the progress notes, or implemention of the treatment plan.

Documentation of periodic review of the treatment plan by the multidisciplinary treatment team and revlsion of the plan as necessary.

Evidence of physician review and approval of the treatment plan developed by the multidisciplinary team.
Yes_____  No_____

COMMENTS

 [Page 14]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

ORGANIZED STAFF (Formerly Medical Staff)

Entire Chapter; Pages 76-87

STANDARD I

There is a single organized staff with o v e r a l l responsibi1ity f o r t he quality of the professional services provided. There is a mechanism to assure that each staff member is qualified to provide services within the scope of clinical privileges granted, including a periodic review of staff membership and hospital specific clinical privileges
Yes_____  No_____

REQUIRED CHARACTERISTICS

1. The organized staff has the following characteristics:
Yes_____  No_____

A. T h e o r g a n i z e d s t a f f included fully licensed physicians and may include ocher individuals who also qualify for clinical privileges and are licensed f o r i n d e p e n d e n t provision of patient care services.

B. All organized staff members have delineated c l i n i c a l p r i v i l e g e s.

2. Initial appointment to the organized staff is made through a hospital s p e c i f i c mechanism that is a p p r o v e d a n d implemented by t he o r g a n i z ed staff and the governing body,fully documented in organized staff by-laws and rules and regulations, and described to each applicant. The mechanism provides for, but is not necessarily limited to, the following:
Yes_____  No_____

A. Organized staff membership is granted by the governing body in accordance with one bylaws, rules and regulations, and policies of the organized staff a n d o f the hospital. Each applicant for membcrship is oriented to these regulations and polices and agrees in writing that his activities as a member of the organized staff, will be bound by them.

B. Professional criteria that are specified in the organized staff bylaws and are uniformly applied to all applicants or staff m e m b e rs constitute the basis for granting initial or continuing staff membership and clinical priivileges. The criteria are designed to assure the organized staff and governing body that patients wil l receive quality care and include at least evidence of relevant training and/or experience, current competence and health status. Criteria that lack professional relevance such as sex, race, creed, o r national origin, a r e not used in making decisions regarding staff membership and clinical privileges.

C. Each applicant for staff membership completes an application form that asks for information a s s p e c i f i e d in the o r g a n i z e d staff bylaws.

D. Each applicant pledges to provide for continuous care of his patients and acknowedges any organized staff bylaw provisions for release and immunity f r o m civil liability.

E. Each applicant consents to the inspection of records and documents pertinent to h i s application and, i f requested, a p p e a r s f o r so interview.

F. Recommendations by peers are part of the basis for development of recommendations for organized staff membership and delineation of clinical privileges.

G. A structured procedure is used for the expeditious processing of applications for appointment, and applications are acted on within a reasonable period of time, as specified in the hospital or orga-nized staff bylaws.

H. There is a mechanism for appropriate action, including a fair hearing, when the recommendations regarding initial appointment. credentialing and clinical privileges or renewal of privileges, are adverse to the applicant. This mechanism is defined in the hospital or organized staff bylaws.

 [Page 15]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

ORGANIZED STAFF (cont.)

Standard I (cont .)

I. The governing body makes the final decision on each application f o r oppointment within, reasonable period of time, a s specified in the hospital or organized staff bylaws. . .

J. Initial appointment and clinical privileges are for a provisional period, which is specified in the organized staff bylaws and i s consistent for all applicants.

K. A separate record is maintained for each organized staff member.

3. An individual's specific privileges are granted through a hospital-specific mechanism. This mechanism is delineated in organized staff bylaws and rules and regulations, implemented by the staff, and described to each applicant. The following requirements are observed:
Yes_____  No_____

A. Specific clinical privileges are graced in accordance with the bylaws, rules and regulations. and policies of the hospital and the organized staff.
Yes_____  No_____

B. Individuals who are not members of the organized staff but who are fully licensed for independent provision of patient care services have delineated clinical privileges.
Yes_____  No_____

C. Recommendations from peers are part of the basis for the development of recommendations for clinical privileges.
Yes_____  No_____

D. The specific clinical privileges granted are also based upon verified information regarding the applicant's specific training, experience and current competence. Action is withheld until such information is made available and is verified.
Yes_____  No_____

E. Departmental and/or major clinical service recomendations are part of the basis for granting specific c1inical privileges.
Yes_____  No_____

F. The mechanism by which the applicant requests, the executive committee of the o r g a n i z e d s t a f f recommends, and the governing body pants clinical privileges is hospital-specific. Whatever method is used, there is evidence that the granting of privileges is based on the individual's demonstrated current competence.
Yes_____  No_____

G. When patient care is provided by members of contractual groups or by individuals, they are members of the organized staff and their clinical privileges are defined f o r admitting and/or treating patients. This does not preclude the provision of emergency care by other members of the organized staff or by properly supervised members of the house staff in hospitals with approved graduate education programs.
Yes_____  No_____

H. Department chairmen have responsibility for the overall quality of patient care provided in their department. Such supervision need not be on a case-by-case basis.
Yes_____  No_____

I. Members of the organized staff appointed to administrative positions and having clinical privileges achieve and maintain organized staff membership, through the same procedure as those provided for all organized staff members.
Yes_____  No_____

4. The delineation of clinical privileges includes the limitations, if any, of an organized staff member's privileges to admit and treat patients or direct the course of their treatment for the condition for which they were admitted.
Yes_____  No_____

A. Patients may be admitted for inpatient care by those members of the organized staff who have been granted such privileges.
Yes_____  No_____

B. A patient admitted for inpatient care has his history taken and physical examination performed by a member of the organized staff who has such privileges.
Yes_____  No_____

C. Inpatient treatment may be provided by an organized staff member within the areas of cmnpetence as provided in approved clinical privileqes.
Yes_____  No_____

D.. A physician is readily available whenever outpatient services are provided.
Yes_____  No_____

 [Page 16]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals.-

ORGANIZED STAFF (cont.)

Standard I (cont.)

5. Organized staff membership and specific clinical privileges are subject to renewal through a hospital-specific mechanism, at an tnterval specified in the organized staff bylaws. The mechanism is approved and implemented by the organized staff and the governing body, f u l ly documented in the organized staff bylaws and rules and regulations. and described to each applicant seeking reappointment and renewal Of privileges. The following requirements are observed:

A. Appointment to the organized staff is made and specific clinical privileges are granted for periods of not more than two years.
Yes_____  No_____

B. Reappointment and renewal of privileges are based on an appraisa1 of the staff member at the time of reappointment. The appraisal includes information concerning the individual's prOfessional p e r f o r m a n c e , judgment, clinical/technical skills, and health status. The bylaws and the rules and regulations of the Staff Sad of the hospital indicate that the applicant for reappoinmcnt and privilege renewal is required to submit any reasonable evidence of current health status that may be requested by the executive committee of the organized staff.
Yes_____  No_____

C. Recommendations by peers are part of the basis for the recommending and granting of continued membership on the organized staff and for the delineation of clinical privileges.
Yes_____  No_____

D. To assure the continuing function of the organized staff staff and governing body action on reappointments and privilege renewal i s carried out in a time specified in the bylaws of the organized staff and of the hospital.
Yes_____  No_____

E. If the appraisal of an individual is performed for other purposes (eg., evaluations r e q u i r e d f o r university s t a f f members) and if the reappraisal uses parameters acceptable to the hospital's organized staff, includes information about the individual's professional performance, is performed in a timely manner and is documented in the organized staff member's file, then no additional appraisal by the organized Staff of the hospital is required.
Yes_____  No_____

F. The governing body is responsible for the final decision based o n organized staff recommendations regarding the individual's reappointment and renewal of specific clinical privileges.
Yes_____  No_____

6. When appropriate, temporary clinical privileges may b e granted for a limited period of time by the chief executive officer on the recommendation of the chairman of the applicable department/service or the president of the organized staff; a designated representative has authority to grant such privileges when these individuals are not available. In the case of an emergency, any member of the organized staff is permitted to do everything possible, within the scope of his license,to save the patient's life or to save the patient from serious harm, regardless of staff status or clinical privileges.
Yes_____  No_____

COMMENTS

 [Page 17]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

ORGANIZED STAFF (cont. )

Standard II

STANDARD II

The organized staff is structured to accomplish its required functions.

REQUIRED CHARACTERISTICS

1. The organized staff meets at least annually.
Yes_____  No_____

2. The organized staff bylaws specify categories of staff membership.
Yes_____  No_____

3. The organized staff bylaws define appropriate off icer positions; define the qualifications. duties. and tenures of officers: define the method Of selecting off icers; and specify the conditions and mechanisms for removing officers from office. Each officer is a member of the organized staff.
Yes_____  No_____

4. There is an executive committee of the organized staff that is empowered to act for t h e organized s t a f f in t h e intervals between organized staff meetings. The function, size, and composition of the committee and the method of selecting its members are defined in the organized staff bylaws and meet the requirements for composition as stated in Standard III, R e q u i r e d Characteristic 7.A. The staff a s a whole may serve as the executive committee. The chief excutive officer of the hospital, or his designee. attends each excutive committee meeting on an ex officio basis, with or without a vote.
Yes_____  No_____

5. Staff organization provides the means by which organized staff functions are specific and relevant to the c l i n i c a l qualifications and responsibilities of organized staff members.
Yes_____  No_____

6. If clinical departments exist, responsibilities of clinical department chairmen are specified in the organized staff bylaws and rules and regulations. Staff members are assigned to at least one department and may be granted clinical privi1eges in other departments. The exercise of clinical privileges within any department is subject to the rules and regulations of that department and to the authority of the department's chairman.
Yes_____  No_____

COMMENTS

 [Page 18]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals”

ORGANIZED STAFF (cont.)

STANDARD III

The organized staff develops and adopts bylaw and rules and regulations to establish a framework for self-governance and for recountability to the governing body.

REQUIRED CHARACTERISTICS

1. The bylaws and the rules and regulations adopted by the organized staff are subject to approval by the governing body.
Yes_____  No_____

2. The organized staff bylaws and rules and regulations create a framework within which organized staff members can act with a reasonable degree of freedom and confidence.
Yes_____  No_____

3. The bylaws and rules and regulations are reviewed according to a frequency that is specified i n the bylaws.
Yes_____  No_____

4. When necessary, the bylaws and rules and regulations are revised to reflect the current practices with respect to staff organization and functions.
Yes_____  No_____

5. New appointees to the o r g a n i z ed staff are p r o v i d e d with written materials that describe the key features of the organized staff bylaws and rules and regulations.a n d t h e y a g r e e to accept the professional obligations therein reflected, along with accepting hospital privileges.
Yes_____  No_____

6. At t he time o f reappointment, members of the organized staff a re provided with written materials that describe substantial changes in the bylaws and rules and regulations of the staff.
Yes_____  No_____

7. Organized staff bylaws include provisions for at least the following:

A. An executive committee of the organized staff, composed of members elected by the organized staff or appointed in accordance with hospital bylaws. The executive committee consists of physicians and other members of the organized staff. Members of the executive committee are in active practice in the hospital. The executive committee is responsible for m a k i n g recommendations d i r e c t l y to the g o v e r n i n g b o d y f or i ts approval. Such recommendations concern, a t least:
Yes_____  No_____

(1) the structure of the organized staff;

(2) the mechanism used to credential, and to delineate the clinical privileges of organized staf f members;

(3) the recommendations for organized staff membership and clinical privileges for each applicant or member of the organized staff;

(4) the organization of the quality assurance activities of the organized staff ,as well as the mechanism used to conduct, evaluate, and revise such activities; . .

(5) the mechanism by which membership on the organized staff may be terminated; and

(6) the mechanism for fair hearing procedures.

B. Mechanisms for corrective action. including indications a nd procedures for automatic and summary suspension of organized staff membership and/or clinical privileges.
Yes_____  No_____

C. Fair hearing and appellate review mechanisms, which may differ for organized staff members end applicants for membership.
Yes_____  No_____

D. Details of the organized staff's organizational structure.
Yes_____  No_____

E. The bylaws or the rules and regulations include the requirements for meeting frequency and attendance.
Yes_____  No_____

F. A mechanism d e s i g n e d t o assure effective communication with thc hospital's administration and governing body.
Yes_____  No_____

 [Page 19]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

ORGANIZED STAFF (cont.)

Standard III (cont.)

G. A mechanism for adopting and amending the bylaws and the rules and regulations o f the organized staff.

H. Provide f o r representative of the organized staff to participate in a n y hospital deliberation affecting the discharge of organized staff responsibilities.

8. In hospitals that have graduate education programs the rules and regulations specify that member of the house staff may write patient care orders. The policy does not prohibit a member of the organized staff from writing orders. Staff members who choose not to participate in the teaching p r o g r a m a r e not subject to denial or limitation of privileges for this reason alone.

9. O r g a n i z ed staff rules and regulations specifically relate to the r o le of organized staff members in the care of inpatients. ambulatory care patients,emergency care patients. and home care patients. The rules and regulations are either general in nature a n d applicable to the whole staff or are specific to departments/services. Rules and regulations of departments/services do not conflict with each o t h e r, with the bylaws and the rules and regulations of the organized staff Or with the bylaws of the governing body. The mechanism for providing emergency care is defined.

10. In hospitals with psychiatric/substance abuse departments/services and in h o s p i t a l s that provide only psvchiatric/substance abuse s e r v i c e s, organized staff bylaws provide for the use of special treatment procedures. Special treatment procedures that require special justi-fication include, but are not limited to, the following:

A. Restraint or seclusion. When r e s t r a i n t o r seclusion is employed a time-limited order f r o m a physician is written within 8 hours after initial use of the procedure. In addition, there is docu-mentation that the needs of the patient, especially in regard to meals, bathing and use of the toilet are attended to at least every 15 minutes The patient's informed consent is not required for the use of restraint or seclusion.

B. Electroconvulsive and other forms of convulsive therapy. Electroconvulsive therapy is n ot a d m i n i s t e r e d to c h i l d r e n or adolescents unless, before the initiation of such t h e r a p y , two q u a l i f i e d c h i l d psychiatrists who have training or experience in the treatment of children and adolescents and are not directly involved in the treatment of t h e patient have examined the patient, consulted with the responsible psychiatrist, a n d d o c u-mented in the patient's record that they concur with the decision to administer such therapy.

C. Psychosurgery or other surgical procedure. to alter or intervene. In an emotional mental, or behavlor. disorder.

D. Behavior modification procedures that use aversive conditioning.

E. Special treatment procedures for children and adolescents. When special treatment procedures are used in psychiatric/substance abuse programs for children and adolescents, there is evidence of consultion with a q u a l i f i e d child psychiacrist who has training and experience in the development of guidelines for specia1 treatment procedures for children and adolescents.

 [Page 20]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

ORGANIZED STAFF ( cont.)

Standard III (cont.)

11. In hospitals with psychiatric/substance abuse departments/services and in hospitals that provide only psychiatric/substance abuse services, organized staff rules and regulations address policies a n d procedures for the following:

A. the early detection of mental health problems tht may be life threatening:

B. the circumstances under which special treatment procedures can be used;

C. the medical record and other documentation requirements:

D. the procedural safeguards taken to protect the patient's safety and rights.

E. provisions to assure proper medical supervision when special treatment procedures are used; and

F. provisions to assure organized staff responsibility in determining whether a multidisciplinary treatment approach is used.

[Page 21]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

ORGANIZED STAFF (cont.)

STANDARD IV

T he organized staff reviews and evaluates each staff member's performance to assure that optimal standards of care which reflect current clinical knowledge and experience, are achieved and maintained.

REQUIRED CHARACTERISTICS

1. A s an integral pert of the hospitals quality assurance program the organized staff monitors, reviews and evaluates, identifies and solves problems or implements opportunities to improve patient care through but not limited to. the following functions:

A. Organized staff and/or clinical department/service meetings;

B. Surveillance activities of the head of the organized staff and the heads of the clinical departments/services.

C. Surgical Case Review Function:

(1) Surgical case review is performed monthly, for uch case, whether or not a tissue specimen w as removed. Such review may include the use of predetemined criteria to identify cases for more intensive review.

(2) The review includes the indications and justification for surgery of each case in which a major discrepancy exists between the preoperative and postoperative (including pathologic) diagnoses.

(3) Written records of conclusions, recommendations, actions, and the results of such actions are maintained.

D. Pharmacy and Therapeutics Review Function:

(1) The review of drug therapy practice of organized staff members and drug utilization within the hospital are reviewed as frequently a s necessary to resolve problems, but at least quarterly .

(2) The pharmacy and therapeutics function is performed in cooperation with pharmaceutical services, nursing services, management services, and with other individuals and services a s required.

(3) The organized staff is responsible for the development of policies and procedures relating to the selection of drugs; to the distribution, handling, and administration, of drugs: to the review of untoward drug reactions; and to the evaIuation and if appropriate the a p p r o v a l o f protocols concerned with the use of investigational or experimental drugs.

(4) Written records of conclusions, recommendations, actions and the results of such actions are maintained.

E. Medical Record Review Function:

(1) Medical records are reviewed as frequently as necessary to improve their quality or resolve problems. but at least quarterly.
Yes_____  No_____

(2) Nursing and medical record personnel a ls o participate in the medical record review function.
Yes_____  No_____

(3) Medical records are reviewed f o r their timely completion, clinical pertinence,overall adequacy for patient care and for use in quality assessment activities.
Yes_____  No_____

(4) Medical record review assures that the records reflect the condition and progress of the patient, the therapy rendered. and the results of diagnostic tests.
Yes_____  No_____

(5) Medical record review functions also include determination of the format of the medical record, the forms to be used in the record,and the use of microfilming and electronic data storage.
Yes_____  No_____

(6) Medical record review and evaluation applies to all patient care services.
Yes_____  No_____

(7) Written records of conclusions. recommendations, actions, and the results of such actions are maintained.
Yes_____  No_____

 [Page 22]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

ORGANIZED STAFF (cont.)

Standard IV (cont.)

F. Blood Utilizaton Review Function:

(1) B l o o d utilization review i s performed as frequently as necessary to assure appropriate utilization and resolve problems, b u t at least quarterly.

(2) T he use of transfusions of b l o o d and b l o o d components is reviewed for quality and appropriateness.

(3) Each actual o r suspected transfusion reaction i s evaluated.

(4) Written records of conclusions, recommendations, actions, and the results of much actions are maintained.

G. Antibiotic Utilization Review Function:
Yes_____  No_____

(1) Antibiotic usage review is performed as f r e q u e n t l y as necessary t o assure quality and apprpriateness and t o resolve problems but at least quarterly.
Yes_____  No_____

(2) The review of the use of antibiotics applies to all areas of patient care services.
Yes_____  No_____

(3) Review is focused on th e prophylactic. empiric. and therapeutic use of antibiotics. A ny selective or restrictive use of an antibiotic is based on documented scientific informa tion and is implemented through the organized staff or the department/service chairman, in consultation with the infection control committee.
Yes_____  No_____

(4) Written records of conclusion, recommendations, actions and the results of such actions are maintained.
Yes_____  No_____

H. In hospitals with psychiatric/substance abuse departments/services and in hospitals that provide o n l y psvchiatric/subsctance abuse s e r v i c e s. the organized staff, in addition to meetings o t h er relevant requirements of this section of the Manual, evaluates the quality a n d appropriateness o f psychiatric/substance abuse services. In conducting this evaluation, the organized s t a ff
Yes_____  No_____

A. defines the goals and objectives of the service;
Yes_____  No_____

B. defines the services provided;
Yes_____  No_____

C. d e f i n es the patients appropriate f o r each service p r o v i d e d , including consideration of the intensity and restrictions of care provided ;
Yes_____  No_____

D. assures that the hospital and the department/service can address the needs of the patients;
Yes_____  No_____

E. assures that the hospital and the department/service h a s adequate staff t o a ss es s a n d address the psychiatric and health care needs of the patients;
Yes_____  No_____

F. assures delineation of the r o l e s and r spons ib il it i es of individual team members when a multidisciplinary treatment approach is used;
Yes_____  No_____

G. implements a concurrent clinical review of individual patients: and
Yes_____  No_____

H. evaluates the effectiveness of t h e psychiatric/substance abuse hospital/department/service in meeting its goals and objectives. This evaluation is performed as an integral part of the hospital's overa11 quality assurance program.
Yes_____  No_____

COMMENTS

(continued next page)

 [Page 23]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

ORGANIZED STAFF (cont.)
Standard IV (cont.)
COMMENTS

STANDARD V
Each member of the organized staff participates in continuing education.

REQUIRED CHARACTERISTICS

1. Each member of the organized staff participates in continuing education activities which relate in part to the patient care for which the staff member is privileged.
Yes_____  No_____

2. Hospital-sponsored educational act i v i t ies are offered. T h es e activities relate, at least in part t o
Yes_____  No_____

A. the type and nature of care offered by t h e hospital;
Yes_____  No_____

B. the findings of quality review activities; and
Yes_____  No_____

C . the expressed educational needs of staff members
Yes_____  No_____

3. Each staff member's participation in continuing education is
Yes_____  No_____

A. documented; and
Yes_____  No_____

B. considered at the time of reappointment to the organized staff and
Yes_____  No_____

COMMENTS

 [Page 24]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

NUCLEAR MEDICINE SERVICES

Page 89, lines 21-50
Standard V

There i s a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by the nuclear medicine department/serrvice.

The nuclear medicine department/service has a program for t he review and evaluation of patient care that is an integral part of the hospital quality assurance program. The physician director of the nuclear medicine department/service is responsible for implementing the program.

Through review and assessment of information obtained . from ongoing monitoring activities and other data sources, important problems in patient care and opportunities for improving care a r e identified

Criteria that reflect current knowledge and clinical experience are used in these review and assesement activities.

Actions are taken t o resolve identified problems, and the effectiveness of those actions i s monitored.

Information obtained through the ongoing review and evaluation of care, including ongoing monitoring activities and information about the impact of actions taken to resolve problems and to improve care is:

*documented. and
* integrated with the hospital's overall quality assurance program.

When nuclear medicine services are provided by source(s) outside the hospital, either the medical staff or the chief executive officer ensures effective review and evaluation of the q ua li t y and appropriateness of the patient care provided by the o u t s i d e source(s).

Refer to the Quality Assurance Section of this Manual.
Yes_____  No_____

COMMENTS

 [Page 25]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

NURSING SERVICES

Page 92, lines 37-42
Standard VI

When a multidisciplinary team approach to treatment is used in hospitals with psychiatric/substance abuse department/services or in hospitals that provide only psychiatric/substance abuse services nursing policies and procedures also shall relate to the role of the nursing staff on multidisciplinary treatment teams.
Yes_____  No_____

Page 73, lines 1-28
Standard VII

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by the nursing department/service.

The nursing department/service has a program for the review and evaluation of patient care that is an integral part of the hospital quality assurance program. The nurse administrator is responsible for implementing the program.

Through review and assessment of information obtained from ongoing monitoring activities and other data sources, important problems in patient care and opportunities for improving care are identified.

Criteria that reflect current knowledge and clinica1 experience are used in these review and assessment activities.

Actions are taken to resolve identified problems, and the effectiveness of those actions is monitored.

Information obtained through the ongoing review and ation of care including ongoing monitoring activities, tion about the impact of actions taken to resolve a and informa problems and to improve care i s:

*documented, and
*integrated with the hospital's overall quality asurance program.
*disseminated within nursing services

When nursing services are provided by source(s) outside the hospital the nurse administrator ensures effective review and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).

Refer to the Quality Assurance Section of this Manual.

Comments
Yes_____  No_____

 [Page 26]

E v a l u a t i on Form
Proposed Revisions to the Accreditation Manual for Hospitals

PATHOLOGY AND MEDICAL LABORATORY SERVICES

Page 96, lines 3 1 -44
Standard I 

A hospital that provides only psychiatric/substance abuse services may provide pathology and medical laboratory services through a contractual agreement with another health care facility that is accredited by JCAH or through a contractual agreement with an independent laboratory that either is approved, by the Commission on Inspection and Accreditation of the College of American Pathologists or meets equivalent standards The hospital shall have a description of the means of providing pathology and medical laboratory services. If the hospital itself provides pathology and medical laboratory services, there shall be a description of the services provided and the position of these services within the organization of the hospital. The hospita1 also must comply with applicable standards in this section of the Manual.

Page 77, lines l-30
Standard VII

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by the pathology and medical laboratory service.
The pathology and medical laboratory service has a program for the review and evaluation of patient care that is an integral part of the hospital quality assurance program. The physician director of the pathology and medical laboratory department/service is responsible for implementing the program.
Through review and assessment of information obtained from ongoing monitoring activities and other data sources, important problems in patient care and opportunities for improving care are identified.
Criteria that reflect current knowledge and clinical experience are used in these review and assessment activities.
Actions are taken to resolve identified problems, and the effectiveness of chose actions is monitored.
Information obtained through the ongoing review and evaluation of care, includinq ongoing monitoring activities, and information about the impact of actions taken tO resolve problems and to improve care is: *documented and
*integrated with the hospital's overall quality assurance p r og ram.
When pathology and medical laboratory services are provided by source(s) outside the hospital either the medical staff or the chief executive officer ensures effective review and evaluation of the quality and apprpropriate the patient care provided bv the outside source(s)
Refer to the Quality Assurance Section of this Manual.
COMMENTS
Yes_____  No_____
 

 [Page 27]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

PHARMACEUTICAL SERVICES

Page 100, lines 27-29
Standard III

Assuring t h e review and evaluation, with medical staff input, of the quality and appropriateness of patient care services provided by the pharmaceutical department/ service.

Page 82, lines l-30
Standard VI

There is a planned program for onqoing review and evaluation of the quality and appropriateness of patient care provided by the pharmaceutical department/service.
The pharmaceutical department/service has a program for the review and evaluation of patient care that is an integral part of the hospital quality assurance program. T he director of t he pharmaceutical department/service is responsible for implementing the program.
Through review and assessment of information obtained from ongoing monotoring activities and other data sources, important problems in patient care and opportunities for improving care are i d e n t i f i e d .
Cr i t e r ia that reflect current knowledge and clinical experience are used i n these review and assessment activities.
Actions are taken to resolve identified problems, and the effectiveness of those actions is monitored.
Information obtained through the ongoing review and e v a l u a t i on of care. including onqoinq monitoring acti v it ies, and information about the impact of actions taken to resolve problems and to improve care is:
*documented, and
*inteqrated with the hospital's overall quality assurance program. -
When pharmaceutical services are provided by source(s) outside the hospital, either the medical staff or the chief executive officer ensures effective review and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).
Refer to the Quality Assurance Section of this Manual
Yes_____  No_____

COMMENTS

 [Page 28]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

RADIOLOGY SERVICES

Page 104, lines 45-53
Standard I

In a hospital that provides only psychiatric/substance abuse services, radiology services may be provided through a contractual agreement with another health care facility that is accredited by JCAH or its equivalent, or through a contractual agreement with a radiology center that is certified in accordance with state or local regulations. The hospital shall have a description of the of providing radiology services. If the hospital itself provides radiology services, there shall be a description of the services provided and the position of these services within the organization of the hospital. The hospital also must comply with applicable standards in this section of the manual.
Yes_____  No_____

Page 85, lines 1-29
Standard VI

There is a planned program for ongoing review and evaluation of the quality and appropriatness of patient care provided by the radiology department/service.

The radiology department/service has a program for the review and evaluation of patient care that is an integral part of the hospital quality assurance program. The physician director of the radiology department/service is responsible for implementing the program.

Through review and assessment of information obtained from ongoing monitoring activities and other data sources, important problems in patient care and opportunities for improving care are identified.

Criteria that reflect current knowledge and clincial experience are used in these review and assessment activities.
Actions are taken to resolve identified problems, and the effectiveness of those actions is monitored.
Information obtained through the ongoing review and evaluation of care, including ongoing monitoring activities, and information about the impact of actions taken to resolve problems and to improve care is:
*documented, and
*integrated with the hospital's overall quality assurance program.

When radiology services are provided by source(s) outside the hospital, either the medical staff or the chief executive officer ensures effective review  and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).
Refer to the Quality Assurance Section of this Manual.
 

 [Page 29]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

REHABILITATION PROGRAMS/SERVICES

Page 109, lines 6-11
Standard I

When a multidisciplinary team approach to treatment is used in hospitals with psychiacric/substance abuse departments/services. or in hospitals that provide only psvchiatric/substance abuse services, rehabilitation policies and procedures also shall relate to the role of rehabilitation staff on multidisciplinary treatment teams.
Yes_____  No_____

Page 91, lines l-30
Standard II

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided bv the rehabilitation department/service.
The rehabilitation department/service has a program for t he review and evaluation of patient care that is an integral part of the hospital quality assurance program. The director of the rehabilitation department/service, with medical staff input _responsible for implementing the program.
Through review end assessment of information obtained from onqoing monitoring activities and other data sources, important problems in patient care and opportunities for improving care are identified.
Criteria that reflect current knowledqe and clinical experience are used in those review and assessment activities.
Actions are taken to resolve identified problems and the effectiveness of those actions is monitored.
Information obtained through t he ongoing review and evaluation of care, including ongoing monitoring activities, and information about the impact of actions taken to resolve problems and to improve care is:
*documented, and
*integrated with the hospital's overall quality assurance program.
When rehabilitation services are provided by source(s) outside the hospital, either the medical staff or the chief executive officer ensures effective review and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).
Refer to the Quality Assurance Section of this Manual. Yes_____  No_____

COMMENTS

 [Page 30]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

RESPIRATORY CARE SERVICES
Page 113, lines 3-32
Standard VI

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by the respiratory care departmentservice.
The respiratory care department/service has a program for th e review and evaluation of patient care that is a n integral part of t he hospital quality assurance program The physician director of t he respiratory department/service iS responsible for implementing the program.
Through review and assessment of information obta from ongoing monitoring activities and other data sour important problems in patient care and opportunities f improvinq care are id e n t i f i e d.
Criteria that reflect current knowledge and clinical experience are used in these review and assesment activities.
Actions are taken to resolve identified problems and effectiveness of those actions is monitored.
Information obtained through the ongoing review and evaluation of care, including ongoing monitoring activities, and information about the impact of actions taken to resolve problems and to improve care is
*documented, and
*integrated with the hospital's overall quality assurance program.
When respiratory care services are provided by source(s) outside the hospital, either the medical staff or the chief executive officer ensures effective review and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).
Refer to the Quality Assurance Section of this Manual
Yes_____  No_____

COMMENTS

SOCIAL WORK SERVICES

Page 94, lines 53-57
Standard III

When a multidisciplinary team approach to treatment i s u s e d i n hospi ta l with psychiatric/substance abuse departments/services or in hospitals that provide only psychiatric/substance abuse services, social work policies and procedures shall also relate to the role of social workers on multidisciplinary treatment teams.

Yes_____  No_____

 [Page 31]

Evaluation Form
Proposed R e v i s i o n s t o t he Accreditation Manual for Hospitals

SOCIAL WORK SERVICES (cont.)

Page 115, lines 1-29
Standard V

There is aplanned program for on going review and evaluation of the quality and apprpriateness of patient care provided by the social work department/service

The social work department/service has a program for the review and evaluation of patient care that is an integral part of the hospitalquality assurance program. The social work department/service is responsiblee director of the for implementing the program.

Through review and assesment of information obtained from ongoing monitoring activities and other data sources, important problems i n patient c a r e and opportunities for improving care are identified.

Criteria that reflect current knowledge and clinical d assesment activities experience are used in these review and assessment activities.
Actions are taken to resolve identified problem. and the effectiveness of those actions is monitored.

Information obtained through the ongoing review and evaluation o f care, including ongoing monitoring activities and information about the impact of actions taken to resolve care is: problems and to improve
*documented. and
*integrated with the hospital's overall quality assurance program.

When social work services are provided by source(s). outside the hospital, either the medical staff or the chief executive officer ensures effective review and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).
Refer to the Quality Assurance Section of this Manual. Yes_____  No_____

COMMENTS

 [Page 32]

Evaluation Form
Proposed Revisions to the Accreditation Manual for Hospitals

SPECIAL CARE UNITS
Page 118, lines 1-31
Standard VI

There is a planned program for ongoing review and evaluation of the quality and appropriateness of patient care provided by special care units.
Special care units have a program for the review and e v a l u a t i on patient care that is an integral part of the hospital quality assurance program. In a specific-purpose special care unit the physician director is responsible for implementing the review and evaluation program. In a multipurpose s p e c i a l care unit, a multidisciplinary committee is responsible for implementing the review and evaluation program.

Through review and assessment of information obtained from ongoing monitoring activities and other data sources, important problems in patient care and opportunities for improving care are identified.

Criteria that reflect current knowledge and clinical experience are used in these review and assessment activities.
Actions are taken to resolve identified problems, and the effectivieness of those actions is monitored.
Information obtained through the ongoing review and evaluation of care, including ongoing monitoring activities, and information about the impact of actions taken to resolve problems and to improve care is:
*documented. and
*integrated with the hospital's overall quality assurance program.

When the services o f special care units are provided by source(s) outside the hospital, either the medical staff or the chief executive officer ensures e f f e c t i v e review and evaluation of the quality and appropriateness of the patient care provided by the outside source(s).
Refer to the Quality Assurance Section of this Manual Yes_____  No_____

COMMENTS
 
 

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