Chapters

The Joint Commission International Accreditation Standards for Hospitals, 8th Edition is organized into five major sections that contain chapters outlining specific standards. The chapters are structured around the important functions common to all health care organizations.

Section I: Accreditation Participation Requirements

• Accreditation Participation Requirements (APR): Outlines specific requirements for participating in the JCI accreditation process and maintaining an accreditation award throughout the three-year cycle.

Section II: Patient-Centered Standards

• Access to Care and Continuity of Care (ACC): Addresses matching patient needs with available services, coordinating care, and planning for discharge and follow-up care.

• Assessment of Patients (AOP): Focuses on patient assessment and reassessment, pain screening, and standards for laboratory and diagnostic imaging services.

• Anesthesia and Surgical Care (ASC): Covers procedural sedation, anesthesia, and surgical interventions, including care planning, patient monitoring, and post-procedure care.

• Care of Patients (COP): Discusses the planning and coordination of basic care, high-risk services, resuscitation, pain management, food and nutrition therapy, end-of-life care, and transplant services.

• International Patient Safety Goals (IPSG): Promotes specific, systemwide improvements in problematic areas of health care to ensure patient safety, such as patient identification, handover communication, and safe surgery.

• Medication Management and Use (MMU): Details systems and processes for safe medication use, including selection, storage, prescribing, preparing, dispensing, administering, and monitoring.

• Patient-Centered Care (PCC): Addresses respecting patients' unique cultural, psychosocial, and spiritual values, establishing open communication, and providing patient and family education to support informed care decisions.

Section III: Health Care Organization Management Standards

• Facility Management and Safety (FMS): Focuses on maintaining a safe, functional physical facility, including fire safety, hazardous materials, emergency management, utility systems, and medical equipment.

• Governance, Leadership, and Direction (GLD): Describes leadership responsibilities in planning, directing, and integrating services, managing resources, and ensuring ethical practices and a culture of safety.

• Health Care Technology (HCT): Establishes processes for adopting and overseeing new technologies, including electronic health records, telehealth, cybersecurity, and artificial intelligence.

• Management of Information (MOI): Examines the management of data and information, including the integrity and security of the patient medical record, to meet the needs of clinical and managerial decision-making.

• Prevention and Control of Infections (PCI): Outlines programs and surveillance activities to identify and reduce the risks of acquiring and transmitting infections.

• Quality and Patient Safety (QPS): Details the framework for a successful quality program, including data collection, analysis of adverse events and near misses, and sustaining performance improvement.

• Staff Qualifications and Education (SQE): Addresses human resources planning, staff orientation and education, competence assessments, staff health, and the credentialing and privileging of health care professionals.

Section IV: Global Health Impact Standards

• Global Health Impact (GHI): An all-new chapter for the 8th Edition focusing on environmental sustainability, helping organizations set goals to reduce greenhouse gas emissions, optimize resource use, and adapt to climate-related hazards.

Section V: Academic Medical Center Standards

• Human Subjects Research Programs (HRP): Describes requirements for ethical, legal, and patient-centric human subjects research programs, including managing conflicts of interest and obtaining informed consent.

• Medical Professional Education (MPE): Addresses how academic medical centers educate, supervise, and grant privileges to medical students and trainees while ensuring the safety and quality of patient care.

In addition to the main chapters, the manual includes three appendices that do not contain new scorable standards but provide critical educational frameworks:

• Interim Measures: Explains actions taken to ensure the safety of building occupants when fire safety systems are compromised or inoperable due to construction or repair.

• Patient Safety Systems (PS): Educates leaders on developing an integrated, proactive patient safety system, emphasizing a strong "learning organization" culture of safety and data-driven harm prevention.

• Sentinel Event Policy (SE): Details JCI's policy for defining, investigating (via comprehensive systematic analysis), and reporting sentinel events to prevent future patient harm.