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JOINT COMMISSION

INTERNATIONAL ACREDITATION

SUMMARY OF REQUIREMENTS

Section I Patient Centered Standards

1. Access to Care and Continuity of Care


2. Patient and Family Rights

3. Assessment of Patients
4. Care of Patients 5. Patient and Family Education

Section II
Health Care Organisation Management Standards

1. Quality Improvement and Patient Safety 2. Prevention and control of Infections 3. Governance, Leadership, and Direction 4. Facility Management and safety 5. Staff Qualification and Education 6. Management of Information

1. Access to Care and Continuity of Care

Core

Total

a) Access to care b) Continuity of Care

03 05

09 05

c) Discharge Referrals and follow up 04


d) Transfer of patients 02

04
07

Total

14

25

2. Patient and Family Rights


Core Total

a) General
b) Informed consent Total

17
12 29

20
15 35

3. Assessment of Patients

Core

Total

a)

General

10 08

17 14

b) Laboratory Services

c) Radiology Services
Total

09
27

13
44

4. Care of Patients
Core Total

a) Care Delivery for All Patients b) Care of High Risk Patients and Provision of High Risk Services c) Anesthesia Care

06 10 07

09 10 07

d) Surgical Care
e) Medical Use

04
17

05
23

f) Food & Nutrition Therapy


g) Pain Mgmt - End of life Care Total

04
00 48

07
09 70

5. Patient and Family Education


Core Total

a)

General
Total

06
06

10
10

SECTION 2 1. Quality Improvement and Patient Safety


Core Total

a) Quality and Safety Leadership

03

09

b) Quality and Safety Design


c) Data Collection for Quality Monitoring d) Analysis of Monitoring Data e) Improvement Total

00 10
02 04 19

04 21
05 07 46

2. Prevention and control of Infections


Core Total

a) Focus of the program

03

06
05

b) Management of the program 03 c) Integration of the Program with Quality Improvement and Patient Safety

01 00 07

07 03 21

d) Education of staff about the Program


Total

3. Governance, Leadership, and Direction


Core Total

a) Governance of the organisation 06


b) Leadership of the Organisation 03

07
14 09 30

c) Direction of Departments and Services


Total

04 13

4. Facility Management and safety


Core Total

a) Planning and Direction b) Medical Equipment and Utility Systems c) Staff Education

07 04 02

15 08 04

Total

13

27

5. Staff Qualification and Education


Core Total

a) Planning
b) Orientation and Education

02
01

08
07

c) Medical Staff
d) Nursing Staff

04
03

05
04

e) Other health professional Staff


Total

03
13

04
28

6. Management of Information

Core Total

a) Planning
b) Patient Clinical Record c) Aggregate Data Information Total

01
03 02 06

19
05 02 26

Pl see 05C word doc Summary of Measurable elements

ACC Access to Care and 1 Continuity of Care a) Access to care

Core Total 3 9

b)
c) d)

Continuity of Care
Discharge Referrals and follow up Transfer of patients

5
4 2

5
4 7

Total

14

25