Advanced Effective Communication, Cultural Competence, and ...

A Roadmap for Hospitals
Appendix B: Current Joint Commission Requirements
Joint Commission RI Requirements
RI.01.01.01 The hospital respects, protects, and
promotes patient rights.
EP 2
EP 5
EP 6
EP 9
The hospital informs the patient of his or her rights.
The hospital respects the patient’s right to and need for
effective communication.
The hospital respects the patient’s cultural and
personal values, beliefs, and preferences.
The hospital accommodates the patient’s right to
religious and other spiritual services.
RI.01.01.03 The hospital respects the patient’s right
to receive information in a manner he or she
understands.
EP 1
EP 2
EP 3
The hospital provides information in a manner tailored
to the patient’s age, language, and ability to
understand.
The hospital provides interpreting and translation
services, as necessary.
The hospital communicates with the patient who has
vision, speech, hearing, or cognitive impairments in a
manner that meets the patient’s needs.
RI.01.02.01 The hospital respects the patient’s right
to participate in decisions about his or her care,
treatment, and services.
EP 1
The hospital involves the patient in making decisions
about his or her care, treatment, and services.
RI.01.03.01 The hospital honors the patient’s right
to give or withhold informed consent.
Rationale for RI.01.03.01
Obtaining informed consent presents an opportunity to
establish a mutual understanding between the patient and the
licensed independent practitioner or other licensed practitioners
with privileges about the care, treatment, and services that the
patient will receive. Informed consent is not merely a signed
document. It is a process that considers patient needs and
preferences, compliance with law and regulation, and patient
education. Utilizing the informed consent process helps the
patient to participate fully in decisions about his or her care,
treatment, or services.
EP 13 Informed consent is obtained in accordance with the
hospital’s policy and processes and, except in
emergencies, prior to surgery.
RI.01.05.01 The hospital addresses patient
decisions about care, treatment, and services
received at the end of life.
EP 6
The hospital provides patients with written information
about advance directives, forgoing or withdrawing lifesustaining
treatment, and withholding resuscitative
services.
EP 8
EP 10
Upon admission, the hospital provides the patient with
information on the extent to which the hospital is able,
unable, or unwilling to honor advance directives.
Upon request, the hospital refers the patient to
resources for assistance in formulating advance
directives.
RI.01.06.03 The patient has the right to be free
from neglect; exploitation; and verbal, mental,
physical, and sexual abuse.
EP 1
The hospital determines how it will protect the patient
from neglect, exploitation, and abuse that could occur
while the patient is receiving care, treatment, and
services within the hospital.
RI.01.07.01 The patient and his or her family have
the right to have complaints reviewed by the hospital.
Rationale for RI.01.07.01
A business is often judged by how it handles dissatisfied
customers; the same is true for health care organizations.
Addressing complaints promptly helps to satisfy the needs of
patients and their families during a vulnerable time in their
lives, and may also prevent adverse events from occurring in
the organization. Complaints can range from the
straightforward, such as the temperature of the patient’s
room, to the complex, such as the patient’s care being
adversely impacted by practitioners’ failure to effectively
communicate. Regardless of the complexity of the complaint,
patients and their families expect the organization to work
toward a resolution as quickly as possible.
EP 1
EP 2
EP 4
EP 7
EP 10
The hospital establishes a complaint resolution
process.
Note: The governing body is responsible for the
effective operation of the complaint resolution
process unless it delegates this responsibility in
writing to a complaint resolution committee.
The hospital informs the patient and his or her family
about the complaint resolution process.
The hospital reviews and, when possible, resolves
complaints from the patient and his or her family.
The hospital provides the patient with the phone
number and address needed to file a complaint with
the relevant state authority.
The hospital allows the patient to voice complaints and
recommend changes freely without being subject to
coercion, discrimination, reprisal, or unreasonable
interruption of care.
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