Advanced Effective Communication, Cultural Competence, and ...
Advanced Effective Communication, Cultural Competence, and ...
Advanced Effective Communication, Cultural Competence, and ...
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A Roadmap for Hospitals<br />
Appendix B: Current Joint Commission Requirements<br />
Joint Commission HR Requirements<br />
HR.01.02.01 The hospital defines staff<br />
qualifications.<br />
EP 1 The hospital defines staff qualifications specific to<br />
their job responsibilities.<br />
HR.01.04.01 The hospital provides orientation<br />
to staff.<br />
EP 3 The hospital orients staff on the following: Relevant<br />
hospitalwide <strong>and</strong> unit-specific policies <strong>and</strong><br />
procedures. Completion of this orientation is<br />
documented.<br />
EP 4 The hospital orients staff on the following: Their<br />
specific job duties, including those related to infection<br />
prevention <strong>and</strong> control <strong>and</strong> assessing <strong>and</strong> managing<br />
pain. Completion of this orientation is documented.<br />
EP 5 The hospital orients staff on the following: Sensitivity<br />
to cultural diversity based on their job duties <strong>and</strong><br />
responsibilities. Completion of this orientation is<br />
documented.<br />
EP 6 The hospital orients staff on the following: Patient<br />
rights, including ethical aspects of care, treatment,<br />
<strong>and</strong> services <strong>and</strong> the process used to address ethical<br />
issues based on their job duties <strong>and</strong> responsibilities.<br />
Completion of this orientation is documented.<br />
HR.01.05.03 Staff participate in ongoing<br />
education <strong>and</strong> training.<br />
EP 1 Staff participate in ongoing education <strong>and</strong> training to<br />
maintain or increase their competency. Staff<br />
participation is documented.<br />
EP 4 Staff participate in ongoing education <strong>and</strong> training<br />
whenever staff responsibilities change. Staff<br />
participation is documented.<br />
EP 5 Staff participate in education <strong>and</strong> training that is<br />
specific to the needs of the patient population served<br />
by the hospital. Staff participation is documented.<br />
HR.01.06.01 Staff are competent to perform<br />
their responsibilities.<br />
EP 1 The hospital defines the competencies it requires of<br />
its staff who provide patient care, treatment, or<br />
services.<br />
improve underst<strong>and</strong>ing between these groups can be an effective<br />
way to promote both patient <strong>and</strong> staff satisfaction.<br />
Leadership (LD)<br />
LD st<strong>and</strong>ards address the foundational elements that support<br />
effective systems for providing quality care, treatment, <strong>and</strong><br />
services; the organization culture; systems <strong>and</strong> policy<br />
development; availability of resources; availability of competent<br />
staff; <strong>and</strong> ongoing evaluation of <strong>and</strong> improvement in<br />
performance. The organization support systems that allow for<br />
effective patient–provider communication, cultural competence,<br />
<strong>and</strong> patient- <strong>and</strong> family-centered care all hinge upon leadership<br />
(see box, page 52).<br />
The mission of many hospitals is to meet the needs of the patient<br />
population <strong>and</strong> their communities. Leaders must reconcile<br />
these needs with the organization’s resources <strong>and</strong> needs. For example,<br />
supports for effective communication do not only benefit<br />
the needs of the patient, but equally benefit the needs of the<br />
care providers <strong>and</strong> the hospital. The Hospitals, Language, <strong>and</strong><br />
Culture: A Snapshot of the Nation study found that several hospitals<br />
invested in language access services to improve communication<br />
because they recognized that the lack of available<br />
interpreters potentially contributed to patient flow problems,<br />
overuse of certain tests, <strong>and</strong> unnecessary readmissions [1].<br />
In addition, experts in the area of patient- <strong>and</strong> family-centered<br />
care recommend that leaders bring the patient <strong>and</strong> family<br />
perspective directly into the planning, delivery, <strong>and</strong> evaluation<br />
of health care. Studies increasingly show that when health care<br />
administrators, providers, <strong>and</strong> patients <strong>and</strong> families work in<br />
partnership, the quality <strong>and</strong> safety of health care rise, costs<br />
decrease, <strong>and</strong> provider <strong>and</strong> patient satisfaction increase.<br />
LD st<strong>and</strong>ards support the concepts outlined in the Roadmap for<br />
Hospitals in many areas, including the following:<br />
• <strong>Communication</strong> of the hospital’s mission, including<br />
supportive systems to effectively communicate<br />
throughout the hospital <strong>and</strong> to the community<br />
• The use of data to plan for <strong>and</strong> monitor care, treatment,<br />
<strong>and</strong> services<br />
• Creation of a culture that supports patient <strong>and</strong> staff safety<br />
• Compliance with applicable laws <strong>and</strong> regulations,<br />
including those that protect patients’ rights, equal<br />
opportunity for workforce, <strong>and</strong> environmental<br />
regulations such as building <strong>and</strong> safety codes. (See<br />
Appendix D: Laws <strong>and</strong> Regulations, page 65, for more<br />
information on some of the laws <strong>and</strong> regulations<br />
relevant to effective communication, cultural<br />
competence, <strong>and</strong> patient- <strong>and</strong> family-centered care.)<br />
Many hospitals include in their mission <strong>and</strong>/or vision<br />
statements the commitment to serve their community. Often, it<br />
is this commitment that drives hospital leaders to embrace<br />
practices that support health equity.<br />
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