NATIONAL INTEGRATED ACCREDITATION FOR HEALTHCARE ...

SAFER, SMARTER, GREENER

NATIONAL INTEGRATED ACCREDITATION FOR HEALTHCARE ORGANIZATIONS (NIAHO?)

Accreditation Requirements, Interpretive Guidelines and Surveyor Guidance - Revision 18

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NIAHO? Accreditation Requirements, Interpretive Guidelines and Surveyor Guidance Revision 18, 02-05-2018

TABLE OF CONTENTS

GLOSSARY ..........................................................................................................................viii QUALITY MANAGEMENT SYSTEM (QM) ..................................................................................... 10 QM.1 QUALITY MANAGEMENT SYSTEM..................................................................................... 10 QM.2 ISO 9001 QUALITY MANAGEMENT SYSTEM ...................................................................... 10 QM.3 QUALITY OUTLINE/PLAN................................................................................................ 11 QM.4 MANAGEMENT REPRESENTATIVE .................................................................................... 12 QM.5 DOCUMENTATION AND MANAGEMENT REVIEWS ............................................................... 12 QM.6 SYSTEM REQUIREMENTS ............................................................................................... 12 QM.7 MEASUREMENT, MONITORING, ANALYSIS........................................................................ 13 QM.8 PATIENT SAFETY SYSTEM .............................................................................................. 14 GOVERNING BODY (GB) ........................................................................................................ 16 GB.1 LEGAL RESPONSIBILITY ................................................................................................ 16 GB.2 INSTITUTIONAL PLAN AND BUDGET ................................................................................ 16 GB.3 CONTRACTED SERVICES................................................................................................ 17 CHIEF EXECUTIVE OFFICER (CE) ............................................................................................ 19 CE.1 QUALIFICATIONS .......................................................................................................... 19 CE.2 RESPONSIBILITIES ....................................................................................................... 19 MEDICAL STAFF (MS)............................................................................................................ 20 MS.1 ORGANIZED MEDICAL STAFF ......................................................................................... 20 MS.2 ELIGIBILITY................................................................................................................. 20 MS.3 ACCOUNTABILITY ......................................................................................................... 20 MS.4 RESPONSIBILITY .......................................................................................................... 21 MS.5 EXECUTIVE COMMITTEE ................................................................................................ 23 MS.6 MEDICAL STAFF PARTICIPATION..................................................................................... 23 MS.7 MEDICAL STAFF BYLAWS ............................................................................................... 24 MS.8 APPOINTMENT ............................................................................................................. 25 MS.9 PERFORMANCE DATA .................................................................................................... 25 MS.10 CONTINUING EDUCATION ............................................................................................ 26 MS.11 GOVERNING BODY ROLE.............................................................................................. 26 MS.12 CLINICAL PRIVILEGES ................................................................................................. 27 MS.13 TEMPORARY CLINICAL PRIVILEGES ............................................................................... 28 MS.14 CORRECTIVE OR REHABILITATION ACTION .................................................................... 29 MS.15 ADMISSION REQUIREMENTS ........................................................................................ 30 MS.16 MEDICAL RECORD MAINTENANCE ................................................................................. 31 MS.17 HISTORY AND PHYSICAL.............................................................................................. 31 MS.18 CONSULTATION.......................................................................................................... 33 MS.19 AUTOPSY ................................................................................................................... 34 MS.20 TELEMEDICINE ........................................................................................................... 34 NURSING SERVICES (NS) ...................................................................................................... 36 NS.1 NURSING SERVICE ....................................................................................................... 36 NS.2 NURSE EXECUTIVE ....................................................................................................... 38 NS.3 ASSESSMENT AND PLAN OF CARE ................................................................................... 39 STAFFING MANAGEMENT (SM) ............................................................................................... 42 SM.1 LICENSURE OR CERTIFICATION ...................................................................................... 42 SM.2 PROFESSIONAL SCOPE.................................................................................................. 42 SM.3 DEPARTMENT SCOPE OF SERVICE................................................................................... 42 SM.4 DETERMINING AND MODIFYING STAFFING ...................................................................... 43 SM.5 JOB DESCRIPTION ........................................................................................................ 43 SM.6 ORIENTATION .............................................................................................................. 43 SM.7 STAFF EVALUATIONS .................................................................................................... 44 MEDICATION MANAGEMENT (MM)........................................................................................... 47 MM.1 MANAGEMENT PRACTICES............................................................................................. 47 MM.2 FORMULARY ................................................................................................................ 57 MM.3 SCHEDULED DRUGS ..................................................................................................... 58 MM.4 MEDICATION ORDERS .................................................................................................. 59 MM.5 REVIEW OF MEDICATION ORDERS.................................................................................. 60 MM.6 OVERSIGHT GROUP...................................................................................................... 63 MM.7 AVAILABLE INFORMATION ............................................................................................. 64 SURGICAL SERVICES (SS) ..................................................................................................... 65 SS.1 ORGANIZATION ............................................................................................................ 65 SS.2 STAFFING AND SUPERVISION......................................................................................... 67

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SS.3 PRACTITIONER PRIVILEGES ........................................................................................... 68 SS.4 HISTORY AND PHYSICAL ................................................................................................ 69 SS.5 AVAILABLE EQUIPMENT ................................................................................................. 71 SS.6 OPERATING ROOM REGISTER ......................................................................................... 72 SS.7 POST-OPERATIVE CARE ................................................................................................. 73 SS.8 OPERATIVE REPORT ...................................................................................................... 74 ANESTHESIA SERVICES (AS) ................................................................................................. 77 AS.1 ORGANIZATION ............................................................................................................ 77 AS.2 ADMINISTRATION ......................................................................................................... 80 AS.3 POLICIES AND PROCEDURES .......................................................................................... 83 LABORATORY SERVICES (LS) ................................................................................................. 87 LS.1 ORGANIZATION ............................................................................................................ 87 LS.2 POTENTIALLY INFECTIOUS BLOOD AND PRODUCTS ........................................................... 87 LS.3 PATIENT NOTIFICATION ................................................................................................. 90 LS.4 GENERAL BLOOD SAFETY ............................................................................................... 92 RESPIRATORY CARE SERVICES (RC) ....................................................................................... 94 RC.1 ORGANIZATION ............................................................................................................ 94 RC.2 ORDERS FOR TREATMENT AND INTERVENTIONS ............................................................... 94 RC.3 POLICIES OR PROTOCOLS .............................................................................................. 95 RC.4 TESTS OUTSIDE THE LABORATORY ................................................................................. 95 MEDICAL IMAGING (MI) ........................................................................................................ 97 MI.1 ORGANIZATION ............................................................................................................ 97 MI.2 RADIATION PROTECTION ............................................................................................... 97 MI.3 EQUIPMENT.................................................................................................................. 98 MI.4 ORDER ........................................................................................................................ 99 MI.5 SUPERVISION ............................................................................................................... 99 MI.6 STAFF........................................................................................................................ 100 MI.7 RECORDS................................................................................................................... 100 MI.8 INTERPRETATION AND RECORDS .................................................................................. 100 NUCLEAR MEDICINE SERVICES (NM) .................................................................................... 102 NM.1 ORGANIZATION ......................................................................................................... 102 NM.2 RADIOACTIVE MATERIALS ........................................................................................... 102 NM.3 EQUIPMENT AND SUPPLIES ......................................................................................... 103 NM.4 INTERPRETATION ....................................................................................................... 104 REHABILITATION SERVICES (RS) ......................................................................................... 105 RS.1 ORGANIZATION .......................................................................................................... 105 RS.2 MANAGEMENT AND SUPPORT ....................................................................................... 105 RS.3 TREATMENT PLAN/ORDERS .......................................................................................... 106 EMERGENCY DEPARTMENT (ED) ........................................................................................... 107 ED.1 ORGANIZATION .......................................................................................................... 107 ED.2 STAFFING .................................................................................................................. 107 ED.3 EMERGENCY SERVICES NOT PROVIDED ......................................................................... 108 ED.4 OFF-CAMPUS DEPARTMENTS ........................................................................................ 109 OUTPATIENT SERVICES (OS) ............................................................................................... 110 OS.1 ORGANIZATION.......................................................................................................... 110 OS.2 STAFFING.................................................................................................................. 110 OS.3 SCOPE OF SERVICE .................................................................................................... 110 OS.4 ORDERS .................................................................................................................... 111 DIETARY SERVICES (DS) ..................................................................................................... 113 DS.1 ORGANIZATION.......................................................................................................... 113 DS.2 SERVICES AND DIETS ................................................................................................. 114 DS.3 DIET MANUAL ............................................................................................................ 115 PATIENT RIGHTS (PR) ......................................................................................................... 117 PR.1 NONDISCRIMINATION ................................................................................................. 117 PR.2 SPECIFIC RIGHTS ....................................................................................................... 117 PR.3 ADVANCE DIRECTIVE .................................................................................................. 121 PR.4 LANGUAGE AND COMMUNICATION ................................................................................ 123 PR.5 INFORMED CONSENT................................................................................................... 123 PR.6 GRIEVANCE PROCEDURE .............................................................................................. 124 PR.7 RESTRAINT OR SECLUSION .......................................................................................... 126 PR.8 RESTRAINT OR SECLUSION: STAFF TRAINING REQUIREMENTS....................................... 138 PR.9 RESTRAINT OR SECLUSION: REPORT OF DEATH .............................................................. 140 INFECTION PREVENTION AND CONTROL (IC) ......................................................................... 143

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NIAHO? Accreditation Requirements, Interpretive Guidelines and Surveyor Guidance Revision 18, 02-05-2018

IC.1 INFECTION PREVENTION and CONTROL SYSTEM .............................................................. 143 MEDICAL RECORDS SERVICE (MR) ....................................................................................... 149 MR.1 ORGANIZATION ......................................................................................................... 149 MR.2 COMPLETE MEDICAL RECORD....................................................................................... 149 MR.3 RETENTION ............................................................................................................... 150 MR.4 CONFIDENTIALITY ...................................................................................................... 150 MR.5 RECORD CONTENT ..................................................................................................... 151 MR.6 IDENTIFICATION OF AUTHORS ..................................................................................... 153 MR.7 REQUIRED DOCUMENTATION ....................................................................................... 154 DISCHARGE PLANNING (DC) ................................................................................................ 157 DC.1 WRITTEN POLICIES..................................................................................................... 157 DC.2 DISCHARGE PLANNING EVALUATION............................................................................. 158 DC.3 PLAN IMPLEMENTATION............................................................................................... 159 DC.4 EVALUATION.............................................................................................................. 160 UTILIZATION REVIEW (UR).................................................................................................. 162 UR.1 DOCUMENTED PLAN .................................................................................................... 162 UR.2 SAMPLING ................................................................................................................. 163 UR.3 MEDICAL NECESSITY DETERMINATION .......................................................................... 163 UR.4 EXTENDED STAY REVIEW............................................................................................. 164 PHYSICAL ENVIRONMENT (PE) ............................................................................................. 165 PE.1 FACILITY.................................................................................................................... 165 PE.2 LIFE SAFETY MANAGEMENT SYSTEM .............................................................................. 175 PE.3 SAFETY MANAGEMENT SYSTEM ..................................................................................... 178 PE.4 SECURITY MANAGEMENT SYSTEM.................................................................................. 179 PE.5 HAZARDOUS MATERIAL (HAZMAT) MANAGEMENT SYSTEM ................................................ 181 PE.6 EMERGENCY MANAGEMENT SYSTEM .............................................................................. 182 PE.7 MEDICAL EQUIPMENT MANAGEMENT SYSTEM.................................................................. 186 PE.8 UTILITY MANAGEMENT SYSTEM..................................................................................... 193 ORGAN, TISSUE AND EYE PROCUREMENT (TO)....................................................................... 197 TO.1 PROCESS................................................................................................................... 197 TO.2 ORGAN PROCUREMENT ORGANIZATION (OPO) WRITTEN AGREEMENT................................ 197 TO.3 ALTERNATIVE AGREEMENT........................................................................................... 199 TO.4 RESPECT FOR PATIENT RIGHTS .................................................................................... 199 TO.5 DOCUMENTATION ....................................................................................................... 200 TO.6 ORGAN TRANSPLANTATION.......................................................................................... 200 TO.7 TRANSPLANT CANDIDATES .......................................................................................... 200 SWING BEDS (SB).............................................................................................................. 202 SB.1 FACILTY ELIGIBILITY ................................................................................................... 202 ADMISSION, TRANSFER AND DISCHARGE (TD) ...................................................................... 203 TD.1 TRANSFER AND DISCHARGE REQUIREMENTS.................................................................. 203 TD.2 DOCUMENTATION ....................................................................................................... 204 TD.3 NOTIFICATION ........................................................................................................... 204 TD.4 ORIENTATION FOR TRANSFER OR DISCHARGE................................................................ 205 TD.5 CHANGE OF ROOM IN COMPOSITE DISTINCT PART.......................................................... 206 TD.6 DISCHARGE SUMMARY ................................................................................................ 206 PLAN OF CARE (PC) ............................................................................................................ 207 PC.1 ASSESSMENT ............................................................................................................. 207 PC.2 CARE PLAN................................................................................................................. 208 RESIDENTS RIGHTS (RR) .................................................................................................... 210 RR.1 EXERCISE OF RIGHTS ................................................................................................. 210 RR.2 NOTICE OF RIGHTS AND SERVICES ............................................................................... 210 RR.3 HEALTH CARE DECISIONS ............................................................................................ 212 RR.4 ADVANCE DIRECTIVES................................................................................................. 212 RR.5 MEDICAID BENEFITS ................................................................................................... 213 RR.6 PERSONAL PRIVACY AND CONFIDENTIALITY ................................................................... 213 RR.7 RESTRAINTS .............................................................................................................. 215 RR.8 FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION ................................................... 215 RR.9 WORK ....................................................................................................................... 218 FACILITY SERVICES (FS) ..................................................................................................... 220 FS.1 PATIENT ACTIVITIES ................................................................................................... 220 FS.2 SOCIAL SERVICES....................................................................................................... 221 FS.3 DENTAL SERVICES ...................................................................................................... 222 FS.4 SPECIALIZED REHABILITATIVE SERVICES ...................................................................... 223

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