JOINTCOMMISSIONINTERNATIONALACCREDITATIONSTANDARDSFORHOSPITALS,4THEDITION美国医疗机构评审国际联合委员会国际医院管理标准国际医院管理标准（第四版）（2011年1月1日起执行）SectionSectionI:I: Patient-Centered Patient-CenteredStandards Standards 患者中心标准患者中心标准InternationalPatientSafetyGoals(IPSG)国际患者安全目标AccesstoCareandContinuityofCare(ACC)医疗护理途径及连续性PatientandFamilyRights(PFR)患者及其家属权益AssessmentofPatients(AOP)患者评估CareofPatients(COP)患者的医疗护理AnesthesiaandSurgicalCare(ASC)麻醉及外科医疗护理MedicationManagementandUse(MMU)药品管理和使用PatientandFamilyEducation(PFE)患者及其家属教育InternationalPatientSafetyGoals(IPSG)国际患者安全目标IPSG.1IdentifyPatientsCorrectlyIPSG.2ImproveEffectiveCommunicationIPSG.3ImprovetheSafetyofHigh-AlertMedicationsIPSG.4EnsureCorrect-Site,Correct-Procedure,Correct-PatientSurgeryIPSG.5ReducetheRiskofHealthCareAssociatedInfectionsIPSG.6ReducetheRiskofPatientHarmResultingfromFallsInternationalPatientSafetyGoals(IPSG)国际患者安全目标IPSG.1正确辨认患者IPSG.2有效地改进沟通IPSG.3改进高敏感性疗程的安全性IPSG.4保证正确部位，正确做法，正确患者手术IPSG.5减少相关医疗风险IPSG.6减少患者摔倒发生伤害的风险AccesstoCareandContinuityofCare(ACC)医疗护理途径及连续性ACC.1Patientsareadmittedtoreceiveinpatientcareorregisteredforoutpatientservicesbasedontheiridentifiedhealthcareneedsandtheorganizationsmissionandresources.ACC.2Theorganizationdesignsandcarriesoutprocessestoprovidecontinuityofpatientcareservicesintheorganizationandcoordinationamonghealthcarepractitioners.ACC.3Thereisapolicyguidingthereferralordischargeofpatients.ACC.4Patientsaretransferredtootherorganizationsbasedonstatusandtheneedtomeettheircontinuingcareneeds.ACC.5Theprocessforreferring,transferring,ordischargingpatients,bothinpatientsandoutpatients,includesplanningtomeetthepatientstransportationneeds.AccesstoCareandContinuityofCare(ACC)医疗护理途径及连续性ACC.1根据患者治疗需求和医院使命及资源，决定患者住院治疗或门诊治疗ACC.2在医院科室和医护人员间制定并实施相互协调的程序，为患者提供连续的医疗服务ACC.3指导患者转诊或出院的制度明确ACC.4根据病情和需要，为让患者得到持续治疗，有患者转院制度ACC.5住院和门诊患者的转诊、转院，或出院程序含有患者运送需求的计划PatientandFamilyRights(PFR)患者及其家属权益PFR.1Theorganizationisresponsibleforprovidingprocessesthatsupportpatientsandfamiliesrightsduringcare.PFR.2Theorganizationsupportspatientsandfamiliesrightstoparticipateinthecareprocess.PFR.3Theorganizationinformspatientsandfamiliesaboutitsprocesstoreceiveandtoactoncomplaints,conflicts,anddifferencesofopinionaboutpatientcareandthepatientsrighttoparticipateintheseprocesses.PFR.4Staffmembersareeducatedabouttheirrolesinidentifyingpatientsvaluesandbeliefsandprotectingpatientsrights.PFR.5Allpatientsareinformedabouttheirrightsandresponsibilitiesinamannerandlanguagetheycanunderstand.PFR.6Patientinformedconsentisobtainedthroughaprocessdefinedbytheorganizationandcarriedoutbytrainedstaffinalanguagethepatientcanunderstand.PatientandFamilyRights(PFR)患者及其家属权益PFR.1医院负责提供支持患者及其家属在治疗期间权益的程序PFR.2医院支持患者及其家属参与治疗过程的权益PFR.3医院告知患者及其家属有关受理投诉、纠风和不同治疗意见的程序，及参与这些程序的权益PFR.4教育员工正确对待不同价值观和信仰的患者，并维护其权益PFR.5以患者能理解的方式和语言告知其权益和责任PFR.6用患者能理解的语言训炼员工，并由其通过医院制定的程序获得患者知情同意PatientandFamilyRights(PFR)患者及其家属权益PFR.7Theorganizationinformspatientsandfamiliesabouthowtogainaccesstoclinicalresearch,clinicalinvestigation,orclinicaltrialsinvolvinghumansubjects.PFR.8Informedconsentisobtainedbeforeapatientparticipatesinclinicalresearch,clinicalinvestigation,andclinicaltrials.PFR.9Theorganizationhasacommitteeoranotherwaytooverseeallresearchintheorganizationinvolvinghumansubjects.PFR.10Theorganizationinformspatientsandfamiliesabouthowtochoosetodonateorgansandothertissues.PFR.11Theorganizationprovidesoversightoftheharvestingandtransplantationoforgansandtissues.PatientandFamilyRights(PFR)患者及其家属权益PFR.7医院告知患者及其家属有关如何获得以人体为对象的临床研究、监床调查和临床试验的途经PFR.8在患者参与临床研究、临床调查和临床试验前，获得患者知情同意PFR.9医院有一个委员会或其他方式监督院内所有以人体为对象的研究PFR.10医院告知患者及其家属有关如何选择捐献人体器官和其他人体组织PFR.11医院监督获取和移植人体器官或组织AssessmentofPatients(AOP)患者评估AOP.1Allpatientscaredforbytheorganizationhavetheirhealthcareneedsidentifiedthroughanestablishedassessmentprocess.AOP.2Allpatientsarereassessedatintervalsbasedontheirconditionandtreatmenttodeterminetheirresponsetotreatmentandtoplanforcontinuedtreatmentordischarge.AOP.3Qualifiedindividualsconducttheassessmentsandreassessments.AOP.4Physicians,nurses,andotherindividualsandservicesresponsibleforpatientcarecollaboratetoanalyzeandtointegratepatientassessments.AOP.5Laboratoryservicesareavailabletomeetpatientneeds,andallsuchservicesmeetapplicablelocalandnationalstandards,laws,andregulations.AOP.6Radiologyanddiagnosticimagingservicesareavailabletomeetpatientneeds,andallsuchservicesmeetapplicablelocalandnationalstandards,laws,andregulations.AssessmentofPatients(AOP)患者评估AOP.1通过已建立的评估程序，医院确定了所有患者的医疗需求AOP.2根据情况和治疗需要，在一定间隔时间内对所有患者进行再评估，观察他们对治疗的反应，制定持续治疗或出院计划AOP.3由有资质的人员指挥评估和再评估AOP.4医师、护士和其他负责患者治疗的人员及科室共同分析和归纳患者评估AOP.5所有实验室服务能有效地满足患者需要，并符合当地和国家标准、法律及法规AOP.6所有放射和影像服务能有效地满足患者需要，并符合当地和国家标准、法律及法规CareofPatients(COP)患者的医疗护理COP.1Policiesandproceduresandapplicablelawsandregulationsguidetheuniformcareofallpatients.COP.2Thereisaprocesstointegrateandtocoordinatethecareprovidedtoeachpatient.COP.3Policiesandproceduresguidethecareofhighriskpatientsandtheprovisionofhigh-riskservices.COP.4Avarietyoffoodchoices,appropriateforthepatientsnutritionalstatusandconsistentwithhisorherclinicalcare,isregularlyavailable.COP.5Patientsatnutritionriskreceivenutritiontherapy.COP.6Patientsaresupportedinmanagingpaineffectively.COP.7Theorganizationaddressesend-of-lifecare.CareofPatients(COP)患者的医疗护理COP.1治疗规范，并符合政策、程序及有关法律和法规COP.2对每位患者提供的治疗有一个集成和协调的程序COP.3高危患者的治疗与高危服务的提供符合政策、程序COP.4各种各样的食物选择规范有效，符合患者营养状况，并与临床治疗一致COP.5有营养风险的患者接受营养治疗COP.6支持患者有效地管理疼通COP.7医院提供临终关怀治疗AnesthesiaandSurgicalCare(ASC)麻醉和外科治疗麻醉和外科治疗ASC.1Anesthesiaservices(includingmoderateanddeepsedation)areavailabletomeetpatientneeds,andallsuchservicesmeetapplicablelocalandnationalstandards,laws,andregulationsandprofessionalstandards.ASC.2Aqualifiedindividual(s)isresponsibleformanagingtheanesthesiaservices(includingmoderateanddeepsedation).ASC.3Policiesandproceduresguidethecareofpatientsundergoingmoderateanddeepsedation.ASC.4Aqualifiedindividualconductsapreanesthesiaassessmentandpreinductionassessment.AnesthesiaandSurgicalCare(ASC)麻醉和外科治疗麻醉和外科治疗ASC.1 所有麻醉服务（包括中度和深度镇静）满足患者需求，并符合当地和国家标准、法律、法规和专业标准ASC.2 由有资质的人员负责管理麻醉服务（包括中度和深度镇静）ASC.3 政策和程序指导患者接受中度及深度镇静治疗ASC.4 由有资质的人员指导麻醉前评估和正式手术前评估AnesthesiaandSurgicalCare(ASC)麻醉和外科治疗麻醉和外科治疗ASC.5Eachpatientsanesthesiacareisplannedanddocumentedinthepatientsrecord.ASC.6Eachpatientspostanesthesiastatusismonitoredanddocumented,andthepatientisdischargedfromtherecoveryareabyaqualifiedindividualorbyusingestablishedcriteria.ASC.7Eachpatientssurgicalcareisplannedanddocumentedbasedontheresultsoftheassessment.AnesthesiaandSurgicalCare(ASC)麻醉和外科治疗麻醉和外科治疗ASC.5 在患者病历中，有每位患者的麻醉治疗计划和纪录ASC.6 监测和纪录每位患者麻醉的状态，由有资质的人员，或按已建立的标准批准患者离开恢复区ASC.7 根据评估结果制定每位患者的外科治疗计划，并纪录在案MedicationManagementandUse(MMU)药品管理和使用药品管理和使用MMU.1Medicationuseintheorganizationcomplieswithapplicablelawsandregulationsandisorganizedtomeetpatientneeds.MMU.2Anappropriateselectionofmedicationsforprescribingororderingisstockedorreadilyavailable.MMU.3Medicationsareproperlyandsafelystored.MMU.4Prescribing,ordering,andtranscribingareguidedbypoliciesandprocedures.MMU.5Medicationsarepreparedanddispensedinasafeandcleanenvironment.MMU.6Theorganizationidentifiesthosequalifiedindividualspermittedtoadministermedications.MMU.7Medicationeffectsonpatientsaremonitored.MedicationManagementandUse(MMU)药品管理和使用药品管理和使用MMU.1 医院用药符合法律法规，并有效地满足患者需求MMU.2 规定或医嘱药品的选择库存可用MMU.3 正确、安全贮存药品MMU.4 按政策和程序开处方、下医嘱和抄录用药MMU.5 在安全和清洁环境下准备、分发药品MMU.6 医院只允许有资质的人员执行用药 MMU.7 监控患者用药疗效PatientandFamilyEducation(PFE)患者和家属教育PFE.1Theorganizationprovideseducationthatsupportspatientandfamilyparticipationincaredecisionsandcareprocesses.PFE.2Eachpatientseducationalneedsareassessedandrecordedinhisorherrecord.PFE.3Educationandtraininghelpmeetpatientsongoinghealthneeds.PFE.4Patientandfamilyeducationincludesthefollowingtopics,relatedtothepatientscare:thesafeuseofmedications,thesafeuseofmedicalequipment,potentialinteractionsbetweenmedicationsandfood,nutritionalguidance,painmanagement,andrehabilitationtechniques.PFE.5Educationmethodsincludethepatientsandfamilysvaluesandpreferencesandallowsufficientinteractionamongthepatient,family,andstaffforlearningtooccur.PFE.6Healthprofessionalscaringforthepatientcollaboratetoprovideeducation.PatientandFamilyEducation(PFE)患者和家属教育PFE.1医院提供教育支持患者和家属参与治疗决策及治疗过程PFE.2评估每位患者的教育需求，并记入病历PFE.3教育与训炼有助于满足患者持续健康需求PFE.4患者和家属教育包括下列患者治疗的相关题目：安全用药、安全使用医疗设备、药品与食物间的潜在相互作用、营养指导、疼通管理，及康复技术PFE.5教育方法包括患者和家属的价值观和特选需求，并允许患者、家属和员工在学习上充足地交流PFE.6为患者治疗的医护人员配合提供教育Section II: Section II: Health Care Organization Management StandardsHealth Care Organization Management Standards医疗机构管理标准医疗机构管理标准QualityImprovementandPatientSafety(QPS)质量改进与患者安全质量改进与患者安全PreventionandControlofInfections(PCI)感染预防与控制感染预防与控制Governance,Leadership,andDirection(GLD)政府、领导和向导政府、领导和向导FacilityManagementandSafety(FMS)设施管理和安全设施管理和安全StaffQualificationsandEducation(SQE)员工资格与教育员工资格与教育ManagementofCommunicationandInformation(MCI)沟通与情报管理沟通与情报管理QualityImprovementandPatientSafety(QPS)质量改进与患者安全质量改进与患者安全QPS.1Thoseresponsibleforgoverningandmanagingtheorganizationparticipateinplanningandmeasuringaqualityimprovementandpatientsafetyprogram.QPS.2Theorganizationdesignsnewandmodifiedsystemsandprocessesaccordingtoqualityimprovementprinciples.QPS.3Theorganizationsleadersidentifykeymeasuresintheorganizationsstructures,processes,andoutcomestobeusedintheorganizationwidequalityimprovementandpatientsafetyplan.QPS.4Individualswithappropriateexperience,knowledge,andskillssystematicallyaggregateandanalyzedataintheorganization.QPS.5Theorganizationusesaninternalprocesstovalidatedata.QPS.6TheorganizationusesadefinedprocessforidentifyingandmanagingsentineleventsQualityImprovementandPatientSafety(QPS)质量改进与患者安全质量改进与患者安全QPS.1医院责任人和管理者参与质量改进、患者安全项目的计划与监控QPS.2医院按照质量改进原则重新设计或修定各种体系与流程QPS.3在完善医院结构、流程及结果中，领导制定应用于医院领域质量改进和患者安全计划的关键措施QPS.4由具有相应经验、知识及技能的人员系统地收集和分析医院数据QPS.5医院用内部程序确认数据QPS.6医院制定程序，确定和管理警哨事件QualityImprovementandPatientSafety(QPS)质量改进与患者安全质量改进与患者安全QPS.7Dataareanalyzedwhenundesirabletrendsandvariationareevidentfromthedata.QPS.8Theorganizationusesadefinedprocessfortheidentificationandanalysisofnear-missevents.QPS.9Improvementinqualityandsafetyisachievedandsustained.QPS.10Improvementandsafetyactivitiesareundertakenforthepriorityareasidentifiedbytheorganizationsleaders.QPS.11Anongoingprogramofriskmanagementisusedtoidentifyandtoreduceunanticipatedadverseeventsandothersafetyriskstopatientsandstaff.QualityImprovementandPatientSafety(QPS)质量改进与患者安全质量改进与患者安全QPS.7数据显示不良趋势和变异时，分析数据QPS.8对临近差错事件的确认和分析，医院按既定程序办理QPS.9质量与安全改进到位并维持QPS.10医院领导确定的重点领域承担了改进与安全活动QPS.11持续的风险管理程序应用于确认和减少对患者及员工的意外有害事件与其他安全风险PreventionandControlofInfections(PCI)感染预防与控制感染预防与控制PCI.1Oneormoreindividualsoverseeallinfectionpreventionandcontrolactivities.Thisindividual(s)isqualifiedininfectionpreventionandcontrolpracticesthrougheducation,training,experience,orcertification.PCI.2Thereisadesignatedcoordinationmechanismforallinfectionpreventionandcontrolactivitiesthatinvolvesphysicians,nurses,andothersasbasedonthesizeandcomplexityoftheorganization.PCI.3Theinfectionpreventionandcontrolprogramisbasedoncurrentscientificknowledge,acceptedpracticeguidelines,applicablelawsandregulations,andstandardsforsanitationandcleanliness.PCI.4Theorganizationsleadersprovideadequateresourcestosupporttheinfectionpreventionandcontrolprogram.PCI.5Theorganizationdesignsandimplementsacomprehensiveprogramtoreducetherisksofhealthcareassociatedinfectionsinpatientsandhealthcareworkers.PCI.6Theorganizationusesarisk-basedapproachinestablishingthefocusofthehealthcareassociatedinfectionpreventionandreductionprogram.PreventionandControlofInfections(PCI)感染预防与控制感染预防与控制PCI.1一个或多个员工负责所有感染预防和控制活动。通过教育、训炼、实践或认证，这些员工在感染预防和控制活动中具有资质。PCI.2根据医院大小和复杂性，对所有的感染预防和控制活动，有一个指定的，包括医师、护士和其他员工在内的协调机制PCI.3建立在现代科学知识、有效实用指南之上的感染预防和控制程序符合法律、法规及卫生与清洁标准PCI.4医院领导提供足够的资源支持感染预防和控制程序。PCI.5医院设计并实施综合方案，减少医疗风险患者和卫生保健工作者的交叉感染。PCI.6在建立医疗重点感染预防和减少方案中，医院使用以风险为基础的方法PreventionandControlofInfections(PCI)感染预防与控制感染预防与控制PCI.7Theorganizationidentifiestheproceduresandprocessesassociatedwiththeriskofinfectionandimplementsstrategiestoreduceinfectionrisk.PCI.8Theorganizationprovidesbarrierprecautionsandisolationproceduresthatprotectpatients,visitors,andstafffromcommunicablediseasesandprotectsimmunosuppressedpatientsfromacquiringinfectionstowhichtheyareuniquelyprone.PCI.9Gloves,masks,eyeprotection,otherprotectiveequipment,soap,anddisinfectantsareavailableandusedcorrectlywhenrequired.PCI.10Theinfectionpreventionandcontrolprocessisintegratedwiththeorganizationsoverallprogramforqualityimprovementandpatientsafety.PCI.11Theorganizationprovideseducationoninfectionpreventionandcontrolpracticestostaff,physicians,patients,families,andothercaregiverswhenindicatedbytheirinvolvementincare.PreventionandControlofInfections(PCI)感染预防与控制感染预防与控制PCI.7 医院确定应对感染风险的程序和过程，并实施减少感染感染风险的策略。PCI.8 医院提供防范屏障和隔离程序，保护患者、探视者及员工免得传染病，特别要保护来自易感人群的免疫抑制患者。PCI.9 提供手套、口具、眼罩,及其他防护设备、肥皂和消液,在需要时能正确使用。PCI.10 感染预防与控制整合于医院总体质量改进和患者安全程序。PCI.11 医院对必须参与治疗的员工、医师、患者、家属及其他护理人员提供感染预防与控制教育。Governance,Leadership,andDirection(GLD)政府、领导和指南政府、领导和指南GLD.1Governanceresponsibilitiesandaccountabilitiesaredescribedinbylaws,policiesandprocedures,orsimilardocumentsthatguidehowtheyaretobecarriedout.GLD.2Aseniormanagerordirectorisresponsibleforoperatingtheorganizationandcomplyingwithapplicablelawsandregulations.GLD.3Theorganizationsleadersareidentifiedandarecollectivelyresponsiblefordefiningtheorganizationsmissionandcreatingtheplansandpoliciesneededtofulfillthemission.GLD.4Medical,nursing,andotherleadersofclinicalservicesplanandimplementaneffectiveorganizationalstructuretosupporttheirresponsibilitiesandauthority.GLD.5Oneormorequalifiedindividualsprovidedirectionforeachdepartmentorserviceintheorganization.GLD.6Theorganizationestablishesaframeworkforethicalmanagementthatensuresthatpatientcareisprovidedwithinbusiness,financial,ethical,andlegalnormsandthatprotectspatientsandtheirrights.Governance,Leadership,andDirection(GLD)政府、领导和指南政府、领导和指南GLD.1政府责任与职责表述为制度、政策和程序，或明确如何贯彻实施类似文件。GLD.2高管或主管对医院运行负责，并遵守适用法律和法规。GLD.3医院领导人确定，并集体负责制定医院使命,创建实现使命所需要的规划和政策。GLD.4医疗、护理及其他临床服务的领导者计划并执行有效的组织结构，支持其责任和权威。GLD.5一个或多个有资质的人员对医院的每个科室或服务提供指导。GLD.6保证为患者提供的治疗符合商业、金融、伦理、法律规范，并保护患者和他们的权利。FacilityManagementandSafety(FMS)设施管理和安全设施管理和安全FMS.1Theorganizationcomplieswithrelevantlaws,regulations,andfacilityinspectionrequirements.FMS.2Theorganizationdevelopsandmaintainsawrittenplan(s)describingtheprocessestomanageriskstopatients,families,visitors,andstaff.FMS.3Oneormorequalifiedindividualsoverseetheplanningandimplementationoftheprogramtomanagetherisksinthecareenvironment.FMS.4Theorganizationplansandimplementsaprogramtoprovideasafeandsecurephysicalenvironment.FMS.5Theorganizationhasaplanfortheinventory,handling,storage,anduseofhazardousmaterialsandthecontrolanddisposalofhazardousmaterialsandwaste.FMS.6Theorganizationdevelopsandmaintainsanemergencymanagementplanandprogramtorespondtolikelycommunityemergencies,epidemics,andnaturalorotherdisasters.FacilityManagementandSafety(FMS)设施管理和安全设施管理和安全FMS.1医院遵守有关法律、法规和设备检查要求。FMS.2医院编写和维护了描写管理患者、家属、探访者和工作人员风险过程的书面方案。FMS.3一个或多个有资格的人员监督管理治疗环境风险程序的计划和实施。FMS.4医院计划和实施了提供安全可靠的硬件环境的程序FMS.5医院有危险物品的清点、处理、贮存、使用及危险品与废物的控制和清理计划。FMS.6医院编写和维护应对可能的社区紧急事件、流行病、自然或其他灾害的紧急管理方案与程序FacilityManagementandSafety(FMS)设施管理和安全设施管理和安全FMS.7Theorganizationplansandimplementsaprogramtoensurethatalloccupantsaresafefromfire,smoke,orotheremergenciesinthefacility.FMS.8Theorganizationplansandimplementsaprogramforinspecting,testing,andmaintainingmedicalequipmentanddocumentingtheresults.FMS.9Potablewaterandelectricalpowerareavailable24hoursaday,sevendaysaweek,throughregularoralternatesources,tomeetessentialpatientcareneeds.FMS.10Electrical,water,waste,ventilation,medicalgas,andotherkeysystemsareregularlyinspected,maintained,and,whenappropriate,improved.FMS.11Theorganizationeducatesandtrainsallstaffmembersabouttheirrolesinprovidingasafeandeffectivepatientcarefacility.FacilityManagementandSafety(FMS)设施管理和安全设施管理和安全FMS.7医院制定和实施了一个程序,确保所有住户是远离设备意外发生的火灾、烟雾、或其他突发事件。FMS.8医院制定和实施一个检查、测试、维护医疗设备的程序，并记录结果。通过常规或备用源，饮用水和电力一周7天、一天24小时可用，以满足基本患者的治疗需求。FMS.10定期检查和维护电气、水、废弃物、通风、医用气体和其它关键系统，并在适当的时候予以改进FMS.11医院教育和培训全体员工在为患者提供安全、有效的治疗设施时所应扮演的角色。StaffQualificationsandEducation(SQE)员工资格与教育员工资格与教育SQE.1Organizationleadersdefinethedesirededucation,skills,knowledge,andotherrequirementsofallstaffmembers.SQE.2Organizationleadersdevelopandimplementprocessesforrecruiting,evaluating,andappointingstaffaswellasotherrelatedproceduresidentifiedbytheorganization.SQE.3Theorganizationusesadefinedprocesstoensurethatclinicalstaffknowledgeandskillsareconsistentwithpatientneeds.SQE.4Theorganizationusesadefinedprocesstoensurethatnonclinicalstaffknowledgeandskillsareconsistentwithorganizationneedsandtherequirementsoftheposition.SQE.5Thereisdocumentedpersonnelinformationforeachstaffmember.SQE.6Astaffingplanfortheorganization,developedcollaborativelybytheleaders,identifiesthenumber,types,anddesiredqualificationsofstaff.StaffQualificationsandEducation(SQE)员工资格与教育员工资格与教育SQE.1医院领导者使全体员工明确渴望得到的教育、技能、知识、和其他要求。SQE.2院领导者制定和实施招聘、评价和委任员工及其他有关医院确定的程序。SQE.3医院使用确定的程序，保证临床医护人员的知识和技能与患者需求一致SQE.4医院使用确定的程序，保证非临床员工的知识和技能与医院及岗位的的需求一致SQE.5每位员工的人事信息都有纪录SQE.6领导者合作制定的员工计划确定了医院员工数量、类型及资格要求StaffQualificationsandEducation(SQE)员工资格与教育员工资格与教育SQE.7Allclinicalandnonclinicalstaffmembersareorientedtotheorganization,thedepartment,orunittowhichtheyareassignedandtotheirspecificjobresponsibilitiesatappointmenttothestaff.SQE.8Eachstaffmemberreceivesongoingin-serviceandothereducationandtrainingtomaintainortoadvancehisorherskillsandknowledge.SQE.9Theorganizationhasaneffectiveprocessforgathering,verifying,andevaluatingthecredentials(license,education,training,competence,andexperience)ofthosemedicalstaffpermittedtoprovidepatientcarewithoutsupervision.SQE.10Theorganizationhasastandardizedobjective,evidence-basedproceduretoauthorizeallmedicalstaffmemberstoadmitandtotreatpatientsandtoprovideotherclinicalservicesconsistentwiththeirqualifications.SQE.11Theorganizationusesanongoingstandardizedprocesstoevaluatethequalityandsafetyofthepatientservicesprovidedbyeachmedicalstaffmember.SQE.12Theorganizationhasaneffectiveprocesstogather,toverify,andtoevaluatethenursingstaffscredentials(license,education,training,andexperience).StaffQualificationsandEducation(SQE)员工资格与教育员工资格与教育SQE.7所有的临床和非临床员工适应于指定的医院、科室、部门，及任命职位的特定工作职责。SQE.8每位员工接受持续的在职，或其他教育与培训，保持或提高其技能和知识水平。SQE.9医院通过有效的方法，收集、审核、评价允许医务人员没有监管而行医的证书(许可证、教育、培训、能力和经验)。SQE.10医院通过标准化的客观循证程序，授权所有医疗人员接纳、治疗患者，并提供与任职资格一致的其他临床服务SQE.11医院通过持续标准化的程序评估每位医务人员服务于患者的质量与安全SQE.12医院通过有效的方法，收集、审核、评价护理人员的资格证书(许可、教育、培训和经验)。StaffQualificationsandEducation(SQE)员工资格与教育员工资格与教育SQE.13Theorganizationhasastandardizedproceduretoidentifyjobresponsibilitiesandtomakeclinicalworkassignmentsbasedonthenursingstaffmemberscredentialsandanyregulatoryrequirements.SQE.14Theorganizationhasastandardizedprocedurefornursingstaffparticipationintheorganizationsqualityimprovementactivities,includingevaluatingindividualperformancewhenindicated.SQE.15Theorganizationhasastandardizedproceduretogather,toverify,andtoevaluateotherhealthprofessionalstaffmemberscredentials(license,education,training,andexperience).SQE.16Theorganizationhasastandardizedproceduretoidentifyjobresponsibilitiesandtomakeclinicalworkassignmentsbasedonotherhealthprofessionalstaffmemberscredentialsandanyregulatoryrequirements.SQE.17Theorganizationhasaneffectiveprocessforotherhealthprofessionalstaffmembersparticipationintheorganizationsqualityimprovementactivities.StaffQualificationsandEducation(SQE)员工资格与教育员工资格与教育SQE.13根据护理人员证书和管理要求，医院通过标准化的程式序确定工作责任，并进行临床工作分配SQE.14医院通过标准化的程序让护理人员参与医院的质量改进活动，必要时包括评估员工绩效SQE.15医院通过标准化的程序，收集、核实、评估其他卫生专业人员的资格证书（许可、教育、培训和经验）SQE.16根据其他卫生专业人员的资格证书和管理要求，医院通过标准化的程序确定工作责任，进行临床工作分配SQE.17医院通过有效的方法，让其他卫生专业人员参与医院的质量改进活动ManagementofCommunicationandInformation(MCI)沟通与信息管理沟通与信息管理MCI.1Theorganizationcommunicateswithitscommunitytofacilitateaccesstocareandaccesstoinformationaboutitspatientcareservices.MCI.2Theorganizationinformspatientsandfamiliesaboutitscareandservicesandhowtoaccessthoseservices.MCI.3Patientandfamilycommunicationandeducationareprovidedinanunderstandableformatandlanguage.MCI.4Communicationiseffectivethroughouttheorganization.MCI.5Theleadersensurethatthereiseffectivecommunicationandcoordinationamongthoseindividualsanddepartmentsresponsibleforprovidingclinicalservices.MCI.6Informationaboutthepatientscareandresponsetocareiscommunicatedamongmedical,nursing,andotherhealthcarepractitionersduringeachstaffingshiftandbetweenshifts.MCI.7Thepatientsrecord(s)isavailabletothehealthcarepractitionerstofacilitatethecommunicationofessentialinformation.ManagementofCommunicationandInformation(MCI)沟通与信息管理沟通与信息管理MCI.1医院与其社区沟通促进获得医疗业务，并获取有关患者的医疗服务信息MCI.2医院告知患者及家属有关治疗和服务内容，并告知如何获取这些服务MCI.3用患者及家属能理解的形式和语言提供沟通和教育服务MCI.4贯穿医院的沟通是有效的MCI.5领导确保医务人员和科室负责提供的临床服务中存在着有效的沟通与协调机制MCI.6每个班次及班次交接期间有关患者治疗和治疗反应情报，在医疗、护理与其卫生治疗者中已经沟通MCI.7病历是医疗工作者的可用资料，有助于基本情信息沟通ManagementofCommunicationandInformation(MCI)沟通与信息管理沟通与信息管理MCI.8Informationrelatedtothepatientscareistransferredwiththepatient.MCI.9Theorganizationplansanddesignsinformationmanagementprocessestomeetinternalandexternalinformationneeds.MCI.10Informationprivacyandconfidentialityaremaintained.MCI.11Informationsecurity,includingdataintegrity,ismaintained.MCI.12Theorganizationhasapolicyontheretentiontimeofrecords,data,andinformation.MCI.13Theorganizationusesstandardizeddiagnosiscodes,procedurecodes,symbols,abbreviations,anddefinitions.MCI.14Thedataandinformationneedsofthoseinandoutsidetheorganizationaremetonatimelybasisinaformatthatmeetsuserexpectationsandwiththedesiredfrequency.ManagementofCommunicationandInformation(MCI)沟通与信息管理沟通与信息管理MCI.8有关患者治疗的信息随患者转移MCI.9医院设计与制定信息管理程序，满足院内外信息需求MCI.10保持信息的私密性和机密性MCI.11保持信息的安全性，包括数据完整性MCI.12医院有病历、数据、信息保留时限的政策MCI.13医院使用标准化的诊断码、程序码、符号、缩略语及定义MCI.14院内外数据与信息需求，以满足使用者期望值和期望频率的形式即时得到满足ManagementofCommunicationandInformation(MCI)沟通与信息管理沟通与信息管理MCI.15Appropriateclinicalandmanagerialstaffparticipateinselecting,integrating,andusinginformationmanagementtechnology.MCI.16Recordsandinformationareprotectedfromloss,destruction,tampering,andunauthorizedaccessoruse.MCI.17Decisionmakersandotherappropriatestaffmembersareeducatedandtrainedintheprinciplesofinformationmanagement.MCI.18Awrittenpolicyorprotocoldefinestherequirementsfordevelopmentandmaintenanceofinternalpoliciesandproceduresandaprocessformanagingexternalpoliciesandprocedures.MCI.19Theorganizationinitiatesandmaintainsaclinicalrecordforeverypatientassessedortreated.MCI.20Aggregatedataandinformationsupportpatientcare,organizationmanagement,andthequalitymanagementprogram.MCI.21Theorganizationsupportspatientcare,education,research,andmanagementwithtimelyinformationfromcurrentsources.ManagementofCommunicationandInformation(MCI)沟通与信息管理沟通与信息管理MCI.15适当的临床和管理人员参与选择、归纳和使用信息管理技术MCI.16保护病历和信息，使之免受丢失、破坏、干预、越权存取或使用MCI.17用信息管理原则教育和训炼决策者与其他适当的员工MCI.18书面政策或协议定义了内部规章和程序建立与维护的需求，及管理外部政策与程序的过程MCI.19医院为每位评估或治疗的患者建立，并保护临床病历MCI.20综合数据与信息支持患者治疗、医院管理，及质量管项目MCI.21医院支持患者治疗、教育、调研和来自目前资源的及时信息管理