Advanced Effective Communication, Cultural Competence, and ...

A Roadmap for Hospitals
Appendix B: Current Joint Commission Requirements
Emergency Management (EM)
The Joint Commission’s EM standards provide guidance to
hospitals about how to plan for and respond to potential
emergencies. While these standards do not explicitly address
effective communication, cultural competence, and patientand
family-centered care, it is necessary to consider the
diverse needs of the patient and community population so
that emergency response efforts provide for the safety of all
who require hospital services (see box, right). For example,
decontamination instructions provided to patients by staff
should not only be verbal, but should also be in the form of
posters or other visual aides for patients who are deaf or have
limited English proficiency.
The hospital may also want to consider ethnic media as
sources for communicating information to minority
populations. The “vulnerable populations” referenced
in Standard EM. 02.02.11, EP 4, may also include
individuals with limited English proficiency or other
communication needs.
Human Resources (HR)
Many recommendations to promote effective communication,
cultural competence, and patient- and family-centered
care include recommendations to build a diverse workforce
through recruitment, retention, and promotion of diverse
staff. The Joint Commission standards do not set this specific
expectation. Instead, Joint Commission standards expect that
hospital staffing is consistent with the organization’s mission.
In addition, The Joint Commission expects the organization’s
leadership to define the qualifications and competencies of
staff (see Leadership on page 51).
From this perspective, HR standards focus mainly on the
specific skill sets and competencies that staff need to perform
their job. Joint Commission standards address orientation on
cultural diversity and sensitivity, and expect ongoing in-services
and other education and training to be appropriate to the needs
of the population(s) served and responsive to learning needs
identified through performance improvement findings and
other data analysis (see box, page 51). Staff must be aware of
relevant policies and procedures, which could include the
hospital’s policies for meeting patient communication needs.
Communication is recognized as a patient right, but is also
clearly part of the provision of safe care. It is vital to make staff
aware of how to identify and address patient communication
needs within the scope of their job duties.
Joint Commission EM Requirements
EM.02.02.01 As part of its Emergency Operations
Plan, the hospital prepares for how it will
communicate during emergencies.
Rationale for EM.02.02.01
The hospital maintains reliable communications capabilities
for the purpose of communication response efforts to staff,
patients, and external organizations. The hospital
establishes backup communications processes and
technologies (for example, cell phones, land lines, bulletin
boards, fax machines, satellite phones, Amateur Radio, text
messages) to communicate essential information if primary
communication systems fail.
EP 5 The Emergency Operations Plan describes the
following: How the hospital will communicate with
patients and their families, including how it will notify
families when patients are relocated to alternative
care sites.
EP 6 The Emergency Operations Plan describes the
following: How the hospital will communicate with the
community or the media during an emergency.
EM.02.02.11 As part of its Emergency Operations
plan, the hospital prepares for how it will manage
patients during emergencies.
Rationale for EM.02.02.11
The fundamental goal of emergency management
planning is to protect life and prevent disability. The
manner in which care, treatment, and services are
provided may vary by type of emergency. However, certain
activities are so fundamental to patient safety (this can
include decisions to modify or discontinue services, make
referrals, or transport patients) that the organization
should take a proactive approach in considering how they
might be accomplished.
The emergency triage process will typically result in
patients being quickly treated and discharged, admitted for
a longer stay, or transferred to a more appropriate source
of care.
EP 4 The Emergency Operations Plan describes the
following: How the hospital will manage a potential
increase in demand for clinical services for vulnerable
populations served by the hospital, such as patients
who are pediatric, geriatric, disabled, or have serious
chronic conditions or addictions.
It may also be appropriate to provide staff training on the
cultural health beliefs and practices of the patient population
if they differ from those of staff. In addition to having a
diverse patient population, many hospitals also operate with a
diverse staff and medical staff. Training and coaching to
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