Intentional mistreatment that may cause either physical or psychological injury.

Determination by The Joint Commission that an eligible organization complies with applicable Joint Commission accreditation requirements.

The primary document that establishes the terms of the relationship between the organization and The Joint Commission.

Categories of accreditation that an organization can achieve based on a Joint Commission survey. These decision categories are as follows: - Limited, Temporary Accreditation - The organization demonstrates compliance with selected standards in surveys conducted under the Early Survey Policy. - Accredited - The organization is in compliance with all applicable standards at the time of the survey or has successfully addressed all Requirements for Improvement (RFIs) in an Evidence of Standards Compliance (ESC) within 60 days following the posting of the Final Accreditation Report and does not meet any other rules for other accreditation decisions. - Accreditation with Follow-up Survey - The organization is in compliance with all standards, as determined by an acceptable ESC submission. A follow-up survey is required within 6 months to assess sustained compliance. - Preliminary Denial of Accreditation - There is justification to deny accreditation to the organization as evidenced by - An Immediate Threat to Health or Safety to patients, residents, or the public, and/or - Submission of falsified documents or misrepresented information, and/or - Lack of a required license or similar issue at the time of survey, and/or - Significant noncompliance with Joint Commission standards, and/or - Patients and residents having been placed at risk for serious adverse outcomes due to significant and pervasive patterns/trends/repeat findings The decision is subject to review and appeal by the organization prior to the determination to deny accreditation. - Denial of Accreditation - The organization has been denied accreditation. All review and appeal opportunities have been exhausted.

A Joint Commission publication, either in print or online, consisting of policies, procedures, and accreditation requirements relating to ambulatory care, assisted living communities, behavioral health care and human services, critical access hospital, home care, hospital, nursing care centers, office-based surgery, and clinical laboratory and point-of-care testing. Organizations should use the manual that contains the set of accreditation requirements that is most appropriate to the primary focus or mission of the organization.

A continuous process whereby organizations are required to demonstrate to The Joint Commission that they are providing safe, high-quality care, as determined by compliance with Joint Commission standards, National Patient Safety Goals, and performance measurement requirements (as applicable). Key components of this process are an evaluation of the organization by a Joint Commission surveyor(s) and, where applicable, quarterly submission of performance measurement data to The Joint Commission.

An evaluation of an organization to assess its level of compliance with applicable Joint Commission accreditation requirements and to make determinations regarding its accreditation status. The survey includes evaluation of documentation of compliance provided by organization staff; verbal information concerning the implementation of standards or examples of their implementation that enable a determination of compliance to be made; observations by the surveyor(s); and an opportunity for education regarding standards compliance and performance improvement.

Findings from an evaluation conducted by Joint Commission surveyors that result in an organization’s accreditation decision.

A document or documentation allowing a person to give directions about future health care or to designate another person(s) to make health care decisions if the individual loses decision-making capacity. Advance directives may include living wills, durable powers of attorney, do-not-resuscitate (DNR) orders, right-to-die documents, or similar documents listed in the Patient Self-Determination Act that express the person’s preferences. See also psychiatric advance directive.

A registered nurse who has gained additional knowledge and skills through successful completion of an organized program of nursing education that prepares nurses for advanced practice roles, and who has been certified by the board of nursing to engage in the practice of advanced practice nursing.

An injury resulting from a medical intervention related to a medication, including harm from an adverse drug reaction or a medication error. See also medication error.

A response to a medicinal product that is noxious and unintended and that occurs at doses normally used in humans for the prophylaxis, diagnosis, or treatment of disease or for the restoration, correction, or modification of physiological or psychological function.

A patient safety event that resulted in harm to a patient.

A person who represents the rights and interests of another individual as though those rights and interests were the person’s own in order to realize the rights to which the individual is entitled, obtain needed services, and remove barriers to meeting the individual’s needs.

An acronym for “as low as reasonably achievable,” which means making every reasonable effort to maintain exposures to ionizing radiation as far below NRC dose limits as practical.

An integrated approach to emergency preparedness that focuses on identifying hazards and developing emergency preparedness capacities and capabilities that can address a wide spectrum of emergencies or disasters. This approach includes preparedness for natural, human-made, and/or facility emergencies that may include but are not limited to care-related emergencies; equipment and power failures; interruptions in communications, including cyberattacks; loss of a portion or all of a facility; and interruptions in the normal supply of essentials, such as water and food. Planning for using an all-hazards approach should also include emerging infectious disease (EID) threats. Examples of EIDs include influenza, Ebola, and Zika viruses.

Health services provided to individuals who are not confined to institutional beds as inpatients during the time services are rendered. Ambulatory care services are provided in many settings ranging from freestanding ambulatory surgery facilities, to primary care settings, to diagnostic radiology; outpatient behavioral health services are not included.

The administration to an individual, in any setting, for any purpose, by any route, of medication to induce a partial or total loss of sensation for the purpose of conducting an operative or other procedure. Definitions of four levels of sedation and anesthesia include the following: 1. Minimal sedation (anxiolysis): A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. 2. Moderate sedation/analgesia (“conscious sedation”): A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. 3. Deep sedation/analgesia: A drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. 4. Anesthesia: Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

One year from the date of the last event, plus or minus 30 days. Synonymous with every 12 months, once a year, or every year.

The process afforded to an organization that receives a Preliminary Denial of Accreditation decision, which includes the organization's right to make a presentation to the Review Hearing Panel before accreditation is denied.

An organization that is seeking either accreditation for the first time or re-accreditation.

See E-App.

The process established by an organization for obtaining appropriate and necessary information about each individual seeking entry into a health care setting or service. The information is used to match an individual's need with the appropriate setting, care level, and intervention.

Tissue intended for transplantation into the individual from whom the tissue was recovered. The recipient and donor are the same individual.

The hospital’s ADC is composed of the average number of inpatients (excluding newborns) receiving care each day in a health care organization during a reporting period.

Procedures in which the patient or individual served is exposed to an unpleasant or noxious stimulus (the aversion) while engaging in the target behavior; the goal is to create an association of the aversion to the target behavior. Positive punishment is considered to be a type of aversive procedure. Positive punishment is a procedure in which target behavior is followed by the presentation of an unpleasant or noxious stimulus to decrease probability that the behavior will occur again (for example, spraying water mist in the face of the individual served. Negative punishment is not an aversive procedure). Negative punishment is a procedure in which the target behavior is followed by the removal of a desirable stimulus to decrease the probability that the behavior will occur again (for example, turning off the television).

The use of basic behavioral or learning-based programs designed to help the patient or resident develop socially appropriate and safe replacement behavior. Characteristics of a behavior management program are that all the direct care staff are trained in the application of the program; it is a written, planned program; it is applied at all times the patient or resident is under the supervision of direct care staff; and it is distinct from other therapeutic interactions with the patient or resident.

See psychiatric advance directive.

A broad array of care, treatment, or services for individuals with mental health issues, child welfare needs, addictive behaviors, chemical dependency issues, or intellectual/developmental disabilities. Care, treatment, or services can be provided in a wide variety of settings, such as inpatient crisis stabilization, residential, day program, outpatient, and community-based settings.

Conduct by staff working in the organization that intimidates others to the extent that quality and safety could be compromised. These behaviors, as determined by the organization, may be verbal or nonverbal, may involve the use of rude language, may be threatening, or may involve physical contact.

Clinical, scientific, or professional practices that are recognized by a majority of professionals in a particular field as being exemplary. These practices are typically evidence based and consensus driven.

Medicines made from living organisms and their products, including serums, vaccines, antigens, and antitoxins.

A sample with known value tested by personnel who do not know the expected result.

A documentation method that can be used when rapid titration of medication is necessary in specific urgent/emergent situations defined in organizational policy. A single “block” charting episode does not extend beyond a four-hour time frame. If a patient’s urgent/emergent situation extends beyond four hours and block charting is continued, a new charting “block” period must be started. The following minimum elements must be documented in each block charting episode: - Time of initiation of the charting block - Name(s) of medications administered during the block - Starting rates and ending rates of medications administered during the charting block - Maximum rate (dose) of medications administered during the charting block - Time of completion of the charting block - Physiological parameters evaluated to determine the administration of titratable medications during the charting block

A fraction of separated whole blood (for example, red blood cells, plasma, platelets, granulocytes).

Patients being held in the emergency department or another temporary location after the decision to admit or transfer has been made.

A governance framework that establishes the roles and responsibilities of a body and its members.

A written plan based on data gathered during assessment that identifies care needs and treatment goals, describes the strategy for meeting those needs and goals, outlines the criteria for terminating any interventions, and documents progress toward meeting the plan’s objectives. The plan may include care, treatment, and services; habilitation; and rehabilitation.

A family member, a significant other, a friend, a volunteer, or an individual employed by the patient, individual served, or resident to provide services in the home.

For purposes of Joint Commission certification, determination by The Joint Commission that an eligible program or service complies with applicable Joint Commission certification requirements.

A person between 0 and 12 years of age, or as determined by applicable law and regulation.

The provision of care to individuals with long-standing, persistent diseases or conditions. It includes oversight and education activities specific to a disease or condition, and measures to encourage self-care, promote health, and prevent loss of function.

A component of some medical devices that is designed to notify caregivers of an important change in a patient’s physiologic status. A clinical alarm typically provides audible and/or visible notification of the changed patient status.

Software designed to assist in clinical decision making. A clinical decision support system matches two or more characteristics of an individual patient to a computerized clinical knowledge base and provides patient-specific assessments or recommendations to the clinician. The clinician makes decisions based on clinical expertise, knowledge of the patient, and the information provided through the clinical decision support system. A clinical decision support system can be used at different points in the care process such as diagnosis, treatment, and posttreatment care, including the prediction of future events.

See laboratory.

Federal legislation that created uniform federal standards for regulating laboratory testing. CLIA '88 unified the disparate federal and state standards regulating clinical laboratories and extended government oversight to all testing facilities, including physician offices.

A behavioral health care professional with overall responsibility to plan, organize, and operate a clinical service or program (for example, a clinical director or a service or program director).

Tools that describe a specific procedure or processes found, through clinical trials or consensus opinion of experts, to be the most effective in evaluating and/or treating a mother and/or newborn, patient, resident, or individual served who has a specific symptom, condition, or diagnosis. Synonyms include practice parameter, protocol, clinical practice recommendation, preferred practice pattern, and guideline.

Authorization granted by the appropriate authority (for example, the governing body) to a physician or other licensed practitioner to provide specific care, treatment, or services in the organization within well-defined limits, based on the following factors: license, education, training, experience, competence, health status, and judgment.

Staff members who provide or have provided clinical services (such as personal care or medical treatment) to the organization's patients, residents, or individuals served. See also staff.

Used to describe any process variation that did not affect an outcome but for which a recurrence carries a significant chance of a serious adverse outcome. Such events fall within the scope of the definition of a sentinel event but outside the scope of those sentinel events that are subject to review by The Joint Commission under its Sentinel Event Policy.

The goal of this exercise is that health care organizations collaborate with state and local entities within their community to promote an integrated emergency response. Conducting integrated planning with state and local entities could identify potential gaps in their capabilities that can then be addressed in advance of an emergency.

The concept of using various building components (for example, fire walls and doors, smoke barriers, fire-rated floor slabs) to prevent the spread of fire and combustion and to provide a safe means of egress to an approved exit. The presence of these features varies depending on the building occupancy classification.

An organization accredited by The Joint Commission under more than one accreditation manual.

A process for identifying basic or causal factors underlying variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis is one type of comprehensive systematic analysis.

A measure of the radiation output of a computed tomography (CT) scanner. It represents CT radiation exposure to a test object and therefore does not represent the patient radiation dose.

1. Restriction of access to data and information to individuals who have a need, a reason, and permission for such access. 2. An individual's right, within the law, to personal and informational privacy, including their health care records.

1. A written opinion by a consultant that reflects, when appropriate, an examination of the individual and the individual’s medical record(s). 2. Information given verbally by a consulting physician or other licensed practitioner to a care provider that reflects, when appropriate, an examination of the individual. The individual’s care provider usually documents those opinions in the medical record.

Care provided over time in various settings, programs, or services and spanning the illness-to-wellness continuum.

The degree to which the care of individuals is coordinated among health care professionals, among organizations, and over time.

An organization's written document that provides guidance on how the organization will continue to perform essential business functions in order to deliver essential or critical services and maintain operations.

A formal agreement for care, treatment, or services with an organization, agency, or individual that specifies the services, personnel, products, or space provided by, to, or on behalf of the organization and specifies the consideration to be expended in exchange.

Services provided through a written agreement with another organization, agency, or person. The agreement specifies the services or personnel to be provided on behalf of the applicant organization and the fees to provide these services or personnel.

An agreement with any organization, group, agency, or individual for services or personnel to be provided by, to, or on behalf of the organization. Such agreements are defined in written form, such as in a contract, letter of agreement, or memorandum of understanding.

The process of coordinating care, treatment, or services provided by a health care organization, including referral to appropriate community resources and liaison with others (such as the individual’s physician or other licensed practitioner, other health care organizations, or community services involved in care or services) to meet the ongoing identified needs of individuals, to ensure implementation of the plan of care, and to avoid unnecessary duplication of services.

The process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a health care organization.

Documented evidence of licensure, education, training, experience, or other qualifications.

Any entity that provides information on an individual's professional credentials. An organization that bases a decision in part on information obtained from a CVO should have confidence in the completeness, accuracy, and timeliness of information. To achieve this level of confidence, the organization should evaluate the entity providing the information initially and then periodically as appropriate. The 10 principles that guide such an evaluation include the following: 1. The entity makes known to the user the data and information it can provide. 2. The entity provides documentation to the user describing how its data collection, information development, and verification process(es) is performed. 3. The user is given sufficient, clear information on database functions, including any limitations of information available from the entity (such as individuals not included in the database), the time frame for entity responses to requests for information, and a summary overview of quality control processes related to data integrity, security, transmission accuracy, and technical specifications. 4. The user and entity agree on the format for transmitting credentials information about an individual from the CVO. 5. The user can easily discern what information transmitted by the CVO is from a primary source and what is not. 6. For information transmitted by the agency that can go out of date (for example, licensure, board certification), the CVO provides the date the information was last updated from the primary source. 7. The CVO certifies that the information transmitted to the user accurately represents the information obtained by it. 8. The user can discern whether the information transmitted by the CVO from a primary source is all the primary source information in the CVO’s possession pertinent to a given item or, if not, where additional information can be obtained. 9. The user can engage the CVO’s quality control processes when necessary to resolve concerns about transmission errors, inconsistencies, or other data issues that may be identified from time to time. 10. The user has a formal arrangement with the CVO for communicating changes in credentialing information.

Test result that is abnormal to a degree that may indicate a life-threatening situation (also known as critical value).

A test or examination that always requires rapid communication of results, whether those results are normal or abnormal.

The accuracy, consistency, and completeness of data that are protected in some way from corruption, misuse, or accidental exposure to unauthorized users.

A primary source used for data collection (for example, physical health and behavioral health information, personnel records, written agreements, safety incident log).

Status conferred by the Centers for Medicare & Medicaid Services (CMS) on an organization whose standards and survey process are determined by CMS to be equivalent to those of the Medicare program or other federal laws, such as the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88). Accreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement.

An individual who has received either a doctor of dental surgery degree or a doctor of dental medicine degree and who is licensed to practice dentistry.

Any structural unit of the medical staff (whether it is called a department, a service, a unit, a section, or something similar) in which the director is responsible for recommending privileges for individuals in the unit to the medical staff executive committee.

The delivery of care pertaining to the provision of nutrition and food service to patients.

A type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain care, safety, or security functions.

The point at which an individual's active involvement with an organization or program ends, and the organization or program no longer maintains active responsibility for the care of the individual. In ambulatory or office-based settings where episodes of care occur even though the organization continues to maintain active responsibility for the care of the individual, discharge is the point at which any encounter or episode of care (that is, an office or clinic visit for the purpose of diagnostic evaluation or testing, procedures, treatment, therapy, or management) ends.

A formalized process in a health care organization through which a program of continuing and follow-up care is planned and carried out for each patient or individual served.

Emergency management exercise that either familiarizes staff with existing plans, policies, or procedures or is used to develop new plans, policies, and procedures. Types of discussion-based exercises include the following: - Seminar: Orients participants to or provides an overview of authorities, strategies, plans, policies, procedures, protocols, resources, concepts, and ideas. - Workshop: Led by a facilitator/presenter with participant interaction. It is typically used to test new ideas, processes, or procedures; may include training on specific procedures. - Tabletop: Involves key personnel discussing simulated scenarios and is used to assess plans, policies, and procedures. It is a discussion-based exercise that familiarizes participants with current plans, policies, agreements, and procedures or may be used to develop new plans, policies, agreements, and procedures. (Refer to Homeland Security Exercise and Evaluation Program, January 2020)

See medication management.

See behaviors that undermine a culture of safety.

In telemedicine, the site at which the individual providing the professional service is located.

A measure of the radiation output of a computed tomography (CT) scanner. It factors in the length of the CT scan as well as the computed tomography dose index (CTDI). It provides an estimate of the radiation dose to a volume of tissue for a given patient in a clinical setting.

See medication.

An electronic form used for collecting information pertaining to the applicant organization. Information collected on this form will be used to determine the accreditation/certification requirements applicable to the organization, the types of surveyors/reviewers needed, the length of survey/review, and the survey fee.

A policy that permits an organization to achieve accreditation in a two-survey process. The first survey is limited in scope, and successful completion results in Preliminary Accreditation. The second survey addresses all accreditation requirements, and successful completion results in full accreditation.

A form of therapy that uses electricity to evoke a convulsive response.

The use of an automated data entry system by an authorized prescriber to transmit a prescription directly to a participating pharmacy. It is also referred to as e-prescribing.

Specific action(s), process(es), or structure(s) that must be implemented to achieve the goal of a standard. The scoring of EP compliance determines an organization’s overall compliance with a standard.

An unexpected or sudden event that significantly disrupts the organization’s ability to provide care, treatment, or services or the environment of care itself or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity.

An organization's written document that describes the process it would implement for managing the consequences of emergencies, including natural and human-made disasters, that could disrupt the organization's ability to provide care, treatment, and services.

For purposes of the National Patient Safety Goals, the phrase “emotional or behavioral disorders” refers to any diagnosis or condition recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), including those related to substance abuse.

The process by which a patient or individual served comes into a setting, including screening and/or assessment by a physician or other licensed practitioner to determine the capacity of the organization to provide the care, treatment, or services required to meet the needs of the patient or individual served.

A disease, such as influenza, that spreads rapidly, attacks many people in a geographic area, causes a high rate of morbidity or mortality, and then subsides. Epidemic applies especially to infectious diseases, as in an epidemic of cholera, but is also applied to any disease, injury, or other health-related event, such as an epidemic of teenage suicide.

Activities selected and implemented by the organization to assess and control the clinical and physical risks of fixed and portable equipment used for diagnosis, treatment, monitoring, and care.

The organized, phased, and supervised withdrawal, dispersal, or removal of patients, staff, and visitors from dangerous or potentially dangerous areas. Full (total) or partial evacuation occurs because conditions make it no longer safe to remain inside a building or in a specific area of a building. These levels of evacuation require persons to either move out and away from a building (full) or away from a specific area inside a building (partial).

Three years from the date of the last event, plus or minus 45 days.

Six months from the date of the last event, plus or minus 20 days.

A report submitted by a surveyed organization, which details the action(s) that it took to bring itself into compliance with an accreditation requirement or clarifies why the organization believes that it was in compliance with the accreditation requirement for which it received a Requirement for Improvement. An ESC report must address compliance at the element of performance level.

Guidelines that have been scientifically developed based on recent literature review and are consensus driven.

Taking unjust advantage of another for one’s own advantage or benefit.

A person or persons who play a significant role in an individual’s life. A family is a group of two or more persons united by blood or adoptive, marital, domestic partnership, or other legal ties. The family may also be a person or persons not legally related to the individual (such as a significant other, friend, support person, or caregiver) whom the individual personally considers to be family. A family member may be the surrogate decision-maker if authorized to make care decisions for the individual should the individual lose decision-making capacity or choose to delegate decision-making to another.

A service in which family members are assigned roles and responsibilities (for example, job coach) on the support team for the patient, resident, or individual served. This term is not synonymous with family therapy/counseling.

Intentionally causing undue fear, fright, panic, or terror in order to obtain compliance by the individual.

An item that is highly attracted to magnets. Such items pose a significant risk if allowed to enter the magnetic resonance imaging (MRI) scanner room or the area immediately preceding it. Ferromagnetic objects can become projectiles when they are rapidly drawn with considerable force toward the MRI unit. Examples of ferromagnetic items are those containing iron and nickel.

Activities selected and implemented by the organization to assess and control the risks of fire, smoke, and other by-products of combustion that could occur during the organization’s provision of care, treatment, or services.

The assignment of a person or persons to an area for the express purpose of protecting occupants from fire or similar emergencies. Examples of this protection include: - Notifying the fire department, the building occupants, or both of an emergency - Preventing a fire from occurring - Extinguishing small fires

Material that has undergone a test and is fire protection rated or fire resistance rated. Two examples of the concept of fire-rated include the following: - fire resistance rating - The time, in minutes or hours, that materials or assemblies have withstood a fire exposure, as determined by tests, or methods based on tests, prescribed by the National Fire Protection Association (NFPA). - fire protection rating - A designation indicating the duration of fire test exposure to which a fire door assembly or fire window assembly was exposed and for which it met all the acceptance criteria, as determined in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, or NFPA 257, Standard on Fire Test for Window and Glass Block Assemblies.

The time-limited evaluation of physician or other licensed practitioner competence in performing a specific privilege. This process is implemented for all initially requested privileges and whenever a question arises regarding a practitioner’s ability to provide safe, high-quality patient care.

A requirement of the accreditation process whereby an organization reviews its compliance with a selected subset of applicable Joint Commission accreditation requirements (including the applicable National Patient Safety Goals, a selection of standards that address accreditation program-specific high-risk areas, and the organization’s Requirements for Improvement [RFIs] from its last biennial survey); completes and submits to The Joint Commission a Plan of Action (POA) for any accreditation requirement with which it is not in full compliance; and chooses whether to engage in a telephone discussion with a member of the Standards Interpretation Group staff to determine the acceptability of the POA or discuss any other area of concern. Alternatives for a Full FSA submission include FSA Option 1 (attestation that an FSA was completed, but not submitted to The Joint Commission), Option 2 (on-site survey with documented findings), and Option 3 (on-site survey without documented findings). The FSA encourages organizations to be in continuous compliance with Joint Commission accreditation requirements and helps them to identify and manage risk. The organization retains the option to complete self-assessment with all applicable accreditation standards in the FSA tool, available on the organization’s Joint Commission Connect® extranet site. See also Intracycle Monitoring (ICM). The FSA tool can also be used as a self-assessment tool by an organization preparing for its initial accreditation survey.

A unit of work done by a force of one pound acting through a distance of one foot in the direction of the force.

A list of medications and associated information related to medication use.

A survey that assesses an organization’s compliance with all applicable Joint Commission accreditation requirements. See also accreditation survey.

An operations-based exercise that tests many facets of preparedness. The exercise involves planning and response partners (for example, state and local agencies) and takes place at the health care organization’s location using, as much as possible, the individuals and equipment that would be called upon in a real event. The emergency operations plan and integration of operational elements are tested in scripted emergency scenarios intended to mimic realistic situations. Through this exercise, participants utilize rapid problem solving in high-stress situations.

See operations-based exercise.

The individual(s), group, or agency that has ultimate authority and responsibility for establishing policy; maintaining quality of care, treatment, or services; and providing for organization management and planning. Governance may be a separate entity or it may fall within the medical advisory or executive committee. Other names for this group include the board, board of trustees, board of governors, board of commissioners, and partnership.

A parent, a trustee, a conservator, a committee, or another individual or agency empowered by law to act on behalf of or be responsible for the patient, resident, or individual served. See also family, surrogate decision-maker.

A systematic approach used to identify the hazards or risks that are most likely to have an impact on a health care facility and the surrounding community.

Materials whose handling, use, and storage are guided or defined by local, state, or federal regulation, such as the Occupational Safety and Health Administration’s Regulations for Bloodborne Pathogens regarding the disposal of blood and blood-soaked items and the Nuclear Regulatory Commission’s regulations for the handling and disposal of radioactive waste. This also includes hazardous vapors (for example, glutaraldehyde, ethylene oxide, nitrous oxide) and hazardous energy sources (for example, ionizing or nonionizing radiation, lasers, microwave, ultrasound). Although The Joint Commission considers infectious waste as falling into this category of materials, federal regulations do not define infectious or medical waste as hazardous waste.

An infection acquired concomitantly by an individual who is receiving or who has received care, treatment, or services from a health care organization. The infection may or may not have resulted from the care, treatment, or services.

Any information, oral or recorded, in any form or medium, that is created by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse that relates to past, present, or future physical or mental health or condition; the provision of health care; or payment for the provision of health care to an individual.

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Activities undertaken by an individual that have a negative impact on their health and increase the risk of disease or injury. Examples of health risk behaviors include substance abuse, tobacco use, inadequate exercise, poor dietary practices, and unsafe sexual activity.

The five levels of actions used to remove or lower exposure to a hazard and reduce risk of illness or injury for staff, patients, and visitors. The preferred order of action based on general effectiveness is as follows: 1. Elimination: Remove the source of the hazard (for example, reduce the number of staff who enter the isolation room) 2. Substitution: Use a safer alternative to the source of the hazard (for example, use videoconferencing instead of face-to-face communication, use needleless intravenous system) 3. Engineering controls: Reduce or prevent the hazard from coming into contact with staff, patients, and visitors (for example, install in-room high-efficiency particulate air (HEPA) filtration units with exhaust through fittings on the patient room window or keep doors closed, when feasible) 4. Administrative controls: Implement policy, procedure, and process changes that reduce the exposure of individuals to an identified hazard (for example, provide as much treatment as possible within the patient’s room by bringing necessary equipment and supplies into the room) 5. Personal protective equipment For more information, refer to https://www.cdc.gov/niosh/hierarchy-of-controls/about

A procedure or process that, if not planned and/or implemented correctly, has a significant potential for affecting the safety of a patient or an individual served.

Information gathered about an individual using a holistic approach for the purpose of establishing a diagnosis and developing a plan for care, treatment, or services to address physical health issues. The history may include information about previous illnesses; previous medical or surgical interventions and response to treatment; family health history; and social, cultural, economic, and lifestyle issues that may affect the individual’s health and well-being. The physical involves the physical examination of the individual’s body by the following means: inspection, palpation, percussion, and auscultation. When used in concert with behavioral health care and human services, the history and physical may be used to rule out physical causes for behavioral health conditions or to assess the impact of a medical diagnosis or treatment on a behavioral health condition or current situation.

The term that is generally used to refer to services provided in the home or in the community to recovering, disabled, or chronically ill persons and their families. These services may include some combination of professional health care services and personal care and supportive services. Professional health care services (also known as “skilled care”) may include physical and/or psychological assessment, nursing and medical care, medication teaching and administration, wound care, pain management, disease education and management, physical therapy, speech therapy, or occupational therapy. Home supportive care services (also known as “non-skilled care”) may include such things as light housekeeping, meal preparation, medication reminders, dressing, laundry, shopping, transportation, and companionship. In addition, home care can provide palliative care, respite care, hospice care, and other related services to those in need, including provision of medical equipment, medications, and supplies.

1. Hospice is an organized program that consists of services provided and coordinated by an interdisciplinary team to meet the needs of patients who are diagnosed with a terminal illness and have a limited life span. This includes all services such as pharmacies, medical equipment, and personal care provided to hospice patients at all sites of care. For example, if the hospice provides pharmacy or home medical equipment services, these services are surveyed as part of the hospice and are not required to be accredited separately under the pharmacy or home medical equipment service eligibility and survey process. Hospice programs specialize in palliative management of pain and other physical symptoms, meeting the psychosocial and spiritual needs of the patient and the patient's family or other primary caregiver through utilization of volunteers and provision of bereavement care to survivors. This includes, but is not limited to, all programs licensed as hospices and Medicare certified hospice programs. All services provided by the hospice (for example, pharmacy and home medical equipment services) and care provided in all settings (for example, inpatient, assisted living community, home, nursing care center, and so forth) are included. 2. For hospices that elect The Joint Commission deemed status option: A public agency or private organization or subdivision of either of these that is primarily engaged in providing hospice care.

The collection of settings and parameters used in the acquisition of medical images. Examples of settings and parameters include the clinical indication for the imaging exam, the use of contrast, patient positioning, and expected radiation dose ranges.

A threat that represents immediate risk and has or may potentially have serious adverse effects on the health or safety of the patient, resident, or individual served. These threats are identified by the surveyor.

Organized educational activity designed to enhance the skills of clinical staff relevant to their disciplines and job responsibilities.

The combination of personnel, procedures, communications, equipment, and facilities, operating within a common organizational structure, designed to aid in incident management activities. ICS is used for a broad spectrum of emergencies, from small to complex incidents, both natural and human-made, including acts of catastrophic terrorism.

The transmission of a pathogenic microorganism to a host, with subsequent invasion and multiplication, with or without resulting symptoms of disease.

Agreement or permission accompanied by full notice about the care, treatment, or service that is the subject of the consent. A patient or resident must be apprised of the nature, risks, and alternatives of a medical procedure or treatment before the physician or other licensed practitioner begins any such course. After receiving this information, the patient or resident then either consents to or refuses such a procedure or treatment.

An accreditation survey of an organization that has not been accredited by The Joint Commission for at least four months or an accreditation survey of an organization undergoing its first Joint Commission survey.

A highly structured environment that provides services to patients who require care that warrants 24-hour treatment or habilitation and who may be incapable of self-preservation in case of an emergency in the organization.

A waived testing device used for recording, measuring, or controlling. The levels of operation vary from manual steps to full automation, and specialized knowledge and skill are required.

Tests with analysis steps that rely on the use of an instrument to produce a test result of a patient, resident, or individual served.

The property that data or information have not been altered or destroyed in an unauthorized manner.

An approach to care, treatment, or services that involves two or more disciplines or professions (for example, social work, nursing, spiritual support, psychology, psychiatry, music, or art therapy) collaborating to plan, treat, or provide care, treatment, or services to an individual served and/or that person's family.

A series of 14 administrative actions intended to temporarily compensate for significant hazards posed by existing National Fire Protection Association 101 - 2012 Life Safety Code deficiencies or construction activities.

A trans-language rendition of a spoken message in which the interpreter comprehends the source language and can speak comprehensively in the target language to convey the meaning intended in the source language. The interpreter knows health and health-related terminology and provides accurate interpretations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source message.

A process to help accredited organizations at various touch points in the triennial accreditation cycle with their continuous compliance efforts. The process involves access to an ICM Profile available on the organization’s Joint Commission Connect® extranet site. The ICM Profile identifies high-risk areas and related standards areas and displays them within a Focused Standards Assessment (FSA) tool, which allows organizations to conduct a self-assessment of standards to identify and manage risk in the organization. See also Focused Standards Assessment (FSA).

A pharmaceutical product whose preparation requires the measured addition of a medication to a 50 mL or greater bag or bottle of IV fluid. It does not include the drawing up of medications into a syringe, the addition of medication to a buretrol, or the assembly and activation of an IV system that does not involve the measurement of the additive.

The puncture or incision of the skin, insertion of an instrument, or insertion of foreign material into the body for diagnostic or treatment-related purposes. Examples of invasive procedures include central line and chest tube insertions, and cardiac catheterization. Venipuncture is not categorized as an invasive procedure.

A medication used as part of a research protocol or clinical trial.

A collection of stored facts, models, and information that can be used for ongoing staff development, for designing and redesigning processes, and for solving problems. Knowledge-based information is found in the clinical, scientific, and management literature.

A facility that is equipped to examine material derived from the human body to provide information for use in the diagnosis, prevention, or treatment of disease; also called clinical laboratory or medical laboratory.

An individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization’s governance, management, and clinical and support functions and processes. At a minimum, leaders include members of the governing body and medical staff, the chief executive officer and other senior managers, the nurse executive, clinical leaders, and staff members in leadership positions within the organization.

Individuals in senior positions with clearly defined, unique responsibilities. These might include governance, management, medical staff, and clinical staff. Not every organization will have all of these groups, and an individual may be a member of more than one group.

An individual who is licensed and qualified to direct or provide care, treatment, and services in accordance with state law and regulation, applicable federal law and regulation, and organizational policy.

A legal right that is granted by a government agency in compliance with a statute governing an occupation (such as medicine, nursing, psychiatry, or clinical social work) or the operation of an activity in a health care occupancy (for example, skilled nursing facility, residential treatment center, hospital).

A set of standards for the construction and operation of buildings intended to provide a reasonable degree of safety during fires. These standards are prepared, published, and periodically revised by the National Fire Protection Association and adopted by The Joint Commission to evaluate health care organizations under its life safety management program.

Any device used for the purpose of sustaining life and whose failure to perform its primary function, when used according to the manufacturer’s instructions and clinical protocol, will lead to patient death in the absence of immediate intervention (for example, ventilators, anesthesia machines, heart-lung bypass machines).

See nursing care center.

Similar medication names, either written or spoken, which may lead to potentially harmful medication errors when confused with each other.

An item that has been demonstrated to pose no known hazards in a specific magnetic resonance (MR) environment under specific conditions of use. Conditions that define the MR environment include static magnetic field strength, radiofrequency fields, specific absorption rate, and other factors. The item label must include the results of testing that characterize the behavior of the item in the MR environment. Any parameter that affects the safety of the item should be listed, and any condition that is known to produce an unsafe condition must be described.

An item that poses no known hazards in all magnetic resonance (MR) environments. MR safe items are nonconducting, nonmetallic, and nonmagnetic items, such as a plastic Petri dish.

There are five types of maintenance — predictive, metered, corrective, interval-based, and reliability-centered: 1. Predictive maintenance - A type of maintenance strategy that provides the means to achieve reliability levels that exceed the performance of a piece of equipment or system. This strategy is designed to measure and track data significant to the piece of equipment or system. It confirms possible faults with the equipment, and specific repairs are completed before the equipment fails. Predictive analysis can be performed using advanced monitoring instruments and predictive software that collects data and performs an analysis. The data collected are analyzed, and corrective maintenance is performed when the equipment is performing outside the desired operating parameters. 2. Metered maintenance - Maintenance strategy based on the hours of run time or the number of times the equipment is used (for example, number of images processed). 3. Corrective maintenance - Maintenance strategy that restores a piece of equipment to operational status after equipment failure. 4. Interval-based maintenance - Maintenance done according to specific intervals (for example, calendar time, running hours). A number of periodic inspections or restoration tasks are completed, based on information/data obtained from the last equipment check. 5. Reliability-centered maintenance - A type of maintenance that begins with a failure mode and effects analysis to identify the critical equipment failure modes in a systematic and structured manner. The process then requires the examination of each critical failure mode to determine the optimum maintenance policy to reduce the severity of each failure. The chosen type of maintenance strategy must take into account cost, safety, and environmental and operational consequences. Some functions are not critical and may be allowed to "run to failure," while other functions must be preserved at all cost. Reliability-centered maintenance emphasizes the use of predictive maintenance techniques in addition to traditional preventive measures (metered, corrective, and interval based).

A continuous and unobstructed way of travel from any point in a building or other structure to a public way consisting of three separate and distinct parts: the exit access, the exit, and the exit discharge.

An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or another similar or related article, including a component part or accessory that is (1) recognized in the official National Formulary or the United States Pharmacopeia or any supplement to them; (2) intended for use in the diagnosis of disease or other conditions or in the cure, mitigation, treatment, or prevention of disease in humans or other animals; or (3) intended to affect the structure or any function of the body of humans or other animals and that does not achieve any of its primary intended purposes through chemical action within or on the body of humans or other animals and that is not dependent on being metabolized for the achievement of any of its primary intended purposes.

Fixed and portable equipment used for the diagnosis, treatment, monitoring, and direct care of individuals.

A component of the medical record consisting of an account of an individual’s physical health history, obtained whenever possible from the individual, and including at least the following information: chief complaint, details of the present illness or care needs, relevant past history, and relevant inventory by body systems.

See record.

Units comprised of locally based medical and public health volunteers who can assist their communities during emergencies, such as an influenza epidemic, a chemical spill, or an act of terrorism.

The group of physicians and other licensed practitioners privileged through the organized medical staff process that is subject to the medical staff bylaws. This group may include others, such as retired practitioners who no longer practice in the organization but who wish to continue their membership in the group, courtesy staff, scientific staff, and so forth. See also medical staff, organized.

A document or group of documents adopted by the voting members of the organized medical staff and approved by the governing body that defines the rights, responsibilities, and accountabilities of the medical staff and various officers, persons, and groups within the structure of the organized medical staff; the self-governance functions of the organized medical staff; and the working relationship with and accountability to the governing body of the organized medical staff.

A group of individuals, the majority of whom are licensed physician members of the medical staff practicing in the organization, that is selected and/or elected and removed according to the process contained in the medical staff bylaws. This group is responsible for making specific recommendations directly to the organization’s governing body for approval, as well as receiving and acting on reports and recommendations from medical staff committees, clinical departments or services, and assigned activity groups. The medical staff executive committee also acts on the behalf of the medical staff between meetings of the organized medical staff, within the scope of its responsibilities as defined by the organized medical staff. The medical staff as a whole may serve as the executive committee.

A self-governing entity accountable to the governing body that operates under a set of bylaws, rules and regulations, and policies developed and adopted by the voting members of the organized medical staff and approved by the governing body. The organized medical staff is comprised of doctors of medicine and osteopathy and, in accordance with the medical staff bylaws, may include other licensed practitioners.

Those physicians and other licensed practitioners within the organized medical staff who have the right to vote on adopting and amending medical staff bylaws, rules and regulations, and policies. See also medical staff, organized.

Medical items, usually of a disposable nature, such as bandages, sterile drapes, and suture materials. These supplies differ from permanent or durable items, such as medical equipment and devices.

Any prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals, vaccines, or over-the-counter drugs; diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications, respiratory therapy treatments, parenteral nutrition, blood derivatives, and intravenous solutions (plain, with electrolytes and/or drugs); and any product designated by the Food and Drug Administration (FDA) as a drug. This definition of medication does not include enteral nutrition solutions (which are considered food products), oxygen, and other medical gases.

A state of hypersensitivity induced by exposure to a particular drug antigen resulting in harmful immunologic reactions on subsequent drug exposures, such as a penicillin drug allergy. See also medication.

A preventable event that may cause or lead to inappropriate medication use or patient or resident harm while the medication is in the control of the health care professional, patient, resident, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. See also significant medication error.

The last date that a medication or product is to be used or administered.

The process an organization uses to provide medication therapy to individuals served by the organization. The components of the medication management process include the following: - procurement - The task of obtaining selected medications from a source outside the organization. It does not include obtaining a medication from the organization’s own pharmacy, which is considered part of the ordering and dispensing processes. - storage - The task of appropriately maintaining a supply of medications on the organization’s premises. - secure - In locked containers, in a locked room, or under constant surveillance. - prescribing or ordering - The process of a physician or other licensed practitioner transmitting a legal order or prescription to an organization, directing the preparing, dispensing, and administration of a specific medication to a specific individual. It does not include requisitions for medication supplies. - transcribing - The process by which an order from a physician or other licensed practitioner is documented either in writing or electronically. - preparing - Compounding, manipulating, or in some way getting a medication ready for administration, exactly as ordered by the physician or other licensed practitioner. - dispensing - Providing, furnishing, or otherwise making available a supply of medications to the individual for whom it was ordered (their representative) by a licensed pharmacy according to a specific prescription or medication order, or by a physician or other licensed practitioner authorized by law to dispense. Dispensing does not involve providing an individual a dose of medication previously dispensed by the pharmacy. - administration - The provision of a prescribed and prepared dose of an identified medication to the individual for whom it was ordered to achieve its pharmacological effect. This includes directly introducing the medication into or onto the individual’s body.

The process of identifying the medications currently being taken by an individual. These medications are compared to newly ordered medications, and discrepancies are identified and resolved.

Medications that bear a heightened risk of causing significant harm to individuals when they are used in error.

Intentional mistreatment of an individual that may cause psychological injury. Examples include humiliation, harassment, exploitation, and threats of punishment or deprivation.

Those activities an organization undertakes in attempting to reduce the severity and impact of a potential emergency. See also emergency.

See operations-based exercise.

A group of staff members composed of representatives from a range of professions, disciplines, or service areas.

See close call.

The absence of the minimal services or resources required to meet basic needs. Neglect includes withholding or inadequately providing medical care and, consistent with usual care, treatment, or services, food and hydration (without approval from the individual, physician or other licensed practitioner, or surrogate), clothing, or good hygiene. It may also include placing an individual in unsafe or unsupervised conditions. See also abuse.

A registered professional nurse who is responsible for the full-time, direct supervision of nursing services and who is currently licensed by the state in which they practice. Attributes of this position may be further defined in regulatory statutes.

The health profession dealing with nursing care and services as (1) defined by the Code of Ethics for Nurses with Interpretive Statements, Nursing’s Social Policy Statement, Nurses’ Bill of Rights, Scope and Standards of Nursing Practice of the American Nurses Association and specialty nursing organizations and (2) defined by relevant state, commonwealth, or territory nurse practice acts and other applicable laws and regulations.

Individuals receiving care in this setting require rehabilitative, supportive, or palliative care. This care may include time-limited medically complex or rehabilitative care, dementia-specific memory care, long term nursing care, and other specialty care services. These services may be provided within a hospital, in an organization affiliated with a hospital, or in a freestanding organization. Synonyms used by the health care field for this setting include nursing home, long term care facility, and skilled nursing facility (SNF).

One or more defined units, departments, programs, or services within the organization that is accountable for the delivery of nursing care to individuals, families, communities, and/or populations.

Personnel within an organization who are accountable for providing and assisting in the provision of nursing care. Such personnel must include registered nurses (RNs), and may include others such as advanced practice registered nurses (APRNs), licensed practical or vocational nurses (LPNs/LVNs), and nursing assistants or other designated unlicensed assistive personnel.

Nutrients (such as protein, sugar, fat, and added vitamins and minerals as needed) that are provided intravenously, bypassing the digestive tract. Related terms are total parenteral nutrition (TPN), partial parenteral nutrition (PPN), and hyperalimentation (HA).

The purpose for which a building or portion thereof is used or intended to be used. Depending on the organization, occupancies may include ambulatory health care occupancy, business occupancy, health care occupancy, and residential occupancy. - health care occupancy - An occupancy used for purposes such as medical or other treatment or care of persons suffering from physical or mental illness, disease, or infirmity; and for the care of infants, convalescents, or infirm aged persons. Health care occupancies provide sleeping facilities for four or more occupants and are occupied by persons who are mostly incapable of self-preservation because of age, physical or mental disability, or security measures not under the occupant’s control. Health care occupancies include hospitals, critical access hospitals, skilled nursing homes, and limited care facilities.

A surgeon-owned or -operated organization (for example, a professional services corporation, private physician office, small group practice) that provides invasive procedures and administers local anesthesia, minimal sedation, conscious sedation, or general anesthesia that renders three or fewer patients incapable of self-preservation at any time, and is classified as a business occupancy.

A document summary of ongoing data collected for the purpose of assessing a physician's or other licensed practitioner’s clinical competence and professional behavior. The information gathered during this process is factored into decisions to maintain, revise, or revoke existing privilege(s) prior to or at the end of the two-year license and privilege renewal cycle.

Emergency management exercise that includes real-time responses, such as initiating communications or mobilizing personnel and resources to validate plans, policies, procedures, and agreements; clarify roles and responsibilities; and identify resource gaps. Types of operations-based exercises include the following: - Full-scale exercise: An exercise that tests the emergency operations plan and integration of operational elements through scripted emergency scenarios intended to mimic realistic situations using real-time movement of resources (staff, space, and supplies) and often involving multiple agencies and jurisdictions/organizations. - Functional exercise: Designed to test and evaluate capabilities and functions while in a realistic, real-time environment; however, movement of resources is usually simulated. - Mock disaster drill: Used to validate a single operation or function within the organization. Mock disaster drills are commonly used to provide training on new equipment, validate procedures, or practice and maintain current skills. (Refer to Homeland Security Exercise and Evaluation Program, January 2020)

Operative or other invasive or noninvasive procedures that place the patient at risk; these procedures are performed to remedy an injury, ailment, defect, or dysfunction. The focus is on procedures and is not meant to include medications that place the patient at risk.

A human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs).

The organ procurement conversion rate is calculated using the number of actual donors (numerator) over the number of eligible donors (denominator) as defined by the organ procurement organization (OPO), using the most current quarterly data. At this time, the conversion rate will only apply to solid organs, such as kidney, liver, heart, lung, pancreas, and small intestine. Tissue such as cornea/eye, skin, bone, tendons, heart valves and veins are excluded from the requirement unless it is part of the procured solid organ and required for reattachment.

The degree to which a component of an organization is overseen and managed by the applicant organization. Organizational integration exists when the applicant organization’s governing body, either directly or ultimately, controls budgetary and resource allocation decisions for the component or, where separate corporate entities are involved, there is greater than 50% common governing board membership on the board of the applicant organization and the board of the component. Functional integration exists when the entity meets at least three of the following eight criteria: 1. The applicant organization and the component use the same process for determining membership of physicians or other licensed practitioners in practitioner panels or medical or professional staff and/or use the same process for credentialing and assigning of privileges or clinical responsibilities to physicians or other licensed practitioners, and/or share a common organized medical or professional staff between the applicant organization and the component. 2. The applicant organization’s human resources function hires and assigns staff at the component and has the authority to terminate staff at the component, to transfer or rotate staff between the applicant organization and the component, and to conduct performance appraisals of the staff who work in the component. 3. The applicant organization’s policies and procedures are applicable to the component with few or no exceptions. 4. The applicant organization manages all operations of the component (that is, the component has little or no management authority or autonomy independent of the applicant organization). 5. The component’s clinical records are integrated into the applicant organization’s clinical record system. 6. The applicant organization applies its performance improvement program to the component and has authority to implement actions intended to improve performance at the component. 7. The applicant organization bills for services provided by the component under the name of the applicant organization. 8. The applicant organization and/or the component portrays to the public that the component is part of the organization through the use of common names or logos; references on letterheads, brochures, telephone book listings, or websites; or representations in other published materials.

A process used to provide initial training and information while assessing the competence of staff relative to job responsibilities and the organization’s mission and goals.

In telemedicine, the site at which the patient is located at the time the service is provided.

An entity consisting of an automated database(s) that facilitates performance improvement in health care organizations through the collection and dissemination of process and/or outcome measures of performance. ORYX vendors must be able to generate internal comparisons of organization performance over time, and external comparisons of performance among participating organizations at comparable times.

The occurrence of more than the expected number of cases of disease, injury, or other health conditions among a specific group during a specified time frame.

A tool used to assess data which indicates the results of performance or nonperformance of a function or procedure.

The entity that has ultimate control of resources and operation of the organization applying for accreditation.

The services that provide information on diagnosis, prevention, or treatment of disease or the assessment of health, through the examination of the structural and functional changes in tissues and organs of the body that cause or are caused by disease. It also includes the biological, microbiological, serological, chemical, immunohematological, hematological, or other examination of materials derived from the human body.

An individual who receives care, treatment, or services. For hospice providers, the patient and family are considered a single unit of care. Synonyms used by various health care fields include client, resident, patient and family unit, consumer, health care consumer, customer, or beneficiary. When appropriate, the term patient may also refer to the “legally responsible individual.”

Information directly associated with an individual that reliably identifies the individual as the person for whom the service or treatment is intended. Acceptable identifiers may be the individual's name, an assigned identification number, telephone number, or other person-specific identifier.

An event, incident, or condition that could have resulted or did result in harm to a patient. See also adverse event, close call, sentinel event.

Information submitted by a physician(s) or other licensed practitioner(s) in the same professional discipline as an applicant, reflecting their perception of the applicant's clinical practice, ability to work as part of a team, and ethical behavior; or the documented peer evaluation of practitioner-specific data collected from various sources for the purpose of evaluating current competence.

Continuous study and adjustment of the health care staffing services firm's operations to increase the probability of achieving a desired outcome to better meet staff and customer needs.

See ORYX® vendor.

An object used in medical imaging that simulates features of the human body. It is scanned or imaged and used to evaluate and analyze imaging equipment performance.

An individual who has a degree in pharmacy and is licensed and registered to prepare, preserve, compound, and dispense drugs and other chemicals.

Pharmaceutical care and services involving the preparation and dispensing of medications and medication-related devices and supplies by a licensed pharmacy, with or without the provision of clinical or consultant pharmacist services.

Intentional mistreatment of an individual that may cause physical injury. Examples include hitting, slapping, pinching, or kicking, and may also include attempts to control behavior through corporal punishment.

As defined by the Centers for Medicare & Medicaid Services in Sec. 1861.[42 U.S.C.1395x] of the Social Security Act: The term “physician,” when used in connection with the performance of any function or action, means (1) A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action (including a physician within the meaning of section 1101(a)(7)), (2) A doctor of dental surgery or of dental medicine who is legally authorized to practice dentistry by the State in which he performs such function and who is acting within the scope of his license when he performs such functions, (3) A doctor of podiatric medicine for the purposes of subsections (k), (m), (p)(1), and (s) of this section and sections 1814(a), 1832(a)(2)(F)(ii), and 1835 but only with respect to functions which he is legally authorized to perform as such by the State in which he performs them, (4) A doctor of optometry, but only for purposes of subsection (p)(1) with respect to the provision of items or services described in subsection (s) which he is legally authorized to perform as a doctor of optometry by the State in which he performs them, or (5) A chiropractor who is licensed as such by the State (or in a State which does not license chiropractors as such, is legally authorized to perform the services of a chiropractor in the jurisdiction in which he performs such services), and who meets uniform minimum standards promulgated by the Secretary, but only for the purpose of sections 1861(s)(1) and 1861(s)(2)(A) and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation) which he is legally authorized to perform by the State or jurisdiction in which such treatment is provided. For the purposes of section 1862(a)(4) and subject to the limitations and conditions provided in the previous sentence, such term includes a doctor of one of the arts, specified in such previous sentence, legally authorized to practice such art in the country in which the inpatient hospital services (referred to in such section 1862(a)(4)) are furnished.

For home health agencies that elect to use The Joint Commission deemed status option: Physician assistant is defined at 42 CFR 410.74(a) and (c). For Medicare Part B coverage of their services, a physician assistant must meet all the following qualifications: - Graduated from a physician assistant educational program that is accredited by the Commission on Accreditation of Allied Health Education Programs; or - Passed the national certification examination that is administered by the National Commission on Certification of Physician Assistants; and - Be licensed by the state to practice as a physician assistant.

For purposes of Joint Commission accreditation, an organization’s written statement that details the procedures to be taken and time frames to correct existing Life Safety Code® deficiencies. See also Life Safety Code, Statement of Conditions™ (SOC).

A plan detailing the action(s) that an organization will take in order to come into compliance with a Joint Commission accreditation requirement. A POA must be completed for each element of performance associated with a non-compliant accreditation requirement.

Analytical testing performed at sites outside the traditional laboratory environment, usually at or near where care is delivered to individuals. Testing may be categorized as waived, moderate, or high complexity under the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88). Testing may range from simple waived procedures, such as fecal occult blood, to more sophisticated chemical analyzers. Guided by CLIA requirements this testing may be under the control of the main laboratory, another specialized laboratory (for example, for arterial blood gas), or the nursing service (for example, for glucose meters). Point-of-care testing may also be known as alternative site testing, decentralized laboratory testing, or distributed site testing.

A principle or method that is developed for the purpose of guiding decisions and activities related to governance, management, care, treatment, and services. A policy is developed by organization leadership, approved by the governing body of the organization, and maintained in writing.

The assessment, monitoring, and management of the health care needs and outcomes of identified groups of patients and communities, rather than individual patients. The goal of population-based care is to improve the health of the population, increase awareness of behavior-related health risks, promote healthy lifestyle activities and patient self-management, and decrease health care inequities.

See clinical practice guidelines.

Activities an organization undertakes to build capacity and identify resources that may be used if an emergency occurs. See also emergency.

See medication management.

The provision of health care that focuses on disease prevention and health maintenance. It includes early diagnosis of disease as well as discovery and identification of individuals at risk for the development of specific health problems or in need of counseling or other necessary interventions to avert a health problem. Screening tests, health education, and immunization programs are common examples of preventive care.

A clinician operating within the primary care medical home who works collaboratively with an interdisciplinary team and in partnership with the patient to address the patient's primary health care needs. Primary care clinicians have the educational background, broad-based knowledge, and experience necessary to handle most medical and other health care needs of the patients who have selected them, including resolving conflicting recommendations for care. The primary care clinician is selected by the patient and serves as the primary point of contact for the patient and family. A primary care clinician operating within the primary care medical home is a doctor of medicine or doctor of osteopathy, or an advanced practice nurse or physician assistant practicing in collaboration with a doctor of medicine or doctor of osteopathy. The term “collaboration” in this context means that health care providers work together to meet the needs of the patient. It is not the intent of this requirement to impose additional restrictions on the scope of practice of an advanced practice nurse, nor is it meant to preempt applicable state law.

A model of primary health care that is based on five operational characteristics: patient-centered care; comprehensive care; coordinated care; superb access to care; and a system-based approach to quality and safety. They address the roles and functions of the patient, organization, primary care clinician, and interdisciplinary team. PCMH Certification is an optional certification that requires compliance with accreditation requirements plus an additional set of PCMH-specific requirements.

The original source or an approved agent of that source of a specific credential that can verify the accuracy of a qualification reported by an individual practitioner. Examples include medical schools, nursing schools, graduate education, state medical boards, federal and state licensing boards, universities, colleges, and community colleges.

Verification of a physician's or other licensed practitioner’s reported qualifications by the original source or an approved agent of that source. Methods for conducting primary source verification of credentials include direct correspondence, documented telephone verification, secure electronic verification from the original qualification source, or reports from credentials verification organizations (CVOs) that meet Joint Commission requirements. See also credentials verification organization (CVO).

The right of an individual to limit the disclosure of personal information.

The process whereby the specific scope and content of services (that is, clinical privileges) are authorized for a physician or other licensed practitioner by a health care organization based on evaluation of the individual’s credentials and performance.

A list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. For accreditation purposes, the prohibited list applies, at a minimum, to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms.

Health information that contains information such that an individual person can be identified as the subject of that information.

A range of socio-legal, assistive, and remedial services that facilitate the exercise of individual rights and provide certain supportive and surrogate services to help children and youth, elderly, and developmentally disabled individuals reach the maximum independence possible yet protect them from exploitation, neglect, or abuse. Depending on the nature and extent of individual needs, protective services may range from counseling to full guardianship.

A licensed individual or organization that provides health care services outside the accredited organization.

A physician who specializes in assessing and treating persons having psychiatric disorders; is certified by the American Board of Psychiatry and Neurology or has the documented equivalent in education, training, or experience; and is fully licensed to practice medicine in the state in which they practice.

An individual who specializes and is licensed in psychological research, testing, or therapy.

Pertaining to the influence of social factors on an individual’s mind or behavior and to the interrelation of behavioral and social factors.

A Joint Commission policy which specifies the information that The Joint Commission may release about accredited organizations. By submitting a signed accreditation contract, the organization is acknowledging that The Joint Commission may make available to the public the accreditation-related information in accordance with this policy.

Knowledge, education, training, experience, competency, licensure, registration, or certification related to specific responsibilities.

As defined by the Centers for Medicare & Medicaid Services in 42 CFR 483.70(p) for swing beds, a qualified social worker is an individual who has a bachelor’s degree in social work or a bachelor’s degree in a human services field including, but not limited to, sociology, special education, rehabilitation counseling, or psychology and has one year of supervised social work experience in a health care setting working directly with individuals.

A set of activities or techniques whose purpose is to ensure that all quality requirements are being met. The organization monitors processes and solves performance problems to achieve this purpose.

The degree to which care, treatment, or services for individuals and populations increases the likelihood of desired health or behavioral health outcomes. Considerations include the appropriateness, efficacy, efficiency, timeliness, accessibility, and continuity of care; the safety of the care environment; and the individual’s personal values, practices, and beliefs.

A test result that is measured as a discrete number.

Every three months, plus or minus 10 days.

Orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or the individual’s status.

A short paragraph that explains the justification for a standard; that is, why the standard is important or how it contributes to quality and/or safety. A rationale is not scored, and not every standard has a rationale.

A method used to ensure understanding of information being communicated, often used between members of a care, treatment, or service team. The process involves the receiver of a verbal or telephone order writing down the complete order or test result or entering it into a computer and then reading it back and receiving confirmation from the person who gave the order or test result.

Ongoing data collection, which begins on initial assessment, comparing the most recent data with the data collected at earlier assessments.

1. An account compiled by physicians and other health care professionals of a variety of health information, such as assessment findings, treatment details, and progress notes. 2. Data obtained from the records or documentation maintained on a patient, individual served, or resident in any health care setting (for example, hospital, home care, nursing care center, licensed practitioner office). The record includes automated and paper medical record systems.

The final phase of emergency management, related to strategies, actions, and individual responsibilities necessary to restore the organization’s services after an emergency. See also emergency.

For home health agencies and hospices that elect to use The Joint Commission deemed status option: A graduate of an approved school of professional nursing, who is licensed as a registered nurse in the state where practicing.

The range of test values over which the relationship between the instrument, kit, or system’s measurement response is shown to be valid.

A recommendation that is required to be addressed in an organization’s Evidence of Standards Compliance in order for the organization to retain its accreditation. Failure to adequately address an RFI after two opportunities may result in a recommendation to place the organization in Accreditation with Follow-up Survey.

Actions taken and procedures implemented by the organization when an emergency occurs. See also emergency.

Any method (chemical or physical) of restricting an individual’s freedom of movement to manage their behavior. This includes any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of an individual to move their arms, legs, body, or head freely. It also includes any drug or medication when it is used as a restriction to manage the individual’s behavior or to restrict their freedom of movement and is not a standard treatment or dosage for their condition. Practices that meet the definition of a restraint include but are not limited to the following: - Using side rails that keep an individual from voluntarily getting out of bed - Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that an individual’s movement is restricted - Using devices in conjunction with a chair, such as trays, tables, bars, or belts, that the individual cannot remove easily and that prevent them from rising - Placing an individual in a chair that prevents them from rising - Placing a chair or bed so close to a wall that the wall prevents the individual from rising out of the chair or voluntarily getting out of bed

Qualified staff, supplies, and processes used to revive an individual.

A panel of three individuals, including one member of The Joint Commission's Board of Commissioners, which evaluates the facts of an organization appealing a Preliminary Denial of Accreditation.

An assessment that examines a process in detail including sequencing of events, actual and potential risks, and failure or points of vulnerability and that prioritizes, through a logical process, areas for improvement based on the actual or potential impact (that is, criticality) of care, treatment, or services provided.

See comprehensive systematic analysis.

As used in these standards, documents other than medical staff bylaws. When adopted by the organized medical staff and approved by the governing body these documents have the force and effect of medical staff bylaws.

The Survey Analysis for Evaluating Risk® (SAFER™) Matrix gives a visual representation of the risk level of each Requirement for Improvement (RFI). Each observation reported by a reviewer is plotted on the SAFER Matrix according to the risk level of the finding. The risk level is determined according to two factors: (1) the likelihood of the finding to cause harm to patients, staff, and/or visitors, and (2) the scope at which the finding was observed.

Risks that may arise from the performance of tasks, from the structure of the physical environment, or from situations beyond the organization's control (such as weather). Safety refers to actions that mitigate such risk to individuals served and other persons including staff.

Activities selected and implemented by the organization to assess and control the impact of environmental risk, and to improve general environmental safety.

Selecting a subset from a larger group of units or observations that provides information that may be used to decide about the larger quantity.

The activities performed by governance, managerial, clinical, or support staff.

1. The involuntary confinement of an individual in a room alone, for any period of time, from which the individual is physically prevented from leaving. Seclusion does not include involuntary confinement for legally mandated but nonclinical purposes, such as the confinement of a person who is facing serious criminal charges or who is serving a criminal sentence. 2. For hospices that elect to use The Joint Commission deemed status option: The involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving.

In a locked container, in a locked room, or under constant surveillance.

Protection of people and property against harm or loss (for example, workplace violence, theft, access to medications). Security incidents may be caused by persons from outside or inside the organization.

Administrative, physical, and technical safeguards to prevent unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system.

Independent use of a medication by a patient or individual served, including medications that may be held by the organization for independent use.

Activities performed by patients with one or more chronic conditions that enable them to take an active role in the management of their health care and improve their clinical outcomes.

Results of tests that are more precise than qualitative tests (negative/positive results) but less precise than quantitative tests (numerical value), usually scored on a graded scale (for example, 1+, 2+, 3+).

A patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm). Sentinel events are a subcategory of adverse events.

Intentional mistreatment of a sexual nature of an individual that may cause physical and/or psychological injury. Examples include sexual harassment, sexual coercion, and sexual assault.

A rapid and effective means of protecting patients, staff, and visitors from an external or internal threat. This may include the movement of persons to selected interior rooms and away from windows; self-preservation by hiding in a safe place; taking immediate actions to protect environment from chemical, biological, or radiological releases.

An adverse medication reaction experienced by an individual that required intervention to preclude or mitigate harm or that requires monitoring to confirm that it resulted in no harm to the individual.

A medication error that reached an individual that required intervention to preclude or mitigate harm and/or that required monitoring to confirm that it resulted in no harm to the individual.

Computer hardware and software allowing realistic interactions and interventions to occur in programmed scenarios to evaluate clinical competence.

A measure of the radiation output of a computed tomography scanner. Along with the computed tomography dose index (CTDI), it factors in the patient’s size to provide a better estimate of the radiation dose to a volume of tissue for a given patient in a clinical setting.

A strategy for reprocessing contaminated medical devices. The system classifies a medical device as critical, semicritical, or noncritical based on the risk to patient safety from a contaminated device. The system also establishes levels of germicidal activity (sterilization, high-level disinfection, intermediate-level disinfection, and low-level disinfection) to use with the three classes of medical devices (critical, semicritical, and noncritical).

All people who provide care, treatment, or services in the organization, including licensed practitioners; permanent, temporary, and part-time personnel; contract employees; volunteers; and health profession students.

A principle of safety of the individual served and quality of care, treatment, or services that a well-run organization meets. A standard defines the performance expectations, structures, or processes that must be substantially in place in an organization to enhance the quality of care, treatment, or services.

A proactive document that helps an organization do a critical self-assessment of its current level of compliance and describe how to resolve any Life Safety Code® deficiencies. The SOC was created to be a “living, ongoing” management tool that should be used in a management process that continually identifies, assesses, and resolves Life Safety Code deficiencies.

The use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores.

Systems that automatically supply illumination or power to critical areas and equipment essential for safety to human life. Included are systems that supply emergency power for such functions as illumination for safe exiting, ventilation where it is essential to maintain life, fire detection and alarm systems, public safety communications systems, and processes where the current interruption would produce serious life safety or health hazards to patients, residents, individuals served, the public, or staff. Note: Other non-SEPSS battery back-up emergency power systems that an organization has determined to be critical for operations during a power failure (for example, laboratory equipment, electronic health records) should be properly tested and maintained in accordance with manufacturer recommendations.

An individual who supports the patient during the course of their stay. A support person could be the patient's representative designated under an advance directive, a family member, friend, or other individual. Not only may the support person visit the patient, but they may also exercise a patient's visitation rights on behalf of the patient with respect to other visitors when the patient is unable to do so.

Services provided in an individual’s place of residence on a per-visit or per-hour basis to meet the identified needs of an individual who requires assistance in the maintenance and management of household routines, such as cleaning or shopping. These services may include, but are not limited to, those provided by homemakers, chore service workers, or companions. These services may be provided directly or through contract with another organization or individual.

Someone legally appointed to make decisions on behalf of another. This decision-maker can be a family member or someone not related to the individual served or patient. A surrogate decision-maker makes decisions when the individual served or patient is without decision-making capacity or when the individual served or patient has given permission to the surrogate to make decisions. Such a decision-maker is sometimes referred to as a legally responsible representative. See also family.

A systematic method of collecting, consolidating, and analyzing data concerning the frequency or pattern of, and causes or factors associated with, a given disease, injury, or other health condition. Data analysis is followed by the dissemination of the information yielded to those who can improve outcomes. Examples of surveillance data are data on hand hygiene, vaccinations, and staff immunization.

A key component in the accreditation process whereby a surveyor(s) conducts an evaluation of an organization’s compliance with Joint Commission accreditation requirements.

For purposes of Joint Commission accreditation, a health care professional who meets The Joint Commission’s surveyor selection criteria, evaluates compliance with accreditation requirements, and provides education regarding compliance with accreditation requirements to surveyed organizations or systems. The type of surveyor(s) assigned is determined by the accreditation program and its services. A surveyor may be, but is not limited to, a licensed physician, surgeon, podiatrist, dentist, nurse, physician assistant, pharmacist, medical technologist, respiratory therapist, administrator, social worker, psychologist, or behavioral health care professional.

Suspensions that are automatically enacted whenever the defined indication occurs, and do not require discussion or investigation. Examples are loss of licensure or exceeding the allowed medical record delinquency rate. Privileges are automatically suspended until the license is renewed, or the records are completed, or the delinquency rate falls to an acceptable level.

While enacted automatically whenever the defined indication occurs, summary suspensions also require a subsequent evaluation or investigation of the reason the indication occurred and a decision as to whether the suspension should be continued and for what length of time. Examples are the occurrence of a sentinel event that might be related to the physician's or other licensed practitioner’s performance, or a significant complaint against the practitioner such as misconduct or assault. The summary suspension is enacted while the incident is under investigation.

See discussion-based exercise.

The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration.

The use of medical information exchanged from one site to another via electronic communication to improve patients' health status. Telemedicine is a subcategory of telehealth.

An independent, not-for-profit organization dedicated to improving the safety and quality of health care through standards development, public policy initiatives, accreditation, and certification. The Joint Commission accredits and certifies more than 20,000 health care organizations and programs in the United States.

A procedure used to help a patient or individual served to regain emotional control that involves removing them from the immediate environment and restricting them to a quiet area or an unlocked quiet room.

An immediate pause by the entire surgical team to confirm the correct patient, procedure, and site.

Any group of cells that perform specific functions.

A process surveyors use during the survey to analyze an organization’s systems or processes for delivering safe, high-quality care by following an individual patient or resident through the organization’s care process in the sequence experienced by each individual. Depending on the setting, this process may require surveyors to visit multiple care programs and services within an organization or within a single program or service to “trace” the care rendered.

As defined by the Centers for Medicare & Medicaid Services in 42 CFR 483.12(a)(1), movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility.

A trans-language rendition of a written document in which the translator comprehends the source language and can write comprehensively in the target language to convey the meaning intended in the source language. The translator knows health and health-related terminology and provides accurate translations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source document.

Infection prevention and control measures to protect against exposure to a suspected or identified pathogen. These precautions are specific and based on the way the pathogen is transmitted. Categories include contact, droplet, airborne, and a combination of these.

For hospitals that use Joint Commission accreditation for deemed status purposes: As defined in 42 CFR 482.70, an organization that performs organ-specific transplants (heart, intestine, kidney, liver, lung, or pancreas) in a Medicare-approved hospital.

Medication to be given to a particular patient at a specific time packaged in the exact dosage required for that time.

A degree of severity of illness or injury that is not immediately life-threatening, but requires care more quickly than elective care.

The delivery of ambulatory medical care to patients who have an injury or illness that requires immediate care but is not serious enough to warrant a visit to an emergency room. Urgent care centers often have extended hours and typically see patients on a walk-in basis without a scheduled appointment. Care may include diagnostic and therapeutic services, on-site x-ray, laboratory testing, pharmacy, and laceration and fracture care.

Building systems that provide support to the environment of care, including electrical distribution and emergency power; vertical and horizontal transport; heating, ventilating, and air conditioning (HVAC); plumbing, boiler, and steam; piped gases; vacuum systems; and communication systems, including data exchange systems.

A measure of the difference in a set of observations; statistically, the square of the standard deviation.

Tests that meet the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88) requirements for waived tests and are cleared by the Food and Drug Administration for home use. These tests employ methodologies that are so simple and accurate that the likelihood of erroneous results is negligible, or they pose no risk of harm to the patient, resident, or individual served if the test is performed incorrectly. See also Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88).

An act or a threat occurring at the workplace that can include any of the following: verbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; or physical assaults involving staff, patients, or visitors.

See discussion-based exercise.

A person 13 years of age or older who has not reached age of majority, or as identified by law and regulation.