The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

• A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
• A time-out is performed before the procedure.
• As part of its Emergency Operations Plan, the hospital prepares for how it will manage utilities during an emergency.
• Before the hospital discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, and services.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
• Care, treatment, and services provided through contractual agreement are provided safely and effectively.
• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.
• Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.
• Reduce the likelihood of harm related to maternal hemorrhage.
• Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia.
• Reduce the risk for suicide. Note: EPs 2–7 apply to patients in psychiatric hospitals or patients being evaluated or treated for behavioral health conditions as their primary reason for care. In addition, EPs 3–7 apply to all patients who express suicidal ideation during the course of care.
• Staff are competent to perform their responsibilities.
• The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
• The hospital assesses and manages the patient’s pain and minimizes the risks associated with treatment.
• The hospital assesses and reassesses its patients.
• The hospital assesses the needs of patients who receive psychosocial services to treat alcoholism or other substance use disorders.
• The hospital conducts fire drills.
• The hospital designs and manages the physical environment to comply with the Life Safety Code.
• The hospital documents the use of restraint or seclusion.
• The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
• The hospital has policies and procedures that guide and support patient care, treatment, and services.
• The hospital identifies the individual(s) responsible for the infection prevention and control program.
• The hospital implements its infection prevention and control plan.
• The hospital inspects, tests, and maintains emergency power systems. Note: This standard does not require hospitals to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The hospital inspects, tests, and maintains medical equipment.
• The hospital inspects, tests, and maintains medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
• The hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
• The hospital maintains complete and accurate medical records for each individual patient.
• The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
• The hospital maintains the integrity of the means of egress.
• The hospital makes food and nutrition products available to its patients.
• The hospital manages fire risks.
• The hospital manages medical equipment risks.
• The hospital manages risks associated with its utility systems.
• The hospital manages risks related to hazardous materials and waste.
• The hospital notifies the public it serves about how to contact its hospital management and The Joint Commission to report concerns about patient safety and quality of care. Note: Methods of notice may include, but are not limited to, distribution of information about The Joint Commission, including contact information in published materials such as brochures and/or posting this information on the hospital's website.
• The hospital plans the patient’s care.
• The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
• The hospital provides and maintains equipment for extinguishing fires.
• The hospital provides and maintains fire alarm systems.
• The hospital provides and maintains systems for extinguishing fires.
• The hospital provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.
• The hospital provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety.”
• The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
• The hospital respects, protects, and promotes patient rights.
• The hospital safely administers medications.
• The hospital safely stores medications.
• The hospital uses restraint or seclusion safely.
• The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.
• The patient and his or her family have the right to have complaints reviewed by the hospital.
• The patient’s medical record contains documentation on any operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

• Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.