Advanced Effective Communication, Cultural Competence, and ...

A Roadmap for Hospitals
Appendix C: New Joint Commission Requirements
when a call button is pushed by a patient who is deaf? Are
interpreter services arranged for patients who are deaf and
communicate through sign language? Are communication
boards available in areas where patients are likely to be intubated
or otherwise unable to speak such as the intensive
care unit or surgical recovery?
• Review the medical record to verify that staff identified
oral and written communication needs.
• If a communication need is identified, follow up with an
interview with the patient to ensure communication needs
were addressed.
• Review complaint data from patients and staff.
• Conduct administrative rounds focused on patient communication.
• Note if available communication resources are available
for clinical rounds at key points of care such as in exam
rooms, at nursing stations, and in patient care rooms.
• Provide staff training module on how to address patient
communication needs such as how to access and work
with an interpreter, how to use a communication board,
and effective communication techniques to support patient
understanding (such as teach back).
Recommendations from the Roadmap
❑ Identify the patient’s preferred language for discussing
health care.
❑ Identify whether the patient has a sensory or
communication need.
❑ Address patient communication needs.
❑ Support the patient’s ability to understand and act on
health information.
❑ Monitor changes in the patient’s communication status.
❑ Integrate unique patient needs into new or existing
hospital policies.
Record of Care, Treatment, and
Services (RC)
The RC chapter contains information about the components
of a complete medical record. Whether the hospital keeps
paper records, electronic records, or a combination of both,
the contents of the record remain the same.
New Joint Commission RC Requirements
RC.02.01.01 The medical record contains
information that reflects the patient's care,
treatment, and services.
EP 1
EP 28
The medical record contains the following
demographic information:
• The patient’s name, address, date of birth, and
the name of any legally authorized
representative
• The patient’s sex
• The legal status of any patient receiving
behavioral health care services
• The patient’s language and communication
needs, including preferred language for
discussing health care (See also PC.02.01.21,
EP 1)
Note: If the patient is a minor, is incapacitated, or
has a designated advocate, the communication
needs of the parent or legal guardian, surrogate
decision-maker, or legally authorized representative
are documented in the medical record.
The medical record contains the patient’s race and
ethnicity.
Note: This element of performance will not affect
the accreditation decision at this time.
RC.02.01.01:
Explanation of Revision
The collection of patient-level demographic data on language,
race, and ethnicity is a crucial component of the process to
identify health care needs and eliminate disparities. The revision
to RC.02.01.01, EP 1, expands on the current requirement
to collect data on the patient’s communication needs,
and new EP 28 includes the collection of race and ethnicity
data in the medical record. These requirements will ensure
that language, race, and ethnicity information is available for
each patient so the hospital has an opportunity to better plan
for needed services. Collecting these data also facilitates monitoring
service provision and analyzing disparities in care.
Joint Commission standards do not specify how to categorize
data when collecting race and ethnicity data. However,
many state reporting entities and payors do specify these
requirements. It is important for each hospital to determine
how it wishes to collect the data and what its reporting
requirements are.
Self-Assessment Guidelines
• Review the hospital policy for collecting patient demographic
data. The policy may specify who, how, when,
what, and where information is recorded.
• Interview staff regarding knowledge of the process for
collecting patient-level data on race, ethnicity, and
communication needs.
60