Effective 1 January 2015

Joint
Commission
International
Accreditation
Standards for
Ambulatory
Care
English

3rd Edition
JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR AMBULATORY CARE, 3RD EDITION

Joint Commission International

A division of Joint Commission Resources, Inc.
The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the
international community through the provision of education, publications, consultation, and evaluation
services. Joint Commission Resources educational programs and publications support, but are separate from,
the accreditation activities of Joint Commission International. Attendees at Joint Commission Resources
educational programs and purchasers of Joint Commission Resources publications receive no special
consideration or treatment in, or confidential information about, the accreditation process.
© 2014 Joint Commission International
All rights reserved. No part of this publication may be reproduced in any form or by any means without
written permission from the publisher.
Printed in the U.S.A. 5 4 3 2 1

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[email protected]

ISBN: 978-1-59940-744-9

For more information about Joint Commission Resources, please visit http://www.jcrinc.com.
For more information about Joint Commission International, please visit
http://www.jointcommissioninternational.org.

ii
 Contents

Foreword ............................................................................................................................. . v
Standards Advisory Panel .................................................................................................. . vii
Introduction ......................................................................................................................... . 1
General Eligibility Requirements .......................................................................................... . 5
Section I: Accreditation Participation Requirements .................................. . 7
Accreditation Participation Requirements (APR) ............................... . 9
Section II: Patient-Centered Standards ...................................................... . 17
International Patient Safety Goals (IPSG) ....................................... . 19
Access to Care and Continuity of Care (ACC) ................................. . 29
Patient and Family Rights (PFR) .................................................... . 37
Assessment of Patients (AOP) ......................................................... . 45
Care of Patients (COP) .................................................................... . 55
Anesthesia and Surgical Care (ASC) ................................................ . 65
Medication Management and Use (MMU) ..................................... . 77
Patient and Family Education (PFE) .............................................. . 83
Section III: Health Care Organization Management Standards ............... . 87
Quality Improvement and Patient Safety (QPS) ............................. . 89
Prevention and Control of Infections (PCI) .................................... . 97
Governance, Leadership, and Direction (GLD) ............................ . 103
Facility Management and Safety (FMS) ........................................ . 123
Staff Qualifications and Education (SQE) .................................... . 135
Management of Information (MOI) .............................................. . 151
Summary of Key Accreditation Policies .............................................................................. 161
Glossary ........................................................................................................................... 171
Index ............................................................................................................................... . 183

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 Foreword

Joint Commission International (JCI) is proud to present this 3rd edition of its international standards for
ambulatory care organizations. Our customers told us clearly and repeatedly they want standards that are
challenging, achievable, and focused on the safety and quality of patient care. We listened and we believe these
standards exceed those expectations.
In this edition, in order to provide consistency with our multiple accreditation programs and accompanying
standards manuals, we standardized the chapter titles, acronyms, and content with the JCI 5th edition hospital
manual. We combined similar requirements, eliminated others that we did not consider essential to better
patient outcomes, and reorganized the content across many chapters to ensure a better, more logical flow of
requirements. We provided more examples of proper compliance within the standards’ intents to ensure that
our requirements are clear. In addition, this manual includes the new Accreditation Participation Requirements
that were first presented in the 5th edition of the hospital standards.
We are thankful for the input and feedback we received from our esteemed Standards Advisory Panel, which
reviewed, informed, and otherwise guided us through the development of these standards. We are grateful to
our customers, who responded to our field review, confirming that we were headed in the right direction with
our proposed standards and making us think longer and more fully about other requirements, all of which
eventually pushed us to do our jobs better and in a more patient-centric way.
We hope you appreciate the effort that we put into this edition of the standards. As always, let us know what
you think—your opinion is as much on these pages as ours.
Paula Wilson
President and CEO
Joint Commission International and Joint Commission Resources

v
 Standards Advisory
Panel

Dana Alexander, RN, MBA, MSN, FHIMSS, Stanley S. Kent, MS, RPh, FASHP
FAAN Evanston, Illinois, US
Colorado Springs, Colorado, US
Tamra Minnier, RN, MSN, FACHE (Chair)
Heleno Costa Jr., RN Pittsburgh, Pennsylvania, US
Rio de Janeiro, Brazil
Kim Montague, AIA, EDAC, LEED BD+C,
Brigit Devolder, MS NCARB
Leuven, Belgium Novi, Michigan, US
Samer Ellahham, MD, FACP, FACC, FAHA, Angela Norton, MA, PGCE, RHV, RM, RN
FCCP, ASHCSH Cheshire, England, United Kingdom
Abu Dhabi, UAE
Voo Yau Onn, MBBS, MMed(PH), FAMS
Hossam E.M. Ghoneim, MB, BCh, MSc, MD, Singapore
FRCOG, HMD
Jeddah, Kingdom of Saudi Arabia Chung-Liang Shih, MD, PhD
Taipei City, Taiwan
Paul B. Hofmann, DrPH, FACHE
Moraga, California, US Paula Vallejo, PhD
Madrid, Spain
Annette Jolly
Kilkenny, Ireland Jorge Augusto Vasco Varanda
Lisbon, Portugal

vii
 Introduction

This 3rd edition of the Joint Commission International Accreditation Standards for Ambulatory Care contains the
standards, intents, measurable elements (MEs), a summary of changes, a summary of accreditation policies and
procedures, a glossary of terms, and an index. This Introduction is designed to provide you with information
on the following topics:
 The origin of these standards
 How the standards are organized
 How to use this standards manual
 What is new in this edition of the manual
If, after reading this publication, you have questions about the standards or the accreditation process, please
contact JCI:
+1-630-268-7400
[email protected]

How were the standards developed and refined for

this 3rd edition?
A 15-member Standards Advisory Panel, composed of experienced physicians, nurses, administrators, and
public policy experts, guided the development and revision process of the JCI accreditation standards. The
panel consists of members from most major world regions. Its work is refined based on the following:
 An international field review of the standards
 Input from experts and others with unique content knowledge
 Ongoing literature searches for key health care practices

How are the standards organized?

The standards are organized around the important functions common to all health care organizations. The
functional organization of standards is now the most widely used around the world and has been validated by
scientific study, testing, and application.
The standards are grouped by functions related to providing patient care: those related to providing a safe,
effective, and well-managed organization. These standards apply to the entire organization as well as to each
department, unit, or service within the organization. The survey process gathers standards compliance
information throughout the entire organization, and the accreditation decision is based on the overall level of
compliance found throughout the entire organization.

Are the standards available for the international

community to use?
Yes. These standards are available in the international public domain for use by individual health care
organizations and by public agencies in improving the quality of patient care. The standards only can be

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JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR AMBULATORY CARE, 3RD EDITION

downloaded at no cost from the JCI website for consideration of adapting them to the needs of individual
countries. The translation and use of the standards as published by JCI requires written permission.

When there are national or local laws related to a

standard, what applies?
When standard compliance is related to laws and regulations, whichever sets the higher or stricter requirement
applies. For example, if a JCI standard on documenting services in the patient record is more stringent than
an ambulatory care organization’s national standard, the JCI standard is applied.

How do I use this standards manual?

This international standards manual can be used to
 guide the efficient and effective management of a health care organization;
 guide the organization and delivery of patient care services and efforts to improve the quality and
efficiency of those services;
 review the important functions of a health care organization;
 become aware of those standards that all ambulatory care organizations must meet to be accredited by JCI;
 review the compliance expectations of standards and the additional requirements found in the
associated intent;
 become aware of the accreditation policies and procedures and the accreditation process; and
 become familiar with the terminology used in the manual.
JCI requirements by category are described in detail below. JCI’s policies and procedures are also summarized
is this manual. Please note that these are neither the complete list of policies nor every detail of each policy.
Current JCI policies are published on JCI’s public website,
http://www.jointcommissioninternational.org/accreditation-policies.
A glossary of important terms and a detailed index follow the standards chapters.

JCI Requirement Categories

JCI requirements are described in these categories:
 Accreditation Participation Requirements (APR)
 Standards
 Intents
 Measurable Elements (MEs)

Accreditation Participation Requirements (APR)

The Accreditation Participation Requirements (APR) section, new in this edition, is composed of specific
requirements for participation in the accreditation process and for maintaining an accreditation award.
Ambulatory care organizations must be compliant with the requirements in this section at all times during the
accreditation process. However, APRs are not scored like standards during the on-site survey; ambulatory care
organizations are considered either compliant or not compliant with the APR. When an ambulatory care
organization is not complaint with a specific APR, the ambulatory care organization will be required to
become complaint or risk losing accreditation.

Standards
JCI standards define the performance expectation, structures, or functions that must be in place for an
ambulatory care organization to be accredited by JCI. JCI’s International Patient Safety Goals are considered
standards and are evaluated as such in the on-site survey.

2
 INTRODUCTION

Intents
A standard’s intent helps explain the full meaning of the standard. The intent describes the purpose and
rationale of the standard, providing an explanation of how the standard fits into the overall program, sets
parameters for the requirement(s), and otherwise “paints a picture” of the requirements and goals.

Measurable Elements (MEs)

Measurable elements (MEs) of a standard indicate what is reviewed and assigned a score during the on-site
survey process. The MEs for each standard identify the requirements for full compliance with the standard.
The MEs are intended to bring clarity to the standards and to help the organization fully understand the
requirements, to help educate leaders and health care workers about the standards, and to guide the
organization in accreditation preparation.

What is new in this 3rd edition of the manual?

There are many changes to this 3rd edition of the ambulatory care organization manual. A thorough review is
strongly recommended. In general, all of the significant changes—changes that, in the view of JCI and the
experts and customers who helped develop the standards, “raise the bar” on compliance expectations—are
listed in a table at the beginning of the chapter in which those standards appear.
In addition to requirement changes, JCI has edited nearly all of the text that appeared in the 2nd edition for
clarity, so it will be important for users to compare this and the 2nd edition carefully to ensure a full
understanding of the new requirements.
Many chapter names are also changed in this edition. Whenever possible, JCI is aligning names of its standards
chapters across programs for easier identification of similar requirements.
Changes include the following:
 A table at the front of each chapter detailing the key changes to that chapter in this edition (compared
to the 2nd edition standards). If a standard is not listed in the table, it has not changed since the 2nd
edition standards. Changes are classified in four ways:
o No significant change—Wording changes were made in the interest of clarity, but the
requirements in the standard have not changed.
o Renumbered—The standard moved from a different place in the same chapter or from another
chapter and is, therefore, renumbered.
o Requirement change—A change(s) to one or more MEs, which will change the way an
organization is evaluated.
o New standard—A new requirement that did not appear in the second edition standards
 New standards and established standards deemed by the field as more difficult to meet are supported
with evidence-based references. With this new feature, JCI is beginning to build an evidence base for
its standards that both cites important clinical evidence and provides assistance with compliance.
References of various types—from clinical research to practical guidelines—are cited in the text of the
standard’s intent and are listed at the end of the applicable standard chapter.
 A new section, “Accreditation Participation Requirements” (APR). See JCI Requirement Categories for
more information.
 Some standards require the ambulatory care organization to have a written policy or procedure for
specific processes. Those standards are indicated by a icon after the standard text. In previous
editions, each required policy or procedure was specified in its own ME. In this edition, all policies
and procedures will be scored together at MOI.7 and MOI.7.1.
 Examples that better illustrate compliance are provided in most standards’ intents. To make the
examples more obvious to the user, the term for example is printed in bold text.
 JCI’s policies and procedures are summarized and moved from the front of the manual to their
current location. This change reflects customer feedback that the policies and procedures, though
important, are secondary in importance to the JCI standards, intents, and MEs. Starting in late 2013,
JCI policies have been published on JCI’s public website at
http://www.jointcommissioninternational.org/accreditation-policies.

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JOINT COMMISSION INTERNATIONAL ACCREDITATION STANDARDS FOR AMBULATORY CARE, 3RD EDITION

 Definitions of key terms used throughout the manual have been created or updated, and text including
those terms has been reevaluated and revised to ensure that terminology is correct and clear. Many
terms are defined within intents; look for these key terms in italics (for example, leadership). All key
terms are defined in the Glossary in the back of this edition.
 Chapter overviews, presented for all chapters in past editions, are present only when
necessary—specifically, in this edition, in the APR section and “Governance, Leadership, and
Direction” (GLD) chapter.
 Widespread wording changes for clarity, including frequently substituting the term program for plan or
process. In past editions, JCI requirements called for ambulatory care organizations to have a plan or a
process for many clinical issues and matters. During the development of these standards, customer
feedback indicated confusion over the definitions of plan and process, but program was considered more
specific and clear.

How frequently are the standards updated?

Information and experience related to the standards will be gathered on an ongoing basis. If a standard no
longer reflects contemporary health care practice, commonly available technology, quality management
practices, and so forth, it will be revised or deleted. It is current practice that the standards are revised and
published approximately every three years.

What does the “effective” date on the cover of this

3rd edition of the standards manual mean?
The “effective” date found on the cover means one of two things:
 For ambulatory care organizations already accredited under the 2nd edition of the standards, this is the
date by which they now must be in full compliance with all the standards in the 3rd edition. Standards
are published at least six months in advance of the effective date to provide time for organizations to
come into full compliance with the revised standards by the time they are effective.
 For ambulatory care organizations seeking accreditation for the first time, the effective date indicates
the date after which all surveys and accreditation decisions will be based on the standards of the 3rd
edition. Any survey and accreditation decisions before the effective date will be based on the standards
of the 2nd edition.