Advanced Effective Communication, Cultural Competence, and ...

A Roadmap for Hospitals
Appendix B: Current Joint Commission Requirements
Joint Commission HR Requirements
HR.01.02.01 The hospital defines staff
qualifications.
EP 1 The hospital defines staff qualifications specific to
their job responsibilities.
HR.01.04.01 The hospital provides orientation
to staff.
EP 3 The hospital orients staff on the following: Relevant
hospitalwide and unit-specific policies and
procedures. Completion of this orientation is
documented.
EP 4 The hospital orients staff on the following: Their
specific job duties, including those related to infection
prevention and control and assessing and managing
pain. Completion of this orientation is documented.
EP 5 The hospital orients staff on the following: Sensitivity
to cultural diversity based on their job duties and
responsibilities. Completion of this orientation is
documented.
EP 6 The hospital orients staff on the following: Patient
rights, including ethical aspects of care, treatment,
and services and the process used to address ethical
issues based on their job duties and responsibilities.
Completion of this orientation is documented.
HR.01.05.03 Staff participate in ongoing
education and training.
EP 1 Staff participate in ongoing education and training to
maintain or increase their competency. Staff
participation is documented.
EP 4 Staff participate in ongoing education and training
whenever staff responsibilities change. Staff
participation is documented.
EP 5 Staff participate in education and training that is
specific to the needs of the patient population served
by the hospital. Staff participation is documented.
HR.01.06.01 Staff are competent to perform
their responsibilities.
EP 1 The hospital defines the competencies it requires of
its staff who provide patient care, treatment, or
services.
improve understanding between these groups can be an effective
way to promote both patient and staff satisfaction.
Leadership (LD)
LD standards address the foundational elements that support
effective systems for providing quality care, treatment, and
services; the organization culture; systems and policy
development; availability of resources; availability of competent
staff; and ongoing evaluation of and improvement in
performance. The organization support systems that allow for
effective patient–provider communication, cultural competence,
and patient- and family-centered care all hinge upon leadership
(see box, page 52).
The mission of many hospitals is to meet the needs of the patient
population and their communities. Leaders must reconcile
these needs with the organization’s resources and needs. For example,
supports for effective communication do not only benefit
the needs of the patient, but equally benefit the needs of the
care providers and the hospital. The Hospitals, Language, and
Culture: A Snapshot of the Nation study found that several hospitals
invested in language access services to improve communication
because they recognized that the lack of available
interpreters potentially contributed to patient flow problems,
overuse of certain tests, and unnecessary readmissions [1].
In addition, experts in the area of patient- and family-centered
care recommend that leaders bring the patient and family
perspective directly into the planning, delivery, and evaluation
of health care. Studies increasingly show that when health care
administrators, providers, and patients and families work in
partnership, the quality and safety of health care rise, costs
decrease, and provider and patient satisfaction increase.
LD standards support the concepts outlined in the Roadmap for
Hospitals in many areas, including the following:
• Communication of the hospital’s mission, including
supportive systems to effectively communicate
throughout the hospital and to the community
• The use of data to plan for and monitor care, treatment,
and services
• Creation of a culture that supports patient and staff safety
• Compliance with applicable laws and regulations,
including those that protect patients’ rights, equal
opportunity for workforce, and environmental
regulations such as building and safety codes. (See
Appendix D: Laws and Regulations, page 65, for more
information on some of the laws and regulations
relevant to effective communication, cultural
competence, and patient- and family-centered care.)
Many hospitals include in their mission and/or vision
statements the commitment to serve their community. Often, it
is this commitment that drives hospital leaders to embrace
practices that support health equity.
51