Referenced from the Comprehensive Accreditation Manual for Hospitals, Update 3, 1999 (Effective Jan. 1, 2001)
PATIENT RIGHTS AND ORGANIZATION ETHICS
(Note: Pain related text in the standards and intents is underlined.)
Standard RI.1.2
Patients are involved in all aspects of their care.
Intent of RI.1.2
Hospitals promote patient and family involvement in all aspects of their care through implementation of policies and procedures that are compatible with the hospital's mission and resources, have diverse input, and guarantee communication across the organization. Patients are involved in at least the following aspects of their care:
· Giving informed consent;
· Making care decisions, including managing pain effectively;
· Resolving dilemmas about care decisions;
· Formulating advance directives;
· Withholding resuscitative services;
· Forgoing or withdrawing life-sustaining treatment; and
· Care at the end of life.
To this end, structures are developed, approved, and maintained through collaboration among the hospital's leaders and others. Patients' psychosocial, spiritual, and cultural values affect how they respond to their care. The hospital allows patients and their families to express their spiritual beliefs and cultural practices, as long as these do not harm others or interfere with treatment.
Standard RI.1.2.7
The hospital addresses care at the end of life.
Intent of RI.1.2.7
Dying patients have unique needs for respectful, responsive care. All hospital staff are sensitized to the needs of patients at the end of life. Concern for the patient's comfort and dignity should guide all aspects of care during the final stages of life.
The hospital's framework for addressing issues related to care at the end of life provide for:
· providing appropriate treatment for any primary and secondary symptoms, according to the wishes of the patient or the surrogate decision maker;
· managing pain aggressively and effectively;
· sensitively addressing issues such as autopsy and organ donation;
· respecting the patient's values, religion, and philosophy;
· involving the patient and, where appropriate, the family in every aspect of care; and
· responding to the psychological, social, emotional, spiritual, and cultural concerns of the patient and the family.
Effective pain management is appropriate for all patients, not just for dying patients (see standards RI.1.2.8 and PE.1.4).
Standard RI.1.2.8
Patients have the right to appropriate assessment and management of pain.
Intent of RI.1.2.8
Pain can be a common part of the patient experience; unrelieved pain has adverse physical and psychological effects. The patient's right to pain management is respected and supported. The organization plans, supports, and coordinates activities and resources to assure the pain of all individuals is recognized and addressed appropriately. This includes:
· initial assessment and regular reassessment of pain;
· education of relevant providers in pain assessment and management;
· education of patients, and families when appropriate, regarding their roles in managing pain as well as the potential limitations and side effects of pain treatments; and
· after taking into account personal, cultural, spiritual, and/or ethnic beliefs, communicating to patients and families that pain management is an important part of care.
ASSESSMENT OF PATIENTS
(Note: New language is underlined.)
Standard PE.1.4
Pain is assessed in all patients.
Intent of PE.1.4
In the initial assessment, the organization identifies patients with pain. When pain is identified, the patient can be treated within the organization or referred for treatment. The scope of treatment is based on the care setting and services provided. A more comprehensive assessment is performed when warranted by the patient's condition. This assessment and a measure of pain intensity and quality (e.g., pain character, frequency, location, duration), appropriate to the patient's age, are recorded in a way that facilitates regular reassessment and follow up according to criteria developed by the organization.
CARE OF PATIENTS
(Note: Pain related text in the standards and intents is underlined.)
Standard TX.3.3
Policies and procedures support safe medication prescription or ordering.
Intent of TX.3.3
Procedures supporting safe medication prescription or ordering address:
· distribution and administration of controlled medications, including adequate documentation and record keeping required by law;
· proper storage, distribution, and control of investigational and clinical trial medications;
· situations in which all or some of a patient's medications must be permanently or temporarily canceled, and mechanisms for reinstating them;
· "as needed" (PRN) and scheduled prescriptions or orders and times of dose administration;
· appropriate use of patient-controlled analgesia (PCA), spinal/epidural, or intravenous administration of medications and other pain management techniques in the care of patients with pain;
· control of sample drugs;
· distribution of medications to patients at discharge;
· procurement, storage, control, and distribution of prepackaged medications obtained from outside sources;
· procurement, storage, control, distribution, and administration of radioactive medications; and
· procurement, storage, control, distribution, administration, and monitoring all blood derivatives and radiographic contrast media.
Standard TX.5.4
The patient is monitored during the post-procedure period.
Intent of TX.5.4
The patient is monitored continuously throughout the post-procedure period. The following items are monitored:
a. Physiological and mental status;
b. Status of or findings related to pathological conditions, such as drainage from incisions;
c. Intravenous fluids and drugs administered, including blood and blood components;
d. Impairments and functional status;
e. Pain intensity and quality (for example, pain character, frequency, location, duration) and responses to treatments; and
f. Unusual events or postoperative complications and their management.
Results of monitoring trigger key decisions, such as transfer to an alternative level of care due to a precipitous change in vital signs, or discharge.
EDUCATION
(Note: Pain related text in the standards and intents is underlined.)
Standard PF.3.4
Patients are educated about pain and managing pain as part of treatment, as appropriate.
Intent of PF.3.4
When appropriate, patients and families are instructed about understanding pain, the risk for pain, the importance of effective pain management, the pain assessment process, and methods for pain management, when identified as part of treatment.
CONTINUUM OF CARE
(Note: Pain related text in the standards and intents is underlined.)
Standard CC.6.1
The discharge process provides for continuing care based on the patient's assessed needs at the time of discharge.
Intent of CC.6.1
Discharge planning focuses on meeting patients' health care needs after discharge. Discharge planning identifies patients' continuing physical, emotional, symptom management (for example, pain, nausea, or dyspnea), housekeeping, transportation, social, and other needs, and arranges for services to meet them. Discharge services may include:
· adult foster care,
· case management,
· home health services,
· hospice,
· long term care facilities,
· ambulatory care,
· support groups,
· rehabilitation services,
· community mental health.
Discharge planning involves the patient, the family, the practitioner primarily responsible for the patient, nursing and social work professionals, and other appropriate staff. Staff members help the patient and family adapt to the plan of care.
IMPROVING ORGANIZATION PERFORMANCE
(Note: Pain related text in the standards and intents is underlined.)
Standard PI.3.1
The organization collects data to monitor its performance.
Intent of PI.3.1
Performance monitoring and improvement are data driven. The stability of important processes can provide the organization with information about its performance. Every organization must choose which processes and outcomes (and thus types of data) are important to monitor based on its mission and the scope of care and services provided. The leaders prioritize data collection based on the organization's mission, care and services provided, and populations served (see LD.4.2 for priority setting). Data that the organization considers for collection to monitor performance include the following:
· Performance measures related to accreditation and other requirements;
· Risk management;
· Utilization management;
· Quality control;
· Staff opinions and needs;
· Behavior management procedures, if used;
· Outcomes of processes or services;
· Autopsy results, when performed;
· Performance measures from acceptable databases;
· Patient demographics and diagnoses;
· Financial data;
· Infection-control surveillance and reporting;
· Research data;
· Performance data identified in various chapters of this manual; and
· The appropriateness and effectiveness of pain management.
Organizations are required to collect data about the needs, expectations, and satisfaction of individuals and organizations served. Individuals served and their family members can provide information that will give an organization insight about process design and functioning. The organization asks them about:
· their specific needs and expectations;
· their perceptions of how well the organization meets these needs and expectations; and
· how the organization can improve.
The organization can use a number of ways to get input from these groups including satisfaction surveys, regularly scheduled meetings held with these groups, and focus groups.
For more information on JCAHO standards, visit their Web site at www.jcaho.org.
Last Published: 5/7/2007
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