Magnet Recognition Program Crosswalk - Patient Care Services

Magnet Recognition Program Crosswalk 

Magnet Recognition Program Standards to 2010 Joint Commission Hospital Standards & EPs 

MRP Number 

MRP Standards 

I. Transformational Leadership (TL) 

Strategic Planning. Describe and Demonstrate 

TL1 

How nursing's mission, vision, values, and strategic and quality plans reflect: 

the organization's current and anticipated strategic priorities. 

Joint Commission 

Equivalent Number 

LD.01.03.01 

EP 6 

Joint Commission Standards 

The governing body is ultimately accountable for the safety and quality of 

care, treatment, and services. 

The governing body works with the senior managers and leaders of the organized medical staff to 

annually evaluate the hospital’s performance in relation to its mission, vision, and goals. 

LD.01.04.01 

A chief executive manages the hospital. 

EP 5 

The chief executive identifies a nurse leader at the executive level who participates in decision-making. 

(See also NR.01.01.01, EPs 3 and 4 for specific nurse leader responsibilities) 

LD.02.01.01 

The mission, vision, and goals of the hospital support the safety and quality of 


EP 1 

The governing body, senior managers, and leaders of the organized medical staff work together to 

create the hospital’s mission, vision, and goals. (See also NR.01.01.01, EP 2) 

EP 2 

The hospital's mission, vision, and goals guide the actions of leaders. 

NR.01.01.01 

The nurse executive directs the delivery of nursing care, treatment, and 

services. 

EP 1 

EP 3 

The nurse executive functions at the senior leadership level to provide effective leadership and to 

coordinate leaders to deliver nursing care, treatment, and services. (See also LD.04.01.05, EP 5) 

An identified nurse leader, at the executive level, assumes an active leadership role with the hospital’s 

governing body, senior leadership, medical staff, management, and other clinical leaders in the 

hospital’s decision-making structure and process. (See also LD.01.01.01, EP 3; LD.01.02.01, EP 1; 

LD.01.03.01, EP 5; LD.01.04.01, EP 5; LD.02.03.01, EP 1; LD.04.01.03, EP 1) 

PI.01.01.01 

The hospital collects data to monitor its performance. 

EP 1 

The leaders set priorities for data collection. (See also LD.04.04.01, EP 1) 

TL2 

How nurses at every level-CNO, nurse administrators, and 

direct-care nurses-advocate for resources, including fiscal and technology 

resources, to support unit/division goals. 

LD.03.01.01 

EP 8 

Leaders create and maintain a culture of safety and quality throughout the 

hospital. 

All individuals who work in the hospital, including staff and licensed independent practitioners, are able 

to openly discuss issues of safety and quality. (See also LD.04.04.05, EP 6) 


Magnet Recognition Program Standards to 

2010 Joint Commission Hospital Standards & EPs 

Page 1 of 60 

Report Generated by DivSSM 

Thursday, August 12, 2010 

© 2010 The Joint Commission on 

Accreditation of Healthcare Organizations

MRP Number 

TL2 

MRP Standards 



LD.03.03.01 


Leaders use hospital-wide planning to establish structures and processes that 

focus on safety and quality. 

EP 3 

Planning is systematic, and it involves designated individuals and information sources. 

EP 4 

Leaders provide the resources needed to support the safety and quality of care, treatment, and 

services. 

LD.03.04.01 

The hospital communicates information related to safety and quality to those 

who need it, including staff, licensed independent practitioners, patients, 

families, and external interested parties. 

EP 5 

Communication supports safety and quality throughout the hospital. (See also LD.04.04.05, EPs 6 and 

12) 

LD.04.01.03 

The leaders develop an annual operating budget and, when needed, a longterm 

capital expenditure plan. 

EP 1 

Leaders solicit comments from those who work in the hospital when developing the operational and 

capital budgets. (See also NR.01.01.01, EP 3) 

LD.04.01.11 

The hospital makes space and equipment available as needed for the 

provision of care, treatment, and services. 

EP 2 

The arrangement and allocation of space supports safe, efficient, and effective care, treatment, and 

services. 

EP 3 

EP 4 

EP 5 

The interior and exterior space provided for care, treatment, and services meets the needs of patients. 

The grounds, equipment, and special activity areas are safe, maintained, and supervised. 

The leaders provide for equipment, supplies, and other resources. 

NR.01.01.01 


services. 

EP 3 





TL3 

The strategic planning structure(s) and process(es) used by nursing to improve 

the healthcare system's: 

• Effectiveness and 

• Efficiency. 

LD.03.02.01 

EP 1 

EP 3 

The hospital uses data and information to guide decisions and to understand 

variation in the performance of processes supporting safety and quality. 

Leaders set expectations for using data and information to improve the safety and quality of care, 

treatment, and services. 

The hospital uses processes to support systematic data and information use. 

EP 5 

The hospital uses data and information in decision making that supports the safety and quality of care, 

treatment, and services. (See also NR.02.01.01, EPs 3 and 6; PI.02.01.01, EP 8) 




Page 2 of 60 





MRP Number 

TL3 

MRP Standards 



LD.03.03.01 




EP 1 

EP 3 

Planning activities focus on improving patient safety and health care quality. 


EP 4 


services. 

EP 6 

Planning activities adapt to changes in the environment. 

LD.03.05.01 

Leaders implement changes in existing processes to improve the performance 

of the hospital. 

EP 1 

Structures for managing change and performance improvements exist that foster the safety of the 

patient and the quality of care, treatment, and services. 

NR.02.01.01 

The nurse executive directs the hospital’s nursing services. 

EP 1 

EP 2 

EP 3 

The nurse executive coordinates: The development of hospital-wide plans to provide nursing care, 


The nurse executive coordinates: The development of hospital-wide programs, policies, and 

procedures that address how nursing care needs of the patient population are assessed, met, and 

evaluated. 

Note: Examples of patient populations include pediatric, diabetic, and geriatric patients. 

The nurse executive coordinates: The development of an effective, ongoing program to measure, 

analyze, and improve the quality of nursing care, treatment, and services. (See also LD.03.02.01, EP 5) 

NR.02.02.01 

The nurse executive establishes guidelines for the delivery of nursing care, 


EP 1 

EP 2 

EP 3 

EP 4 

EP 5 

The nurse executive, registered nurses, and other designated nursing staff write: Standards of nursing 

practice for the hospital. 

The nurse executive, registered nurses, and other designated nursing staff write: Nursing standards of 

patient care, treatment, and services. 

The nurse executive, registered nurses, and other designated nursing staff write: Nursing policies and 

procedures. 

The nurse executive, registered nurses, and other designated nursing staff write: Nurse staffing 

plan(s). (See also LD.04.03.11, EP 6) 

The nurse executive, registered nurses, and other designated nursing staff write: Standards to 

measure, assess, and improve patient outcomes. 

TL3EO 

The outcome(s) that resulted from the planning described in TL3. 

Comment: Although this subject is addressed as part of the survey process, The Joint Commission does not 

survey to this level of specificity by discipline or department. 




Page 3 of 60 





MRP Number 

TL4 

MRP Standards 


Advocacy and Influence. Describe and Demonstrate 

TL4 

The process(es) that enable the CNO to influence organization-wide changes. 



LD.01.04.01 

EP 5 





LD.02.03.01 

The governing body, senior managers and leaders of the organized medical 

staff regularly communicate with each other on issues of safety and quality. 

EP 1 

Leaders discuss issues that affect the hospital and the population(s) it serves, including the following: 

- Performance improvement activities 

- Reported safety and quality issues 

- Proposed solutions and their impact on the hospital’s resources 

- Reports on key quality measures and safety indicators 

- Safety and quality issues specific to the population served 

- Input from the population(s) served 

(See also NR.01.01.01, EP 3) 

LD.03.05.01 



EP 1 



EP 3 

The hospital has a systematic approach to change and performance improvement. 

LD.04.01.05 

The hospital effectively manages its programs, services, sites, or departments. 

EP 1 

Leaders of the program, service, site, or department oversee operations. 

LD.04.01.07 

The hospital has policies and procedures that guide and support patient care, 


EP 1 

Leaders review and approve policies and procedures that guide and support patient care, treatment, 

and services. (See also NR.02.03.01, EP 1; RI.01.07.01, EP 1) 

LD.04.04.01 

Leaders establish priorities for performance improvement. (Refer to the 

"Performance Improvement" (PI) chapter.) 

EP 3 

Leaders reprioritize performance improvement activities in response to changes in the internal or 

external environment. 

NR.01.01.01 


services. 

EP 1 

EP 2 



The nurse executive has the authority to speak on behalf of nursing to the same extent that other 

hospital leaders speak for their respective disciplines, departments, or service lines. (See also 

LD.01.02.01, EP 1 and LD.02.01.01, EP 1) 




Page 4 of 60 





MRP Number 

TL4 

MRP Standards 



EP 3 

EP 4 






The nurse executive participates in defined and established meetings of the hospital’s corporate 

leaders (when such leaders exist) and with other senior clinical and managerial leaders. (See also 

LD.01.04.01, EP 5) 

NR.02.01.01 


EP 1 

EP 2 

EP 3 

EP 4 

EP 5 

EP 6 





evaluated. 




The nurse executive directs: The implementation of hospital-wide plans to provide nursing care, 


The nurse executive directs: The implementation of hospital-wide programs, policies, and procedures 

that address how nursing care needs of the patient population are assessed, met, and evaluated. (See 

also LD.04.04.07, EP 1) 


The nurse executive directs: The implementation of an effective, ongoing program to measure, 


TL4EO 

One CNO-influenced organization-wide change. 



TL5 

How nurse leaders guide the transition during periods of planned or unplanned 

change. 

LD.03.03.01 

EP 1 

EP 6 





LD.03.04.01 




EP 6 

When changes in the environment occur, the hospital communicates those changes effectively. 




Page 5 of 60 





MRP Number 

TL5 

MRP Standards 



LD.03.05.01 

EP 1 






EP 3 


EP 4 

Leaders provide the resources required for performance improvement and change management, 

including sufficient staff, access to information, and training. 

NR.02.01.01 


EP 4 

EP 5 

EP 6 





also LD.04.04.07, EP 1) 




PI.03.01.01 

The hospital improves performance on an ongoing basis. 

EP 1 

Leaders prioritize the identified improvement opportunities. (See also PI.02.01.01, EP 8; MS.05.01.01, 

EPs 1-11) 

EP 2 

The hospital takes action on improvement priorities. (See also MS.05.01.01, EPs 1-11) 

EP 4 

The hospital takes action when it does not achieve or sustain planned improvements. (See also 

MS.05.01.01, EPs 1-11) 

TL6 

HR.01.07.01 

The hospital evaluates staff performance. 

How the organization supports: 

• Leadership development 

• Performance management 

• Mentoring activities 

• Succession planning for nurse leaders 

EP 1 

LD.01.07.01 

EP 1 

The hospital evaluates staff based on performance expectations that reflect their job responsibilities. 

The governing body, senior managers, and leaders of the organized medical 

staff have the knowledge needed for their roles in the hospital or they seek 

guidance to fulfill their roles. 

The governing body, senior managers, and leaders of the organized medical staff work together to 

identify the skills required of individual leaders. 




Page 6 of 60 





MRP Number 

TL6 

MRP Standards 



EP 2 

EP 3 


Individual members of the governing body, senior managers, and leaders of the organized medical 

staff are oriented to all of the following: 

- The hospital’s mission and vision 

- The hospital’s safety and quality goals 

- The hospital’s structure and the decision-making process 

- The development of the budget as well as the interpretation of the hospital’s financial statements 

- The population(s) served by the hospital and any issues related to that population(s) 

- The individual and interdependent responsibilities and accountabilities of the governing body, senior 

managers, and leaders of organized medical staff as they relate to supporting the mission of the 

hospital and to providing safe and quality care 

- Applicable law and regulation 

The governing body provides leaders with access to information and training in areas where they need 

additional skills or expertise. 

LD.02.03.01 

The governing body, senior managers and leaders of the organized medical 

staff regularly communicate with each other on issues of safety and quality. 

EP 1 

Leaders discuss issues that affect the hospital and the population(s) it serves, including the following: 

- Performance improvement activities 

- Reported safety and quality issues 

- Proposed solutions and their impact on the hospital’s resources 

- Reports on key quality measures and safety indicators 

- Safety and quality issues specific to the population served 

- Input from the population(s) served 

(See also NR.01.01.01, EP 3) 

LD.03.05.01 



EP 4 



LD.03.06.01 

Those who work in the hospital are focused on improving safety and quality. 

EP 6 

Leaders evaluate the effectiveness of those who work in the hospital to promote safety and quality. 

LD.04.01.05 


EP 4 

Staff are held accountable for their responsibilities. 

NR.01.02.01 

The nurse executive is a licensed professional registered nurse qualified by 

advanced education and management experience. 

EP 3 

The nurse executive possesses a postgraduate degree in nursing or a related field; or the knowledge 

and skills associated with an advanced degree; or a written plan to obtain these qualifications. 

Note: A related field may include health care administration or business administration. 

TL7 

LD.04.04.03 

New or modified services or processes are well designed. 

How nurse leaders value, encourage, recognize/reward, and implement 

innovation. 

EP 7 

Leaders involve staff and patients in the design of new or modified services or processes. 




Page 7 of 60 





MRP Number 

TL7 

MRP Standards 



NR.02.02.01 

EP 5 






PI.01.01.01 


EP 30 

The hospital considers collecting data on the following: 

- Staff opinions and needs 

- Staff perceptions of risk to individuals 

- Staff suggestions for improving patient safety 

- Staff willingness to report adverse events 

PI.03.01.01 


EP 2 





Page 8 of 60 





MRP Number 

TL8 

MRP Standards 




Visibility, Accessibility, and Communication. Describe and Demonstrate 

TL8 

The various methods by which the CNO is visible and accesses direct-care 

nurses. 

LD.02.01.01 

EP 3 

LD.03.04.01 


The mission, vision, and goals of the hospital support the safety and quality of 


Leaders communicate the mission, vision, and goals to staff and the population(s) the hospital serves. 




EP 1 

Communication processes foster the safety of the patient and the quality of care. 

EP 5 


12) 

LD.04.01.05 


EP 1 


NR.01.01.01 


services. 

EP 1 



NR.02.01.01 


EP 4 

EP 5 





also LD.04.04.07, EP 1) 


NR.02.03.01 

The nurse executive directs the implementation of nursing policies and 

procedures, nursing standards, and a nurse staffing plan(s). 

EP 1 

EP 2 

EP 3 

The nurse executive or designee approves nursing policies; nursing standards of patient care, 

treatment, and services; and standards of nursing practice for the hospital before implementation. (See 

also LD.04.01.07, EP 1) 

The nurse executive implements nursing policies, procedures, and standards that describe and guide 

how the staff provide nursing care, treatment, and services. (See also LD.04.01.07, EP 2) 

The nurse executive provides access to all nursing policies, procedures, and standards to the nursing 

staff. 




Page 9 of 60 





MRP Number 

TL9 

MRP Standards 

TL9 

The various methods by which direct-care nurses access nurse leaders. 



LD.03.01.01 

EP 7 



hospital. 

Leaders establish a team approach among all staff at all levels. 

EP 8 



LD.03.04.01 




EP 1 

EP 3 


Communication is designed to meet the needs of internal and external users. 

EP 4 

EP 5 

Leaders provide the resources required for communication, based on the needs of patients, the 

community, physicians, staff, and management. 


12) 

LD.04.01.05 


EP 1 


LD.04.04.05 

The hospital has an organization-wide, integrated patient safety program 

within its performance improvement activities. 

EP 6 

The leaders provide and encourage the use of systems for blame-free internal reporting of a system or 

process failure, or the results of a proactive risk assessment. (See also LD.03.01.01, EP 8; 

LD.03.04.01, EP 5; LD.04.04.03, EP 3; PI.01.01.01, EP 8) 

PI.01.01.01 


EP 30 






TL10 

How nurse leaders use input from direct-care nurses to improve the work 

environment and patient care. 

LD.03.01.01 

EP 2 

LD.04.01.03 


hospital. 

Leaders prioritize and implement changes identified by the evaluation. 



EP 1 






Page 10 of 60 





MRP Number 

TL10 

MRP Standards 



LD.04.04.01 

EP 1 




Leaders set priorities for performance improvement activities and patient health outcomes. (See also 

PI.01.01.01, EPs 1 and 3) 

LD.04.04.03 


EP 1 

The hospital's design of new or modified services or processes incorporates the needs of patients, 

staff, and others. 

NR.02.02.01 



EP 5 



PI.01.01.01 


EP 1 


PI.03.01.01 


EP 1 

Leaders prioritize the identified improvement opportunities. (See also PI.02.01.01, EP 8; MS.05.01.01, 

EPs 1-11) 

EP 2 


TL10EO 

Changes in the work environment and patient care based on input from the 

direct-care nurses. 






Page 11 of 60 





MRP Number 

SE1 

MRP Standards 

II. Structural Empowerment (SE) 

Professional Engagement. Describe and Demonstrate 

SE1 

The structure(s) and process(es) that enable nurses from all settings and roles 

to actively participate in organizational decision-making groups such as 

committees, councils, and task forces. 



LD.03.01.01 

EP 3 

EP 7 



hospital. 

Leaders provide opportunities for all individuals who work in the hospital to participate in safety and 

quality initiatives. 


EP 8 



LD.03.03.01 



EP 3 

EP 5 


Safety and quality planning is hospital-wide. 

LD.04.01.05 


EP 5 

Leaders provide for the coordination of care, treatment, and services among the hospital's different 

programs, services, sites, or departments. (See also NR.01.01.01, EP 1) 

LD.04.04.03 


EP 7 


LD.04.04.05 



EP 4 

All departments, programs, and services within the hospital participate in the safety program. 

NR.01.01.01 


services. 

EP 1 



NR.02.01.01 


EP 1 

EP 2 

EP 3 





evaluated. 







Page 12 of 60 





MRP Number 

SE1 

MRP Standards 



NR.02.02.01 

EP 1 

EP 2 

EP 3 

EP 4 

EP 5 









procedures. 





SE1E0 

Two improvements in different practice settings because of nurse involvement 

in organizational decision-making groups such as committees, councils, and 

task forces. 



SE2 

HR.01.05.03 

Staff participate in ongoing education and training. 

The structure(s) and process(es) that enable nurses at all levels to participate 

in professional organizations at the local, state, and national levels. Include 

international participation, if any. 

EP 1 

LD.01.04.01 

Staff participate in ongoing education and training to maintain or increase their competency. Staff 

participation is documented. 


EP 2 

The chief executive provides for the following: Recruitment and retention of staff. 

LD.03.05.01 



EP 4 



SE2EO 

Two improvements in different practice settings that occurred because of nurse 

involvement in a professional organization(s). 






Page 13 of 60 





MRP Number 

SE3 

MRP Standards 




Commitment to Professional Development. Describe and Demonstrate 

SE3 

HR.01.02.01 

The hospital defines staff qualifications. 


How the organization sets expectations and supports nurses at all levels who 

seek additional formal nursing education (e.g., baccalaureate, master's, 

doctoral degrees). 

EP 1 

The hospital defines staff qualifications specific to their job responsibilities. (See also IC.01.01.01, EP 3 

and RI.01.01.03, EP 2) 

Note 1: Qualifications for infection control may be met through ongoing education, training, experience, 

and/or certification (such as that offered by the Certification Board for Infection Control). 

Note 2: Qualifications for laboratory personnel are described in the Clinical Laboratory Improvement 

Amendments of 1988 (CLIA '88), under Subpart M: “Personnel for Nonwaived Testing” §493.1351- 

§493.1495. A complete description of the requirement is located at 

http://wwwn.cdc.gov/clia/regs/toc.aspx. 

Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified 

physical therapists, physical therapist assistants, occupational therapists, occupational therapy 

assistants, speech-language pathologists, or audiologists (as defined in 42 CFR 484.4) provide 

physical therapy, occupational therapy, speech-language pathology, or audiology services, if these 

services are provided by the hospital. 

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.) 

HR.01.05.03 


EP 1 



LD.01.04.01 


EP 2 


LD.03.03.01 



EP 4 


services. 

SE3EO 

That the organization has met goals for improvement in formal education. 

Graphically summarize at least 2 years of data to display changes over time. 



SE4 

LD.01.04.01 


How the organization sets goals and supports professional development and 

professional certification, such as tuition/ registration reimbursement and 

participation in external local, regional, national, and international conferences 

or meetings. 

EP 2 





Page 14 of 60 





MRP Number 

SE4 

MRP Standards 



LD.03.03.01 

EP 4 





services. 

LD.04.01.03 



EP 3 

The operating budget reflects the hospital’s goals and objectives. 

NR.01.01.01 


services. 

EP 2 



LD.01.02.01, EP 1 and LD.02.01.01, EP 1) 

SE4EO 

That the organization has met goals for improvement in professional 

certification. Graphically summarize at least 2 years of data to display changes 

over time. Include participation of nurses in all specialties. 



SE5 

HR.01.05.03 


The structure(s) and process(es) used by nursing to develop and provide 

continuing education programs for nurses at all levels and settings. Include how 

the organization provides onsite internal electronic and classroom methods. Do 

not include orientation. 

EP 1 

EP 4 



Staff participate in ongoing education and training whenever staff responsibilities change. Staff 


EP 5 

EP 6 

Staff participate in education and training that is specific to the needs of the patient population served 

by the hospital. Staff participation is documented. (See also PC.01.02.09, EP 3) 

Staff participate in education and training that incorporates the skills of team communication, 

collaboration, and coordination of care. Staff participation is documented. 

HR.01.06.01 

Staff are competent to perform their responsibilities. 

EP 1 

EP 2 

The hospital defines the competencies it requires of its staff who provide patient care, treatment, or 

services. 

The hospital uses assessment methods to determine the individual's competence in the skills being 

assessed. 

Note: Methods may include test taking, return demonstration, or the use of simulation. 

SE5EO 

The effectiveness of two educational programs provided in SE5. 






Page 15 of 60 





MRP Number 

SE6 

SE6 

MRP Standards 



LD.01.04.01 



How the organization provides career development opportunities for non-nurse 

employees and members of the community interested in becoming nurses. 

EP 2 





Page 16 of 60 





MRP Number 

SE7 

MRP Standards 


Teaching and Role Development. Describe and Demonstrate 

SE7 



HR.01.04.01 

The hospital provides orientation to staff. 


The structure(s) and process(es) used by the organization to promote the 

teaching role of nurses. Include examples related to patients and staff 

members. 

EP 3 

HR.01.06.01 

The hospital orients staff on the following: Relevant hospital-wide and unit-specific policies and 

procedures. Completion of this orientation is documented. 


EP 3 

An individual with the educational background, experience, or knowledge related to the skills being 

reviewed assesses competence. 

Note: When a suitable individual cannot be found to assess staff competence, the hospital can utilize 

an outside individual for this task. Alternatively, the hospital may consult the competency guidelines 

from an appropriate professional organization to make its assessment. 

LD.03.04.01 




EP 1 


EP 5 


12) 

PC.02.03.01 

The hospital provides patient education and training based on each patient’s 

needs and abilities. 

EP 1 

EP 10 

The hospital performs a learning needs assessment for each patient, which includes the patient’s 

cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive 

limitations, and barriers to communication. 

Based on the patient’s condition and assessed needs, the education and training provided to the 

patient by the hospital include any of the following: 

- An explanation of the plan for care, treatment, and services 

- Basic health practices and safety 

- Information on the safe and effective use of medications (See also MM.06.01.01, EP 9; MM.06.01.03, 

EPs 3-6) 

- Nutrition interventions (for example, supplements) and modified diets 

- Discussion of pain, the risk for pain, the importance of effective pain management, the pain 

assessment process, and methods for pain management 

- Information on oral health 

- Information on the safe and effective use of medical equipment or supplies provided by the hospital 

- Habilitation or rehabilitation techniques to help the patient reach maximum independence 

- Fall reduction strategies 

SE8 

How nursing facilitates the effective transition of new graduate nurses into the 

work environment. 

EC.03.01.01 

EP 1 

Staff and licensed independent practitioners are familiar with their roles and 

responsibilities relative to the environment of care. 

Staff and licensed independent practitioners can describe or demonstrate methods for eliminating and 

minimizing physical risks in the environment of care. (See also HR.01.04.01, EP 1) 

EP 2 

Staff and licensed independent practitioners can describe or demonstrate actions to take in the event 

of an environment of care incident. (See also HR.01.04.01, EP 1) 




Page 17 of 60 





MRP Number 

SE8 

MRP Standards 



EP 3 


Staff and licensed independent practitioners can describe or demonstrate how to report environment of 

care risks. (See also HR.01.04.01, EP 1) 

HR.01.04.01 


EP 1 

EP 2 

EP 3 

EP 4 

EP 5 

EP 6 

The hospital determines the key safety content of orientation provided to staff. (See also EC.03.01.01, 

EPs 1-3) 

Note: Key safety content may include specific processes and procedures related to the provision of 

care, treatment, and services; the environment of care; and infection control. 

The hospital orients its staff to the key safety content before staff provides care, treatment, and 

services. Completion of this orientation is documented. (See also IC.01.05.01, EP 6) 

The hospital orients staff on the following: Relevant hospital-wide and unit-specific policies and 

procedures. Completion of this orientation is documented. 

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. (See also IC.01.05.01, EP 6; IC.02.01.01, EP 7; IC.02.04.01, EP 2; RI.01.01.01, EP 8) 

The hospital orients staff on the following: Sensitivity to cultural diversity based on their job duties and 

responsibilities. Completion of this orientation is documented. 

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 


SE9 

How nurses support community educational activities. 

LD.03.03.01 

EP 1 




LD.03.04.01 




EP 1 

EP 3 



EP 4 



SE10 

HR.01.02.07 

The hospital determines how staff function within the organization. 

How nurses support academic practicum experiences and serve as preceptors, 

instructors, adjunct faculty, or faculty. 

EP 5 

Staff oversee the supervision of students when they provide patient care, treatment, and services as 

part of their training. 




Page 18 of 60 





MRP Number 

SE11 

MRP Standards 




Commitment to Community Involvement. Describe and Demonstrate 

SE11 

The structure(s) and process(es) used to identify and allocate resources for 

affiliations with schools of nursing, consortiums, or community outreach 

programs. 

LD.04.01.03 

EP 1 

EP 3 






The operating budget reflects the hospital’s goals and objectives. 

NR.01.01.01 


services. 

EP 3 





SE11EO 

The result(s) of the affiliations with schools of nursing, consortiums, or 

community outreach programs described in SE11. 



SE12 

How the organization supports and recognizes the participation of nurses at all 

levels in service to the community. 

SE13 

How the organization or nursing addresses the healthcare needs of the 

community by establishing partnerships. 

NR.01.01.01 

EP 1 

LD.03.04.01 

EP 4 


services. 











Page 19 of 60 





MRP Number 

SE14 

MRP Standards 


Recognition of Nursing. Describe and Demonstrate 

SE14 

The structure(s) and process(es) the organization uses to recognize and make 

visible the contributions of nurses. 



LD.01.04.01 

EP 2 

EP 5 






NR.01.01.01 


services. 

EP 1 

EP 2 

EP 3 

EP 4 





LD.01.02.01, EP 1 and LD.02.01.01, EP 1) 







LD.01.04.01, EP 5) 

SE15 

Comment: There is no comparable Joint Commission requirement. 

That the nursing community and the community at large (e.g., local, state, 

national, international) recognize the value of nursing in the organization. 




Page 20 of 60 





MRP Number 

EP1 

MRP Standards 

III. Exemplary Professional Practice (EP) 

Professional Practice Model. Describe and Demonstrate 

EP1 

How nurses develop, apply, evaluate, adapt, and modify the Professional 

Practice Model. 



LD.04.04.03 

EP 1 





EP 2 

EP 3 

EP 4 

The hospital's design of new or modified services or processes incorporates the results of performance 

improvement activities. 

The hospital's design of new or modified services or processes incorporates information about potential 

risks to patients. (See also LD.04.04.05, EPs 6, 10-11) 

Note: A proactive risk assessment is one of several ways to assess potential risks to patients. For 

suggested components, refer to the Proactive Risk Assessment section at the beginning of this chapter. 

The hospital's design of new or modified services or processes incorporates evidence-based 

information in the decision-making process. 

Note: For example, evidence-based information could include practice guidelines, successful practices, 

information from current literature, and clinical standards. 

NR.02.01.01 


EP 1 

EP 2 

EP 3 

EP 4 

EP 5 

EP 6 





evaluated. 








also LD.04.04.07, EP 1) 




NR.02.02.01 



EP 1 

EP 2 

EP 3 






procedures. 




Page 21 of 60 





MRP Number 

EP1 

MRP Standards 



EP 5 




NR.02.03.01 



EP 1 

EP 2 



also LD.04.01.07, EP 1) 



EP1EO 

The result of applying the Professional Practice Model. Include two examples 

related to nursing practice, collaboration, communication, or professional 

development activities. 



EP2 

How nurses investigate, develop, implement, and systematically evaluate 

standards of practice and standards of care. 

IM.03.01.01 

EP 1 

Knowledge-based information resources are available, current, and 

authoritative. 

The hospital provides access to knowledge-based information resources 24 hours a day, 7 days a 

week. (See also IM.01.01.03, EPs 2 and 6) 

EP 2 

The hospital makes cooperative or contractual arrangements with another institution(s) to provide 

knowledge-based information resources that are not available on site. 

LD.04.04.03 


EP 1 

EP 2 

EP 3 

EP 4 

EP 5 

EP 6 













The hospital's design of new or modified services or processes incorporates information about sentinel 

events. 

The hospital tests and analyzes its design of new or modified services or processes to determine 

whether the proposed design or modification is an improvement. 

EP 7 





Page 22 of 60 





MRP Number 

EP2 

MRP Standards 



LD.04.04.07 

EP 1 

EP 2 

EP 3 


The hospital considers clinical practice guidelines when designing or 

improving processes. 

The hospital considers using clinical practice guidelines when designing or improving processes. (See 

also NR.02.01.01, EP 5) 

When clinical practice guidelines will be used in the design or modification of processes, the hospital 

identifies criteria to guide their selection and implementation. 

The hospital manages and evaluates the implementation of the guidelines used in the design or 

modification of processes. 

EP 4 

The leaders of the hospital review and approve the clinical practice guidelines. 

NR.02.01.01 


EP 1 

EP 2 





evaluated. 


EP3 

The structure(s) and process(es) that include direct-care nurse involvement in 

tracking and analyzing nurse satisfaction or engagement data. 

LD.03.01.01 

EP 1 

LD.03.03.01 


hospital. 

Leaders regularly evaluate the culture of safety and quality using valid and reliable tools. 



EP 3 


LD.03.05.01 



EP 1 



PI.01.01.01 


EP 30 






PI.02.01.01 

The hospital compiles and analyzes data. 

EP 4 

EP 8 

The hospital analyzes and compares internal data over time to identify levels of performance, patterns, 

trends, and variations. 

The hospital uses the results of data analysis to identify improvement opportunities. (See also 

LD.03.02.01, EP 5; PI.03.01.01, EP 1) 




Page 23 of 60 





MRP Number 

EP3EO 

EP3EO 

MRP Standards 





That nurse satisfaction or engagement aggregated at the organizational level 

outperforms the mean, median or other benchmark statistic of the national 

database used. Include participation rates, analysis, and evaluation of the data. 




Page 24 of 60 





MRP Number 

EP4 

MRP Standards 


Care Delivery System(s). Describe and Demonstrate 

EP4 

That the structure(s) and process(es) of the Care Delivery System(s) involve 

the patient and/or his or her support system in the planning and delivery of 

care. Provide at least two examples of a plan of care that included patient 

and/or family member involvement. 



PC.01.03.01 

EP 1 

EP 5 

The hospital plans the patient’s care. 


The hospital plans the patient’s care, treatment, and services based on needs identified by the 

patient’s assessment, reassessment, and results of diagnostic testing. (See also RC.02.01.01, EP 2) 

The written plan of care is based on the patient’s goals and the time frames, settings, and services 

required to meet those goals. 

PC.02.01.01 

The hospital provides care, treatment, and services for each patient. 

EP 1 

The hospital provides the patient with care, treatment, and services according to his or her 

individualized plan of care. 

PC.02.01.05 

The hospital provides interdisciplinary, collaborative care, treatment, and 

services. 

EP 1 

Care, treatment, and services are provided to the patient in an interdisciplinary, collaborative manner. 

PC.02.03.01 



EP 1 

EP 5 

EP 10 

The hospital performs a learning needs assessment for each patient, which includes the patient’s 

cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive 

limitations, and barriers to communication. 

The hospital coordinates the patient education and training provided by all disciplines involved in the 

patient’s care, treatment, and services. 






EPs 3-6) 








RI.01.01.01 

The hospital respects, protects, and promotes patient rights. 

EP 5 

The hospital respects the patient’s right to and need for effective communication. (See also 

RI.01.01.03, EP 1) 




Page 25 of 60 





MRP Number 

EP4 

MRP Standards 



RI.01.02.01 

EP 1 

EP 2 

EP 3 

EP 6 

EP 7 

EP 8 

EP 20 

EP 21 

EP 22 


The hospital respects the patient's right to participate in decisions about his or 

her care, treatment, and services. 

Note: For hospitals that use Joint Commission accreditation for deemed 

status purposes: This right is not to be construed as a mechanism to demand 

the provision of treatment or services deemed medically unnecessary or 

inappropriate. 

The hospital involves the patient in making decisions about his or her care, treatment, and services, 

including the right to have his or her own physician promptly notified of his or her admission to the 

hospital. 

The hospital provides the patient with written information about the right to refuse care, treatment, and 

services. 

The hospital respects the patient’s right to refuse care, treatment, and services, in accordance with law 

and regulation. 

When a patient is unable to make decisions about his or her care, treatment, and services, the hospital 

involves a surrogate decision-maker in making these decisions. (See also RI.01.03.01, EP 6) 

When a surrogate decision-maker is responsible for making care, treatment, and services decisions, 

the hospital respects the surrogate decision-maker’s right to refuse care, treatment, and services on 

the patient’s behalf, in accordance with law and regulation. 

The hospital involves the patient’s family in care, treatment, and services decisions to the extent 

permitted by the patient or surrogate decision-maker, in accordance with law and regulation. 

The hospital provides the patient or surrogate decision-maker with the information about the outcomes 

of care, treatment, and services that the patient needs in order to participate in current and future 

health care decisions. 

The hospital informs the patient or surrogate decision-maker about unanticipated outcomes of care, 

treatment, and services that relate to sentinel events considered reviewable by The Joint Commission. 

(Refer to the "Sentinel Events" (SE) chapter for a definition of reviewable sentinel events.) 

The licensed independent practitioner responsible for managing the patient's care, treatment, and 

services, or his or her designee, informs the patient about unanticipated outcomes of care, treatment, 

and services related to sentinel events when the patient is not already aware of the occurrence or 

when further discussion is needed. 

Note: In settings where there is no licensed independent practitioner, the staff member responsible for 

managing the care of the patient is responsible for sharing information about such outcomes. 

RI.01.03.01 

The hospital honors the patient's right to give or withhold informed consent. 

EP 7 

EP 9 

EP 11 

The informed consent process includes a discussion about the patient's proposed care, treatment, and 

services. 

The informed consent process includes a discussion about potential benefits, risks, and side effects of 

the patient's proposed care, treatment, and services; the likelihood of the patient achieving his or her 

goals; and any potential problems that might occur during recuperation. 

The informed consent process includes a discussion about reasonable alternatives to the patient's 

proposed care, treatment, and services. The discussion encompasses risks, benefits, and side effects 

related to the alternatives and the risks related to not receiving the proposed care, treatment, and 

services. 




Page 26 of 60 





MRP Number 

EP4 

MRP Standards 



EP 12 


The informed consent process includes a discussion about any circumstances under which information 

about the patient must be disclosed or reported. 

Note: Such circumstances may include requirements for disclosure of information regarding cases of 

HIV, tuberculosis, viral meningitis, and other diseases that are reported to organizations such as health 

departments or the Centers for Disease Control and Prevention. 

RI.01.03.05 

The hospital protects the patient and respects his or her rights during 

research, investigation, and clinical trials. 

EP 2 

EP 3 

To help the patient determine whether or not to participate in research, investigation, or clinical trials, 

the hospital provides the patient with all of the following information: 

- An explanation of the purpose of the research 

- The expected duration of the patient’s participation 

- A clear description of the procedures to be followed 

- A statement of the potential benefits, risks, discomforts, and side effects 

- Alternative care, treatment, and services available to the patient that might prove advantageous to 

the patient 

The hospital informs the patient that refusing to participate in research, investigation, or clinical trials, 

or discontinuing participation at any time will not jeopardize his or her access to care, treatment, and 

services unrelated to the research. 

RI.01.04.01 

The hospital respects the patient's right to receive information about the 

individual(s) responsible for, as well as those providing, his or her care, 


EP 1 

EP 2 

The hospital informs the patient of the name of the physician, clinical psychologist, or other practitioner 

who has primary responsibility for his or her care, treatment, or services. 

Note: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid 

Services (CMS) (refer to the Glossary). 

The hospital informs the patient of the name of the physician(s), clinical psychologist(s), or other 

practitioner(s) who will provide his or her care, treatment, and services. 

Note: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid 


EP5 

How nurses use the Care Delivery System(s) to make patient care assignments 

that ensure continuity, quality, and effectiveness of care within and across 

services and settings. 

NR.02.02.01 

EP 4 

PC.01.02.03 





The hospital assesses and reassesses the patient and his or her condition 

according to defined time frames. 

EP 6 

A registered nurse completes a nursing assessment within 24 hours after the patient’s inpatient 

admission. (See also RC.02.01.01, EP 2) 

PC.01.02.05 

Qualified staff or licensed independent practitioners assess and reassess the 

patient. 

EP 1 

Based on the initial assessment, a registered nurse determines the patient’s need for nursing care, as 

required by hospital policy and law and regulation. 




Page 27 of 60 





MRP Number 

EP5 

MRP Standards 



PC.01.03.01 

EP 1 

The hospital plans the patient’s care. 


The hospital plans the patient’s care, treatment, and services based on needs identified by the 

patient’s assessment, reassessment, and results of diagnostic testing. (See also RC.02.01.01, EP 2) 

PC.02.01.01 


EP 1 



PC.02.02.01 

The hospital coordinates the patient’s care, treatment, and services based on 

the patient’s needs. 

EP 2 

EP 3 

EP 10 

The hospital's process for hand-off communication provides for the opportunity for discussion between 

the giver and receiver of patient information. 

Note: Such information may include the patient’s condition, care, treatment, medications, services, and 

any recent or anticipated changes to any of these. 

The hospital coordinates the patient’s care, treatment, and services. 

Note: Coordination involves resolving scheduling conflicts and duplication of care, treatment, and 

services. 

When the hospital uses external resources to meet the patient’s needs, it coordinates the patient’s 


EP6 

LD.04.01.01 

The hospital complies with law and regulation. 

How regulatory and professional standards are incorporated into the Care 

Delivery System(s). 

EP 2 

LD.04.04.07 

The hospital provides care, treatment, and services in accordance with licensure requirements, laws, 

and rules and regulations. 



EP 1 

EP 2 

EP 3 


also NR.02.01.01, EP 5) 





EP 4 


NR.01.01.01 


services. 

EP 1 



NR.02.01.01 


EP 1 






Page 28 of 60 





MRP Number 

EP6 

MRP Standards 



EP 2 

EP 3 




evaluated. 




NR.02.02.01 



EP 1 

EP 2 

EP 3 

EP 4 

EP 5 






procedures. 





EP7 

The structure(s) and process(es) used to engage internal experts and external 

consultants to improve care in the practice setting. 

LD.01.03.01 

EP 5 

The governing body is ultimately accountable for the safety and quality of 


The governing body provides for the resources needed to maintain safe, quality care, treatment, and 

services. (See also NR.01.01.01, EP 3) 

LD.04.04.03 


EP 7 


MS.03.01.03 

The management and coordination of each patient’s care, treatment, and 

services is the responsibility of a practitioner with appropriate privileges. 

EP 4 

The organized medical staff, through its designated mechanism, determines the circumstances under 

which consultation or management by a doctor of medicine or osteopathy, or other licensed 

independent practitioner, is required. 

EP 5 

Consultation is obtained for the circumstances defined by the organized medical staff. 

EP7EO 

Two improvements in the practice setting that occurred as a result of the use of 

internal experts or external consultants. 






Page 29 of 60 





MRP Number 

EP8 

MRP Standards 




Staffing. Scheduling, and Budgeting Processes. Describe and Demonstrate 

EP8 

How nurses use trended data to formulate the staffing plan and acquire 

necessary resources to assure consistent application of the Care Delivery 

System(s). 

LD.03.02.01 

EP 1 

EP 3 

EP 4 

EP 5 

EP 6 







Leaders provide the resources needed for data and information use, including staff, equipment, and 

information systems. 



The hospital uses data and information to identify and respond to internal and external changes in the 

environment. 

LD.03.03.01 



EP 4 


services. 

LD.03.06.01 


EP 3 

Leaders provide for a sufficient number and mix of individuals to support safe, quality care, treatment, 

and services. (See also IC.01.01.01, EP 3) 

Note: The number and mix of individuals is appropriate to the scope and complexity of the services 

offered. 

NR.02.02.01 



EP 4 



PI.01.01.01 


EP 1 


PI.02.01.01 


EP 3 

The hospital uses statistical tools and techniques to analyze and display data. 

EP 4 






Page 30 of 60 





MRP Number 

EP8 

MRP Standards 



EP 12 

EP 13 


When the hospital identifies undesirable patterns, trends, or variations in its performance related to the 

safety or quality of care (for example, as identified in the analysis of data or a single undesirable 

event), it includes the adequacy of staffing, including nurse staffing, in its analysis of possible causes. 

Note 1: Adequacy of staffing includes the number, skill mix, and competency of all staff. In their 

analysis, hospitals may also wish to examine issues such as processes related to work flow; 

competency assessment; credentialing; supervision of staff; and orientation, training, and education. 

Note 2: Hospitals may find value in using the staffing effectiveness indicators (which include National 

Quality Forum Nursing Sensitive Measures) to help identify potential staffing issues. (Refer to the 

“Staffing Effectiveness Indicators” (SEI) chapter) 

When analysis reveals a problem with the adequacy of staffing, the leaders responsible for the hospitalwide 

patient safety program (as addressed at LD.04.04.05, EP 1) are informed, in a manner 

determined by the safety program, of the results of this analysis and actions taken to resolve the 

identified problem(s). (See also LD.03.05.01, EP 7) 

PI.03.01.01 


EP 2 


EP9 

How direct-care nurses participate in staffing and scheduling processes. 

LD.03.03.01 

EP 3 




NR.02.02.01 



EP 4 



EP10 

LD.01.04.01 


How nurses develop, implement, and evaluate action plans related to unitbased 

staff recruitment and retention. 

EP 2 

LD.03.03.01 




EP 1 

EP 3 



EP 4 


services. 

EP 7 

Leaders evaluate the effectiveness of planning activities. 

EP11 

How guidelines such as the ANA Principles of Nurse Staffing (American Nurses 

Association, 2005) standards for scheduling, delegation, and from nursing 

specialty organizations and/or state-mandated requirements are incorporated 

into staffing and scheduling processes. 

IM.03.01.01 

EP 1 

EP 2 










Page 31 of 60 





MRP Number 

EP11 

MRP Standards 



LD.03.01.01 

EP 9 



hospital. 

Literature and advisories relevant to patient safety are available to all individuals who work in the 

hospital. 

LD.03.06.01 


EP 3 




offered. 

LD.04.01.01 


EP 2 



LD.04.04.07 



EP 1 

EP 2 

EP 3 


also NR.02.01.01, EP 5) 





NR.02.02.01 



EP 1 

EP 2 

EP 4 







EP12 

How nurses analyze data to guide decisions regarding unit and department 

budget formulation, implementation, monitoring, and evaluation. 

LD.03.02.01 

EP 5 





EP 6 


environment. 

LD.04.01.03 



EP 5 

Leaders monitor the implementation of the budget and long-term capital expenditure plan. 




Page 32 of 60 





MRP Number 

EP12 

MRP Standards 



NR.01.01.01 

EP 3 

EP 4 



services. 







LD.01.04.01, EP 5) 

NR.02.01.01 


EP 6 






Page 33 of 60 





MRP Number 

EP13 

MRP Standards 


Interdisciplinary Care. Describe and Demonstrate 

EP13 

How nurses have assumed leadership roles in interdisciplinary collaboration. 



LD.01.02.01 

EP 1 


The hospital identifies the responsibilities of its leaders. 

Senior managers and leaders of the organized medical staff work with the governing body to define 

their shared and unique responsibilities and accountabilities. (See also NR.01.01.01, EPs 2 and 3) 

LD.04.01.05 


EP 5 



NR.01.01.01 


services. 

EP 1 

EP 2 

EP 3 





LD.01.02.01, EP 1 and LD.02.01.01, EP 1) 





PC.02.01.05 


services. 

EP 1 


EP14 

How the organization ensures the participation of nurses at all levels in 

interdisciplinary activities to develop policy and standards of care. 

LD.03.04.01 

EP 1 





EP 3 


EP 4 

EP 5 




12) 

LD.04.01.07 



EP 1 






Page 34 of 60 





MRP Number 

EP14 

MRP Standards 



LD.04.04.07 




EP 4 


NR.01.01.01 


services. 

EP 3 





EP15 

Interdisciplinary collaboration using continuous quality and process 

improvement. 

LD.03.01.01 

EP 3 


hospital. 



EP 7 


EP 8 



LD.03.03.01 



EP 3 

EP 5 



LD.03.04.01 




EP 5 


12) 

LD.03.05.01 



EP 3 


EP16 

Interdisciplinary collaboration across multiple settings to ensure the continuum 

of care. 

LD.03.04.01 

EP 5 





12) 

PC.02.01.05 


services. 

EP 1 





Page 35 of 60 





MRP Number 

EP16 

MRP Standards 



PC.02.02.01 

EP 1 

EP 2 

EP 3 

EP 10 




The hospital has a process to receive or share patient information when the patient is referred to other 

internal or external providers of care, treatment, and services. (See also PC.04.02.01, EP 1) 

The hospital's process for hand-off communication provides for the opportunity for discussion between 

the giver and receiver of patient information. 

Note: Such information may include the patient’s condition, care, treatment, medications, services, and 

any recent or anticipated changes to any of these. 



services. 



PC.04.01.01 

The hospital has a process that addresses the patient’s need for continuing 

care, treatment, and services after discharge or transfer. 

EP 2 

The hospital describes the method for shifting responsibility for a patient’s care from one clinician, 

hospital, program, or service to another. 

PC.04.01.03 

The hospital discharges or transfers the patient based on his or her assessed 

needs and the organization’s ability to meet those needs. 

EP 3 

The patient, the patient’s family, licensed independent practitioners, physicians, clinical psychologists, 

and staff involved in the patient’s care, treatment, and services participate in planning the patient’s 

discharge or transfer. 

Note 1: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid 


Note 2: For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: 

Social service staff responsibilities include, but are not limited to, participating in discharge planning, 

arranging for follow-up care, and developing mechanisms for exchange of information with sources 

outside the hospital. 

PC.04.02.01 

When a patient is discharged or transferred, the hospital gives information 

about the care, treatment, and services provided to the patient to other service 

providers who will provide the patient with care, treatment, or services. 

EP 1 

At the time of the patient’s discharge or transfer, the hospital informs other service providers who will 

provide care, treatment, or services to the patient about the following: 

- The reason for the patient’s discharge or transfer 

- The patient’s physical and psychosocial status 

- A summary of care, treatment, and services it provided to the patient 

- The patient’s progress toward goals 

- A list of community resources or referrals made or provided to the patient 

(See also PC.02.02.01, EP 1) 




Page 36 of 60 





MRP Number 

EP17 

EP17 

MRP Standards 



IM.01.01.01 


The hospital plans for managing information. 

Interdisciplinary collaboration to ensure that information systems and 

technology used for clinical care monitoring, documentation, and 

communication are integrated and evaluated. 

EP 1 

EP 2 

EP 3 

The hospital identifies the internal and external information needed to provide safe, quality care. 

The hospital identifies how data and information enter, flow within, and leave the organization. 

The hospital uses the identified information to guide development of processes to manage information. 

EP 4 

Staff and licensed independent practitioners, selected by the hospital, participate in the assessment, 

selection, integration, and use of information management systems for the delivery of care, treatment, 

and services. 

IM.04.01.01 

The hospital maintains accurate health information. 

EP 1 

The hospital has processes to check the accuracy of health information. 

LD.03.02.01 



EP 1 



EP 3 


EP 5 



EP 7 

Leaders evaluate how effectively data and information are used throughout the hospital. 

LD.03.04.01 




EP 1 


EP 5 


12) 

EP 7 

Leaders evaluate the effectiveness of communication methods. 

EP18 

Interdisciplinary collaboration to develop, implement, and evaluate a 

comprehensive set of patient education programs and resources within the 

organization. 

IM.03.01.01 

EP 1 

EP 2 







LD.03.02.01 



EP 4 






Page 37 of 60 





MRP Number 

EP18 

MRP Standards 



LD.03.04.01 

EP 5 






12) 

PC.02.03.01 



EP 5 

EP 10 

The hospital coordinates the patient education and training provided by all disciplines involved in the 

patient’s care, treatment, and services. 






EPs 3-6) 











Page 38 of 60 





MRP Number 

EP19 

MRP Standards 




Accountability, Competence, and Autonomy. Describe and Demonstrate 

EP19 

That nurses have ready access to, and routinely use, current literature, 

professional standards, and other data sources to support autonomous practice. 

IM.03.01.01 

EP 1 

EP 2 








EP20 

HR.01.06.01 


That nurses at all levels routinely use self-appraisal performance review and 

peer review, including annual goal setting, for the assurance of competence 

and professional development. 

EP 3 

An individual with the educational background, experience, or knowledge related to the skills being 

reviewed assesses competence. 

Note: When a suitable individual cannot be found to assess staff competence, the hospital can utilize 

an outside individual for this task. Alternatively, the hospital may consult the competency guidelines 

from an appropriate professional organization to make its assessment. 

EP 6 

Staff competence is assessed and documented once every three years, or more frequently as required 

by hospital policy or in accordance with law and regulation. 

HR.01.07.01 

The hospital evaluates staff performance. 

EP 1 

The hospital evaluates staff based on performance expectations that reflect their job responsibilities. 

EP 2 

The hospital evaluates staff performance once every three years, or more frequently as required by 

hospital policy or in accordance with law and regulation. This evaluation is documented. 

EP21 

LD.01.04.01 


The structure(s) and process(es) that support shared leadership/participative 

decision-making and promote nursing autonomy. 

EP 5 

NR.01.01.01 




services. 

EP 1 

EP 2 

EP 3 





LD.01.02.01, EP 1 and LD.02.01.01, EP 1) 





NR.02.02.01 



EP 1 






Page 39 of 60 





MRP Number 

EP21 

MRP Standards 



EP 2 

EP 3 

EP 4 

EP 5 





procedures. 





EP22 

LD.04.01.05 


That nurses are accountable to resolve issues related to patient care or 

operational issues. 

EP 3 

The hospital defines, in writing, the responsibility of those with administrative and clinical direction of its 


Note: For hospitals that use Joint Commission accreditation for deemed status purposes: This includes 

the full-time employee who directs and manages dietary services. 

EP 4 

Staff are held accountable for their responsibilities. 

NR.01.01.01 


services. 

EP 1 

EP 2 

EP 3 





LD.01.02.01, EP 1 and LD.02.01.01, EP 1) 








Page 40 of 60 





MRP Number 

EP23 

MRP Standards 




Ethics, Privacy, Security, and Confidentiality. Describe and Demonstrate 

EP23 

HR.01.04.01 



How nurses use available resources, such as the ANA Code of Ethics for 

Nurses (American Nurses Association, 2001b) to address complex ethical 

issues. Provide examples from different practice settings. 

EP 6 

IM.03.01.01 






EP 1 

EP 2 





LD.03.01.01 


hospital. 

EP 9 


hospital. 

LD.04.02.03 

Ethical principles guide the hospital’s business practices. 

EP 1 

The hospital has a process that allows staff, patients, and families to address ethical issues or issues 

prone to conflict. 

EP24 

EC.02.01.01 

The hospital manages safety and security risks. 

How nurses have resolved issues related to patient privacy, security, and 

confidentiality. 

EP 3 

IM.02.01.03 

The hospital takes action to minimize or eliminate identified safety and security risks in the physical 

environment. 

The hospital maintains the security and integrity of health information. 

EP 5 

EP 8 

The hospital protects against unauthorized access, use, and disclosure of health information. 

The hospital monitors compliance with its policies on the security and integrity of health information. 

RI.01.01.01 


EP 7 

The hospital respects the patient’s right to privacy. (See also IM.02.01.01, EPs 1-5) 

Note: This element of performance (EP) addresses a patient's personal privacy. For EPs addressing 

the privacy of a patient's health information, please refer to Standard IM.02.01.01. 

RI.01.07.01 

The patient and his or her family have the right to have complaints reviewed by 

the hospital. 

EP 1 

The hospital establishes a complaint resolution process. (See also LD.04.01.07, EP 1; MS.09.01.01, 

EP 1) 

Note: The governing body is responsible for the effective operation of the complaint resolution process 

unless it delegates this responsibility in writing to a complaint resolution committee. 




Page 41 of 60 





MRP Number 

EP24 

MRP Standards 



EP 18 


For hospitals that use Joint Commission accreditation for deemed status purposes: In its resolution of 

complaints, the hospital provides the individual with a written notice of its decision, which contains the 

following: 

- The name of the hospital contact person 

- The steps taken on behalf of the individual to investigate the complaint 

- The results of the process 

- The date of completion of the complaint process 




Page 42 of 60 





MRP Number 

EP25 

MRP Standards 


Diversity and Workplace Advocacy. Describe and Demonstrate 

EP25 



LD.04.01.01 



How the organization identifies and addresses disparities in the management of 

the healthcare needs of diverse patient populations, Include the role of the 

nurse. 

EP 2 

LD.04.02.03 




EP 5 

Care, treatment, and services are provided based on patient needs, regardless of compensation or 

financial risk-sharing with those who work in the hospital, including staff and licensed independent 

practitioners. 

LD.04.03.07 

Patients with comparable needs receive the same standard of care, treatment, 

and services throughout the hospital. 

EP 1 

Variances in staff, setting, or payment source do not affect outcomes of care, treatment, and services 

in a negative way. 

EP 2 

Care, treatment, and services are consistent with the hospital’s mission, vision, and goals. 

PC.02.01.01 


EP 1 



RI.01.01.01 


EP 2 

EP 4 

The hospital informs the patient of his or her rights. (See also RI.01.01.03, EPs 1-3) 

The hospital treats the patient in a dignified and respectful manner that supports his or her dignity. 

EP 5 


RI.01.01.03, EP 1) 

EP 6 

The hospital respects the patient’s cultural and personal values, beliefs, and preferences. 

EP26 

How nurses use resources to meet the unique and individual needs of patients. 

IM.03.01.01 

EP 1 





EP 2 



LD.03.03.01 



EP 4 


services. 




Page 43 of 60 





MRP Number 

EP26 

MRP Standards 



LD.03.04.01 

EP 4 







PC.02.01.01 


EP 1 



PC.02.02.01 



EP 3 

EP 10 



services. 



EP27 

HR.01.04.01 


How the organization promotes a non-discriminatory climate for patients. 

EP 5 

The hospital orients staff on the following: Sensitivity to cultural diversity based on their job duties and 


EP 6 




LD.04.01.01 


EP 2 



RI.01.01.01 


EP 2 

EP 6 

The hospital informs the patient of his or her rights. (See also RI.01.01.03, EPs 1-3) 


EP28 

The organizational structure(s) and process(es) that are in place to identify and 

manage problems related to incompetent, unsafe, or unprofessional conduct. 

APR.09.02.01 Any individual who provides care, treatment, and services can report concerns 

about safety or the quality of care to The Joint Commission without retaliatory 

action from the hospital. 

EP 1 

The hospital educates its staff, medical staff, and other individuals who provide care, treatment, and 

services that concerns about the safety or quality of care provided in the organization may be reported 

to The Joint Commission. 

EP 2 

The hospital informs its staff and medical staff that it will take no disciplinary or punitive action because 

an employee, physician, or other individual who provides care, treatment, and services reports safety 

or quality-of-care concerns to The Joint Commission. 




Page 44 of 60 





MRP Number 

EP28 

MRP Standards 



EP 3 


The hospital takes no disciplinary or punitive action against employees, physicians, or other individuals 

who provide care, treatment, and services when they report safety or quality-of-care concerns to The 

Joint Commission. 

HR.01.06.01 


EP 1 

The hospital defines the competencies it requires of its staff who provide patient care, treatment, or 

services. 

EP 15 

The hospital takes action when a staff member’s competence does not meet expectations. 

LD.03.01.01 


hospital. 

EP 1 

EP 2 


Leaders prioritize and implement changes identified by the evaluation. 

EP 3 



EP 4 

EP 5 

EP 6 

EP 7 

Leaders develop a code of conduct that defines acceptable, disruptive, and inappropriate behaviors. 

Leaders create and implement a process for managing disruptive and inappropriate behaviors. 

Leaders provide education that focuses on safety and quality for all individuals. 


EP 8 

EP 9 

EP 10 




hospital. 

Leaders define how members of the population(s) served can help identify and manage issues of 

safety and quality within the hospital. 

LD.03.06.01 


EP 4 

EP 6 

Those who work in the hospital are competent to complete their assigned responsibilities. 

Leaders evaluate the effectiveness of those who work in the hospital to promote safety and quality. 

MS.11.01.01 

The medical staff implements a process to identify and manage matters of 

individual health for licensed independent practitioners which is separate from 

actions taken for disciplinary purposes. 

EP 1 

EP 3 

Process design addresses the following issues: Education of licensed independent practitioners and 

other organization staff about illness and impairment recognition issues specific to licensed 

independent practitioners (at-risk criteria). 

Process design addresses the following issues: Referral by others and maintaining informant 

confidentiality. 




Page 45 of 60 





MRP Number 

EP29 

EP29 

MRP Standards 



LD.04.01.01 



The organization's workplace advocacy initiatives for: 

• Caregiver stress 

• Diversity 

• Rights 

• Confidentiality 

EP 2 

LD.04.02.03 

EP 6 




When leaders excuse staff members from a job responsibility, care, treatment, and services are not 

affected in a negative way. 

LD.04.04.05 



EP 9 

The leaders make support systems available for staff who have been involved in an adverse or 

sentinel event. 

Note: Support systems recognize that conscientious health care workers who are involved in sentinel 

events are themselves victims of the event and require support. Support systems provide staff with 

additional help and support as well as additional resources through the human resources function or an 

employee assistance program. Support systems also focus on the process rather than blaming the 

involved individuals. 




Page 46 of 60 





MRP Number 

EP30 

MRP Standards 


Culture of Safety. Describe and Demonstrate 

EP30 

The structure(s) and process(es) used by the organization to improve 

workplace safety for nurses, based on standards such as the ANA's Safe 

Patient Handling and Movement 

(http://www.nursingworld.org/MainMenuCategories/ANAPoliticaIPower/Federal/I 

ssues/SPHM.aspx). 



EC.02.01.01 

EP 3 

EP 10 

EC.03.01.01 


The hospital manages safety and security risks. 

The hospital takes action to minimize or eliminate identified safety and security risks in the physical 

environment. 

When a security incident occurs, the hospital follows its identified procedures. 

Staff and licensed independent practitioners are familiar with their roles and 

responsibilities relative to the environment of care. 

EP 1 

Staff and licensed independent practitioners can describe or demonstrate methods for eliminating and 

minimizing physical risks in the environment of care. (See also HR.01.04.01, EP 1) 

EC.04.01.05 

The hospital improves its environment of care. 

EP 1 

The hospital takes action on the identified opportunities to resolve environmental safety issues. (See 

also EC.04.01.03, EP 2) 

HR.01.04.01 


EP 2 

The hospital orients its staff to the key safety content before staff provides care, treatment, and 

services. Completion of this orientation is documented. (See also IC.01.05.01, EP 6) 

LD.03.06.01 


EP 1 

Leaders design work processes to focus individuals on safety and quality issues. 

EP 3 




offered. 

NR.01.01.01 


services. 

EP 1 

EP 2 

EP 3 





LD.01.02.01, EP 1 and LD.02.01.01, EP 1) 








Page 47 of 60 





MRP Number 

EP30EO 

EP30EO 

MRP Standards 

Two workplace safety improvements for nurses that resulted from the 

structure(s) and process(es) in EP30. 






EP31 

How the organization uses a facility wide approach for proactive risk 

assessment and error management. 

LD.04.04.01 

EP 1 



Leaders set priorities for performance improvement activities and patient health outcomes. (See also 

PI.01.01.01, EPs 1 and 3) 

EP 2 

EP 3 

Leaders give priority to high-volume, high-risk, or problem-prone processes for performance 

improvement activities. (See also PI.01.01.01, EPs 4, 6-8, 11-12, and 14-15) 

Leaders reprioritize performance improvement activities in response to changes in the internal or 

external environment. 

EP 4 

Performance improvement occurs hospital-wide. 

LD.04.04.03 


EP 3 





LD.04.04.05 



EP 3 

EP 10 

EP 11 

EP 12 

The scope of the safety program includes the full range of safety issues, from potential or no-harm 

errors (sometimes referred to as near misses, close calls, or good catches) to hazardous conditions 

and sentinel events. 

At least every 18 months, the hospital selects one high-risk process and conducts a proactive risk 

assessment. (See also LD.04.04.03, EP 3) 

Note: For suggested components, refer to the Proactive Risk Assessment section at the beginning of 

this chapter. 

To improve safety and to reduce the risk of medical errors, the hospital analyzes and uses information 

about system or process failures and the results of proactive risk assessments. (See also LD.04.04.03, 

EP 3) 

The leaders disseminate lessons learned from root cause analyses, system or process failures, and 

the results of proactive risk assessments to all staff who provide services for the specific situation. (See 

also LD.03.04.01, EP 5) 

EP32 

The nursing structure(s) and process(es) that support a culture of patient safety. 

LD.03.01.01 

EP 1 


hospital. 


EP 3 






Page 48 of 60 





MRP Number 

EP32 

MRP Standards 



LD.03.03.01 




EP 1 

EP 5 



LD.03.04.01 




EP 1 


EP 5 


12) 

LD.03.05.01 



EP 1 



LD.04.04.05 



EP 1 

EP 4 

The leaders implement a hospital-wide patient safety program. 

All departments, programs, and services within the hospital participate in the safety program. 

NR.01.01.01 


services. 

EP 1 



EP32EO 


That nursing-sensitive indicator data aggregated at the organization level 

outperform the mean, median or other benchmark statistic of the national 

database used. Provide analysis and evaluation of data related to patient falls, 

nosocomial pressure ulcer prevalence and/or incidence, and two of the 

following: 

• Blood stream infections 

• Urinary tract infections 

• Ventilator-associated pneumonia 

• Restraint use 

• Pediatric IV infiltrations 

• Other specialty-specific nationally benchmarked indicators(use only for units 

for which the above do not apply) 




Page 49 of 60 





MRP Number 

EP33 

MRP Standards 




Quality Care Monitoring and Improvement. Describe and Demonstrate 

EP33 

The structure(s) and process(es) used by the organization to allocate and/or 

reallocate resources to monitor and improve the quality of nursing, and total 

patient care. The nurse has responsibility for ensuring the coordination of care 

among other disciplines and support staff. 

LD.03.02.01 

EP 1 

EP 3 

EP 4 









LD.03.03.01 



EP 1 

EP 3 



EP 4 


services. 

EP 5 

EP 6 

EP 7 



Leaders evaluate the effectiveness of planning activities. 

LD.03.05.01 



EP 4 



LD.03.06.01 


EP 1 

Leaders design work processes to focus individuals on safety and quality issues. 

EP 3 




offered. 

LD.04.01.05 


EP 5 






Page 50 of 60 





MRP Number 

EP33 

MRP Standards 



NR.01.01.01 

EP 3 



services. 





EP33EO 

How the allocation and/or reallocation of resources improved the quality of 

nursing care. 



EP34 

How nurse leaders ensure the dissemination of comprehensive quality data to 

direct-care nurses. 

LD.03.04.01 

EP 1 





EP 3 


EP 4 

EP 5 




12) 

EP 6 

When changes in the environment occur, the hospital communicates those changes effectively. 

LD.04.04.05 



EP 12 

The leaders disseminate lessons learned from root cause analyses, system or process failures, and 

the results of proactive risk assessments to all staff who provide services for the specific situation. (See 

also LD.03.04.01, EP 5) 

NR.01.01.01 


services. 

EP 1 



EP35 

NR.02.01.01 


The structure(s) and process(es) used to identify significant findings and trends 

in overall patient satisfaction with nursing as compared to benchmarked 

sources. 

EP 3 

EP 6 








Page 51 of 60 





MRP Number 

EP35 

EP35EO 

MRP Standards 



PI.01.01.01 

EP 16 



The hospital collects data on the following: Patient perception of the safety and quality of care, 



That patient satisfaction data aggregated at the organization level outperform 

the mean, median or other benchmark statistic of the national database used. 

Provide analysis and evaluation of data and resultant action plans related to 

patient satisfaction with nursing addressing four of the following: 

• Pain 

• Education 

• Courtesy and respect from nurses 

• Careful listening by nurses 

• Response time 

• Other nurse-related national survey questions 




Page 52 of 60 





MRP Number 

NK1 

MRP Standards 

IV. New Knowledge, Innovotions, ond Improvements (NK) 

Research. Describe and Demonstrate 

NK1 

That nurses at all levels evaluate and use published research findings in their 

practice. 



IM.03.01.01 

EP 1 






EP 2 



LD.03.01.01 


hospital. 

EP 9 


hospital. 

LD.04.04.03 


EP 4 





LD.04.04.07 



EP 1 

EP 2 

EP 3 


also NR.02.01.01, EP 5) 





NR.02.02.01 



EP 1 

EP 2 

EP 3 

EP 4 

EP 5 






procedures. 








Page 53 of 60 





MRP Number 

NK1 

MRP Standards 



NR.02.03.01 

EP 1 

EP 2 






also LD.04.01.07, EP 1) 



NK2 

LD.04.02.03 


Consistent membership and involvement by at least one nurse in the governing 

body responsible for the protection of human subjects in research, and that a 

nurse votes on nursing-related protocols. 

EP 1 

NR.01.01.01 

The hospital has a process that allows staff, patients, and families to address ethical issues or issues 

prone to conflict. 


services. 

EP 3 

EP 4 







LD.01.04.01, EP 5) 

RI.01.03.05 



EP 1 

The hospital reviews all research protocols and weighs the risks and benefits to the patient 

participating in the research. 

NK3 

MM.06.01.05 

The hospital safely manages investigational medications. 

That direct-care nurses support the human rights of participants in research. 

EP 1 

The hospital has a written process addressing the use of investigational medications that includes 

review, approval, supervision, and monitoring. 

EP 3 

The written process for the use of investigational medications specifies that when a patient is involved 

in an investigational protocol that is independent of the hospital, the hospital evaluates and, if no 

contraindication exists, accommodates the patient’s continued participation in the protocol. 

EP 4 

The hospital implements its processes for the use of investigational medications. 

RI.01.01.01 


EP 1 

EP 4 

The hospital has written policies on patient rights. 

The hospital treats the patient in a dignified and respectful manner that supports his or her dignity. 

EP 5 


RI.01.01.03, EP 1) 

EP 6 





Page 54 of 60 





MRP Number 

NK3 

MRP Standards 



RI.01.03.05 

EP 1 

EP 2 

EP 3 




The hospital reviews all research protocols and weighs the risks and benefits to the patient 

participating in the research. 

To help the patient determine whether or not to participate in research, investigation, or clinical trials, 

the hospital provides the patient with all of the following information: 

- An explanation of the purpose of the research 

- The expected duration of the patient’s participation 

- A clear description of the procedures to be followed 

- A statement of the potential benefits, risks, discomforts, and side effects 

- Alternative care, treatment, and services available to the patient that might prove advantageous to 

the patient 

The hospital informs the patient that refusing to participate in research, investigation, or clinical trials, 

or discontinuing participation at any time will not jeopardize his or her access to care, treatment, and 

services unrelated to the research. 

EP 7 

The research consent form describes the patient's right to privacy, confidentiality, and safety. 

NK4 

The structure(s) and process(es) used by the organization to develop, expand, 

and/or advance nursing research. 

IM.03.01.01 

EP 1 





EP 2 



LD.04.04.07 



EP 1 

EP 2 

EP 3 


also NR.02.01.01, EP 5) 





NK4EO 





Page 55 of 60 





MRP Number 

NK4EO 

MRP Standards 

Nursing research studies from the past 2 years, ongoing or completed, 

generated from the structure(s) and process(es) in NK4. Provide a table 

including: 

• Study title 

• Study status 

• Principal investigator name(s) 

• Principal investigator credential(s) 

• Role(s) of nurses in the study 

• Study scope (internal to a single organization, multiple 

organizations within a system, independent organizations 

collaboratively) 

• Study type (replication--yes or no; qualitative, quantitative, 

or both) Select one completed research study and respond to the four criteria 

listed in the EO guidelines provided on page 24. 




NK5 

How the organization disseminates knowledge generaled through nursing 

research to internal and external audiences. 

LD.03.04.01 

EP 1 





EP 3 


EP 4 

EP 5 




12) 

NR.01.01.01 


services. 

EP 1 

EP 2 

EP 3 





LD.01.02.01, EP 1 and LD.02.01.01, EP 1) 








Page 56 of 60 





MRP Number 

NK6 

MRP Standards 


Evidence-Based Practice. Describe and Demonstrate 

NK6 

The structure(s) and process(es) used to evaluate existing nursing practice, 

based on evidence. 



IM.03.01.01 

EP 1 






EP 2 



LD.03.02.01 



EP 3 


EP 5 

EP 6 




environment. 

LD.04.04.03 


EP 1 

EP 2 

EP 3 

EP 4 

EP 5 

EP 6 













The hospital's design of new or modified services or processes incorporates information about sentinel 

events. 



EP 7 


NR.02.01.01 


EP 3 

EP 6 








Page 57 of 60 





MRP Number 

NK6 

MRP Standards 



PI.02.01.01 

EP 4 





EP 5 

The hospital compares data with external sources, when available. 

NK7 

The structure(s) and process(es) used to translate new knowledge into nursing 

practice. 

LD.04.01.07 

EP 1 





EP 2 

The hospital manages the implementation of policies and procedures. (See also NR.02.03.01, EP 2) 

LD.04.04.03 


EP 6 



LD.04.04.07 



EP 3 



NR.02.01.01 


EP 4 

EP 5 





also LD.04.04.07, EP 1) 


NK7EO 

How translation of new knowledge into nursing practice has affected patient 

outcomes. 






Page 58 of 60 





MRP Number 

NK8 

MRP Standards 


Innovation. Describe and Demonstrate 

NK8 





Innovations in nursing practice. 

NK9 

IM.01.01.01 

The hospital plans for managing information. 

The structure (s) and process(es) by which nurses are involved with the 

evaluation and allocation of technology and information systems to support 

practice, or nurses' participation in architecture and space design to support 

practice. 

EP 1 

EP 3 

EP 4 

The hospital identifies the internal and external information needed to provide safe, quality care. 

The hospital uses the identified information to guide development of processes to manage information. 

Staff and licensed independent practitioners, selected by the hospital, participate in the assessment, 

selection, integration, and use of information management systems for the delivery of care, treatment, 

and services. 

LD.03.02.01 



EP 4 

EP 5 

EP 6 






environment. 

EP 7 

Leaders evaluate how effectively data and information are used throughout the hospital. 

LD.04.04.03 


EP 1 



EP 7 


NK9EO 


An improvement in practice due to nurse involvement in technology and 

information system decision-making, or due to nurses' participation in 

architecture and space design. 




Page 59 of 60 





MRP Number 

MRP Standards 







Page 60 of 60

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