Constant Readiness Handout PDF

CONSTANT READINESS:
RECOMMENDATIONS FOR JOINT

COMMISSION STANDARDS
Elevate Your Program to the Next Level!

MARY MCCORMACK, CAVS, CDVS
Information Enterprises
Jacksonville, Florida
CONSTANT READINESS:
RECOMMENDATIONS FOR JOINT COMMISSION STANDARDS
THE JOINT COMMISSION

PAST, PRESENT, AND FUTURE OF THE JOINT COMMISSION
2012 NATIONAL PATIENT SAFETY GOALS
JOINT COMMISSION STANDARDS
FOCUS ON USING STANDARDS TO TAKE VOLUNTEER
PROGRAMS TO THE NEXT LEVEL OF EXCELLENCE!
PAST HISTORY OF THE JOINT COMMISSION
Established in 1951
Private, non-profit organization.
Considered the Gold Standard of accreditation
Accreditation qualifies organizations for important third-party payments that can make or break the
financial bottom line.
Seven of the Joint Commissions programs are recognized and approved by the federal Centers for
Medicare and Medicaid Services, meaning that certain health care organizations accredited by the Joint
Commission meet Medicare and Medicaid certification requirements and may participate in and receive
payment from these programs.
VOLUNTARY ACCREDITATION: Over 19,000 healthcare organizations pay to be surveyed to

achieve accreditation.
PERSPECTIVE OF JOINT PARTNERSHIPS
Website: www.jointcommission.org
PRESENT: THE JOINT COMMISSION TODAY

MISSION: "The mission of the Joint Commission is to continuously improve health care for the
public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring
them to excel in providing safe and effective care of the highest quality and value."
Source: www.jointcommission.org
VISION: All people always experience the safest quality, best-value health care across all settings.
CONSTANT READINESS: Recommendations for Joint Commission Standards
2012 Mary McCormack. All rights reserved worldwide. Tel/Fax: (904) 262-9874 Mobile: (904) 233-7973
Post Office Box 57122, Jacksonville, Florida 32241-7122 [email protected] http://www.keyspeaker.com
CONSTANT READINESS:
TJC FREQUENTLY ASKED QUESTIONS (FAQ):
How to use the Standards FAQs Source: www.jointcommission.org
One of the most visited sections of The Joint Commission website is Standards FAQs.
The FAQs can be found under the Standards tab.
The questions are organized by accreditation/certification manual and by chapter to which they
pertain.
To view all the FAQs for a particular manual:

1. Choose the manual from the drop down menu on the page and click the Go button or hit enter
2. You will then see a complete listing of FAQs for the manual selected.
To limit your search for standards FAQs by keyword:
1.
Choose the manual from the drop down menu on the page and enter a word in the optional box,
e.g. Credentialing
2. Click the Go button or hit enter
If there are any FAQs with the keyword entered, they will be displayed in the results. If no FAQs
are displayed you will see this message, No results found for your selection
Two other important items to help use the standards FAQs are:
1. If an FAQ is new or updated it will display at the top of the manual page for 30 days.
2. Each FAQ has status. You can view the status definitions by mousing over the Status
Definitions? link on the top of standards FAQs page.
Note: You can also enter the word volunteer in any of the standards search boxes, to see if there
are any new references to volunteer services. (There are none as of May, 2012.)
NOTES: _________________________________________________

CONSTANT READINESS:
Survey Format Tracer Methodology: Patient Tracers examines care throughout patients stay.
System Tracers focus on high-risk system processes (medication management, infection control and
use of data)
S3: The Strategic Surveillance System

o Provides a series of risk assessment and comparative performance measure reports to help
hospitals improve their care processes and helps hospitals prioritize the actions to take for
improvement. Source: www.jointcommission.org
Tool 1 Performance Risk Assessment
Tool 2 Performance Measure Compare ORYX core measure data reports
2008 Approval for methodology for conducting surveys in 18-39 months

2008 Approval for scoring change.
o Only category A and C Elements of Performance will remain.
o Category A = yes or no (TJC requirement is present or absent.) 100% compliance is needed to
meet the requirement.
o Category B (eliminated)
o Category C = multiple observations of non-compliance necessary for the Elements of
Performance to be scored as Partial Compliance or Insufficient Compliance
2008 Three point Elements of Performance Scoring Scale:

o Satisfactory Compliance
o Partial Compliance
o Insufficient Compliance
Sample list of types of surveyors (may be more or less depending on type and size of facility
and scope of services:
o
o
o
o
Administrator
Physician
Nurse
Home Health
o Ambulatory
o Safety Code Specialist
o Generalist
VOLUNTEER FOCUS AREAS:

Information Desk
Patient Transportation (Admitting, etc.)
Nursing Services and sleeping floors
Gift Shop (safety review not Human Resources review)
Surgery Waiting
Pet Therapy
Spiritual Care/Chaplaincy
CONSTANT READINESS:
According to TJC, the hospital is responsible for:
Planning:
o Defining the qualifications, competencies, and staffing necessary to provide for the
organizations care, treatment, and services.
Providing competent staff:
o Through traditional employer-employee arrangements or through contractual
arrangements with other entities or persons.
Orienting, training, and educating staff:
o Ongoing in-service and other education and training to increase staff knowledge of
specific work-related issues
Assessing, maintaining, and improving staff competence:
o Ongoing, periodic competence assessment to evaluate staff members continuing abilities
to perform throughout their association with the organization.
PATIENT CARE CATEGORY:
Volunteer services administrators must determine which volunteer duties are in the patient care
category.
There must be standards and documented compliance of volunteers who perform the identified
duties and tasks covered under the Provision of Care, Treatment, and Services (PC) Chapter.
Four questions regarding core processes or elements can be used to determine which volunteers
fall into the patient care category:
1.
Does this volunteer assess patient needs in any way?
2. Does this volunteer plan patient care, treatment, and services in any way?
3. Does this volunteer provide any care, treatment and services that the patient needs?
4. Does this volunteer coordinate patient care, treatment and services in any way?
FUTURE PREDICTIONS FOR VOLUNTEER SERVICES

Fewer Standards and Elements of Performance will explicitly include the word volunteers.
More Standards and Elements of Performance will explicitly use the word staff which includes
volunteers who provide patient care and services.
More focus will be on reviewing documentation that training and compliance is maintained and
documented by Volunteer Administration.
More questions will be asked by surveyors of volunteers and volunteer services administrators than
ever before.
CONSTANT READINESS:
FOCUS AREAS FOR 2012 STANDARDS

TJC Patient Safety Centers website, www.jcipatientsafety.org
Any area where volunteers have direct contact with patients especially patient sleeping floors
February 2008: Approved methodology for conducting unannounced surveys within an 18-39 month
window.
Changes for Volunteer Administration requirements occurred mainly in 2004, 2006, 2007, and 2009.
Since 2007, the infection control standard requires hospitals to offer influenza vaccinations to
staff, which includes volunteers, and licensed independent practitioners with close patient contact.
In 2007, the orientation standard required that the organization determine what elements of
orientation needed to occur before staff provided care, treatment and services and what elements
could take place while staff was providing care, treatment and services.
2012 NATIONAL PATIENT SAFETY GOALS:

o The
o
National Patient Safety Goals focus: Reducing the risk of health care associated
infections (through proper hand-washing) and improving patient identification accuracy
Many of these areas have applicability to volunteers. More information is available through
www.jointcommission.org and the Centers for Disease Control at www.cdc.gov.
Life Safety Chapter:

o Includes the National Fire Protection Association Life Safety Code 101
Danger to Life from Fire.

The Code addresses those construction, protection, and occupancy features necessary to
minimize danger to life from fire, including smoke, fumes, or panic.
Leadership Chapter:
o Volunteers who are asked questions by a surveyor should ask to see their identification.
o
Surveyors will have Joint Commission badges.

Organizational leadership requirements can apply to volunteer managers. Use this section as a
guide to align volunteer management processes with TJC requirements
Infection Control and Prevention (IC.02.04.01) Effective July 1, 2012

o
Vaccination against influenza offered to staff (providing care, treatment, or service on-site)
with focus on improving vaccination rates working towards the 2020 goal of 90% according to
CDC performance measures
Annually evaluate reasons for volunteers declining the influenza vaccination

CONSTANT READINESS:
Sample Joint Commission Questions

Questions for Volunteers:
o Who is your administrator?
o What is the mission of the hospital?
o Do you feel safe volunteering?
o What would you do if a violent person threatened you while volunteering?
o What would you do if you discovered a fire here in your service department?
o What would you do if you heard a code for a fire in the building (but not in your area)?
o What are you expected to do if there is a community disaster?
o What would you do in the event of a child abduction?
o What would you do if you suspected that a hospital employee was doing something illegal?
o __________________________________________________________________
o __________________________________________________________________
o __________________________________________________________________
Questions: Volunteer Administrator or Volunteer:
o Are your over-the-counter medicines sold in your Gift Shop within their freshness dates?
o Volunteer Administrator or Volunteer: Are your Gift Shop shelves made out of safety glass?
o Volunteer Administrator or Volunteer: Are your shelves stocked no higher than eighteen
inches from the ceiling for fire safety?
o __________________________________________________________________
o __________________________________________________________________
o __________________________________________________________________
Questions for Volunteer Administrator:
o What is the responsibility that Nursing has to train and supervise volunteers?
o Do you have a policy that states this?
o How are volunteers work performances evaluated?
o Who supervises the volunteers?
o Do you conduct background checks on your direct patient care volunteers?
o How do you screen students?
o What type of medical screening do you require? (TB, drug screens, etc.)
o Where do you maintain your volunteer files?
o Where do you maintain your volunteer medical information (such as annual TB test results)?
o How do you document your orientation training (or annual training)?
o __________________________________________________________________
o __________________________________________________________________
o __________________________________________________________________

CONSTANT READINESS:
TERMINOLOGY AND ACRONYMS
2012 Source: Hospital Accreditation Standards (HAS) and www.jointcommission.org
APR
CDC
CSGs
e-App
EP
ESC
FMEA
Life Safety Code
H.A.I.
MDRO
MOS
NPSGs
PDA
PFA
PFP Output
PI
POA
PPR
PRA
QM
RFI
S3
S3-PRA
Sentinel
Event
SIG
SII
SVNP
TJC
UP
WHO
JOINT COMMISSION ABBREVIATIONS

Accreditation Participation Requirement
Center for Disease Control (Atlanta, Georgia)
Clinical/Service Groups
Electronic Application for Accreditation
Elements of Performance
Evidence for Standards Compliance (report)
Failure Mode and Effects Analysis
National Fire Protection Association Code 101: Danger to Life from Fire
Health Care Associated Infection
Multiple Drug Resistant Organism
Measure of Success
National Patient Safety Goals
Preliminary Denial of Accreditation
Priority Focus Area
Priority Focus Process (PFP) Output automated tool that integrates data to identify
clinical/service groups and Priority Focus Areas (PFAs)
Performance Improvement
Plans of Action
Periodic Performance Review: compliance assessment at midpoint of accreditation
cycle)
Performance Risk Assessment: Strategic Surveillance System (S3 system) tool
Quality Management
Requirement for Improvement
Strategic Surveillance System
Management tool for systems improvement through strategic objectives
Any unexpected event occurrences involving death or serious physical or
psychological injury or risk thereof. The most frequently reported events include
patient suicide, operative/post-operative complications, wrong site surgery, medication
error, and delays in treatment.
Joint Commission Standards Interpretation Group
Standards Improvement Initiative
Shared Vision--New Pathways
The Joint Commission
Universal Protocol
World Health Organization

CONSTANT READINESS:
2012 National Patient Safety Goals (NPSG)

How can volunteers help their healthcare institution meet patient safety goals jointly accepted by
the Joint Commission, the Center for Disease Control and/or the World Health Organization?
Suggestions for applicability for volunteers/volunteer programs are in italicized text.
Recommendation: Consult with your Risk Management director and other staff responsible for Joint
Commission standards review for interpretation of how volunteers can be involved in helping the
hospital achieve these goals.
2012 NATIONAL PATIENT SAFETY GOALS

(Easy to understand language)
GOAL 1: Identify patients correctly (2 identifiers)
Applicability to Volunteer Services:
Volunteers providing any direct care or service (such as patient transportation) must use two
patient identifiers that are consistent with identifiers used by paid staff. The patients room
number or physical location may not be used as identifiers.
GOAL 2: Improve staff communication (test results)

Recording test results is a staff function. This goal addresses effective handing off of
information between staff.
This concept would apply to volunteers sharing information with staff or volunteers who need to
know that information before they leave the department or as is appropriate according to the
situation.
GOAL 3: Use medicines safely

Volunteers do not ever administer medications to patients as this is strictly a staff function.

CONSTANT READINESS:
GOAL 7: Prevent infection (hand cleaning)
NPSG.07.01.01
Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for
Disease Control and Prevention (CDC) hand hygiene guidelines.
World Health Organization Hand Hygiene Guidelines
Hand hygiene can be also found on the Center for Disease Control and Prevention website:
http://www.cdc.gov/handhygiene/
1. Indications for hand washing and hand antisepsis
A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled
with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an
antimicrobial soap and water (IA) (66).
B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands
in all other clinical situations described in items 1C--J (IA) (74,93,166,169,283,294,312,398).
Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in
items 1C--J (IB) (69-71,74).
C. Decontaminate hands before having direct contact with patients (IB) (68,400).
2. Hand-hygiene technique
A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand
and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB)
(288,410). Follow the manufacturer's recommendations regarding the volume of product to use.
B. When washing hands with soap and water, wet hands first with water, apply an amount of product
recommended by the manufacturer to hands, and rub hands together vigorously for at least 15
seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly
with a disposable towel. Use towel to turn off the faucet (IB) (90-92,94,411). Avoid using hot
water, because repeated exposure to hot water may increase the risk of dermatitis (IB)
(254,255).
C. Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a nonantimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small
bars of soap should be used (II) (412-415).
D. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care
settings (II) (137,300).

CONSTANT READINESS:
Fingernails
Updated June 2010
Source: TJC Website www.jointcommission.org FAQ: under NPSG 07.01.01
QUESTION: The CDC guidelines say that health care personnel should not wear artificial nails and should
keep natural nails less than one quarter inch long if they care for patients at high risk of acquiring infections
(e.g. patients in intensive care units or in transplant units). The WHO guidelines prohibit artificial nails and
extenders for all healthcare workers. Will Joint Commission actually be requiring this?
ANSWER: Each organization must follow the IA, IB and IC recommendations from the guideline it chooses (CDC or
WHO). Therefore, if WHO is chosen, no direct care providers should have artificial nails or extenders. If CDC is
chosen, providers in high-risk areas must not wear artificial nails. Please note that many organizations following CDC
guidelines have chosen to expand the ban on artificial nails to all care providers in the interest of safety. Regarding
the length of natural nails, each organization may choose its own approach since the level of recommendation in both
the CDC and WHO guidelines is "II", thereby making compliance optional.
Elements of Performance for NPSG.07.03.01

6. January 1, 2010: Based on the results of the risk assessment, the hospital educates staff and
licensed independent practitioners about health care associated infections, multi-drug resistant
organisms, and prevention strategies at hire and annually thereafter.
Note: The education provided recognizes the diverse roles of staff and licensed independent
practitioners and is consistent with their roles within the hospital. (See also HR.01.05.03, EP 4)

-Volunteers must be trained about and utilize Center for Disease Control or World Health
Organization-approved hand hygiene techniques to help reduce health care associated infections.
-As of 2010, training about health care associated infections, multi-drug resistant organisms, and
prevention strategies is provided during initial orientation and annually thereafter.
GOAL: Identify patient safety risks (suicide-prone patients)

Note: Updating the status of a patients medications is also an important component of all patient care hand-offs.

Volunteers who observe high-risk behaviors or who hear a patient make any references to suicide
must immediately report their observations to appropriate staff.

10
CONSTANT READINESS:
2012 JOINT COMMISSION STANDARDS

Environment of Care (EC)
Emergency Management (EM)
Management of Human Resources (HR)
Infection Control and Prevention (IC)
Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM)
Medical Staff (MS)
National Patient Safety Goals (NPSGs)

Nursing (NR)
Provision of Care (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Transplant Safety (TS)
Waived Testing (WT)
ELEMENTS OF PERFORMANCE
The Joint Commission specifies the elements of performance they expect to be in compliance under
each standard.
FOCUS ON VOLUNTEERS
Special attention to volunteers "providing care, treatment and services
(who work in the same capacity as staff and provide care, treatment and services)
Direct contact and access to patients

Screening, qualification, and education of these volunteers = level of attention that is given to
employed staff to insure the safety, security, and the highest quality of care for patients.
BEST PRACTICES: Train all volunteers thoroughly before they start. By providing comprehensive
training, volunteers can be cross-trained for new areas.
MINIMUM: Volunteers who do have patient access must be educated regarding all elements of
performance related to staff before beginning their volunteer service.
DISCLAIMER AND RECOMMENDED RESOURCES

Following these recommendations will help achieve compliance, but are not an assurance that a Joint
Commission survey will be passed.
All volunteer programs and policies should be reviewed by the institutions Joint Commission
compliance staff member, Human Resources, and Legal Affairs for ongoing compliance and process
improvement.
11
CONSTANT READINESS:
VOLUNTEER SERVICES STANDARDS QUICK REFERENCE

Environment of Care (EC)
EC.01.01.01 (Minimize Risks)

EC.02.01.01 (Manage Safety and Security Risks)
EC.02.01.03 (Smoking)
EC.02.02.01 (Hazardous Materials and Wastes)
EC.02.03.01 (Fire Risks)
EC.02.03.03 (Fire Drills)
EC.02.06.01 (Safe, Functional Environment)
EC.03.01.01 (Staff Environment of Care Roles and Responsibilities)
Notes: _________________________________________________________________________
_______________________________________________________________________________
Emergency Management (EM)
EM.01.01.01 (Emergency Planning)

EM.02.01.01 (Emergency Operations Plan)
EM.02.02.01 (Emergency Communications)
EM.02.02.05 (Emergency Security and Safety)
EM.02.02.07 (Management of Staff)
EM.02.02.13 (Volunteer Licensed Independent Practitioners)
Use of Paper Patient During Emergency Exercises
TJC FAQ Updated November 24, 2008
Source: www.jointcommission.org
Question:
Can paper patients be used in lieu of mock patients during an external disaster exercise?
Answer:
Organizations are finding it increasingly difficult to conduct disaster exercises with mock victims,
sometimes because of a shortage of volunteers. Because volunteer victims have been injured during the course of a
exercise, liability concerns have increased. Many of the youth groups that were consistently involved in exercises are
now declining to participate. In response to the issues, the Joint Commission has allowed paper patients to replace live
victims. Paper patient exercises should not be confused with tabletop events. The simulated paper patients must be
treated as if they were live patients and must therefore be processed through.
Notes: _________________________________________________________________________
_______________________________________________________________________________
12
CONSTANT READINESS:
Management of Human Resources (HR)
Standard HR.01.02.05 (Verifying Staff Qualifications including Criminal Background Check and
Health Screening)
HR.01.02.07 (Staff Functioning)
HR.01.04.01 (Orientation)
HR.01.05.03 (Ongoing Training and Education)
HR.01.06.01. (Staff Competence)
HR.01.07.01. (Staff Performance)
Human Resource Standards Applicability to Contracted and Volunteer Personnel
TJC FAQ Updated Revised May 10, 2011
Source:
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=344&StandardsFAQChapterId=66
Question: Do the standards in the human resource chapter apply to contracted and volunteer personnel? If
yes, how is compliance with the standards surveyed?
Answer: The standards in the human resource chapter apply to direct, contract, and volunteer personnel
providing patient care and/or services on behalf of an organization, regardless of whether the contracted
organization is accredited.
Patient care personnel can include, but are not limited to:
nursing, therapy, dietary, pharmacy, activities staff, drug and alcohol counselors such as AA counselors, and
nursing assistants/aides
Patient services personnel can include but are not limited to:
homemakers, companions, sitters, chore workers, drivers, home medical equipment delivery and repair
technicians, volunteers transporting patients
Non-patient care or service personnel that would not be included are, for example:
volunteers who deliver the mail or flowers, staff the information desk, gift shop or library
services, perform patient errands (e.g. writing and mailing letters or obtaining magazines and
toiletries from the gift shop), conduct marketing or fund raising activities
Contracted Personnel: Organizations must manage contracted services and personnel just as they must manage
services and personnel who are provided by direct employees. They can either define in the contract or in policy
criteria for performance of the contracted service; or, review and adopt the contract organization's policies and
practices.
The human resource standards are applicable to any contracted service which provides any element of care or service
which is eligible for survey with the following exception:

13
CONSTANT READINESS:
Home Care: The human resource standards do not apply to delivery of home medical equipment and pharmaceutical
products via a contracted common carrier, i.e., UPS, FEDEX, or similar, US Postal Service, local courier companies,
etc., where there is no education and setup involved. The standards do apply when provided by a direct employee.
The contract should specify that the contracted organization will provide only staff who are qualified in relation to
their education, training, licensure, and competence as defined by the organization.
Volunteers: When volunteers perform patient care or services the organizations

must manage volunteer personnel just as they must manage services and personnel
who are provided by direct employees
Contract or volunteer Staff Information: The organization should have verified information, (where relevant) of
their:
1.
2.
3.
4.
5.
6.
7.
8.
Education and training that is consistent with applicable legal and regulatory requirements and organization
policy;
Evidence of license, certification, or registration, when applicable; and
Evidence that individual's knowledge and experience and competence are appropriate for his or her assigned
responsibilities as required by the contracting organization.
Orientation to the contracting organization
Evaluations of performance
Health status as required by job responsibilities, as defined by the organization, and as required by law and
regulation.
Criminal background check or pre-employment verification of convictions for abuse or neglect, when required
by law and regulation
References, when applicable
Evidence of verification may include:
appropriate information for each contracted person maintained by the contracting organization
copies of appropriate information for each contracted person obtained from the contracted
organization/individual
the results of an audit of appropriate information for contracted individuals conducted by the contractor.
The organization determines whether to include a percentage or all contracted individuals in the audit.
the results of an audit of personnel, health, and education records of contracted individuals conducted by
the contracted organization. In this case the organization defines the specific information to be included in
the audit and whether the audit is to include a percentage or all contracted individuals.
Note: The audit must include an attestation as to the accuracy of the information. A simple attestation letter
indicating that the information is current and on file at the organization site, without the audit is not sufficient.
The actual services provided by any contracted organization or individual must meet the intent of all applicable
standards in all chapters in the manual that are surveyed for compliance.

14
CONSTANT READINESS:
Requirements for Criminal Background Checks
Updated | November 24, 2008
Source: TJC Website www.jointcommission.org FAQ: under Human Resources
Q: What is the Joint Commission requirement for criminal background checks and for which type of individual
must it be performed?
A: Staff, students and volunteers who work in the same capacity as staff who provide care, treatment, and
services, would be expected to have criminal background checks verified when required by law and regulation and
organization policy.
This means that if state law, regulation or organization policy requires background checks on all employees, volunteers
and students, Joint Commission expects them to be done on all three categories.
If state law requires background checks on only specified types of health care providers (e.g. nursing assistants/child
care workers), then Joint Commission would require background checks on only those specified in state law (unless
organization policy goes beyond state law).
If state law requires background checks on all "employees", the organization should seek an opinion from the state on
what categories of health care workers are considered "employees".
If the state clearly does not consider volunteers or students to be employees, then Joint Commission would not
require background checks on them (unless organization policy goes beyond state law and requires it).
If state law is ambiguous as to the definition of employee, the organization can define the scope of background
checks to fit its own definition. As such, they may include or exclude students and volunteers, and Joint
Commission would survey to hospital policy.
In the absence of a state law on criminal background checks, each organization can develop its own
expectations, e.g., and organization elects to screen employees and not students/volunteers. Joint Commission
would evaluate compliance with the organization's internal policy only. There would be no Joint Commission
expectation that an organization check categories of providers beyond what is required in their own policy, which
must comply with law and regulation.
All criminal background checks must be documented by the organization.
Notes: _________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
15
CONSTANT READINESS:
Infection Control and Prevention (IC)
IC.01.03.01 (Infection Risks)

IC.01.04.01 (Hand Hygiene, Standard Precautions, Protective Equipment, Policies)
IC.01.05.01 (Infection Prevention and Control Plan)
IC.01.06.01 (Influx of Potentially Infectious Patients)
IC.02.01.01 (Infection Prevention and Control Plan)
IC.02.02.01 (Medical Equipment, Devices, and Supplies)
IC.02.03.01 (Transmission of Infectious Diseases)
IC.02.04.01 (Influenza Vaccinations) Effective July 1, 2012
Notes: _________________________________________________________________________
_______________________________________________________________________________
Information Management (IM)
IM.01.01.01 (Managing Information)

IM.01.01.03 (Continuity of Information Processes)
IM.02.01.01 (Privacy of Health Information)
IM.02.01.03 (Security and Integrity of Health Information)
Notes: _________________________________________________________________________
_______________________________________________________________________________
Leadership (LD)
LD.01.07.01 (Staff Training)

LD.02.02.01 (Conflict of Interest Among Leadership)
LD.02.03.01 (Leadership Communication)
LD.02.04.01 (Conflict Management)
LD.03.01.01 (Culture of Safety and Quality)
LD.03.02.01 (Use of Data and Information)
LD.03.03.01 (Planning)
LD.03.05.01 (Change Management)
LD.03.06.01 (Staffing and Competencies)
LD.04.01.01 (Laws and Regulations)
LD.04.01.03 (Annual Operating Budget)
LD.04.01.05 (Program/Department Management)
LD.04.01.07 (Policies and Procedures)
LD.04.01.11 (Space and Equipment)
LD.04.02.01 (Conflict of Interest)
LD.04.02.03 (Ethical Business Practices)
LD.04.04.01 (Performance Improvement)
LD.04.04.03 (Well-Designed Services)
LD.04.04.05 (Safety Program)
Notes: _________________________________________________________________________
_______________________________________________________________________________
16
CONSTANT READINESS:
Life Safety (LS)

LS.01.01.01. (Life Safety Code)
LS.01.02.01 (Building Construction)
LS.02.01.30 (Fire Protection including Gift Shops)
LS.02.01.35 (Systems for Extinguishing Fires)
LS.02.01.70 (Fire and Smoke Prevention Requirements)
Notes: _________________________________________________________________________
_______________________________________________________________________________
Medication Management (MM)

MM.01.01.01 (Medication Management Processes)
Notes: _________________________________________________________________________
_______________________________________________________________________________
Medical Staff (MS)
No direct applications to Volunteer Services
Nursing (NR)
Quality practice recommendations, but no direct standards applied to Volunteer Services
Notes: _________________________________________________________________________
_______________________________________________________________________________
Provision of Care (PC)

PC.01.02.09 (Patient Protection and Prevention of Abuse and Neglect)
PC.02.02.13 (End-of-Life Care)
Notes: _________________________________________________________________________
_______________________________________________________________________________
Performance Improvement (PI)

PI.01.01.01. (Performance Improvement Data Collection)
PI.03.01.01. (Performance Improvement)
Notes: _________________________________________________________________________
_______________________________________________________________________________
17
CONSTANT READINESS:
Record of Care, Treatment, and Services (RC)

RC.01.02.01. (Medical Records)
Notes: _________________________________________________________________________
_______________________________________________________________________________
Rights and Responsibilities of the Individual (RI)
RI.01.01.01 (Patient Rights)

RI.01.03.03 (Patient Rights regarding Recordings, Films, and Images)
RI.01.05.01 (End of Life Decisions)
RI.01.06.03 (Freedom from Neglect, Exploitation, and Abuse)
Transplant Safety (TS)
TS.01.01.01 (Transplant Policies)
Waived Testing (WT)
No direct applications to Volunteer Services
DOCUMENTATION AND EDUCATION
Follow your organizations established policies and procedures for documenting work competence,
work performance evaluations, training, appropriate health and background screenings, and ongoing
performance/risk management improvement.
Training and evaluating volunteers on an ongoing basis is a best practice recommendation.
Documentation of those efforts is a Joint Commission requirement.
EXCELLENT RESOURCES
The Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance

Boulevard, Oakbrook Terrace, Illinois, 60181. Main telephone number: 630-792-5000
Customer service telephone number: 630-792-5800.
The Joint Commission Web Site: www.JointCommission.org
Current Year: Hospital Accreditation Standards (HAS). Oakbrook Terrace: Joint Commission
Resources, Inc.
Publisher contact information: Joint Commission Resources, One Renaissance Boulevard, Oakbrook
Terrace, Illinois, 60181. Customer service: 877-223-6866.
Many hospitals now use the online version which can be accessed through each
staff members personal computer. Versions will be available for phones as well.
18
CONSTANT READINESS:
ABOUT YOUR SPEAKER
Mary McCormack has shown thousands of people and organizations how to successfully apply creative
solutions to challenges involving leadership, standards compliance, fundraising, and best business practices.
Mary has specialized in business and healthcare management for over 38 years. She is an international
speaker, author and consultant. Since 1996, she has been President and CEO of Information Enterprises and
twice a past-president of the National Speakers Association-North Florida Chapter. Also a member of the
Association of Healthcare Volunteer Resource Professionals, Mary has made great contributions to the
Association. In 2006, AHVRP presented Mary their highest honor, the national Award for Excellence.
CONSTANT READINESS:
RECOMMENDED PRACTICES FOR JOINT
COMMISSION STANDARDS, 2nd Edition
Mary V. McCormack, CAVS, CDVS
The Joint Commission recognizes the importance and impact that volunteers can have on health care safety,
quality, and service excellence. Constant Readiness offers recommendations for volunteer administrators to
use as a foundation for standards compliance that impacts volunteer services. Equipped with over 200 pages of
insightful information and professional development resources, volunteer administrators gain a must-have
reference tool and assistance in achieving a level of constant readiness.
Have you been wondering?
What did the Joint Commission change about expectations for transportation volunteers?
Which volunteers need background checks, competency assessments, and/or evaluations?
What are Second Generation Tracers and Levels of Criticality?
How can you stay informed about the latest TJC updates impacting Volunteer Services?
Get these answers and more when you explore the past, present, and future standards discussed in Constant
Readiness, 2nd Edition. Mary McCormack reviews the current standards for applicability to volunteer services
administration and offers practical options for understanding and complying with Joint Commission expectations.
Volunteer administrators and volunteer leaders will gain a must-have tool and assistance in achieving a level of
constant readiness.
Constant Readiness: Recommended Practices for Joint Commission Standards 2nd Edition provides:
321 quality practice and process improvement recommendations
261 pages of insightful information
75 Joint Commission standards reviewed for applicability to volunteer services administration
69 professional development resources, publications, lists, and helpful websites
54 quotes to use in motivating and training volunteers about safety, excellence and risk management
40-page Constant Readiness Process Improvement Assessment Tool that includes:
70 mock-survey sample questions to help prepare volunteers and/or auxilians
123 pre-survey sample questions for volunteer services administrators and volunteer leaders
25 easy-to-navigate chapters and a detailed Table of Contents
16 pages provided for you to track your Constant Readiness Review Notes and Action Steps
ORDERING INFORMATION
Association of Healthcare Volunteer Resources Professionals. www.todaysvolunteer.org
Education/Publications, Catalog # 200821 312-422-3936
AHVRP members: $99 Non-members: $149
19
CONSTANT READINESS:
JOINT COMMISSION REVIEW NOTES
Jot down areas to be reviewed within 48 hours of returning to the office.
Even if you make some preliminary notes and set timelines for review, this
will get you started in keeping your program in a state of constant
readiness! Quality, safety, and performance improvement are priorities!
If you have a specific concern/or question or wish to share a success story,

you may contact Mary directly at [email protected]

20

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CONSTANT READINESS:

RECOMMENDATIONS FOR JOINT

Elevate Your Program to the Next Level!

THE JOINT COMMISSION

PAST HISTORY OF THE JOINT COMMISSION

Private, non-profit organization.

Considered the Gold Standard of accreditation

VOLUNTARY ACCREDITATION: Over 19,000 healthcare organizations pay to be surveyed to

PERSPECTIVE OF JOINT PARTNERSHIPS

PRESENT: THE JOINT COMMISSION TODAY

To view all the FAQs for a particular manual:

CONSTANT READINESS: Recommendations for Joint Commission Standards

S3: The Strategic Surveillance System

2008 Approval for methodology for conducting surveys in 18-39 months

2008 Three point Elements of Performance Scoring Scale:

VOLUNTEER FOCUS AREAS:

Does this volunteer assess patient needs in any way?

FUTURE PREDICTIONS FOR VOLUNTEER SERVICES

FOCUS AREAS FOR 2012 STANDARDS

2012 NATIONAL PATIENT SAFETY GOALS:

Life Safety Chapter:

Danger to Life from Fire.

Surveyors will have Joint Commission badges.

Infection Control and Prevention (IC.02.04.01) Effective July 1, 2012

CONSTANT READINESS: Recommendations for Joint Commission Standards

Sample Joint Commission Questions

CONSTANT READINESS: Recommendations for Joint Commission Standards

TERMINOLOGY AND ACRONYMS

2012 Source: Hospital Accreditation Standards (HAS) and www.jointcommission.org

JOINT COMMISSION ABBREVIATIONS

CONSTANT READINESS: Recommendations for Joint Commission Standards

2012 National Patient Safety Goals (NPSG)

Suggestions for applicability for volunteers/volunteer programs are in italicized text.

2012 NATIONAL PATIENT SAFETY GOALS

GOAL 2: Improve staff communication (test results)

GOAL 3: Use medicines safely

CONSTANT READINESS: Recommendations for Joint Commission Standards

World Health Organization Hand Hygiene Guidelines

CONSTANT READINESS: Recommendations for Joint Commission Standards

Elements of Performance for NPSG.07.03.01

Applicability to Volunteer Services:

GOAL: Identify patient safety risks (suicide-prone patients)

Applicability to Volunteer Services:

CONSTANT READINESS: Recommendations for Joint Commission Standards

2012 JOINT COMMISSION STANDARDS

National Patient Safety Goals (NPSGs)

Direct contact and access to patients

DISCLAIMER AND RECOMMENDED RESOURCES

VOLUNTEER SERVICES STANDARDS QUICK REFERENCE

EC.01.01.01 (Minimize Risks)

Emergency Management (EM)

EM.01.01.01 (Emergency Planning)

Management of Human Resources (HR)

CONSTANT READINESS: Recommendations for Joint Commission Standards

Volunteers: When volunteers perform patient care or services the organizations

Evidence of verification may include:

CONSTANT READINESS: Recommendations for Joint Commission Standards

Infection Control and Prevention (IC)