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object_repr: Procédure
action_time: 2018-03-14 13:03:21.116772
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# jci_intent

content:
  Wrong-patient errors occur in virtually all aspects of diagnosis and treatment. 1 Patients may be sedated, disoriented, not fully alert, or comatose; may change beds, rooms, or locations within the hospital; may have sensory disabilities; may not remember their identity; or may be subject to other situations that may lead to errors in correct identification. The intent of this goal is twofold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. (Also see MMU.4.1)

  The identification process used throughout the hospital requires at least two ways in which to identify a patient, such as the patient’s name, identification number, birth date, a bar-coded wristband, or other ways. (Also see MOI.9, ME 2 and MOI.9.1, ME 1) The patient’s room number or location in the hospital cannot be used for identification. The *process* for using two different patient identifiers is uniform throughout the hospital. However, the two identifiers used in the inpatient department may be different from the two identifiers in the outpatient department. For example, the patient’s name and identification number or medical record number may be used in all inpatient areas, and the patient name and birth date may be used in all outpatient departments, such as the emergency department, ambulatory care department, or other outpatient location.

  There are special circumstances in which the hospital may need to develop a specific process for patient identification; for example, when a comatose or confused/disoriented patient arrives with no identification, in the case of a newborn when the parents have not immediately chosen a name, and other examples. The process takes into account the unique needs of the patients, and staff use the process for patient identification in these special circumstances to prevent error. 2

  Two different patient identifiers are required in any circumstance involving patient interventions. For
  example, patients are identified before providing treatments (such as administering medications, blood, or blood products; serving a restricted diet tray; or providing radiation therapy); performing procedures (such as insertion of an intravenous line or hemodialysis); and before any diagnostic procedures (such as taking blood and other specimens for clinical testing, or performing a cardiac catheterization or diagnostic radiology procedure).


content:
  Effective communication, which is timely, accurate, complete, unambiguous, and understood by the
  recipient, reduces errors and results in improved patient safety. Communication can be electronic, verbal, or written. Patient care circumstances that can be critically impacted by poor communication include verbal and telephone patient care orders, verbal and telephone communication of critical test results, and handover communications.

  Patient care orders given verbally in-person and over the telephone, if permitted under local laws and regulations, are some of the most error-prone communications. Different accents, dialects, and pronunciations can make it difficult for the receiver to understand the order being given. For example, drug names and numbers that sound alike, such as erythromycin and azithromycin or fifteen and fifty, can affect the accuracy of the order. Background noise, interruptions, and unfamiliar drug names and terminology often compound the problem. Once received, a verbal order must be transcribed as a written order, which adds complexity and risk to the ordering process. (Also see COP.2.2 and MMU.4, ME 1).

  The reporting of critical results of diagnostic tests is also a patient safety issue. Diagnostic tests include, but are not limited to, laboratory tests, radiology exams, nuclear medicine exams, ultrasound procedures, magnetic resonance imaging, and cardiac diagnostics. This includes critical results from any diagnostic tests performed at the bedside, such as point-of-care testing, portable radiographs, bedside ultrasounds, or transesophageal echocardiograms. Results that are significantly outside the normal range may indicate a high-risk or life- threatening condition. A formal reporting system that clearly identifies how critical results of diagnostic tests are communicated to health care practitioners and how the information is documented reduces patient risks. 3–5
  (Also see AOP.5.4)

  Handover communications can also be referred to as handoff communications. Handovers of patient care within a hospital occur
  * between health care practitioners (for example, physician to physician, physician to nurse, nurse to
  nurse, and so on);
  * between different levels of care in the same hospital (for example, when the patient is moved from an intensive care unit to a medical unit or from an emergency department to the operating theatre);
  * from inpatient units to diagnostic or other treatment departments, such as radiology or physical therapy; and
  * between staff and patients/families, such as at discharge. (Also see ACC.4.1) 

  Breakdowns in communication can occur during any handover of patient care and can result in adverse events. 6–8 Interruptions and other distractions from unit activities can inhibit clear communication of important patient information. Standardized, critical content for communication between the patient, family, caregiver, and health care practitioners can significantly improve the outcomes related to handovers of patient care. 9–14 (Also see ACC.3)

  Standardized forms, tools, or methods support a consistent and complete handover process. The content of the handover communication and the form, tool, or method used is standardized for the type of handover. The handover process may be different for different types of handovers within the hospital. For example, handovers of patient care for the emergency department to a medical ward may require a different process or different content than handovers for the operating theatre to the intensive care unit; however, the handovers are standardized for the type of handover occurring. Handover forms or tools, if used by the hospital, are not required to be part of the medical record. In addition, the detailed information communicated during the handover is not required to be documented in the medical record; however, the hospital may want to have documentation that the handover occurred. For example, the health care practitioner would record that he or she completed the handover and to whom he or she endorsed care, and then sign, date, and time the entry. (Also see MOI.11.1, MEs 1, 2, and 3)

  Safe practices for effective communication include the following:
  * Limiting verbal communication of prescription or medication orders to urgent situations in which immediate written or electronic communication is not feasible. For example, verbal orders can be disallowed when the prescriber is present and the patient’s chart is available. Verbal orders can be restricted to situations in which it is difficult or impossible for hard-copy or electronic order transmission, such as during a sterile procedure.
  * The development of guidelines for requesting and receiving test results on an emergency or STAT basis, the identification and definitions of critical tests and critical values, to whom and by whom critical test results are reported, and monitoring compliance (Also see AOP.5.1.1, ME 3)
  * Writing down, or entering into a computer, the complete order or test result by the receiver of the information; the receiver reading back the order or test result; and the sender confirming that what has been written down and read back is accurate. Permissible alternatives for when the read-back process may not always be possible may be identified, such as in the operating theatre and in emergent situations in the emergency department or intensive care unit. (Also see COP.2.2; MMU.4) 
  * Use of standardized, critical content for communication between the patient, family, health care practitioner, and others involved in the patient’s care during handovers of patient care.
  * Use of standardized methods, forms, or tools to facilitate consistent and complete handovers of patient care


content:
  When medications are part of the patient treatment plan, appropriate management is critical to ensuring patient safety. Any medication, even those that can be purchased without a prescription, if used improperly can cause injury. However, high-alert medications cause harm more frequently, and the harm they produce is likely to be more serious when they are given in error. This can lead to increased patient suffering and potentially additional costs associated with caring for these patients. High-alert medications are those medications involved in a high percentage of errors and/or sentinel events, as well as medications that carry a higher risk for abuse or other adverse outcomes. Examples of high-alert medications include investigational medications, controlled medications, medications with a narrow therapeutic range, chemotherapy, anticoagulants, psychotherapeutic medications, and look-alike/sound-alike medications (LASA).

  There are many medication names that sound or look like other medication names. Confusing names is a
  common cause of medication errors throughout the world. Contributing to this confusion are

  * incomplete knowledge of drug names;
  * newly available products;
  * similar packaging or labeling;
  * similar clinical use; and
  * illegible prescriptions or misunderstanding during issuing of verbal orders.

  Examples of lists of high-alert medications are available from organizations such as the Institute for Safe
  Medication Practices (ISMP) and the World Health Organization (WHO). For safe management, the hospital needs to develop its own list(s) of high-alert medications based on its unique utilization patterns
  of medications and its own internal data about near misses, medication errors, and sentinel events. (Also see
  MMU.7.1 and QPS.7) The list includes medications identified as high risk for adverse outcomes. Information
  from the literature and/or Ministry of Health may also be useful in helping to identify which medications
  should be included. These medications are stored in a way that reduces the likelihood of inadvertent
  administration or ideally provides directions on the proper use of the medication. Strategies to improve the
  safety of high-alert medications may be tailored to the specific risk of each medication and should include
  consideration of prescribing, preparation, administration, and monitoring processes, in addition to safe storage
  strategies. 

  Medications at risk for look-alike/sound-alike confusion, such as similar medication names and similar product packaging, may lead to potentially harmful medication errors. Hospitals need to institute risk management strategies to minimize adverse events with LASA medications and enhance patient safety. (Also see MMU.4.1) 

  A frequently cited medication safety issue is the incorrect or unintentional administration of concentrated electrolytes (for example, potassium chloride [equal to or greater than 2 mEq/mL concentration], potassium phosphate [equal to or greater than 3 mmol/mL concentration], sodium chloride [greater than 0.9% concentration], and magnesium sulfate [equal to or greater than 50% concentration]). The most effective means to reduce or to eliminate these occurrences is to develop a process for managing concentrated electrolytes that includes removing the concentrated electrolytes from the patient care units to the pharmacy. (Also see MMU.3) The hospital identifies any areas where concentrated electrolytes are clinically necessary in the concentrated form as determined by evidence and professional practice, such as the intensive care unit or cardiac operating theatre, and identifies how they are clearly labeled and how they are stored in those areas in a manner that restricts access to prevent inadvertent administration.


content:
  Significant patient injury and adverse and sentinel events resulting from wrong-site, wrong-procedure, and wrong-patient surgery are ongoing concerns for hospitals. Such events can result from ineffective or inadequate communication between members of the team conducting the surgical/invasive procedure, lack of a process for marking the procedure site, and lack of patient involvement in the site marking. In addition, inadequate patient assessment, inadequate medical record review, a culture that does not support open communication among team members, problems related to illegible handwriting, and the use of abbreviations are frequent contributing factors.

  Surgical and invasive procedures include all procedures involving an incision or puncture, including, but not limited to, open surgical procedures, percutaneous aspiration, selected injections, biopsy, percutaneous cardiac and vascular diagnostic or interventional procedures, laparoscopies, and endoscopies.

  Organizations need to identify all areas within the hospital where surgical and invasive procedures take place; for example, the cardiac catheterization lab, interventional radiology department, gastrointestinal lab, and the like. The approach the hospital takes to ensuring safe surgery applies to all areas of the hospital in which surgical and invasive procedures occur.

  The (US) Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person SurgeryTM is based in part on the principle of using multiple strategies to achieve the goal of always identifying the correct patient, correct procedure, and correct site. 25 The essential elements of the Universal Protocol are

  * the preoperative verification process;
  * marking the surgical site; and
  * the time-out that is held immediately before the start of the procedure.

  ## Preoperative Verification Process

  Preoperative verification is an ongoing process of information gathering and confirmation. The purpose of the preoperative verification process is to
  * verify the correct patient, procedure, and site;
  * ensure that all relevant documents, images, and studies are available, properly labeled, and displayed; and
  * verify that any required blood products, special medical equipment, and/or implants are present. (Also see ASC.7.4)

  There are various elements of the preoperative verification process that can be completed before the patient arrives at the preoperative area—such as ensuring that documents, imaging, test results, and paperwork are properly labeled and match the patient’s identifiers. Waiting until the time-out to complete the preoperative verification process may unnecessarily delay surgery if paperwork or imaging are not labeled or available when surgery is about to begin. It is more likely that portions of the preoperative verification may occur more than once and in more than one place. For example, the surgical consent may be obtained in the surgeon’s office, and then verification that it has been completed may take place in the preoperative holding area.

  ## Marking the Site

  Marking the surgical/invasive site involves the patient and is done with an instantly recognizable and unambiguous mark. Ideally, an “X” is not used as the mark as it may be interpreted as “not here” or “wrong side” and could potentially lead to errors in patient care. 26,27 The mark must be consistent throughout the hospital. The site is marked in all cases involving laterality, multiple structures (fingers, toes, lesions), or multiple levels (spine). 

  The surgical/invasive procedure site marking is done by the person who will perform the procedure. This person will do the entire surgical/invasive procedure and remain with the patient throughout the entire procedure. In cases of surgical procedures, the responsible surgeon typically performs the surgery and therefore would mark the site. There are different titles used for the responsible surgeon, such as attending or consultant surgeon. For nonsurgical invasive procedures, it may be a physician who will do the procedure, and it may take place in an area of the hospital outside of the operating theatre.

  There are circumstances when a trainee may perform the site marking—this is when the trainee performs the entire procedure, requiring minimal or no supervision from the responsible surgeon or physician. In these circumstances, the trainee marks the surgical site. When a trainee is in the role of assisting the responsible surgeon or physician, only the responsible surgeon or physician may perform the site marking.

  The site marking may take place any time before the surgical/invasive procedure begins as long as the patient is actively involved in the site marking whenever possible and the mark is visible after the patient is prepped and draped. Examples of when patient participation may not be possible include patients who are not competent to make health care decisions, children, and patients requiring emergent surgery.

  ## Time-Out

  The time-out is held immediately before the start of the procedure with all team members present. During the time-out, the team agrees on the following components:

  a) Correct patient identity
  b) Correct procedure to be done
  c) Correct surgical/invasive procedure site

  The time-out allows any unanswered questions or confusion to be resolved. The time-out is conducted in the location at which the procedure will be done and involves the active participation of the entire team. The patient does not have to participate in the time-out. Once the time-out is complete, no one from the team leaves the room. Completion of the time-out is documented and includes the date and time the time-out was completed. The hospital determines the amount and type of any additional documentation.

  ## Sign-Out

  The WHO Surgical Safety Checklist includes a sign-out process, which is conducted in the area where the procedure was performed before the patient leaves. 28 The following components of the sign-out are verbally confirmed by a member of the team, typically a nurse:
  d) Name of the surgical/invasive procedure that was recorded/written
  e) Completion of instrument, sponge, and needle counts (as applicable)
  f ) Labeling of specimens (when specimens are present during the sign-out process, labels are read aloud, including patient name) (Also see IPSG.1, ME 2 and AOP.5.7, ME 2)
  g) Any equipment problems to be addressed (as applicable)


content:
  Infection prevention and control are challenging in most health care settings, and rising rates of health care-associated infections are a major concern for patients and health care practitioners. Infections common to all health care settings include catheter-associated urinary tract infections, bloodstream infections, and pneumonia (often associated with mechanical ventilation). 

  Central to the elimination of these and other infections is proper hand hygiene. Evidence-based hand-hygiene guidelines are available from the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (US CDC), and various other national and international organizations. 29,30 (Also see GLD.11.2) 

  The hospital adopts and implements current evidence-based hand-hygiene guidelines. Hand-hygiene guidelines are posted in appropriate areas, and staff are educated in proper hand-washing and hand-disinfection procedures. Soap, disinfectants, and towels or other means of drying are located in those areas where hand- washing and hand-disinfecting procedures are required. (Also see PCI.9)


content:
  Many injuries in hospitals to both inpatients and outpatients are a result of falls. The risk for falls is related to
  the patient, the situation, and/or the location. Risks associated with patients might include patient history of
  falls, medications use, alcohol consumption, gait or balance disturbances, visual impairments, altered mental
  status, and the like. Patients who have been initially assessed to be at low risk for falls may suddenly become
  at high risk. Reasons include, but are not limited to, surgery and/or anesthesia, sudden changes in patient
  condition, and adjustment in medications. Many patients require reassessment during their hospitalization.
  (Also see AOP.1.4)

  Fall risk criteria identify the types of patients who are considered at high risk for falls. These criteria and any
  interventions applied are documented in the patient’s medical record as they provide the evidence to support
  the patient’s fall risk category. The hospital has the responsibility to identify the types of patients within their
  patient population who may be at high risk for falls. The documented criteria facilitate the continuity of care
  among the health care practitioners caring for a patient. (Also see ACC.3) For example, a practitioner caring
  for a patient after he or she leaves the operating theatre may not know if the patient, who is at high risk for
  falls was properly assessed and if interventions were applied unless proper documentation was completed.
  In the context of the populations it serves, the services it provides, and its facilities, the hospital evaluates
  patient falls, and takes action to reduce the risk of falling and reduce the risk of injury should a fall occur.
  The hospital establishes a fall-risk reduction program based on appropriate policies and/or procedures. A fall
  reduction program includes risk assessment and periodic reassessment of a particular patient population and/
  or of the environment in which care and services are provided (such as those conducted during periodic safety
  tours). Measures and interventions are implemented to reduce fall risk for those identified patients, situations,
  and locations assessed to be at risk. 31–33
  Specific situations can pose a risk for falls. An example of a potential situational risk is when a patient arrives
  at the outpatient department from a long term care facility by ambulance for a radiologic examination. The
  patient may be at risk for falls in that situation when transferring from ambulance cart to exam table, or when
  changing positions while lying on the narrow exam table.
  Specific locations may present higher fall risks because of the services provided. For example, a physical
  therapy department (inpatient or outpatient) has many types of specialized equipment used by patients that
  may increase the risk for falls, such as parallel bars, freestanding staircases, and exercise equipment.
  All inpatients are assessed for fall risk using assessment tools and/or methods appropriate for the hospital’s
  patient population(s). 34,35 For example, pediatric patients require a pediatric fall risk assessment tool, as a tool
  developed for adults will not accurately assess their risk for falls.
  In the outpatient department(s), patients are screened for fall risk; however, only those patients whose
  condition, diagnosis, situation, and/or location identifies them as at risk for falls are screened. 36,37 If fall risk is indicated from the screening, measures and/or interventions are implemented to reduce fall risk for those
  patients.

  Screening generally involves performing a simple evaluation of the patient to determine if he or she exhibits a
  fall risk. Screening tools are commonly used, and include questions or items that are used to identify fall risk
  patients. For example, the questions may require a simple yes/no answer, or the tool may involve assigning a
  score to each item based on the patient’s responses.

  The hospital determines which outpatients are screened for fall risk. Location and situational risk as well as
  patient condition and characteristics may help identify those who should be screened for falls. Examples
  could include all patients in a physical therapy outpatient department, all patients arriving from long term
  care facilities by ambulance for outpatient procedures, patients scheduled for outpatient surgery involving
  procedural sedation or anesthesia, patients with gait or balance disturbances, patients with visual impairments,
  pediatric patients under the age of two, and so on.


# jci_measurable

content:
  Patients are identified using two patient identifiers, not including the use of the patient’s room number and location in the hospital.


content:
  After preparation, medications not immediately administered are labeled with the name of the med- ication, the dosage/concentration, the date prepared, the expiration date, and two patient identifiers


content:
  Patient medical records are maintained through the use of an identifier unique to the patient or some other effective method


content:
  2. Patients are identified before performing diagnostic procedures, providing treatments, and perform- ing other procedures. (Also see IPSG.4.1; AOP.5.7, ME 2; MMU.5.2, ME 4; and MMU.6.1)


content:
  The hospital ensures the correct identification of patients in special circumstances, such as the coma- tose patient or newborn who is not immediately named. (Also see COP.3)


content:
  The complete verbal order is documented and read back by the receiver and confirmed by the indi-
  vidual giving the order. (Also see MMU.4.1)


content:
  The complete telephone order is documented and read back by the receiver and confirmed by the
  individual giving the order. (Also see MMU.4.1)


content:
  The complete test result is documented and read back by the receiver and confirmed by the individual giving the result.


content:
  Standardized critical content is communicated between health care practitioners during handovers of
  patient care.


content:
  Data from adverse events resulting from handover communications are tracked and used to identify
  ways in which handovers can be improved, and improvements are implemented.


content:
  The hospital identifies in writing its list of high-alert medications and develops and implements a
  process for managing these high-alert medications.


content:
  The hospital has a list of look-alike/sound-alike medications and develops and implements a process
  for managing look-alike sound-alike medications.


content:
  The process for managing high-alert medications and the process for managing look-alike/sound-
  alike medications are uniform throughout the hospital.


content:
  Concentrated electrolytes are present only in patient care units identified as clinically necessary in the
  concentrated form. (Also see MMU.5.2, ME 2)


content:
  Concentrated electrolytes that are stored in patient care units are clearly labeled and stored in a man-
  ner that restricts access and promotes safe use.


content:
  The hospital implements a preoperative verification process through the use of a checklist or other mechanism to document, before the surgical/invasive procedure, that the informed consent is appro- priate to the procedure; that the correct patient, correct procedure, and correct site are verified; and that all required documents, blood products, medical equipment, and implantable medical devices are on hand, correct, and functional.


content:
  The hospital uses an instantly recognizable and unambiguous mark for identifying the surgical/invasive site that is consistent throughout the hospital.


content:
  Surgical/invasive site marking is done by the person performing the procedure and involves the patient in the marking process.


content:
  The full team actively participates in a time-out process, which includes a) through c) in the intent, in the area in which the surgical/invasive procedure will be performed, immediately before starting the procedure. Completion of the time-out is documented. (Also see MOI.11.1)


content:
  Before the patient leaves the area in which the surgical/invasive procedure was performed, a sign-out process is conducted, which includes at least d) through g) in the intent.


content:
  When surgical/invasive procedures are performed, including medical and dental procedures done in settings other than the operating theatre, the hospital uses uniform processes to ensure safe surgery.


content:
  Hand-washing and hand-disinfection procedures are used in accordance with hand-hygiene guide- lines throughout the hospital. (Also see IPSG.9, ME 4)


content:
  The hospital implements a process for assessing all inpatients for fall risk and uses assessment tools/ methods appropriate for the patients being served.


content:
  The hospital implements a process for the reassessment of inpatients who may become at risk for falls due to a change in condition, or are already at risk for falls based on the documented assessment.


content:
  Measures and/or interventions to reduce fall risk are implemented for those identified inpatients, situations, and locations within the hospital assessed to be at risk. Patient interventions are documented.


content:
  The hospital implements a process for screening outpatients whose condition, diagnosis, situation, or location may put them at risk for falls and uses screening tools/methods appropriate for the patients being served.


content:
  When fall risk is identified from the screening process, measures and/or interventions are implemented to reduce fall risk for those outpatients identified to be at risk, and the screening and interventions are documented.


content:
  Measures and/or interventions to reduce fall risk are implemented in situations and locations in the outpatient department(s) assessed to be a risk for falls.


# jci_standard

order: 2
name:
  The hospital develops and implements a process to improve the effectiveness of verbal and/or telephone communication among caregivers


order: 4
name:
  The hospital develops and implements a process for the preoperative verification and surgical/ invasive procedure site-marking


order: 5
name:
  The hospital adopts and implements evidence-based hand-hygiene guidelines to reduce the risk of health care–associated infections


order: 6
name:
  The hospital develops and implements a process to reduce the risk of patient harm resulting from falls for the inpatient population


order: 4.1
name:
  The hospital develops and implements a process for the time-out that is performed immediately prior to the start of the surgical/invasive procedure and the sign out that is conducted after the procedure


order: 1
name:
  Patients who may be admitted to the hospital or who seek outpatient services are screened to identify if their health care needs match the hospital’s mission and resources


order: 1.2
name:
  The hospital considers the clinical needs of patients and informs patients when there are unusual delays for diagnostic and/or treatment services


order: 2.1
name:
  Patient needs for preventive, palliative, curative, and rehabilitative services are prioritized based on the patient’s condition at the time of admission as an inpatient to the hospital.


order: 2.2
name:
  At admission as an inpatient, the patient and family receive education and orientation to the inpatient ward, information on the proposed care and any expected costs for care, and the expected outcomes of care


order: 2.3
name:
  Admission to departments/wards providing intensive or specialized services is determined by established criteria


order: 2.3.1
name:
  Discharge from departments/wards providing intensive or specialized services is determined by established criteria.


order: 3
name:
  The hospital designs and carries out processes to provide continuity of patient care services in the hospital and coordination among health care practitioners


order: 3.1
name:
  During all phases of inpatient care, there is a qualified individual identified as responsible for the patient’s care.


order: 4
name:
  There is a process for the referral or discharge of patients that is based on the patient’s health status and the need for continuing care or services.


order: 4.2
name:
  The hospital cooperates with health care practitioners and outside agencies to ensure timely referrals.


order: 4.3.1
name:
  Patient education and follow-up instructions are given in a form and language the patient can understand


order: 4.4
name:
  The records of outpatients requiring complex care or with complex diagnoses contain profiles of the medical care and are made available to health care practitioners providing care to those patients.


order: 4.5
name:
  The hospital has a process for the management and follow-up of patients who notify hospital staff that they intend to leave against medical advice.


order: 4.5.1
name:
  The hospital has a process for the management of patients who leave the hospital against medical advice without notifying hospital staff.


order: 5
name:
  Patients are transferred to other organizations based on status, the need to meet their continuing care needs, and the ability of the receiving organization to meet patients’ needs.


order: 5.2
name:
  The receiving organization is given a written summary of the patient’s clinical condition and the interventions provided by the referring hospital.


order: 6
name:
  The hospital’s transportation services comply with relevant laws and regulations and meet requirements for quality and safe transport


order: 6.1
name:
  The hospital develops and implements a process to reduce the risk of patient harm resulting from falls for the outpatient population.


order: 1
name:
  The hospital is responsible for providing processes that support patients’ and families’ rights during care


order: 1.1
name:
  The hospital seeks to reduce physical, language, cultural, and other barriers to access and delivery of services


order: 1.2
name:
  The hospital provides care that supports patient dignity, is respectful of the patient’s personal values and beliefs, and responds to requests for spiritual and religious observance.


order: 1.5
name:
  Patients are protected from physical assault, and populations at risk are identified and protected from additional vulnerabilities


order: 2
name:
  Patients are informed about all aspects of their medical care and treatment and participate in care and treatment decisions


order: 2.1
name:
  The hospital informs patients and families about their rights and responsibilities to refuse or discontinue treatment, withhold resuscitative services, and forgo or withdraw life-sustaining treatments


order: 2.2
name:
  The hospital supports the patient’s right to assessment and management of pain and respectful compassionate care at the end of life


order: 3
name:
  The hospital informs patients and families about its process to receive and to act on complaints, conflicts, and differences of opinion about patient care and the patient’s right to participate in these processes


order: 4
name:
  All patients are informed about their rights and responsibilities in a manner and language they can understand


order: 5
name:
  General consent for treatment, if obtained when a patient is admitted as an inpatient or is registered for the first time as an outpatient, is clear in its scope and limits.


order: 5.1
name:
  Patient informed consent is obtained through a process defined by the hospital and carried out by trained staff in a manner and language the patient can understand


order: 5.3
name:
  Patients and families receive adequate information about the patient’s condition, proposed treatment(s) or procedure(s), and health care practitioners so that they can grant consent and make care decisions.


order: 5.4
name:
  The hospital establishes a process, within the context of existing law and culture, for when others can grant consent.


order: 5.2
name:
  Informed consent is obtained before surgery, anesthesia, procedural sedation, use of blood and blood products, and other high-risk treatments and procedures


order: 1
name:
  All patients cared for by the hospital have their health care needs identified through an assessment process that has been defined by the hospital


order: 1.1
name:
  Each patient’s initial assessment includes a physical examination and health history as well as an evaluation of psychological, spiritual/cultural (as appropriate), social, and economic factors


order: 1.2
name:
  The patient’s medical and nursing needs are identified from the initial assessments, which are completed and documented in the medical record within the first 24 hours after admission as an inpatient or earlier as indicated by the patient’s condition


order: 1.3
name:
  The hospital has a process for accepting initial medical assessments conducted in a physician’s private office or other outpatient setting prior to admission or outpatient procedure.


order: 1.3.1
name:
  A preoperative medical assessment is documented before anesthesia or surgical treatment and includes the patient’s medical, physical, psychological, social, economic, and discharge needs.


order: 1.4
name:
  Patients are screened for nutritional status, functional needs, and other special needs and are referred for further assessment and treatment when necessary.


order: 1.6
name:
  Individualized medical and nursing initial assessments are performed for special populations cared for by the hospital


order: 1.7
name:
  Dying patients and their families are assessed and reassessed according to their individualized needs


order: 2
name:
  All patients are reassessed at intervals based on their condition and treatment to determine their response to treatment and to plan for continued treatment or discharge


order: 4
name:
  Medical, nursing, and other individuals and services responsible for patient care collaborate to analyze and integrate patient assessments and prioritize the most urgent/important patient care needs.


order: 5
name:
  Laboratory services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations


order: 5.1
name:
  A qualified individual(s) is responsible for managing the clinical laboratory service or pathology service


order: 5.1.1
name:
  A qualified individual is responsible for the oversight and supervision of the point-of-care testing program


order: 5.2
name:
  All laboratory staff have the required education, training, qualifications, and experience to administer and perform the tests and interpret the results


order: 5.3
name:
  A laboratory safety program is in place, followed, and documented, and compliance with the facility management and infection control programs is maintained


order: 5.3.1
name:
  The laboratory uses a coordinated process to reduce the risks of infection as a result of exposure to infectious diseases and biohazardous materials and waste


order: 5.5
name:
  All equipment used for laboratory testing is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities


order: 5.6
name:
  Essential reagents and supplies are available and all reagents are evaluated to ensure accuracy and precision of results


order: 5.7
name:
  Procedures for collecting, identifying, handling, safely transporting, and disposing of specimens are established and implemented


order: 5.10
name:
  Reference/contract laboratories used by the hospital are licensed and accredited or certified by a recognized authority.


order: 5.10.1
name:
  The hospital identifies measures for monitoring the quality of the services to be provided by the reference/contract laboratory


order: 5.11
name:
  A qualified individual is responsible for blood bank and/or transfusion services and ensures that services adhere to laws and regulations and recognized standards of practice.


order: 6
name:
  Radiology and diagnostic imaging services are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations


order: 6.2
name:
  Individuals with proper qualifications and experience perform diagnostic imaging studies, interpret the results, and report the results


order: 6.3
name:
  Radiation safety guidelines for staff and patients are in place, followed, and documented; and compliance with the facility management and infection control programs is maintained


order: 6.4
name:
  Radiology and diagnostic imaging study results are available in a timely way as defined by the hospital


order: 6.5
name:
  All equipment used to conduct radiology and diagnostic imaging studies is regularly inspected, maintained, and calibrated, and appropriate records are maintained for these activities


order: 6.8
name:
  The hospital regularly reviews quality control results for all outside contracted sources of diagnostic services


order: 2.3
name:
  Clinical and diagnostic procedures and treatments are carried out and documented as ordered, and the results or outcomes, are recorded in the patient’s medical record.


order: 3
name:
  The care of high-risk patients and the provision of high-risk services are guided by professional practice guidelines, laws, and regulations


order: 3.3
name:
  Clinical guidelines and procedures are established and implemented for the handling, use, and administration of blood and blood products


order: 4
name:
  A variety of food choices, appropriate for the patient’s nutritional status and consistent with his or her clinical care, is available


order: 7
name:
  The hospital provides end-of-life care for the dying patient that addresses the needs of the patient and family and optimizes the patient’s comfort and dignity


order: 8.2
name:
  The transplant program includes a multidisciplinary team that consists of people with expertise in the relevant organ-specific transplant programs


order: 8.3
name:
  There is a designated coordination mechanism for all transplant activities that involves physicians, nurses, and other health care practitioners


order: 8.4
name:
  The transplant program uses organ-specific transplant clinical eligibility, psychological, and social suitability criteria for transplant candidates


order: 8.5
name:
  The transplant program obtains informed consent specific to organ transplantation from the transplant candidate


order: 8.6
name:
  The transplant program has documented protocols, clinical practice guidelines,or procedures for organ recovery and organ receipt to ensure the compatibility, safety, efficacy, and quality of human cells, tissues, and organs for transplantation.


order: 9
name:
  Transplant programs that perform living donor transplantation adhere to local and regional laws and regulation and protect the rights of prospective or actual living donors


order: 9.1
name:
  Transplant programs performing living donor transplants obtain informed consent specific to organ donation from the prospective living donor


order: 9.2
name:
  Transplant programs that perform living donor transplants use clinical and psychological selection criteria to determine the suitability of potential living donors


order: 1
name:
  Sedation and anesthesia services are available to meet patient needs, and all such services meet professional standards and applicable local and national standards, laws, and regulations


order: 3.1
name:
  Practitioners responsible for procedural sedation and individuals responsible for monitoring patients receiving procedural sedation are qualified


order: 3.3
name:
  The risks, benefits, and alternatives related to procedural sedation are discussed with the patient, his or her family, or those who make decisions for the patient


order: 5
name:
  Each patient’s anesthesia care is planned and documented, and the anesthesia and technique used are documented in the patient’s medical record.


order: 5.1
name:
  The risks, benefits, and alternatives related to anesthesia and post-operative pain control are discussed with the patient and/or those who make decisions for the patient


order: 6
name:
  Each patient’s physiological status during anesthesia and surgery is monitored according to professional practice guidelines and documented in the patient’s medical record.


order: 6.1
name:
  Each patient’s postanesthesia status is monitored and documented, and the patient is discharged from the recovery area by a qualified individual or by using established criteria


order: 7.1
name:
  The risks, benefits, and alternatives are discussed with the patient and his or her family or those who make decisions for the patient


order: 7.2
name:
  Information about the surgical procedure is documented in the patient’s medical record to facilitate continuing care


order: 7.4
name:
  Surgical care that includes the implanting of a medical device is planned with special consideration of how standard processes and procedures must be modified


order: 1
name:
  Medication use in the hospital is organized to meet patient needs, complies with applicable laws and regulations, and is under the direction and supervision of a licensed pharmacist or other qualified professional


order: 1.1
name:
  The hospital develops and implements a program for the prudent use of antibiotics based on the principle of antibiotic stewardship


order: 2
name:
  Medications for prescribing or ordering are stocked, and there is a process for medications not stocked or normally available to the hospital or for times when the pharmacy is closed


order: 3.1
name:
  There is a process for the management of medications and nutritional products that require special handling.


order: 3.2
name:
  Emergency medications are available, uniformly stored, monitored, and secure when stored out of the pharmacy.


order: 5.2
name:
  A system is used to safely dispense medications in the right dose to the right patient at the right time.


order: 6.1
name:
  Medication administration includes a process to verify the medication is correct based on the medication prescription or order


order: 6.2
name:
  Policies and procedures govern medications brought into the hospital for patient selfadministration or as samples


order: 7.1
name:
  The hospital establishes and implements a process for reporting and acting on medication errors and near misses


order: 1
name:
  The hospital provides education that supports patient and family participation in care decisions and care processes


order: 3
name:
  Education methods take into account the patient’s and family’s values and preferences and allow sufficient interaction among the patient, family, and staff for learning to occur


order: 1
name:
  A qualified individual guides the implementation of the hospital’s program for quality improvement and patient safety and manages the activities needed to carry out an effective program of continuous quality improvement and patient safety within the hospi


order: 2
name:
  Quality and patient safety program staff support the measure selection process throughout the hospital and provide coordination and integration of measurement activities throughout the hospital.


order: 3
name:
  The quality and patient safety program uses current scientific and other information to support patient care, health professional education, clinical research, and management


order: 4
name:
  The quality and patient safety program includes the aggregation and analysis of data to support patient care, hospital management, and the quality management program and participation in external databases


order: 4.1
name:
  Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the hospital


order: 5
name:
  The data analysis process includes at least one determination per year of the impact of hospitalwide priority improvements on cost and efficiency


order: 11
name:
  An ongoing program of risk management is used to identify and to proactively reduce unanticipated adverse events and other safety risks to patients and staff


order: 1
name:
  One or more individuals oversee all infection prevention and control activities. This individual(s) is qualified in infection prevention and control practices through education, training, experience, or certification


order: 2
name:
  There is a designated coordination mechanism for all infection prevention and control activities that involves physicians, nurses, and others based on the size and complexity of the hospital


order: 3
name:
  The infection prevention and control program is based on current scientific knowledge, accepted practice guidelines, applicable laws and regulations, and standards for sanitation and cleanliness


order: 5
name:
  The hospital designs and implements a comprehensive infection control program that identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk


order: 6
name:
  The hospital uses a risk-based approach in establishing the focus of the health care–associated infection prevention and reduction program


order: 6.1
name:
  The hospital tracks infection risks, infection rates, and trends in health care–associated infections to reduce the risks of those infections


order: 7
name:
  The hospital reduces the risk of infections associated with medical/surgical equipment, devices, and supplies by ensuring adequate cleaning, disinfection, sterilization, and storage; and implements a process for managing expired supplies


order: 7.1
name:
  The hospital identifies and implements a process for managing the reuse of single-use devices consistent with regional and local laws and regulations


order: 7.5
name:
  The hospital reduces the risk of infection in the facility associated with mechanical and engineering controls and during demolition, construction, and renovation.


order: 8
name:
  The hospital provides barrier precautions and isolation procedures that protect patients, visitors, and staff from communicable diseases and protects immunosuppressed patients from acquiring infections to which they are uniquely prone


order: 8.1
name:
  The hospital develops and implements a process to manage a sudden influx of patients with airborne infections and when negative-pressure rooms are not available


order: 8.2
name:
  The hospital develops, implements, and tests an emergency preparedness program to respond to the presentation of global communicable diseases


order: 9
name:
  Gloves, masks, eye protection, other protective equipment, soap, and disinfectants are available and used correctly when required


order: 10
name:
  The infection prevention and control process is integrated with the hospital’s overall program for quality improvement and patient safety, using measures that are epidemiologically important to the hospital


order: 11
name:
  The hospital provides education on infection prevention and control practices to staff, physicians, patients, families, and other caregivers when indicated by their involvement in care


order: 1
name:
  The structure and authority of the hospital’s governing entity are described in bylaws, policies and procedures, or similar documents


order: 1.1
name:
  The operational responsibilities and accountabilities of the governing entity are described in a written document(s).


order: 1.2
name:
  The governing entity approves the hospital’s program for quality and patient safety and regularly receives and acts on reports of the quality and patient safety program


order: 2
name:
  A chief executive(s) is responsible for operating the hospital and complying with applicable laws and regulations


order: 3
name:
  Hospital leadership is identified and is collectively responsible for defining the hospital’s mission and creating the programs and policies needed to fulfill the mission


order: 3.1
name:
  Hospital leadership identifies and plans for the type of clinical services required to meet the needs of the patients served by the hospital


order: 3.3
name:
  Hospital leadership ensures that there are uniform programs for the recruitment, retention, development, and continuing education of all staff.


order: 4
name:
  Hospital leadership plans, develops, and implements a quality improvement and patient safety program.


order: 4.1
name:
  Hospital leadership communicates quality improvement and patient safety information to the governing entity and hospital staff on a regular basis


order: 5
name:
  The chief executive and hospital leadership prioritize which hospitalwide processes will be measured, which hospitalwide improvement and patient safety activities will be implemented, and how success of these hospitalwide efforts will be measured


order: 6
name:
  Hospital leadership is accountable for the review, selection, and monitoring of clinical or nonclinical contracts


order: 6.1
name:
  Hospital leadership ensures that contracts and other arrangements are included as part of the hospital’s quality improvement and patient safety program.


order: 6.2
name:
  Hospital leadership ensures that independent practitioners not employed by the hospital have the right credentials and are privileged for the services provided to the hospital’s patients


order: 7
name:
  Hospital leadership makes decisions related to the purchase or use of resources—human and technical—with an understanding of the quality and safety implications of those decisions


order: 7.1
name:
  Hospital leadership seeks and uses data and information on the safety of the supply chain to protect patients and staff from unstable, contaminated, defective, and counterfeit supplies.


order: 8
name:
  Medical, nursing, and other leaders of departments and clinical services plan and implement a professional staff structure to support their responsibilities and authority


order: 10
name:
  Each department/service leader identifies, in writing, the services to be provided by the department, and integrates or coordinates those services with the services of other departments


order: 11
name:
  Department/service leaders improve quality and patient safety by participating in hospitalwide improvement priorities and in monitoring and improving patient care specific to the department/ service


order: 11.1
name:
  Measures selected by the department/service leaders that are applicable to evaluating the performance of physicians, nurses, and other professional staff participating in the clinical care processes, are used in the staff’s performance evaluation


order: 11.2
name:
  Department/service leaders select and implement clinical practice guidelines, and related clinical pathways, and/or clinical protocols, to guide clinical care


order: 12
name:
  Hospital leadership establishes a framework for ethical management that promotes a culture of ethical practices and decision making to ensure that patient care is provided within business, financial, ethical, and legal norms and protects patients and thei


order: 12.1
name:
  The hospital’s framework for ethical management addresses operational and business issues, including marketing, admissions, transfer, discharge, and disclosure of ownership and any business and professional conflicts that may not be in patients’ best inte


order: 12.2
name:
  The hospital’s framework for ethical management addresses ethical issues and decision making in clinical care


order: 13.1
name:
  Hospital leadership implements, monitors, and takes action to improve the program for a culture of safety throughout the hospital


order: 14
name:
  Health professional education, when provided within the hospital, is guided by the educational parameters defined by the sponsoring academic program and the hospital’s leadership


order: 15
name:
  Human subjects research, when provided within the hospital, is guided by laws, regulations, and hospital leadership.


order: 16
name:
  Patients and families are informed about how to gain access to clinical research, clinical investigations, or clinical trials involving human subjects


order: 17
name:
  Patients and families are informed about how patients who choose to participate in clinical research, clinical investigations, or clinical trials are protected


order: 18
name:
  Informed consent is obtained before a patient participates in clinical research, clinical investigations, or clinical trials


order: 19
name:
  The hospital has a committee or another way to oversee all research in the hospital involving human subjects


order: 1
name:
  The hospital complies with relevant laws, regulations, building and fire safety codes and facility inspection requirements


order: 2
name:
  The hospital develops and maintains a written program(s) describing the processes to manage risks to patients, families, visitors, and staff


order: 3
name:
  One or more qualified individuals oversee the planning and implementation of the facility management program to reduce and control risks in the care environment


order: 4
name:
  The hospital plans and implements a program to provide a safe physical facility through inspection and planning to reduce risks


order: 4.1
name:
  The hospital plans and implements a program to provide a secure environment for patients, families, staff, and visitors


order: 4.2
name:
  The hospital plans and budgets for upgrading or replacing key systems, buildings, or components based on the facility inspection and in keeping with laws and regulations


order: 4.2.1
name:
  When planning for demolition, construction, or renovation, the organizations conducts a preconstruction risk assessment


order: 5
name:
  The hospital has a program for the inventory, handling, storage, and use of hazardous materials and waste.


order: 6
name:
  The hospital develops, maintains, and tests an emergency management program to respond to emergencies and natural or other disasters that have the potential of occurring within the community


order: 7
name:
  The hospital establishes and implements a program for the prevention, early detection, suppression, abatement, and safe exit from the facility in response to fires and nonfire emergencies


order: 7.1
name:
  The hospital regularly tests its fire and smoke safety program, including any devices related to early detection and suppression, and documents the results


order: 7.2
name:
  The fire safety program includes limiting smoking by staff and patients to designated non–patient care areas of the facility


order: 8
name:
  The hospital establishes and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results


order: 8.1
name:
  The hospital has a system in place for monitoring and acting on medical equipment hazard notices, recalls, reportable incidents, problems, and failures


order: 9
name:
  The hospital establishes and implements a program to ensure that all utility systems operate effectively and efficiently


order: 9.2
name:
  The hospital utility systems program ensures that potable water and electrical power are available at all times and establishes and implements alternative sources of water and power during system disruption, contamination, or failure


order: 10
name:
  The hospital collects and analyzes data from each of the facility management and safety programs to support planning for replacing or upgrading medical equipment, technology and systems, and reducing risks in the environment


order: 11
name:
  The hospital educates, trains, and tests all staff about their roles in providing a safe and effective patient care facility


order: 11.1
name:
  Staff members are trained and knowledgeable about their roles in the hospital’s programs for fire safety, security, hazardous materials, and emergencies


order: 1
name:
  Leaders of hospital departments and services define the desired education, skills, knowledge, and other requirements of all staff members


order: 2
name:
  Leaders of hospital departments and services develop and implement processes for recruiting, evaluating, and appointing staff as well as other related procedures identified by the hospital


order: 3
name:
  The hospital uses a defined process to ensure that clinical staff knowledge and skills are consistent with patient needs


order: 4
name:
  The hospital uses a defined process to ensure that nonclinical staff knowledge and skills are consistent with hospital needs and the requirements of the position


order: 6
name:
  A staffing strategy for the hospital, developed by the leaders of hospital departments and services, identifies the number, types, and desired qualifications of staff.


order: 7
name:
  All clinical and nonclinical staff members are oriented to the hospital, the department or unit to which they are assigned, and to their specific job responsibilities at appointment to the staff


order: 8
name:
  Each staff member receives ongoing in-service and other education and training to maintain or to advance his or her skills and knowledge


order: 8.1
name:
  Staff members who provide patient care and other staff identified by the hospital are trained and can demonstrate appropriate competence in resuscitative techniques


order: 8.2
name:
  The hospital provides a staff health and safety program that addresses staff physical and mental health and safe working conditions


order: 8.2.1
name:
  The hospital identifies staff who are at risk for exposure to and possible transmission of vaccine-preventable diseases and implements a staff vaccination and immunization program


order: 9
name:
  The hospital has a uniform process for gathering the credentials of those medical staff members permitted to provide patient care without supervision


order: 9.1
name:
  Medical staff members’ education, licensure/registration, and other credentials required by law or regulation and the hospital are verified and kept current


order: 9.2
name:
  There is a uniform, transparent decision process for the initial appointment of medical staff members


order: 10
name:
  The hospital has a standardized, objective, evidence-based procedure to authorize medical staff members to admit and to treat patients and/or to provide other clinical services consistent with their qualifications


order: 11
name:
  The hospital uses an ongoing standardized process to evaluate the quality and safety of the patient care provided by each medical staff member


order: 12
name:
  At least every three years, the hospital determines, from the ongoing monitoring and evaluation of each medical staff member, if medical staff membership and clinical privileges are to continue with or without modification


order: 13
name:
  The hospital has a uniform process to gather, to verify, and to evaluate the nursing staff’s credentials (license, education, training, and experience).


order: 14
name:
  The hospital has a standardized process to identify job responsibilities and to make clinical work assignments based on the nursing staff member’s credentials and any regulatory requirements.


order: 14.1
name:
  The hospital has a standardized process for nursing staff participation in the hospital’s quality improvement activities, including evaluating individual performance when indicated.


order: 15
name:
  The hospital has a uniform process to gather, to verify, and to evaluate other health care practitioners’ credentials (license, education, training, and experience).


order: 16
name:
  The hospital has a uniform process to identify job responsibilities and to make clinical work assignments based on other health care practitioners’ credentials and any regulatory requirements


order: 16.1
name:
  The hospital has a uniform process for other health care practitioners’ participation in the hospital’s quality improvement activities.


order: 1.1
name:
  Hospital leadership complies with all regulatory and professional requirements and provides adequate resources for effective operation of the research program.


order: 3
name:
  Hospital leadership establishes requirements for sponsors of research to ensure their commitment to the conduct of ethical research


order: 3.1
name:
  When one or more of the research-related duties and functions of the sponsor are provided through an outside commercial or academic contract research organization, the accountabilities of the outside contract research organization are clearly defined.


order: 4
name:
  Hospital leadership creates or contracts for a process to provide the initial and ongoing review of all human subjects research


order: 6
name:
  The hospital integrates the human subjects research program into the quality and patient safety program of the hospital


order: 7
name:
  The hospital establishes and implements an informed consent process that enables patients to make informed and voluntary decisions about participating in clinical research, clinical investigations, or clinical trials.


order: 7.1
name:
  The hospital informs patients and families about how to gain access to clinical research, clinical investigations, or clinical trials and includes protections for vulnerable populations to minimize potential coercion or undue influence.


order: 1
name:
  The hospital’s governing body and leadership of the hospital approve and monitor the participation of the hospital in providing medical education.


order: 2
name:
  The hospital’s clinical staff, patient population, technology, and facility are consistent with the goals and objectives of the education program.


order: 3
name:
  Clinical teaching staff are identified, and each staff member’s role and relationship to the academic institution is defined.


order: 4
name:
  The hospital understands and provides the required frequency and intensity of medical supervision for each type and level of medical student and trainee


order: 5
name:
  Medical education provided in the hospital is coordinated and managed through a defined operational mechanism and management structure.


order: 6
name:
  Medical students and trainees comply with all hospital policies and procedures, and all care is provided within the quality and patient safety parameters of the hospital6


order: 7
name:
  Medical trainees who provide care or services within the hospital—outside of the parameters of their academic program—are granted permission to provide those services through the hospital’s established credentialing, privileging, job specification, or oth


order: 1
name:
  The hospital plans and designs information management processes to meet internal and external information needs.


order: 4
name:
  The hospital uses standardized diagnosis and procedure codes and ensures the standardized use of approved symbols and abbreviations across the hospital.


order: 5
name:
  The data and information needs of those in and outside the hospital are met on a timely basis in a format that meets user expectations and with the desired frequency.


order: 6
name:
  Records and information are protected from loss, destruction, tampering, and unauthorized access or use


order: 7
name:
  Decision makers and other staff members are educated and trained in the principles of information use and management.


order: 8
name:
  Written documents, including policies, procedures, and programs, are managed in a consistent and uniform manner


order: 8.1
name:
  The policies, procedures, plans, and other documents that guide consistent and uniform clinical and nonclinical processes and practices are fully implemented


order: 9
name:
  The hospital initiates and maintains a standardized medical record for every patient assessed or treated and determines the record’s content, format, and location of entries


order: 10
name:
  The medical records of patients receiving emergency care include the time of arrival and departure, the conclusions at termination of treatment, the patient’s condition at discharge, and follow-up care instructions.


order: 11.1
name:
  Every patient medical record entry identifies its author and when the entry was made in the medical record.


order: 11.1.1
name:
  The hospital has a process to address the proper use of the copy-andpaste function when electronic medical records are used


order: 12
name:
  As part of its monitoring and performance improvement activities, the hospital regularly assesses patient medical record content and the completeness of patient medical records.


order: 13
name:
  Health information technology systems are assessed and tested prior to implementation within the hospital and evaluated for quality and patient safety following implementation


order: 14
name:
  The hospital develops, maintains, and tests a program for response to planned and unplanned downtime of data systems


# reversion_version

object_id: 1
format: json
object_repr: Liste des sages-femmes pour retour domicile
db: default
serialized_data:
  [{"model": "dms.document", "pk": 1, "fields": {"title": "Liste des sages-femmes pour retour domicile", "overview": "", "type": 5, "created_at": "2017-11-16T21:07:07.721Z", "manager": 1}}]


object_id: 2
format: json
object_repr: Transfert des nouvelles accouchées vers la maternité
db: default
serialized_data:
  [{"model": "dms.document", "pk": 2, "fields": {"title": "Transfert des nouvelles accouch\u00e9es vers la maternit\u00e9", "overview": "", "type": 4, "created_at": "2017-11-16T21:07:23.768Z", "manager": 1}}]


object_id: 3
format: json
object_repr: Monitoring programmé en salle d'accouchement
db: default
serialized_data:
  [{"model": "dms.document", "pk": 3, "fields": {"title": "Monitoring programm\u00e9 en salle d'accouchement", "overview": "", "type": 4, "created_at": "2017-11-16T21:07:54.442Z", "manager": 1}}]


object_id: 4
format: json
object_repr: Remboursement d'une contraception
db: default
serialized_data:
  [{"model": "dms.document", "pk": 4, "fields": {"title": "Remboursement d'une contraception", "overview": "", "type": 5, "created_at": "2017-11-16T21:08:06.468Z", "manager": 1}}]


object_id: 5
format: json
object_repr: Identification d'un nouveau-né
db: default
serialized_data:
  [{"model": "dms.document", "pk": 5, "fields": {"title": "Identification d'un nouveau-n\u00e9", "overview": "", "type": 4, "created_at": "2017-11-16T21:08:19.244Z", "manager": 1}}]


object_id: 6
format: json
object_repr: Surveillance de la saturométrie du nouveau-né en salle de naissance
db: default
serialized_data:
  [{"model": "dms.document", "pk": 6, "fields": {"title": "Surveillance de la saturom\u00e9trie du nouveau-n\u00e9 en salle de naissance", "overview": "", "type": 4, "created_at": "2017-11-16T21:08:44.754Z", "manager": 1}}]


object_id: 7
format: json
object_repr: Accueil d'un nouveau-né en salle de naissance
db: default
serialized_data:
  [{"model": "dms.document", "pk": 7, "fields": {"title": "Accueil d'un nouveau-n\u00e9 en salle de naissance", "overview": "", "type": 4, "created_at": "2017-11-16T21:08:56.746Z", "manager": 1}}]


object_id: 8
format: json
object_repr: Bilans sanguins
db: default
serialized_data:
  [{"model": "dms.document", "pk": 8, "fields": {"title": "Bilans sanguins", "overview": "", "type": 4, "created_at": "2017-11-16T21:09:04.210Z", "manager": 1}}]


object_id: 9
format: json
object_repr: Accueil de la parturiente en salle de naissance
db: default
serialized_data:
  [{"model": "dms.document", "pk": 9, "fields": {"title": "Accueil de la parturiente en salle de naissance", "overview": "", "type": 4, "created_at": "2017-11-16T21:09:15.699Z", "manager": 1}}]


object_id: 10
format: json
object_repr: La contraception en post-partum
db: default
serialized_data:
  [{"model": "dms.document", "pk": 10, "fields": {"title": "La contraception en post-partum", "overview": "", "type": 5, "created_at": "2017-11-16T21:09:32.730Z", "manager": 1}}]


object_id: 11
format: json
object_repr: Menace d'accouchement prématuré
db: default
serialized_data:
  [{"model": "dms.document", "pk": 11, "fields": {"title": "Menace d'accouchement pr\u00e9matur\u00e9", "overview": "", "type": 4, "created_at": "2017-11-16T21:09:46.901Z", "manager": 1}}]


object_id: 12
format: json
object_repr: Pré-éclampsie
db: default
serialized_data:
  [{"model": "dms.document", "pk": 12, "fields": {"title": "Pr\u00e9-\u00e9clampsie", "overview": "", "type": 3, "created_at": "2017-11-16T21:09:55.434Z", "manager": 1}}]


object_id: 13
format: json
object_repr: Accouchement dans l'eau
db: default
serialized_data:
  [{"model": "dms.document", "pk": 13, "fields": {"title": "Accouchement dans l'eau", "overview": "", "type": 4, "created_at": "2017-11-16T21:10:04.983Z", "manager": 1}}]


object_id: 1
format: json
object_repr: v0.1 (Draft)
db: default
serialized_data:
  [{"model": "dms.version", "pk": 1, "fields": {"document": 13, "file": "revisions/a_acheter.md", "major": 0, "revision": 1, "is_published": false, "created_at": "2017-11-16T21:19:40.410Z", "restricted": false, "keywords": [], "audiences": [], "sites": [], "nodes": [], "authors": [], "reviewers": [], "validators": []}}]


object_id: 1
format: json
object_repr: Accouchement dans l'eau v0.1 (Draft)
db: default
serialized_data:
  [{"model": "dms.version", "pk": 1, "fields": {"document": 13, "file": "revisions/a_acheter.md", "major": 0, "revision": 1, "is_published": false, "created_at": "2017-11-16T21:19:40.410Z", "restricted": false, "keywords": [], "audiences": [3], "sites": [1], "nodes": [4]}}]


object_id: 13
format: json
object_repr: Accouchement dans l'eau
db: default
serialized_data:
  [{"model": "dms.document", "pk": 13, "fields": {"title": "Accouchement dans l'eau", "overview": "", "type": 4, "created_at": "2017-11-16T21:10:04.983Z", "manager": 1, "jci_standard": 1}}]


object_id: 14
format: json
object_repr: Liste pédiatres pour retour à domicile
db: default
serialized_data:
  [{"model": "dms.document", "pk": 14, "fields": {"title": "Liste p\u00e9diatres pour retour \u00e0 domicile", "overview": "", "type": 5, "created_at": "2018-03-14T13:45:12.736Z", "manager": 1, "jci_standard": 11}}]


object_id: 15
format: json
object_repr: Césarienne non programmée
db: default
serialized_data:
  [{"model": "dms.document", "pk": 15, "fields": {"title": "C\u00e9sarienne non programm\u00e9e", "overview": "", "type": 4, "created_at": "2018-03-14T13:45:30.177Z", "manager": 1, "jci_standard": 12}}]


object_id: 1
format: json
object_repr: Accouchement dans l'eau v0.1 (Draft)
db: default
serialized_data:
  [{"model": "dms.version", "pk": 1, "fields": {"document": 13, "file": "revisions/a_acheter.md", "snapshot": "", "major": 0, "revision": 1, "is_published": false, "created_at": "2017-11-16T21:19:40.410Z", "restricted": false, "keywords": [1], "audiences": [3], "sites": [1], "nodes": [4]}}]


# django_session

session_key: pmrb12tjjw1fu379kferazvze9u8m8jn
expire_date: 2017-11-30 20:48:45.456252
session_data:
  NDM3ZTdmMjY2ZDZkN2M5NGJmYjM4YjIxNjk4MDkzMTViMjIxNDhkNjp7Il9hdXRoX3VzZXJfaWQiOiIxIiwiX2F1dGhfdXNlcl9iYWNrZW5kIjoiZGphbmdvLmNvbnRyaWIuYXV0aC5iYWNrZW5kcy5Nb2RlbEJhY2tlbmQiLCJfYXV0aF91c2VyX2hhc2giOiJmZjgxMDIyZmY2MmU0ODdkNmM5N2E3YjlmNjg0MDMzMTVjM2YzZGY5In0=


# writer_section

title: Objet
content:
  # Séparation

  ## titre niveau 2

  **élément en gras**

  *en italique*

   * une liste
   * Deuxième élément


title: Champ d'application
content:
  Ce paragraphe reprend le champ d'application de mon document.

  Je devrais y ajouter quelques informations.


title: Procédure
content:
  * Maria Carey
   * Madonna
   * Gwen Stefany
   * Laetitia Haliday

  Ne pas oublier de **prévenir le médecin de garde**.

  Hey :-) *ici*


title: Objet
content:
  Définir ici l’objet du mode opératoire, son but
  Ex : Ce mode opératoire a pour objet la gestion de X dans le cadre de….


title: Champ d'application
content:
  Définir le champ d’application du document ainsi que les exclusions si besoin
  Ex : Ce mode opératoire est applicable pour l’ensemble du département X et concerne le matériel Y.


title: Responsabilités
content:
  Définir les responsabilités impliquées par ce document
  Ex : l’application de ce mode opératoire s’effectue sous la responsabilité de la fonction Z. La formation du personnel dans ce cadre est effectuée par la fonction X.


title: Références
content:
  ## Documents liés

   * Citer ici les procédures, modes opératoires et formulaires liés
   * Titre du document, référence SharePoint et/ou lien hypertexte

  ## Documents de références

   * Citer ici les documents de références (ex : publication, texte législatif…) 
   * Nom de l’auteur, Prénom. Année de publication. Titre : sous-titre. Numéro et nature de l’édition s’il y a lieu. Titre de la collection et numéro du document dans la collection. Publication (lieu : éditeur). Nombre de pages.


title: Mode opératoire
content:
  ## Résumé (facultatif)

  Possibilité d’ajouter un flux résumé du mode opératoire pour plus de clarté (insérer un objet visio)

  ## Titre de niveau 2

  Le mode opératoire est un document opérationnel découlant généralement des procédures. Il décrit le mode d’exécution d’une tâche, d’une prestation technique liée à un poste. Elle répond précisément à la question « comment ».

  ### Titre de niveau 3

  #### Titre de niveau 4


title: Modifications par rapport à la version précédente
content:
  Ce paragraphe est complété à chaque révision du document afin de conserver l’historique des modifications.
  Ex : Création du document en version 01
  Ex : Mise à jour du §5.5.6 Nettoyants utilisés


title: Annexes
content:
  Si nécessaire, ajouter ici des documents en lien avec le mode opératoire mais qui ne peuvent pas être enregistrés séparément.


# writer_modelsection

title: Objet
content:
  Définir ici l’objet de ce document, son but

  Ex : *Ce document a pour objet la gestion de X dans le cadre de….*


title: Champ d'application
content:
  Définir le champ d’application du document ainsi que les exclusions si besoin

  Ex : *Ce document est applicable pour l’ensemble du département X et concerne le matériel Y. *


title: Responsabilités
content:
  Définir les responsabilités impliquées par ce document.

  Ex : *l’application de ce document s’effectue sous la responsabilité de la fonction Z. La formation du personnel dans ce cadre est effectuée par la fonction X.*


title: Références
content:
  ## Documents liés

   * Citer ici les modes opératoires et formulaires liés
   * Titre du document, référence SharePoint et/ou lien hypertexte

  ## Documents de références

   * Citer ici les documents de références (ex : publication, texte législatif…)
   * Nom de l’auteur, Prénom. Année de publication. Titre : sous-titre. Numéro et nature de l’édition s’il y a lieu. Titre de la collection et numéro du document dans la collection. Publication (lieu : éditeur). Nombre de pages.


title: Contenu
content:
  ## Résumé (facultatif)

  Possibilité d’ajouter un résumé du document.

  ## Titre de niveau 2 

  Déclaration des attentes, généralement sous forme d’écrit, destinée à influencer ou à régir des décisions et des actions. Les politiques sont constituées de la réglementation, des règlements ou des lois qui informent sur les procédures et les modes opératoires.

  ### Titre de niveau 3

  #### Titre de niveau 4


title: Modifications par rapport à la version précédente
content:
  Ce paragraphe est complété à chaque révision du document afin de conserver l’historique des modifications.

  Exemples : 

   * Création du document en version 01
   * Mise à jour des nettoyants utilisés


title: Annexes
content:
  Si nécessaire, ajouter ici des documents en lien avec la politique mais qui ne peuvent pas être enregistrés séparément.


title: Objet
content:
  Définir ici l’objet de la procédure, son but

  Ex : Cette procédure a pour objet la gestion de X dans le cadre de….


title: Champ d'application
content:
  Définir le champ d’application du document ainsi que les exclusions si besoin

  Ex : Cette procédure est applicable pour l’ensemble du département X et concerne le matériel Y.


title: Responsabilités
content:
  Définir les responsabilités impliquées par ce document

  Ex : l’application de cette procédure s’effectue sous la responsabilité de la fonction Z. La formation du personnel dans ce cadre est effectuée par la fonction X.


title: Procédure
content:
  ## Résumé (facultatif)

  Possibilité d’ajouter un flux résumé de la procédure pour plus de clarté (insérer un objet visio)

  ## Titre de niveau 2

  Décrit un process global en le décomposant en plusieurs étapes. Très synthétique.

  Renvoie vers les modes opératoires et/ou formulaires liés.

  Répond aux questions Qui, Quoi, Quand, Où, Pourquoi.

  Répond à la question Comment uniquement s’il n’y a pas de mode opératoire associé (process très simple)

  ### Titre de niveau 3

  #### Titre de niveau 4


title: Annexes
content:
  Si nécessaire, ajouter ici des documents en lien avec la procédure mais qui ne peuvent pas être enregistrés séparément.


