Joint Commission International Accreditation Standards for Hospitals Including Standards for Academic Medical Center Hospitals 8th Edition | Effective 1 January 2025
Joint Commission International Accreditation Standards for Hospitals, 8th Edition Joint Commission International Mission A division of Joint Commission Resources, Inc. The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the international community through the provision of education, publications, consultation, and evaluation and accreditation services. © 2024 The Joint Commission, on behalf of Joint Commission International “Global Health Impact” (GHI) chapter only: © 2024 The Joint Commission on behalf of Joint Commission International, and the International Hospital Federation Geneva Sustainability Centre Published by Joint Commission Resources Oakbrook Terrace, Illinois 60181 USA https://www.jcrinc.com Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of Joint Commission International. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation and certification process. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Requests for permission to make copies of any part of this work should be sent to
[email protected]. ISBN (print): 978-1-63585-347-6 ISBN (e-book): 978-1-63585-348-3 Printed in the USA For more information about Joint Commission International, please visit https://www.jointcommissioninternational.org. Development Team for the 8th Edition Director, Standards Development and Interpretation: Ron Quicho, MS, MBA Associate Director, Standards Development and Interpretation: Laura Evans, MS, RN Associate Director, Standards Development and Interpretation: Antigone E. Kokalias, MBA, MSN, RN Associate Director, Standards Development and Interpretation: Victoria Nalezny, MS, OTR/L, CSRS Associate Director, Production: Johanna Harris Executive Director, Global Publishing: Catherine Chopp Hinckley, MA, PhD Associate Director, Editorial, Accreditation Content: Mary Beth Curran
iii Technical Advisory Panel for the 8th Edition Dave Allegaert Manager kwaliteit & innovatie Belgium Yvonne P. Burdick, MHA, FACHE, EDAC Consultant Joint Commission International USA Chinhak Chun, MD Consultant Joint Commission International USA Haroon Hafeez, FRCP, FRCPE Consultant Physician Internal/Palliative Medicine Director, Quality and Patient Safety Department SKMCH & RC Pakistan Paul Hofmann, DrPH, LFACHE President Hofmann Healthcare Group USA James Kendig, MS, CHSP, HEM Field Director, Surveyor Management and Development The Joint Commission USA Eve Lai Performance Improvement/Risk Manager Hong Kong Adventist Hospital Hong Kong Rinat Megreleshvili, RN, MN Director, Department of Hospital Accreditation Clalit Health Services Israel Shaik Mohiuddin Chief Quality Officer SEHA Abu Dhabi United Arab Emirates Patricia O’Shea, MD, MPH, MBA Surveyor Joint Commission International USA Babak Pazooki, MD, MS, FACE, CPHQ Surveyor Joint Commission International USA Thomas Schaefer, DDS, MS Surveyor Joint Commission International USA Smadar Sharbi RN, MPA Director of Quality and Accreditation, Division of Government Medical Centers Israel Ministry of Health Israel Renee Thompson, DNP, RN, FAAN CEO and Founder Healthy Workforce Institute USA Shin Ushiro, MD, PhD Professor and Director, Division of Patient Safety Kyushu University Hospital Japan Özlem Yıldırım Veenstra, PhD, BSIE, MSEM Surveyor Joint Commission International USA Bryan Warren, MBA, CHPA, CPO-I President WarSec Security USA Ann Watkins, BNS, MEd Surveyor Joint Commission International USA