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 C: New Joint Commission Requirements<br />
when a call button is pushed by a patient who is deaf? Are<br />
interpreter services arranged for patients who are deaf <strong>and</strong><br />
communicate through sign language? Are communication<br />
boards available in areas where patients are likely to be intubated<br />
or otherwise unable to speak such as the intensive<br />
care unit or surgical recovery?<br />
• Review the medical record to verify that staff identified<br />
oral <strong>and</strong> written communication needs.<br />
• If a communication need is identified, follow up with an<br />
interview with the patient to ensure communication needs<br />
were addressed.<br />
• Review complaint data from patients <strong>and</strong> staff.<br />
• Conduct administrative rounds focused on patient communication.<br />
• Note if available communication resources are available<br />
for clinical rounds at key points of care such as in exam<br />
rooms, at nursing stations, <strong>and</strong> in patient care rooms.<br />
• Provide staff training module on how to address patient<br />
communication needs such as how to access <strong>and</strong> work<br />
with an interpreter, how to use a communication board,<br />
<strong>and</strong> effective communication techniques to support patient<br />
underst<strong>and</strong>ing (such as teach back).<br />
Recommendations from the Roadmap<br />
❑ Identify the patient’s preferred language for discussing<br />
health care.<br />
❑ Identify whether the patient has a sensory or<br />
communication need.<br />
❑ Address patient communication needs.<br />
❑ Support the patient’s ability to underst<strong>and</strong> <strong>and</strong> act on<br />
health information.<br />
❑ Monitor changes in the patient’s communication status.<br />
❑ Integrate unique patient needs into new or existing<br />
hospital policies.<br />
Record of Care, Treatment, <strong>and</strong><br />
Services (RC)<br />
The RC chapter contains information about the components<br />
of a complete medical record. Whether the hospital keeps<br />
paper records, electronic records, or a combination of both,<br />
the contents of the record remain the same.<br />
New Joint Commission RC Requirements<br />
RC.02.01.01 The medical record contains<br />
information that reflects the patient's care,<br />
treatment, <strong>and</strong> services.<br />
EP 1<br />
EP 28<br />
The medical record contains the following<br />
demographic information:<br />
• The patient’s name, address, date of birth, <strong>and</strong><br />
the name of any legally authorized<br />
representative<br />
• The patient’s sex<br />
• The legal status of any patient receiving<br />
behavioral health care services<br />
• The patient’s language <strong>and</strong> communication<br />
needs, including preferred language for<br />
discussing health care (See also PC.02.01.21,<br />
EP 1)<br />
Note: If the patient is a minor, is incapacitated, or<br />
has a designated advocate, the communication<br />
needs of the parent or legal guardian, surrogate<br />
decision-maker, or legally authorized representative<br />
are documented in the medical record.<br />
The medical record contains the patient’s race <strong>and</strong><br />
ethnicity.<br />
Note: This element of performance will not affect<br />
the accreditation decision at this time.<br />
RC.02.01.01:<br />
Explanation of Revision<br />
The collection of patient-level demographic data on language,<br />
race, <strong>and</strong> ethnicity is a crucial component of the process to<br />
identify health care needs <strong>and</strong> eliminate disparities. The revision<br />
to RC.02.01.01, EP 1, exp<strong>and</strong>s on the current requirement<br />
to collect data on the patient’s communication needs,<br />
<strong>and</strong> new EP 28 includes the collection of race <strong>and</strong> ethnicity<br />
data in the medical record. These requirements will ensure<br />
that language, race, <strong>and</strong> ethnicity information is available for<br />
each patient so the hospital has an opportunity to better plan<br />
for needed services. Collecting these data also facilitates monitoring<br />
service provision <strong>and</strong> analyzing disparities in care.<br />
Joint Commission st<strong>and</strong>ards do not specify how to categorize<br />
data when collecting race <strong>and</strong> ethnicity data. However,<br />
many state reporting entities <strong>and</strong> payors do specify these<br />
requirements. It is important for each hospital to determine<br />
how it wishes to collect the data <strong>and</strong> what its reporting<br />
requirements are.<br />
Self-Assessment Guidelines<br />
• Review the hospital policy for collecting patient demographic<br />
data. The policy may specify who, how, when,<br />
what, <strong>and</strong> where information is recorded.<br />
• Interview staff regarding knowledge of the process for<br />
collecting patient-level data on race, ethnicity, <strong>and</strong><br />
communication needs.<br />
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