JCI医院评审标准(第四版)

JOINTCOMMISSIONINTERNATIONALACCREDITATIONSTANDARDSFORHOSPITALS,4THEDITION美国医疗机构评审国际联合委员会国际医院管理标准（第四版）（2011年1月1日起执行）SectionI:Patient-CenteredStandards患者中心标准•InternationalPatientSafetyGoals(IPSG)•国际患者安全目标•AccesstoCareandContinuityofCare(ACC)•医疗护理途径及连续性•PatientandFamilyRights(PFR)•患者及其家属权益•AssessmentofPatients(AOP)•患者评估•CareofPatients(COP)•患者的医疗护理•AnesthesiaandSurgicalCare(ASC)•麻醉及外科医疗护理•MedicationManagementandUse(MMU)•药品管理和使用•PatientandFamilyEducation(PFE)•患者及其家属教育InternationalPatientSafetyGoals(IPSG)国际患者安全目标•IPSG.1IdentifyPatientsCorrectly•IPSG.2ImproveEffectiveCommunication•IPSG.3ImprovetheSafetyofHigh-AlertMedications•IPSG.4EnsureCorrect-Site,Correct-Procedure,Correct-PatientSurgery•IPSG.5ReducetheRiskofHealthCare–AssociatedInfections•IPSG.6ReducetheRiskofPatientHarmResultingfromFallsInternationalPatientSafetyGoals(IPSG)国际患者安全目标•IPSG.1正确辨认患者•IPSG.2有效地改进沟通•IPSG.3改进高敏感性疗程的安全性•IPSG.4保证正确部位，正确做法，正确患者手术•IPSG.5减少相关医疗风险•IPSG.6减少患者摔倒发生伤害的风险AccesstoCareandContinuityofCare(ACC)医疗护理途径及连续性•ACC.1Patientsareadmittedtoreceiveinpatientcareorregisteredforoutpatientservicesbasedontheiridentifiedhealthcareneedsandtheorganization’smissionandresources.•ACC.2Theorganizationdesignsandcarriesoutprocessestoprovidecontinuityofpatientcareservicesintheorganizationandcoordinationamonghealthcarepractitioners.•ACC.3Thereisapolicyguidingthereferralordischargeofpatients.•ACC.4Patientsaretransferredtootherorganizationsbasedonstatusandtheneedtomeettheircontinuingcareneeds.•ACC.5Theprocessforreferring,transferring,ordischargingpatients,bothinpatientsandoutpatients,includesplanningtomeetthepatient'stransportationneeds.AccesstoCareandContinuityofCare(ACC)医疗护理途径及连续性•ACC.1根据患者治疗需求和医院使命及资源，决定患者住院治疗或门诊治疗•ACC.2在医院科室和医护人员间制定并实施相互协调的程序，为患者提供连续的医疗服务•ACC.3指导患者转诊或出院的制度明确•ACC.4根据病情和需要，为让患者得到持续治疗，有患者转院制度•ACC.5住院和门诊患者的转诊、转院，或出院程序含有患者运送需求的计划PatientandFamilyRights(PFR)患者及其家属权益•PFR.1Theorganizationisresponsibleforprovidingprocessesthatsupportpatients’andfamilies’rightsduringcare.•PFR.2Theorganizationsupportspatients’andfamilies’rightstoparticipateinthecareprocess.•PFR.3Theorganizationinformspatientsandfamiliesaboutitsprocesstoreceiveandtoactoncomplaints,conflicts,anddifferencesofopinionaboutpatientcareandthepatient’srighttoparticipateintheseprocesses.•PFR.4Staffmembersareeducatedabouttheirrolesinidentifyingpatients’valuesandbeliefsandprotectingpatients’rights.•PFR.5Allpatientsareinformedabouttheirrightsandresponsibilitiesinamannerandlanguagetheycanunderstand.•PFR.6Patientinformedconsentisobtainedthroughaprocessdefinedbytheorganizationandcarriedoutbytrainedstaffinalanguagethepatientcanunderstand.PatientandFamilyRights(PFR)患者及其家属权益•PFR.1医院负责提供支持患者及其家属在治疗期间权益的程序•PFR.2医院支持患者及其家属参与治疗过程的权益•PFR.3医院告知患者及其家属有关受理投诉、纠风和不同治疗意见的程序，及参与这些程序的权益•PFR.4教育员工正确对待不同价值观和信仰的患者，并维护其权益•PFR.5以患者能理解的方式和语言告知其权益和责任•PFR.6用患者能理解的语言训炼员工，并由其通过医院制定的程序获得患者知情同意PatientandFamilyRights(PFR)患者及其家属权益•PFR.7Theorganizationinformspatientsandfamiliesabouthowtogainaccesstoclinicalresearch,clinicalinvestigation,orclinicaltrialsinvolvinghumansubjects.•PFR.8Informedconsentisobtainedbeforeapatientparticipatesinclinicalresearch,clinicalinvestigation,andclinicaltrials.•PFR.9Theorganizationhasacommitteeoranotherwaytooverseeallresearchintheorganizationinvolvinghumansubjects.•PFR.10Theorganizationinformspatientsandfamiliesabouthowtochoosetodonateorgansandothertissues.•PFR.11Theorganizationprovidesoversightoftheharvestingandtransplantationoforgansandtissues.PatientandFamilyRights(PFR)患者及其家属权益•PFR.7医院告知患者及其家属有关如何获得以人体为对象的临床研究、监床调查和临床试验的途经•PFR.8在患者参与临床研究、临床调查和临床试验前，获得患者知情同意•PFR.9医院有一个委员会或其他方式监督院内所有以人体为对象的研究•PFR.10医院告知患者及其家属有关如何选择捐献人体器官和其他人体组织•PFR.11医院监督获取和移植人体器官或组织AssessmentofPatients(AOP)患者评估•AOP.1Allpatientscaredforbytheorganizationhavetheirhealthcareneedsidentifiedthroughanestablishedassessmentprocess.•AOP.2Allpatientsarereassessedatintervalsbasedontheirconditionandtreatmenttodeterminetheirresponsetotreatmentandtoplanforcontinuedtreatmentordischarge.•AOP.3Qualifiedindividualsconducttheassessmentsandreassessments.•AOP.4Physicians,nurses,andotherindividualsandservicesresponsibleforpatientcarecollaboratetoanalyzeandtointegratepatientassessments.•AOP.5Laboratoryservicesareavailabletomeetpatientneeds,andallsuchservicesmeetapplicablelocalandnationalstandards,laws,andregulations.•AOP.6Radiologyanddiagnosticimagingservicesareavailabletomeetpatientneeds,andallsuchservicesmeetapplicablelocalandnationalstandards,laws,andregulations.AssessmentofPatients(AOP)患者评估•AOP.1通过已建立的评估程序，医院确定了所有患者的医疗需求•AOP.2根据情况和治疗需要，在一定间隔时间内对所有患者进行再评估，观察他们对治疗的反应，制定持续治疗或出院计划•AOP.3由有资质的人员指挥评估和再评估•AOP.4医师、护士和其他负责患者治疗的人员及科室共同分析和归纳患者评估•AOP.5所有实验室服务能有效地满足患者需要，并符合当地和国家标准、法律及法规•AOP.6所有放射和影像服务能有效地满足患者需要，并符合当地和国家标准、法律及法规CareofPatients(COP)患者的医疗护理•COP.1Policiesandproceduresandapplicablelawsandregulationsguidetheuniformcareofallpatients.•COP.2Thereisaprocesstointegrateandtocoordinatethecareprovidedtoeachpatient.•COP.3Policiesandproceduresguidethecareofhighriskpatientsandtheprovisionofhigh-riskservices.•COP.4Avarietyoffoodchoices,appropriateforthepatient’snutritio