Advanced Effective Communication, Cultural Competence, and ...

Appendix C
NEW JOINT COMMISSION
STANDARDS
FOR PATIENT-CENTERED COMMUNICATION
In January 2010, The Joint Commission released a set of new and
revised standards for patient-centered communication as part of
its project to advance effective communication, cultural competence,
and patient- and family-centered care. These standards,
designed to improve the safety and quality of care for all patients
and to inspire hospitals to adopt practices promoting better communication
and patient engagement, are highlighted here in Appendix
C in the shaded boxes. Any new or revised content in the
standards is underlined, and deleted content is identified by
strikethrough text. This appendix includes standards and elements
of performance (EPs) from the following chapters from
the Comprehensive Accreditation Manual for Hospitals:
• Human Resources (HR)
• Provision of Care, Treatment, and Services (PC)
• Record of Care, Treatment, and Services (RC)
• Rights and Responsibilities of the Individual (RI)
Joint Commission surveyors will evaluate compliance with the
patient-centered communication standards beginning January
1, 2011; however, findings will not affect the accreditation decision.
The information collected by Joint Commission surveyors
and staff during this implementation pilot phase will be
used to address common implementation questions and concerns.
Compliance with the patient-centered communication
standards will be included in the accreditation decision no earlier
than January 2012.
The following information accompanies each revised
standard:
• Explanation of Revision contains background information
and additional context for the standard.
• Self-Assessment Guidelines includes information that
hospitals should consider when determining how to meet
the intent of the standard or references to specific survey
activities that address the standard.
• Recommendations from the Roadmap refers readers to
the detailed information within guidelines referenced in
Chapters 1 to 6 of the Roadmap for Hospitals.
The recommendations from the Roadmap represent a variety of
ways a hospital can comply with these new standards; some may
not apply to all hospital types, sizes, or settings. As there is no
“one size fits all” solution, we encourage hospitals to use the
guidelines and recommendations as a foundation to create
processes, policies, and programs that best suit their organizations.
(Please refer to the Table of Contents to locate the chapters
that address each recommendation.)
Human Resources (HR)
The HR chapter addresses the hospital’s responsibility to establish
and verify staff qualifications, orient staff, and provide
staff with the training they need to support the care, treatment,
and services the hospital provides.
New Joint Commission HR Requirement
HR.01.02.01 The hospital defines staff qualifications.
EP 1
The hospital defines staff qualifications specific to
their job responsibilities.
Note 4: Qualifications for language interpreters and
translators may be met through language proficiency
assessment, education, training, and experience.
The use of qualified interpreters and translators is
supported by the Americans with Disabilities Act,
Section 504 of the Rehabilitation Act of 1973, and
Title VI of the Civil Rights Act of 1964. (Inclusion of
these qualifications will not affect the accreditation
decision at this time.)
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