Editor's note: Each installment of Joint Commission Standards will review a chapter of the Comprehensive Accreditation Manual for Hospitals and may be distributed to staff as a teaching tool. Joint Commission Standards will be updated monthly online and appear regularly in print.
The Provision of Care, Treatment and Services (PC) chapter focuses on the coordination and completion of processes from initial assessment through discharge. The core elements reflect the nursing process of assessment of needs, plan for care, provision and coordination of care, and reassessment.
New for 2007
PC.9.30 Resuscitation services are available throughout the hospital.
Element of Performance (EP) 4. An evidence-based training program(s) (new for 2007) is used to train appropriate staff to recognize the need for and use of designated equipment and techniques in resuscitation efforts (i.e., the program must be based on empirical evidence or, in the absence of empirical evidence, supported by consensus statements promoted by professional societies. A return demonstration component should be part of the training program).
Avoiding Common Pitfalls
PC.2.120 The hospital defines the time frame(s) for conducting the initial assessment(s).
Thirteen percent of the hospitals surveyed in 2006 were not compliant with one or more of the seven EPs listed for this standard.
The Joint Commission expectation is that the history and physical are completed within 24 hours of inpatient admission or, if completed within 30 days prior to patient's admission or readmission, an update to the patient's condition since the assessment is documented at the time of admission. State regulations may be more stringent; the more stringent standard or regulation will be used. Misrepresentation or falsification related to time and date will not sit well with surveyors.
Other assessments that must be completed within 24 hours of admission include a nursing assessment by an RN and, when warranted by patient condition or need, nutritional and functional status screenings.
PC.4.10 Development of a plan of care, treatment and services is individualized and appropriate to the patient's needs, strengths, limitations and goals.
Thirteen percent of the hospitals surveyed in 2006 were not compliant with one or more of the six EPs listed for this standard.
The initial plan for care, treatment and services is based on the individual patient's assessed needs. Need to know:
The plan is based on assessment of needs; care is performed based on plan. Needs are prioritized.
The plan can be found in the history and physical, initial orders, problem lists, care plans, pathways, care maps and protocols. Location is based on hospital policy.
The plan, whether standardized or free text, electronic or written, always addresses the specific needs of the individual patient.
Planning is performed by qualified individuals using an interdisciplinary approach. Need to know:
A common plan is not required by standard, but the method of communication between providers of care needs to be clearly articulated by all disciplines and evidenced by their documentation within the medical record. If an interdisciplinary format is used, all disciplines involved in providing care, treatment or services should have input into the plan.
Patient involvement, to the extent possible, is evident. Need to know:
Informed consent, progress notes, patient education forms, care plans, pathways, care maps and protocols often evidence patient involvement in the planning process. When using standardized forms that require check-offs, make certain the form is individualized and complete.
The plan contains realistic measurable goals. The plan and goals are revised when necessary. Need to know:
Planning is a dynamic process. As patients' conditions change, so do needs. Revision of the plan is not limited to time frames based on hospital policy, but includes assessment and reassessment of response to interventions, progress toward goals, and changes in condition, care setting and resources.
The plan for care considers strategies to limit the use of restraints or seclusion as appropriate. Need to know:
Patient safety issues are priority. Assessment determines the need, potential or actual, to address use of alternatives to restraints or seclusion in the plan for care. Ongoing assessment of the effectiveness/lack of effectiveness of specific alternatives is documented in the progress note and the plan is revised accordingly.
PC.8.10 Pain is assessed in all patients.
Eighteen percent of the hospitals surveyed in 2006 were not compliant with one or more of the four EPs listed for this standard.
Comprehensive pain assessment is conducted as appropriate to patient's condition and scope of care. Reassessment and follow-up based on hospital-developed criteria. Assessment methods are age- and ability-appropriate. Pain is treated by the hospital or referred for treatment. Need to know:
Hospital policies related to assessment, intervention and reassessment.
Practice must follow policy.
Compliance issues related to pain assessment at time of transfer to another level of care, reassessment following intervention and consistency of pain management documentation throughout the course of hospitalization.
PC.13.20 Operative or other procedures and/or administration of moderate or deep sedation or anesthesia is planned.
Fifteen percent of the hospitals surveyed in 2006 were not compliant with one or more of the 12 EPs listed for this standard.
The most consistent problem is related to failure to complete the required documentation prior to the administration of sedation:
Plan for appropriate level of post-procedure care
Time out immediately prior to start of procedure
Plan for anesthesia/sedation
Re-evaluation immediately before induction.
Jean Kalemba was previously director of performance improvement at Mountainside Hospital, Montclair, NJ. She is skilled in developing and implementing programs to meet hospital regulatory agency requirements and has an excellent record in preparing organizations for licensing and accreditation surveys.