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JOINT COMMISSION
INTERNATIONAL ACREDITATION
SUMMARY OF REQUIREMENTS
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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
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Core Total
a) Access to care 03 09
b) Continuity of Care 05 05
c) Discharge Referrals and follow up 04 04
d) Transfer of patients 02 07
Total 14 25
1. Access to Care and Continuity of Care
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Core Total
a) General 17 20
b) Informed consent 12 15
Total 29 35
2. Patient and Family Rights
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Core Total
a) General 10 17
b) Laboratory Services 08 14
c) Radiology Services 09 13
Total 27 44
3. Assessment of Patients
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Core Total
a) Care Delivery for All Patients 06 09b) Care of High Risk Patients and
Provision of High Risk Services 10 10
c) Anesthesia Care 07 07
d) Surgical Care 04 05
e) Medical Use 17 23
f) Food & Nutrition Therapy 04 07
g) Pain Mgmt - End of life Care 00 09
T t l 48 70
4. Care of Patients
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Core Total
a) Quality and Safety Leadership 03 09
b) Quality and Safety Design 00 04
c) Data Collection for
Quality Monitoring 10 21
d) Analysis of Monitoring Data 02 05
e) Improvement 04 07
Total 19 46
SECTION 2
1. Quality Improvement and Patient Safety
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Core Total
a) Governance of the organisation 06 07
b) Leadership of the Organisation 03 14
c) Direction of Departments
and Services 04 09
Total 13 30
3. Governance, Leadership, and Direction
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Core Total
a) Planning and Direction 07 15
b) Medical Equipmentand Utility Systems 04 08
c) Staff Education 02 04
Total 13 27
4. Facility Management and safety
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Core Total
a) Planning 02 08
b) Orientation and Education 01 07
c) Medical Staff 04 05
d) Nursing Staff 03 04
e) Other health professional Staff 03 04
Total 13 28
5. Staff Qualification and Education
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Core Total
a) Planning 01 19
b) Patient Clinical Record 03 05
c) Aggregate Data Information 02 02
Total 06 26
6. Management of Information
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Pl see 05C word doc
Summary of Measurable elements
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ACC
1
Access to Care and
Continuity of Care
Core Total
a) Access to care 3 9
b) Continuity of Care 5 5
c) Discharge Referrals and
follow up
4 4
d) Transfer of patients 2 7
Total 14 25